The Cardiovascular Health Strategy (CVHS) of Spain's National Health System

Objectives

Spain’s Cardiovascular Health Strategy seeks to improve population cardiovascular health, extend healthy life and quality of life, reduce cardiovascular disease incidence, prevalence and complications, and improve care for people living with cardiovascular disease. It adopts a comprehensive, multidisciplinary, coordinated and person-centred public-health approach that addresses health inequalities, particularly gender-related inequalities, while supporting the sustainability of the National Health System.[1][2][3][4]

• Promote healthy and sustainable lifestyles and environments, addressing tobacco, unhealthy diet, physical inactivity, harmful alcohol consumption and wider social, economic, environmental and digital determinants of cardiovascular risk.[1][5][6]
• Prevent disease and complications through early detection, risk-factor management, primary and secondary prevention, rehabilitation, disability prevention and recovery support.[1][2][7]
• Strengthen citizen, patient and carer knowledge, self-care capacity, participation and shared decision-making.[2][8][9]
• Advance equity and gender-responsive cardiovascular care by improving awareness, prevention, diagnosis, treatment and rehabilitation access for women, and by analysing inequalities by sex, age, socioeconomic status, education and location where feasible.[10][11][12]
• Improve integrated, safe and continuous care for ischaemic heart disease, heart failure, valvular heart disease, arrhythmia, cardiogenic shock and cardiac arrest.[1][13][14]
• Develop knowledge management, research, innovation, interoperable information systems and virtual-care tools that improve cardiovascular outcomes and value-based healthcare.[15][16][17]

The strategy is structured through four strategic goals: improve health outcomes, equity and National Health System sustainability; strengthen the autonomy and capacity of participating agents; improve social and professional processes for healthy lifestyles and cardiovascular care; and ensure access to training, resources, research, innovation and knowledge management.[18][19]Its strategic maps cover promotion, prevention and citizen capacity building; knowledge management, research and innovation; equity and gender; ischaemic heart disease; heart failure; valvular heart disease; and arrhythmia.[20][19]

Priority disease-specific ambitions include timely acute coronary syndrome reperfusion and angiography, accessible cardiac rehabilitation and secondary prevention, early heart failure and valvular disease diagnosis, multidisciplinary cardiogenic shock care, improved cardiac-arrest survival with good neurological recovery, and earlier detection and appropriate management of atrial fibrillation.[7][21][22][23][24]

Implementation

Implementation is based on collaboration between the Ministry of Health, Autonomous Communities, national health institutions, scientific societies, health professionals, managers, researchers, patients, families and patient organisations.[25][26][27]Multidisciplinary working groups identify and prioritise critical problems, while Technical and Institutional Committees review goals, actions, strategic maps, indicators and the final report.[28][29][30]

• Deliver 32 general goals, 68 specific goals and 136 actions through thematic strategic maps that connect desired outcomes with the processes, organisational capacity and resources needed to achieve them.[29][18][19]
• Coordinate prevention, health promotion, primary care, specialist care, hospitals, emergency services, rehabilitation, social care and community resources through integrated care processes and referral pathways.[27][29][6]
• Strengthen primary care as the accessible base for cardiovascular risk assessment, early detection, lifestyle support, patient education, blood-pressure control and referral to specialist services where required.[31][32][33]
• Organise regional networks for acute myocardial infarction, cardiogenic shock and cardiac arrest, including standardised diagnosis, transport, referral, reperfusion and quality-assessment arrangements.[34][35][23]
• Establish multidisciplinary heart failure, severe aortic stenosis and cardiac rehabilitation models, with shared protocols linking hospital and primary care and tailored support for patients and families.[36][21][22]
• Use telemedicine, electronic health records, artificial intelligence applications, patient-reported outcome measures and patient-reported experience measures where these tools are assessed as accessible, effective and safe.[37][38][17]
• Build research capacity through national cardiovascular research institutions, collaborative research networks, needs mapping, research calls and transfer of findings into clinical practice.[15][16][39]

The strategy incorporates a monitoring and evaluation model using strategic maps, scorecards, indicator fact sheets and a proposed core dataset on cardiovascular health and cardiovascular disease care.[40][24][30]It proposes 61 indicators covering intermediate and final outcomes, implementation and effectiveness, with disaggregation by sex, cardiovascular risk, age, socioeconomic level and region where possible.[24]Annual cardiovascular health reports are envisaged using agreed indicators, including tobacco use, body mass index, physical activity, diet, cholesterol, blood pressure and fasting blood glucose.[40]

Operational monitoring includes outcome and equity measures for acute coronary syndrome networks, cardiac rehabilitation, heart failure services, valvular interventions, cardiac arrest, atrial fibrillation, patient safety, professional training, research activity and access to virtual-care tools.[41][42][17][43][14]The source does not specify a consolidated implementation budget, financing allocation, funding gap, reporting deadlines or formal sanctions for non-performance.[27][29][24]

Monitoring & Evaluation

The Strategy establishes a broad monitoring and evaluation approach that links strategic goals, actions, intermediate and final outcomes, implementation and effectiveness. It proposes 61 indicators, supported by indicator fact sheets with formulas and expected information sources, and envisages working groups during the first implementation year to define data required for indicators that cannot yet be calculated within the Spanish National Health System.[24]The framework also calls for an implementation-monitoring scorecard, periodic review and validation of indicators by the Technical and Institutional Committees, and annual cardiovascular health reports using agreed indicators.[30][40]

• Monitor population cardiovascular health through the seven ideal cardiovascular health metrics: tobacco use, body mass index, physical activity, diet, cholesterol, blood pressure and fasting blood glucose.[40]
• Establish a core dataset, identify information sources and collection methods, and standardise communication to assess cardiovascular health and cardiovascular disease care, including previously unknown aspects.[44][40]
• Analyse outcomes and inequalities by sex, age, cardiovascular risk, socioeconomic status, educational level, location and other relevant determinants where feasible.[11][24][30]
• Incorporate patient-reported outcome and experience measures into institutional reporting and compare outcomes across Autonomous Communities and different continuity-of-care models.[13][29]
• Use national surveys, clinical databases, administrative records, structured questionnaires and Autonomous Community reporting to monitor risk factors, service delivery, treatment control, health outcomes and care access.[45][46][42][47]

Monitoring covers prevention, equity, safety, research and disease-specific care pathways. Prevention indicators include tobacco prevalence, compliance with tobacco-control legislation, blood-pressure detection and control, healthy behaviours and lifestyle advice recorded in primary-care records.[32][33][45][42]Equity monitoring includes sex-disaggregated treatment, diagnosis, mortality and rehabilitation data, together with assessment of socioeconomic inequalities and digital exclusion.[48][49][50][11]Safety monitoring includes clinical incident reporting through each Autonomous Community’s system, safe medicines use, infection prevention, medical-device safety and patient identification.[44][45]

• Track acute myocardial infarction network performance through standardised indicators on clinical practice, equity and unwarranted variation, including reperfusion, primary angioplasty, coronary angiography, in-hospital mortality and access for vulnerable groups.[7][34][43]
• Assess heart-failure care through prevalence, access to natriuretic peptide testing, multidisciplinary team availability, referral protocols, hospital mortality, readmissions, emergency visits and length of stay.[51][52][14]
• Monitor valvular heart disease through cardiac-auscultation registration, professional training, referral and follow-up protocols, multidisciplinary decision-making and sex-disaggregated intervention and non-intervention rates.[41][14][9]
• Measure cardiac-arrest care through treatment volumes, response times, cardiopulmonary resuscitation and automated external defibrillator use, survival and neurological recovery, including variation by sex and Autonomous Community.[53][23][41][9]
• Assess atrial-fibrillation detection, anticoagulant use, treatment monitoring, dose adaptation and systematic pulse-taking for people aged over 65.[53][24][9]

The Strategy also supports regular updating of a cardiovascular research and development needs map, assessment of research results, evaluation of health-related and economic impacts, and validation of e-health tools before their implementation or replication.[16][38]Although the framework identifies committees, data responsibilities and reporting mechanisms, it does not specify a consolidated reporting timetable beyond annual cardiovascular health reports, quantitative targets for most indicators, sanctions for non-performance or a single named evaluation body.[29][40][24]

Costing & Financing

The Strategy contains no quantified implementation budget, costed action plan, financing allocation, funding-gap estimate or dedicated resource-mobilisation framework.[27][1][16][39]It nevertheless recognises cardiovascular disease as a major economic burden and treats National Health System sustainability as a strategic goal.[54][18][19]

• Recognise an estimated economic impact of cardiovascular health problems equivalent to 0.7% of gross domestic product in 2014.[54]
• Record annual temporary-disability costs of more than 145 million euros associated with cardiovascular disease.[54]
• Note that atrial fibrillation directly accounts for an estimated 1% of total healthcare expenditure.[55]
• Recognise tobacco use as generating high healthcare and social costs, although no monetary value is provided.[56]
• Report Spain’s research and development expenditure at 1.24% of gross domestic product in 2018, below the European Union average of 2.18%.[15]

For cardiovascular research and innovation, the Strategy proposes identifying the costs or investment associated with each prioritised need and estimating the expected economic impact of meeting cardiovascular health goals.[16][39]It also proposes identifying European, national and regional research programmes and grant calls, and seeking funding instruments to implement or replicate effective e-health tools in Autonomous Community health systems.[39][38]The source does not provide monetary allocations, financing commitments, responsible funders, time-bound investment plans or assumptions for these mechanisms.[16][39][38]