Europe’s value-based healthcare blind spot in cardiology: near-zero clinical penetration of VBHC evaluation frameworks across 15 countries

Background Value-based healthcare (VBHC) is increasingly endorsed in European cardiovascular policy, yet depends on foundational capabilities (routine quality-of-life measurement, digital data integration, cross-institutional linkage) that are assumed rather than verified. Whether these prerequisites are present in routine European cardiology has not been systematically assessed. Purpose To determine the prevalence of VBHC evaluation frameworks in European cardiology centres and the availability of the infrastructure VBHC requires to function. Methods Multinational cross-sectional survey (106 respondents, 82 unique centres, 15 countries, 2025). Where multiple respondents represented the same centre, majority-rule aggregation was applied (ties resolved in favour of adoption). Primary endpoint: presence of a VBHC evaluation framework (yes/no). Secondary endpoints: QoL measurement across four modules (CAD n=25; HF n=31; CA n=35; OOHCA n=28), wearable/smartwatch data collection (CAD n=25; HF n=31), HF event tracking, between-centre data sharing, and cross-institutional linkage. Composite “VBHC readiness”: co-occurrence of (1) VBHC framework, (2) any QoL measurement, (3) between-centre data sharing. Pre-specified subgroup: countries with national VBHC programmes (Netherlands, UK, Sweden) versus others. Wilson 95% CIs. Results Only 12/82 centres (14.6%; 95% CI 8.6–23.9) reported a VBHC framework, with no difference between VBHC-policy countries and others (4/24 [16.7%] vs 8/58 [13.8%]). Among 17 centres with multiple respondents, none achieved internal consensus: in all 8 where at least one respondent reported VBHC, at least one colleague did not, indicating adoption has not permeated clinical awareness even where frameworks nominally exist. Foundational prerequisites were largely absent. QoL did not exceed 50% in any subspecialty: CAD 20.0% (5/25), HF 32.3% (10/31), OOHCA 25.0% (7/28), CA 45.7% (16/35); pooled 31.9% (38/119). Wearable data collection was 8.0% in CAD (2/25) and 19.4% in HF (6/31). Only 51.6% of HF centres (16/31) had event tracking. Data-sharing gaps compounded these deficits: 41.5% (34/82) lacked between-centre sharing and 48.8% (40/82) cross-institutional linkage. Only 4/82 centres (4.9%; 95% CI 1.9–11.9) met all three readiness conditions (sensitivity range: 1.2–8.5% across deduplication strategies). Conclusion VBHC has very low clinical penetration in European cardiology (~15%), with no difference between policy-leading countries and others, and universal within-centre disagreement where frameworks were reported. The infrastructure required by VBHC is largely absent: QoL never exceeds 46%, wearable capture is near-zero in CAD, and data linkage is unavailable in half of centres. Under 5% meet minimal readiness. European cardiology is attempting value assessment without the infrastructure to measure value: a measurability-first strategy will be needed before VBHC can operate at scale.