"In Cardiology there is a two-year delay in the adoption of new drugs"

Toledo, the city where he lives and works as a cardiologist, is a sort of transcript of Luis Rodríguez Padial. From the strict centrality given to it by its geographical location, the capital of Castile-La Mancha lives, however, oblivious to the maelstrom of other centralities..., and of other peripheries. If Charles I made the imperial city the central seat of his court, Rodríguez Padial has his in the Hospital Complex of Toledo. There he takes refuge from the visibility and relevance of presiding over the scientific society that brings together more than 7,000 Spanish cardiologists. Until 2025. Two years of centrality for our interviewee.

Head of Cardiology at the calm Toledo, professor at the Faculty of Albacete and full academic in Castilla-La Mancha, Rodríguez Padial knows about heart rate and, with hardly any variation in his own, denounces healthcare inequities, calls on the ministry and the communities to listen to those who know and talks about interoperability in the NHS. But it is also his voice – beating up, beating down – that mentions his grandchildren, that asks people to take care of his heart and that renews his vows as a specialist, with a declaration of love for cardiology today, but also for the one to come. Castilian bonhomie.

I don't think I'm far wrong if I tell you that the SEC is one of the star companies of the NHS, in terms of the number of members and the relevance of its specialty. Tell me three unavoidable subjects that you cannot fail to pass in these two years at the head of this society. Well, look, the first one is very continuist and has to do with the quality of care and with the Recalcar registry, one of the cornerstones for measuring that quality. The registry is based on healthcare data from all over Spain, but now it is not so easy to get them, or not quickly enough, because we are receiving them from the Ministry of Health almost a year late. In addition to the necessary updating of this data, we also want to add the patient experience. The second subject also has to do with quality, but within the scientific society itself, with the accreditation of some internal processes. And, finally, we want to emphasize the importance that cardiovascular disease has in women. Obviously in all of them, but if we focus especially on women, it is because we believe that neither women themselves nor cardiologists have been sufficiently aware that cardiovascular disease is the main cause of disease and death among them. Coinciding with the week of 8 March, we are going to organise a prevention, information and dissemination conference focused on women and with a scientific perspective. Going back to your first answer, that it takes almost a year for the ministry to provide you with healthcare data, what do you want me to say, sounds scandalous to me. Well, it's not raw data. Before sending them, they have to be coded, and that's where there is a major bottleneck, because there are hospitals that code them directly, others that have outsourced the coding... From there, the communities send it to the Ministry of Health and then the Ministry of Health sends the data to us. As you can see, the process is not immediate, because it does not depend only on the report made by the clinician in the hospital. But yes, I agree with you that it shouldn't take a year. Well, you could try to shorten or avoid any of the intermediate steps. In fact, last year we started talking to the communities to see if they can send the data to us, to the scientific society, while sending them to the ministry. It can't be that complicated... What do you want me to tell you: we are 17 health systems, no matter how much we say. In many cases, in fact, we are the ones who have given the ministry the global information of these data: when years ago there were communities that had not yet implemented the Heart Attack Code, it was very evident that mortality was higher in those that did not have it, and the information we transmitted to the Ministry in this regard facilitated the full implementation of the Heart Attack Code across the NHS. We also have information on the heterogeneity of heart failure mortality, for example, and our idea is to use that data as a comparison tool as well. By the way, going back to coding, I will also tell you that the SEC has already worked on a system to homogenize the recording of diagnoses, so that the data is as even as possible and thus facilitate the subsequent work of the coders. He told me that another of the objectives of the SEC is to ask the patient, to tell them how they see it. How is that question going to be concretized? We are going to do it through the patient platform that we have just created with the help of the Spanish Heart Foundation. This platform brings together patients from all over Spain and, thanks to it, we will be able to collect the opinions and perceptions of people who are treated by cardiologists from all communities. Opinions and perceptions that don't necessarily coincide with those of your cardiologist... No, no, of course. We can sometimes be very happy with what we do, but we lack the perspective of the other, and that is what we want to collect. The risk of asking the patient is that they will answer you, right? Yes, but we're not afraid of that. I'm sure that one of the first things they'll say is that in certain places there's a long waiting list, but let each mast hold its own sail. We are interested in the perception they have of the care that we, the cardiologists, give them. I think the balance will be favorable, but, if not, having the information will surely help us improve. If we don't count on the patient, we run the risk of falling into a kind of..., how would I say?...A kind of enlightened despotism? That's the expression I was looking for. A kind of enlightened welfare despotism: everything for the patient, but without the patient. Here we want to count on the patient. And I'm not talking about putting them at the center, which they are, but about them being active in decision-making. Come on, the patient in the center doesn't really believe it, right? Does that sound more like a slogan than a palpable reality? Well, look, it's sad, but yes, indeed: it's more of a slogan than anything else. The patient in the center would be as simple as the patient coming to the hospital, telling their problem and the specialists would mobilize to try to solve it in the most agile and effective way possible. Point. And I am afraid that we are still not able to change the internal structure that hospitals have. The quality of care is a kind of obsession embedded in the genetic code of those who have preceded you in the SEC, and I see that you share that obsession. To what extent has progress been made since the company launched the SEC-Quality project? Would you dare to quantify that progress? Progress has been made, of course, but it is also true that in some specific cases we would need to measure those results. However, there is a clear sign of improvement: we have been accrediting the procedures for some time, and if the procedure we follow is correct and accredited, it is logical that the results have also improved. We have Recalcar, which has been part of SEC-Calidad since 2012, and there is concrete data there, but we are not monitoring, for example, the accreditation of heart failure units. In Toledo, for example, we have an accredited unit and I am sure that patients with heart failure are being treated much better, but we need to systematize the measurement of results at a general level, in all units, and to reliably verify how the quality of care for these patients is improving. You just mentioned Emphasize, a study that the SEC has been doing for more than a decadea to detect possible healthcare inequities in the NHS. In the latest edition of that study, in 2022, it is literally said that there is still "ample room for improvement". Ten years later, is the room for improvement still "wide"? Isn't that a little disheartening? I fear that there are and will continue to be inequities. I don't want to look the other way, obviously, but there are things that the SEC can denounce, but not improve, because it's not in their power. We can recommend ways of acting, but that, ultimately, depends on the managements and the health systems themselves. In line with the projects I was wondering about at the beginning, we also want to have closer collaboration with the Ministry of Health and with the ministries in the implementation and development of the Cardiovascular Health Strategy that was created in 2021. That can be a good opportunity to mitigate the inequities that persist. And so much so that they persist. In the chapter that Emphasize 2022 dedicates to inequalities, the study literally says that the "remarkable" healthcare inequities should be "cause for alarm" for administrations. Do you have a more or less chance of dying of a heart attack? Man, it is impossible for the patient who suffers a heart attack in the Pyrenees to be as safe as the one who suffers it 500 meters from a hospital... Yes, but I'm not talking about extreme cases. I am talking about two heart attacks in the very centre of two autonomous communities. Yes, yes, I know, and I can't avoid the answer. Inequalities exist; without going any further, in the supply of medicines. To begin with, there is a delay of about 2 years in the adoption of new drugs once they are approved; But then, in addition, each community puts up a different barrier. There is, for example, a large percentage of patients who still do not have access to direct-acting anticoagulants, even though we have been using them for some time, they have been shown to be safe, more effective than sintrom and probably cheaper. It is, therefore, the Autonomous Communities - I imagine by virtue of their budget or their attitude - that also contribute to the maintenance of these great differences. And we have to continue to be there, playing Jiminy Cricket, putting information on the table and denouncing that these inequalities, far from being reduced, persist. You mentioned it earlier. The board of directors, which he will preside over until 2025, speaks of the need to become a "necessary collaborator" of the ministry and the Autonomous Communities. Are they really not at this point? I don't think so. Without going any further, in the approval of drugs, which we have just talked about, we are hardly asked. When the final decision has been made, they send you the report and ask you what you think. We may not be the only ones in this country who know about cardiovascular disease, but no one can deny that we are one of the ones who know the most. Such an attitude does not in any way contribute to reducing inequality. You'll agree with me that this is a shared cry, or at least all societies tell similar bedtime stories. Yes, yes, definitely. The question is perhaps why the administrations do not see us as trustworthy people, committed to the NHS and looking for the best for that system. Nor are we going to ask that any drug be applied to all patients, because we are aware that this is not feasible. There will be to select those drugs in which the benefit has been greatest. If we spend everything on medicines, we don't have enough for bread, and bread is a good medicine, I don't know if I understand. In other words, we are perfectly aware of the importance of the cost-opportunity principle. Cardiovascular disease is systematically listed as the main cause of death in Spain, but I don't know if the public is aware of that, no matter how much you scream. I'm afraid not. I told him that before, when we were talking about women. It seems that we have become accustomed to the fact that dying of the heart is natural and not given the importance it deserves. Not only is it the most common cause of death, but it is also the most common cause of death among men and women; Deaths are also occurring at younger and younger ages and, in many cases, are preventable. And the saddest thing is that the Ministry of Health does not seem to be very aware of the problem either, because it would have to carry out many more prevention and information campaigns. Don't tell me that there are no prevention campaigns: alcohol, tobacco, promotion of healthy living... It is true that, perhaps, many of these campaigns are shared, for the prevention of various pathologies, but there are campaigns, right? I don't know what other specialties will think then? Frankly, I don't see a lot of TV ads promoting exercise or healthy diet. On TV, paid for by the ministry, not by the SEC. It is not a question of comparing deaths, obviously, because they all matter, but on the road, for example, there are about 1,000 deaths a year and some 30 or 40 million are invested in DGT campaigns, and they are welcome. But it makes no sense to invest much less in the prevention of diseases that cause some 120,000 deaths. As I was saying, I get the feeling that we have all given up a bit by assuming that dying of the heart is something relatively normal. We don't compete with anyone, but I would like to see preventive campaigns in all media, and not just for 10 days, but permanently. He told me earlier that the prevention, diagnosis and treatment of cardiovascular disease in women is another of the strategic lines of his mandate. Only with a scientific perspective or also with a gender perspective? Aren't they afraid of being accused of a certain political correctness? Look, the gender perspective is unavoidable, but we are a scientific society and our priority point of view is that, the scientific one. About 40% of our current members are women, and that percentage is going to continue to grow, so the gender perspective is fundamental, and not only in cardiology, but in the entire medical field. However, I insist, the concern behind this strategic line is that women, in general, are not aware that cardiovascular diseases are the leading cause of death and disease among them, even ahead of cancer, and they pay little attention to it. Clinical trials are now being able to include an increasingly high percentage of women, and this is an important step in evaluating aspects such as differentiated response to drugs, for example.