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Background
Guideline-directed medical therapy (GDMT) is the cornerstone in the treatment of patients with heart failure and reduced ejection fraction (HFrEF) and novel substances such as sacubitril/valsartan (S/V) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) have demonstrated marked clinical benefits. We investigated their implementation into real-world HF care in Germany before, during, and after the COVID-19 pandemic period.
Methods
The IQVIA LRx data set is based on ∼80% of 73 million people covered by the German statutory health insurance. Prescriptions of S/V were used as a proxy for HFrEF. Time trends were analysed between Q1/2016 and Q2/2023 for prescriptions for S/V alone and in combination therapy with SGLT2i.
Findings
The number of patients treated with S/V increased from 5260 in Q1/2016 to 351,262 in Q2/2023. The share of patients with combination therapy grew from 0.6% (29 of 5260) to 14.2% (31,128 of 219,762) in Q2/2021, and then showed a steep surge up to 54.8% (192,429 of 351,262) in Q2/2023, coinciding with the release of the European Society of Cardiology (ESC) guidelines for HF in Q3/2021. Women and patients aged >80 years were treated less often with combined therapy than men and younger patients. With the start of the COVID-19 pandemic, the number of patients with new S/V prescriptions dropped by 17.5% within one quarter, i.e., from 26,855 in Q1/2020 to 22,145 in Q2/2020, and returned to pre-pandemic levels only in Q1/2021.
Interpretation
The COVID-19 pandemic was associated with a 12-month deceleration of S/V uptake in Germany. Following the release of the ESC HF guidelines, the combined prescription of S/V and SGLT2i was readily adopted. Further efforts are needed to fully implement GDMT and strengthen the resilience of healthcare systems during public health crises.
Current crises have highlighted the importance of integrating research, politics and practice to work on solutions for complex social problems. In recent years, policy deliberation fora, policy pilots and policy labs have increasingly been deployed to mobilise science to produce solutions, help create popular support and guide implementation of policies addressing major public policy problems. Yet, we know little about how these approaches manage to transcend the boundaries between research, politics and practice. By systematically comparing policy deliberation fora, policy pilots and policy labs, this paper explores their mechanisms of boundary spanning including relationship and trust building, knowledge translation and developing solutions. We situate our analysis in healthcare policy and climate change policy in Germany, two contrasting policy fields that share a perpetual and escalating sense of crisis. Our findings suggest that deliberation fora, policy pilots and policy labs address different dilemmas of policymaking, namely the idea dilemma, the implementation dilemma and the legitimacy dilemma. All three approaches reduce wicked problems to a manageable scale, by grounding them in local decision-making, reducing their scope or reducing the problem analytically. We argue that despite their ambition to modernise democratic practices, unless they are institutionally well embedded, their effects are likely to be small scale, local and temporary.