The Global Relevance of Disease Management Programmes for Heart Failure

Heart failure is a worldwide health-care problem, recently highlighted in a report from the Global Heart Failure Awareness Programme of the Heart Failure Association of the European Society of Cardiology. 1 For nearly all countries for which there are data, heart failure consumes 1-2% of expenditure, chiefly related to the costs of hospitalization.Despite differences in heart failure aetiology and demographics in high-and middle-income countries, the need for accurate and speedy diagnosis, access to life-saving therapies, and appropriate support for individuals and their families is universal.International guidelines strongly support disease management programmes, 2,3 including follow-up shortly after discharge from hospital and in the high-risk period (the first 3 months) thereafter.The most recent edition of the American College of Cardiology/American Heart Association guidelines suggest that a follow-up visit within 7-14 days and/or a telephone follow-up within 3 days of hospital discharge are 'reasonable', with a B grading for level of evidence and a IIa class of recommendation.Standards have also been suggested for disease management programmes, with the goal of providing a seamless system of care across primary and hospital care.4 Patient education to support self-monitoring and self-care, where appropriate, is seen as central to any such programme.However, the evidence base for such recommendations is largely confined to randomized trials from high-income countries.In a recent meta-analysis of disease management programmes for heart failure, including 46 studies, 5 30 (65%) were based in the USA or Canada, nine in Europe, six in Australia or New Zealand, and only one came from a middle-income country (Argentina).Despite international guidelines, the relevance of a randomized clinical trial (RCT) to routine practice is often questioned.This is particularly the case when the RCT is based in a health-care system that is constructed (and funded) in a very different way from that found in the geography considering how to organize heart failure services.Reimbursement authorities and health-care insurance companies frequently question the relevance of studies from other geographies.Of course, the biology of the heart failure is unlikely to be different, but the impact of a health-care intervention on the pattern of health-care utilization may be very different.Where the quality or relevance of the

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