[Disease management programs in heart failure: one step beyond pharmacology].

Despite pharmacological advances, both mortality and the incidence of hospital admissions are high for heart failure. As with many other chronic diseases, the findings of clinical trials are difficult to implement due to lack of adherence to treatment, frequent comorbidities not considered in clinical trials, and health systems’ typical focus on acute diseases. Public health systems usually pay less attention to ongoing monitoring and the therapeutic measures necessary for chronic diseases. Unlike acute diseases, chronic conditions require adherence tomedication, nonpharmacologic approaches such as diet, and prolonged follow-up at different levels of the health services. Since the mid-nineties, various initiatives such as that of Rich et al. began to show promising results in reducing admissions for decompensated heart failure via heart failure management programs. Other publications have also reported reduced costs and improved quality of life. Various strategies framed in what might be called chronic disease management were used, such as heart failure consultations, home visits, scheduled discharge programs, telephone follow-ups and monitoring systems. A recently published clinical trial that used only telemonitoring did not show favorable results. However, in this study physiological variables were monitored and there was very low adherence to monitoring during the follow-up. Other studies have had greater adherence to the originally scheduled strategy, such as the DIAL study which, using a more comprehensive strategy by telephone, managed to reduce heart failure admissions by 30%, with a long-term effect after the end of the intervention. In the article published in Revista Española de Cardiologı́a (official publication of the Spanish Society of Cardiology), Domingo et al. describe the results of a telemonitoring system. Evaluating patients beforeandafter treatmentwaseffective in reducinghospitalizations for heart failure and cardiovascular problems. Admissions for heart failure decreased by 67%, and the quality of life assessed by the Minnesota questionnaire showed significant improvement after a 1-year follow-up. Most patients accepted the telemonitoring, although 22% were not actually receiving this intervention (the monitoring) at the end of follow-up. Adherence to daily selfmonitoringwas low (<50%). Therewas no evidence of an increase in any benefit provided by additional self-monitoring for blood