A plea for data-informed quality-driven Healthcare systems

In Switzerland it's interesting to observe how quickly life is getting back to normal when traveling around. No masks, no quarantine, open restaurants, hugs and handshaking. Despite that COVID is still around us, public life is completely normal again as if nothing happened. I'm not even starting about geopolitical pressures and displacement of Ukrainian citizens throughout the world. The worry that I have is that we quickly forget how COVID exposed the weaknesses in Healthcare systems and run the risk that we fail to learn.

Why is strengthening the Healthcare system so important?

In their landmark paper, Xie et al (Long-term cardiovascular outcomes of COVID-19 | Nature Medicine) demonstrated substantial worse cardiovascular outcomes in acute COVID-19 survivors. At 12 months, and compared to a contemporary control group, for every 1000 people, COVID-19 was associated with an excess of: 23 incidents of MACE (myocardial infarction, stroke and all-cause mortality), 12 incidents of Heart Failure, 5 incidents of acute coronary disease, 3 incidents of myocardial infarction and 4 incidents of stroke.

Just to put things in perspective, assuming the full population of Paris (France is holding the presidency of the European Council) will have had COVID-19, then in Paris alone there will be an excess of 49680 MACE incidents, 25920 incidents of HF, 10800 incidents of acute coronary disease, 6480 incidents of Myocardial infarction and 8640 incidents of stroke alone. Are Healthcare systems equipped to deal with this additional influx of unplanned care demand? I don't think so.

What is the solution?

The great news is that much of the knowledge is readily available in clinical evidence-based guidelines. For example we've seen the release of new Heart Failure guidelines in Europe and US as well as new ASCVD prevention guidelines. These guidelines set clear targets: in HF patients need to receive quadruple therapy to reduce hospitalizations and mortality and improve functional status and quality of life. In ASCVD, achieving risk-based targets for blood pressure, glucose and lipids are set. Despite these clear guideline, what we continue to see is that evidence-based treatment goals are not met. I often use the following example in Heart Failure. In a disease with a mortality rate of 50% in 5 years after diagnosis why does it that long to optimize these patients to guideline-directed medical therapy? Equally important, in ASCVD after an event we largely fail to titrate patients to combination therapy to achieve guideline-based LDLc goals. Both examples are leading to unnecessary morbidity and mortality.

What we need are Healthcare systems that are driven by guideline implementation and utilize quality metrics to determine performance. We need incentives in the healthcare system that stimulate delivery of guideline-based care. We need single Healthcare budgets versus the fragmented budget allocation. When we are able to implement guideline-based care in combination with treat-to-target behavior we will likely create value due to longer & healthier lives.

Where this all starts is with member states designing fit-for-purpose healthcare plans that fully build on digital technology, data and dashboards to move from unplanned care due to excess CV events caused by COVID to planned & preventable care. This map from WHO in 2017 is sobering thought: most of the major countries do not routinely track progress of their national health policy, strategy or plan Health Systems Strengthening (who.int).

Do not let the perception of life going back to normal let you believe that things are normal. They are not.