We appreciate the interest shown in our article1 published in Revista Española de Cardiología and the comments made. We agree with Lozano et al. that our intervention is only one option and that it could complement other ways to improve quality of care. Undoubtedly, the 2 strategies suggested by the authors could enhance our proposed model.

In our case, we realized the need to reduce the incidence of bleeding events in patients with acute coronary syndrome due to an exhaustive coding of diagnoses. In addition to participating in the RECALCAR program, the cardiology service of Hospital General Universitario Gregorio Marañón also participates in the Cardiac Section of the Benchmarking Club, which publishes an annual series of data comparing the participating hospitals. In 2009, patients (most with acute coronary syndromes) who underwent a percutaneous coronary intervention and who were admitted to the cardiology service of our hospital had a crude bleeding rate of 12.5%, higher than the mean of the hospitals in the Benchmarking Club (9.5%) and the national average (8.6%).2 However, the bleeding rate reported by each center is entirely reliant on the degree of hospital coding (because the analyses are based on the Spanish Minimum Basic Data Set), as correctly noted by the authors of the letter, and our hospital performed one of the most exhaustive coding of diagnoses and complications of all participating in the Benchmarking Club.

Despite the limitations inherent to these voluntary programs, our results were key to the identification of improvement opportunities and guided us toward the need to develop a multidisciplinary strategy to reduce bleeding events and assess their economic and health effects.

Adequate monitoring of health care quality requires measurement of both activity and outcomes.3 While acknowledging the limitations noted in the measurement tools and the different monitoring systems, we believe that incomplete or imperfect information is still better than no information at all. This knowledge should be the starting point for the development of strategies to improve quality of care or, in the worst case scenario, of measurement instruments or systems. Declaring that instruments do not work without doing anything to change them is not a responsible approach.