We read with interest the letter by Dr Elola Somoza regarding our editorial published in Revista Española de Cardiología (REC)1 in which we reflect on components of clinical management, focusing on cardiovascular medicine. We included a proposal for organization, as well as indicators that would allow us both to determine the efficiency of our activity and to make comparisons with certain benchmarks and outcomes from centers of excellence, and, essentially, identify opportunities for improvement. In his letter, Dr Elola Somoza makes some statements that we would like to clarify, although we believe that a careful reading of the editorial would clarify most of his questions.

In his letter, Dr Elola Somoza suggests that only a third of our indicators refer to health outcomes and that in many cases they are “overlapping”. This is not the case. Two thirds are outcome indicators. It all depends on what Dr Elola Somoza understands as an outcome indicator. Is low frequency of hospitalization not, perhaps, a good outcome indicator of quality of outpatient care? And, if by overlapping he means redundant, we did not believe it necessary to clarify that in the design of key outcome indicators, such as mortality or health care-associated complications, it was essential to identify which area or areas of care show deviation in order to effectively apply corrective measures. The letter also refers to the existence of limitations with the measurement of indicators related to cardiology units, health care area management, epidemiology, etc, when our proposal for indicators was concerned exclusively with the organizational structure of heart disease care. In addition, although already mentioned in our editorial, we have a specific program for costs and professionals’ and patients’ experience.

We do not share his opinion on the lack of adjustment in the indicators, which extends to those proposed in INCARDIO.2 In both cases, the indicators are similar to those suggested by top-ranking scientific societies and agencies and which should be used as reference standards for health care areas dealing with large volumes of patients, and they are good markers of quality. As indicated in both documents, certain analyses require adjustment techniques that go far beyond the age- and sex-adjustment mentioned by Dr Elola Somoza.

We reiterate our appreciation for the letter received and we suggest a re-read of the editorial. We agree that the Spanish Society of Cardiology should encourage this type of debate, as it can help clarify areas of uncertainty and identify opportunities for improvement for all of us.