Trends in gout management before and after publication of NICE guidance in England: a population-based study in OpenSAFELY

Objectives: To evaluate gout management in England before and after publication of a national clinical guideline by the National Institute for Health and Care Excellence (NICE) and assess the feasibility of using routinely collected health data to monitor guideline implementation at scale. Design: Observational cohort study with interrupted time-series analysis. Setting: Primary care and hospital admission data, with the approval of NHS England. Participants: 22,618,945 individuals aged 18 to 110 years registered with general practices in England contributing data to the NHS OpenSAFELY Data Analytics Service between July 1, 2016, and June 30, 2025. Intervention: Publication of NICE guidance for the diagnosis and management of gout in June 2022. Main outcome measures: Trends in evidence-based measures for gout management, including new prescription of urate-lowering therapy (ULT) and attainment of a target serum urate below 360 micromol/L. Changes in temporal trends after guideline publication were estimated using interrupted time-series models. Results: Of 245,445 individuals newly diagnosed with gout who had available follow-up, 87,885 (35.8%) were prescribed ULT within 12 months of diagnosis. ULT initiation increased from 26.6% in July 2016 to 43.0% in June 2025; however, the rate of increase slowed after publication of the NICE guideline (change in trend: 0.76 percentage-point decrease per year; 95% CI 0.35 to 1.17; p<0.001). Among 108,380 people initiating ULT at any point after diagnosis, 35,865 (33.1%) had at least one recorded serum urate level below target within 12 months of initiation. Urate target attainment improved modestly following publication of the NICE guideline (change in trend: 1.25 percentage-point increase per year; 95% CI 0.64 to 1.86; p<0.001), although sensitivity analyses suggested that was a continuation of an existing trend rather than a guideline-specific effect. Younger adults and males were more likely to be prescribed ULT but less likely to achieve urate targets than older adults and females. Conclusions: Substantial gaps remain between observed gout management and NICE guideline recommendations, particularly for ULT initiation and serum urate target attainment. Guideline publication was not associated with marked improvements beyond existing temporal trends, highlighting the need for implementation strategies to improve gout care. Importantly, routinely collected health data can be used to monitor guideline implementation at scale and identify priorities for improvement.