DMP for coronary heart disease: current guidelines indicate some need for revision

On 7 February 2011, the German Institute for Quality and Efficiency in Health Care (IQWiG) published the results of a search update for evidence-based clinical practice guidelines on coronary heart disease (CHD). The aim of the report is to identify those recommendations from current guidelines of high methodological quality that may be relevant for the planned revision of the corresponding disease management programme (DMP). According to the results of the report, there is no compelling need for revision of any part of the DMP. However, IQWiG identified various aspects that could be supplemented and specified. This particularly applies to general measures, drug therapy, as well as the medical indication for undergoing heart catheterization.

Evidence was documented in detail

One of IQWiG's responsibilities specified by law (Social Code Book V) is to develop and issue recommendations for DMPs. In the commission now completed, which was awarded by the Federal Joint Committee (G-BA), IQWiG systematically searched for new guidelines, assessed their methodological quality, and extracted relevant recommendations on the diagnosis, treatment and rehabilitation of patients with CHD. In addition, they documented how high the guideline authors graded the robustness of the recommendations. However, the sources of the recommendations were not examined again; this is where the Institute's guideline appraisals and benefit assessments differ.

In March 2008, IQWiG had already completed the original commission awarded by the Federal Joint Committee, which the Committee had used for an update of the DMP-CHD. For the original report IQWiG had searched for guidelines published between 2002 and June 2007. In the follow-up project, the results of which are now available, the search could therefore be limited to the period after June 2007.

No contradictions between the DMP and current recommendations

A total of 14 guidelines were included which contained recommendations on the treatment of chronic CHD. As the assessment showed, the recommendations in the guidelines are by and large consistent with the requirements of the DMP. No contradictions in content were found. The Director of IQWiG, Professor Dr. med. Jürgen Windeler, stresses that "patients with coronary heart disease can thus be sure that the current DMP is consistent with the current status of medical knowledge on all main points." However, the current guidelines deal with many aspects of health care in more detail than the DMP does.

The IQWiG report therefore notes a potential need for revision, in particular in the form of an extension and specification of the DMP. For example, the items "Nutritional advice", "Physical activity", and "Counselling on smoking cessation" could be described more precisely and in more detail. In addition, the comorbidities hypertension and diabetes mellitus could be dealt with as new separate items in the DMP, and the recommendations on influenza vaccination could be included. For drug therapy, too, the guidelines include recommendations going beyond the statements of the DMP-CHD with regard to the drug classes nitrates, angiotensin-converting enzyme inhibitors, aldosterone antagonists, and blood clotting inhibitors.

Regarding the medical indication for interventional therapy (revascularization of the coronary vessel), under certain preconditions a new European guideline recommends an earlier intervention in patients with a lower grade of stenosis than is recommended in the DMP. Regarding "Training programmes for insured members", the requirements of the DMP could be supplemented: patients could learn to better recognize situations in which they should call a doctor or independently take a fast-acting drug.

IQWiG cannot make any statements on the need for updating and supplementation of the current DMP concerning the included items "Definition of coronary heart disease", "Therapy goals", and "Cooperation of health care levels", as the guidelines analysed do not provide recommendations in this regard.

Procedure of report production

IQWiG published the preliminary results in the form of the preliminary report at the end of August 2010 and interested parties were invited to submit comments. When the comments stage ended, the preliminary report was revised and sent as a final report to the contracting agency, the Federal Joint Committee, in mid-December 2010. The written comments are published in a separate document at the same time as the final report. The report was produced in collaboration with external experts.

An overview of the background, methods and further results of the final report is provided in the following executive summary.

Contact: Tel. ++49(0)221-35685-0, info@iqwig.de