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DMP ‘chronic heart failure’: Guidelines do not cover all health-care aspects

On 15 January 2016 the German Institute for Quality and Efficiency in Health Care (IQWiG) published the results of a search for evidence-based guidelines on the treatment of people with chronic heart failure. The aim of the report is to identify those recommendations from current guidelines of high methodological quality that may be relevant for the potential new disease management programme (DMP) “Chronic heart failure”.

According to the results of the report the recommendations are largely consistent, but do not cover all health care aspects. The new European guideline planned for publication in spring 2016 could contain important additional Information.

A total of 22 guidelines included

The 22 guidelines that IQWiG could include and analyse address a wide range of health care aspects. Besides diagnostic procedures and non-drug interventions, including lifestyle changes, the guideline recommendations cover drugs as well as interventional therapies in the form of cardiac resynchronization or implantable defibrillators. The recommendations also cover monitoring, patient training, palliative care of patients with end-stage disease, and care of pregnant patients. In addition, recommendations could be identified on right heart failure and the long-term management of patients with heart failure living in nursing homes. The corresponding recommendations are largely consistent.

Gaps for certain concomitant diseases

Patients with heart failure very often suffer from further diseases also requiring treatment. It is thus surprising that even for common concomitant diseases such as renal failure, diabetes mellitus or chronic obstructive pulmonary disease (COPD), guidelines lack recommendations. In addition, the care of multimorbid patients and polypharmacy (i.e. the simultaneous use of different drugs) are insufficiently considered.

Switch between chronic and acute stages

While chronic heart failure develops over a longer period of time, acute heart failure occurs suddenly, for instance, after a severe heart attack. It is typical of the disease that the disease stage changes and patients switch between the chronic and acute stages. This implies that, in the chronic stage, patients are treated in the outpatient setting; in the event of acute and often life-threatening deterioration (decompensation) they are hospitalized and after overcoming the acute situation, are then treated as outpatients again.

Provision of continuous care inadequately depicted in guidelines

However, acute and chronic disease stages are presented separately in guidelines. The commission awarded to IQWiG by the Federal Joint Committee (G-BA) was explicitly restricted to guidelines on chronic heart failure. In this respect, the relatively common transitions between the outpatient and inpatient sectors, which are typical for the disease, are in part only inadequately depicted.

Information from guidelines alone is thus probably insufficient to define optimal care pathways for a DMP. The G-BA may therefore use further information sources in order to formulate the requirements for the future DMP.

The European Society of Cardiology plans to publish an updated guideline in May 2016. Health care experts expect this guideline to include important information that could be incorporated in the DMP. This applies in particular to cardiac resynchronization and treatment of patients with heart failure also suffering from sleep apnoea.