The effectivity of a disease management programme (DMP) for outpatients suffering from chronic heart insufficiency (CHI) in primary care is presented. The programme is predominantly based on a weekly telephone monitoring by a case manager using a standardised questionnaire that scores CHI-relevant information of the patient. If the score exceeds a predefined limit the patient's general practitioner is alarmed. An observational study including a total of 115 patients indicates a significant decline of the hospital admission rate (p < 0.0001), as the primary outcome measure, whereas the total length of hospitalization remained constant. The findings are compared with other studies' results and the aims of a randomised controlled trial on the efficacy of DMP on patients with chronic heart failure are discussed.
