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 highand 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