Evaluating heart failure care in Germany: insights from the CONNECT study

Background Heart failure (HF) is the most common cause of disease-related hospitalisation in Germany. In order to enhance the care of HF patients, the German Cardiac Society certifies so-called Heart Failure Units (HFU) and promotes their network formation. A key focus of these quality of care centres and networks is the implementation of treatment guidelines. However, the benefits of such structures have not been evaluated. Purpose To provide insights into HF patient characteristics and HF care in Germany across care sectors. Methods CONNECT is a multicentre, prospective, non-interventional study that utilises the HF quality indicators developed by the European Society of Cardiology (ESC) to assess the quality of care of patients with heart failure and a reduced ejection fraction (HFrEF) in Germany. The study employs an opportunity-based quality indicator (QI score; Aktaa 2022) to evaluate the quality of care and the level of guideline adoption in different structural settings. Five care structures are mapped: Hospitals with and without HFU certification, residential cardiologists with and without HFU certification, and general practitioners. Adult HFrEF patients with a decompensation event within the past 3 months were eligible. Patients were followed for 6 months after the index event. Results 899 patients were enrolled at 97 sites: n=23 hospitals with and n=11 hospitals without HFU certificate, n=20 cardiologists with and n=25 without HFU certificate, and n=18 general practitioners. The mean age of CONNECT participants was 71.4±12.4 years at baseline. The majority of patients (74.7 %) were men and in NYHA functional class II or III (27.8 % and 52.4 % respectively). Mean systolic blood pressure was 124.4±21.6 mmHg, heart rate 79.8±20.0 bpm, BMI 28.21±5.89 kg/m2, LVEF 39.5±7.7%. The median time between HFrEF diagnosis and index date was 26.09±55.56 months, and 37% of patients had suffered decompensation(s) also prior to the index event. The mean QI score reached by the different care structures was: HFU hospital, 0.642±0.121; HFU cardiologist, 0.653±0.141; non-HFU cardiologist, 0.621±0.152; non-HFU hospital, 0.618±0.135; general practitioner, 0.593±0.192. Conclusions The CONNECT study indicates that certified HF care structures may offer superior care, as evidenced by higher opportunity-based quality indicators in HFU-associated settings compared to non-HFU settings. Certified networks present a valuable opportunity to study the effectiveness of implementing processes such as updated guideline recommendations. The potential health-economic and prognostic impact of HF care structures merits a systematic evaluation in future studies.