Dr Arne Björnberg

Björnberg said that these three do best by virtue of the fact that they have the highest healthcare spending per capita in Europe, illustrating the fact that financial muscle seems to make it easier to attain really good cardiac care. France follows hot on the heels of these countries "on the strength of prevention," he told heartwire. One of the most important factors in this, he believes, is that the French have very low rates of obesity and "the highest number of hours of physical exercise in schools of all European countries." The red-wine consumption of the French was not an indicator on the index, and besides, said Björnberg, the French do not differ much from their Mediterranean neighbors in this respect.

Behind the four leaders, with a rather large score gap, come a number of "competent" countries, said Björnberg: Austria, the Netherlands, Sweden, Slovenia, the UK, Finland, Italy, and Denmark.

One surprise success story from the index is Poland, he added. "Although they don't get a very prominent position on the whole index, the Poles actually report pretty good case fatality rates for heart disease, and they have heart-disease mortality only slightly higher than that of Germany or Sweden, which is certainly a lot lower than their neighbors in Eastern Europe. It appears that the Poles devote an unusually high proportion of their healthcare budget to cardiac disease, and they have an awful lot of cardiologists. By sheer brute force, the Poles are doing a particularly good job on cardiac care."

Discussant of the study, Dr Günter Breithardt (Universitätsklinikum Münster, Germany), said: "This excellent report has yielded important and interesting results. As always, there is still room for improvement [and] due to [some] weaknesses, which the group is well aware of, one might debate the ranking of individual countries. However, the overall picture is more important. Even if not perfect, the Cardiovascular Healthcare Index is an important step in the right direction. Sometimes, it is better to do something, even if not perfect, instead of merely discussing what one might do."

Björnberg told heartwire that the Euro Cardiovascular Healthcare Index (also known as the Euro Consumer Heart Index) is a compilation of data from public sources such as WHO/Organisation for Economic Co-operation and Development databases, Eurobarometers (surveys of the social and political opinions of those living in the member countries), national healthcare registries, and scientific papers. Representatives from ministries of health, cardiac societies, and other national bodies were also consulted, and all 29 states received their score sheet and were given the opportunity to validate, correct, or update the findings.

There are 28 indicators reflecting the performance of healthcare systems in five subdisciplines: information, consumer rights, choice (125); access (125); prevention (250); procedures (150); and outcomes (350). The numbers in parentheses add up to a total maximum total score of 1000.

[France has] the highest number of hours of physical exercise in schools of all European countries.

A public-survey element was used as an additional way to evaluate discrepancies between official policies and the real "situation on the ground," which can frequently be very substantial, Björnberg said.

An expert panel of doctors was also consulted, and they had two major tasks: to assist in the invention, selection, and design of the indicators; and to review the research based on their knowledge.

One of the core messages of the Health Consumer Powerhouse—the Swedish organization behind the index—is that weak patients should grow into empowered consumers, says Björnberg. He bemoans the fact that no more than two out of 29 countries currently present consumer information about available cardiac-care providers.

The report results once again reinforce the importance of prevention, Björnberg said. Although many governments publicly advocate the importance of prevention, few take efficient action: less than a third of the countries have something akin to a national cardiac-screening program, and ambitions regarding exercise in schools "seem even lower."

Most countries have room for significant improvement in the area of prevention, which will require long-term commitment and "could result in very substantial reductions of the numbers of cardiac death across Europe."

The same message applies to rehabilitation, he said, with only a few countries offering efficient rehab programs.

Another important component identified was massive undertreatment, with a lack of correlation between the use of vital medications, such as statins and clopidogrel, and the prevalence of heart disease. Adherence to guidelines seems to vary across Europe, he notes, with presumed undertreatment that could be causing significantly more cardiac deaths than there would be if all patients were medicated according to guidelines.

And on the flip side, for a couple of countries, the per-capita use of certain drugs is so high that it could actually represent what would be considered overuse.

However, there are some success stories. "The British and the Irish are the European champions of statin treatment, and one would hope that this would show up in blood lipid levels, and it did, as reported in the EUROASPIRE data presented by David Wood," he noted.

Other areas where there is room for significant improvement include prehospital care—although some countries—Norway, Sweden, the UK, and Ireland—are doing better than average on this.

And finally, patient information on where to seek cardiac care is still a "European disaster area," says Björnberg. Only Denmark, Austria, and the UK provide such information, and the UK patients do not seen to know where or how to access this, the public survey revealed.