Disease management programmes in Germany – IQWiG says it’s time for an update

How are DMPs working in practice?

1. The BAS checks whether the DMP meets the requirements set out in the G-BA guidelines. Then the BAS can approve the DMP.
2. Patients with certain chronic diseases can sign up for such a treatment program with their SHI fund.
3. These SHI funds then negotiate regional contracts with physicians and / or hospitals for the DMP.

DMP rheumatoid arthritis

This DMP targets adult patients with a confirmed diagnosis of rheumatoid arthritis. Correct and careful diagnosis is very important in this disease to differentiate the various non-inflammatory rheumatic causes, especially from the degenerative joint changes. In addition, it is also crucial to assess the further course of the disease and to choose the optimal therapeutic strategy.

The key aims of the DMP are to

• achieve a long-lasting remission, i.e. almost complete freedom from inflammation and symptoms or a low level of disease activity
• avoid joint damage
• improve functionality and mobility
• reduce pain, and
• increase the life expectancy by also treating comorbidities.

The G-BA has included a wide range of therapeutic measures in the DMP requirements. In detail, the DMP covers lifestyle-related training, physical and occupational therapy, recommendations for drug therapy with glucocorticoids or disease-modifying anti-inflammatory drugs in three therapy stages, and “tapering” of drug administration.

DMP chronic heart failure / cardiac insufficiency

As mentioned above, the G-BA updates the DMPs at regular intervals.

Therefore, the G-BA had commissioned the IQWiG in November 2020 to conduct a review of the most recent guidelines for chronic heart failure.

Chronic heart failure in Germany

After coronary artery disease and myocardial infarction, myocardial insufficiency (cardiac insufficiency) is one of the most common causes of hospital admissions and deaths in Germany: In 2018, 456,012 people in Germany were hospitalized because of cardiac insufficiency; 35,297 patients died of heart failure in 2019.

A large proportion of patients with heart failure also suffer from concomitant diseases such as type 2 diabetes mellitus, chronic kidney failure or COPD. These comorbidities affect the patient’s quality of life. Taking them into account is important because it can impact disease progression and life expectancy. When the transfer of patients with heart failure from inpatient treatment to outpatient care is inadequate, this can result in repeated hospital admissions. On the other hand, multidisciplinary discharge management improves the long-term prognosis of heart failure. However, despite the introduction of discharge management rules in 2017, there are still care problems after discharge from the hospital. Telemedical measures have been continuously further developed in recent years and have become increasingly important in patient care – also in the care of patients with heart failure.

Required changes of DMP

In November 2021, the IQWiG completed its comparison of the latest guidelines and the requirements of the DMP for chronic heart failure and concluded that the DMP needs to be updated. They found 14 guidelines covering 591 recommendations. But the conclusion for the DMP is that most aspects have to be amended and new ones will be added. For example,

• Pharmacological treatment of chronic heart failure should now also include SGLT-2 inhibitors, whether or not patients also have type 2 diabetes.
• Alternatively, guidelines now recommend combination treatment with sacubitril/valsartan (in exchange for the ACE inhibitor/angiotensin receptor blocker) to intensify the drug therapy.
• In addition, guidelines now consider various forms and characteristics of heart failure, whereas the DMP currently only accounts for systolic heart failure (from a defined degree of severity) as a criterion for enrollment in the DMP.
• Furthermore, two international guidelines and the NVL 2021 provide recommendations for the use of multidisciplinary treatment teams and their specific tasks, which the DMP does not yet include.
• The NVL 2021 and several international guidelines consider further comorbidities, that the DMP does not yet include.
• A new component within the aspect “cooperation of care levels” should be discharge management.
• The updated DMP should also include telemedical care (e.g. video calls), since both the NVL 2021 and an Australian guideline recommend the use of these as part of intensified care. In addition, the IQWiG previously assessed the benefit of “telemonitoring in heart failure“, and the G-BA decided in 2020 to reimburse telemedical care for patients with advanced heart failure in the outpatient service.