The Brazilian healthcare system is segmented into public and private subsystems. The public subsystem named the Sistema Único de Saúde (SUS) provides free and universal healthcare access to all citizens, covering nearly 75% of the population. Most of the patients get treated by general practitioners at first and are unable to get cardiology consultations unless there are any established coronary diseases, core comorbidities or secondary complications. On the other hand, in the private subsystem, the patient can go directly to the specialist they want to see irrespective of their health condition. Approximately 30% of the Brazilian CVD patients directly visit private care specialists because of better access to diagnostic tests, quicker appointments, and better customized care. The approach to treatment in public and private institutions is also different. For example, risk factors control is limited in the case of primary care, general practitioners, or family physicians. Some studies worldwide suggest that private specialist clinics have been more successful in delivering care and achieving the recommended goals when treating the patients, and local publications are in line with these observations. [33–37]
4.1 Challenges with patient journey touchpoints
Combined results of several studies and awareness campaigns conducted by the Brazilian Society of Cardiology showed that nearly one-third of the Brazilian population is hypertensive and general awareness is low.[38] Low patient awareness could be attributable to low patient education and prevailing social inequalities, which affect access to and use of health services and medications, as well as adherence to medical prescription.[39] In Brazil, nearly half of all CVD-related deaths in patients aged < 65 years are attributable to poverty, social inequalities, and low educational status.[40–42] Furthermore, awareness regarding the benefit of a healthy lifestyle is limited, and we observe the adoption of unhealthy diets, low physical activity, and high consumption of alcohol and tobacco especially in low-income communities.[40] It is important that both patients and health care professionals belonging to the public health system[43, 44] receive continued education and updates from the latest available clinical practice guidelines from the Brazilian Society of Cardiology, and that they understand the importance of adopting the guidelines and achieving the goals in daily practice.
A limited sense of urgency in the Brazilian population for timely diagnosis and management of CVDs due to the asymptomatic nature of the conditions was observed. As a result, although the number of screened patients with SAH and dyslipidemia was high, it did not convert into effective care. Moreover, the diagnosis of complex diseases that require molecular diagnosis, like familial hypercholesterolemia, is hindered by the limited availability of specialized laboratories. [45][46]
The percentage of patients receiving treatment for SAH was higher than that for dyslipidemia. This could be attributable to better screening and diagnosis of SAH and limited access to lipid lowering medications in certain regions in Brazil. Limited access to healthcare and regional variations in treatment protocols further complicates the scenario.
Addressing adherence-related issues is fundamental for reducing CVD-related morbidity and mortality. In Brazil, pharmacological treatment guidelines developed by international or local societies/associations for CVD prevention are not strictly followed. Reasons for low patient adherence in SUS primary healthcare were limited access, forgetfulness, and adverse effects of medicines, with several studies reporting unintentional non-adherence in most patients.[30]
4.2 Challenges identified in government initiatives
There are programs run by the Brazilian government ensuring free-of-cost access to selected medications.[47] This initiative works rather well owing to the involvement of drugstore chains; however, there are limitations regarding the type of medications available as part of such programs. Furthermore, there are no specific programs in either public or private health systems to monitor and optimize patient adherence. A few public healthcare professionals in several regions of Brazil visit patients[48] at home to follow up on chronic and genetic diseases, but data about the effectiveness of this initiative are limited.
4.3 Proposed healthcare model
The proposed healthcare model for CVD care in Brazil focuses on 3 pillars: patient education, guideline adoption, and overall optimization of the patient journey.
Population-based approaches in awareness campaigns should be prioritized over individual-based approaches for the prevention, detection and control of CVDs, for it is known that early detection may translate into better control. Blood pressure(BP) and cholesterol levels measurements could be made mandatory at issuance places for government documents, like passports, driver’s license, marriage certificate, or other security cards, contributing to a substantial increase in screening and awareness.[21] The healthcare providers should explain the importance of routine check-ups and the negative consequences of non-adherence and delayed treatments of SAH and dyslipidemia to the patients. This could help develop a sense of urgency and proactivity, leading to better compliance and adherence to treatment. Also, encouraging the population to adopt healthy lifestyle habits, including healthier diets and exercise programs, along with the guidance about the medications, can help lower the risk of the patients.
Secondly, strategic adoption of up-to-date clinical practice guidelines with customization based on the regional context could enhance healthcare professionals’ compliance. Healthcare programs should be designed to align with the needs of the most affected populations, such as the older patients, which may not be the target of current initiatives. Not only medications guidelines should be followed. For example, reinforcing dietary portfolios, such as reduction in sodium intake and the dietary approaches to stop hypertension (DASH) type of diet,[49] should be considered as an early measure with the potential to decrease the progression from prehypertension to hypertension.
The third and most important pillar of our proposed healthcare model is the overall optimization of the patient journey in SAH and dyslipidemia. Non-physician healthcare workers should be trained to screen for the diseases, helping overcome the shortage of physicians in primary care centers. ‘Hospital to home’ initiative should be followed aiming to improve treatment compliance, resulting in better patient quality of life, and outcomes.[50] This initiative focuses on smooth transitioning from hospitals to homes by providing psychological and medication-related care to patients based on their requirements and has been effective in reducing rehospitalization by as much as 61% in the high-risk adult population.[51] Besides ensuring adequate treatment from the healthcare system, it is important to provide easy access and availability of antihypertensive and lipid-lowering medications for patients with SAH and dyslipidemia, demanding an active role of pharmacy professionals. Also, technological upgrades of existing medical centers can help improve the management of these diseases. For example, the World Heart Federation recommends point-of-care testing for measuring cholesterol in less developed regions.[52] Hand-held echocardiography in primary care centers should be encouraged over conventional echocardiography as a prioritization tool for patients with heart disease because of its resource-friendliness. As a step forward, integrating echocardiographic tracking and distance interpretation through telemedicine can help resolve the problems of late diagnosis and long queues for patients requiring specialized care.[53] Partnering with academia could help in building up the healthcare workforce capacity and skills at individual, family, and community levels. Clinical outcome analysis should be performed with a patient-centered care delivery focus, with the possible incorporation of new technologies to help facilitate this delivery. Engaging patients in health care decision-making could contribute to integrating personalized care concepts. Lastly, the government could devise innovative financing models comprising funds to healthcare facilities for conducting local surveys regarding patient journey mapping, and also for establishing a universal and sustainable healthcare system. Figure 4 summarizes the challenges and proposed solutions related to CVD patient journey in Brazil.