We appreciate the comments by Cequier et al. on our article,1 which are both timely and illuminating. Our reference to the RECALCAR project was peripheral to the main focus of our editorial. We are nevertheless fully aware of the effort this registry represents and the valuable information it has provided over the past decade through its reports and publications. All of us in the Spanish cardiology community can feel justly proud of this initiative.

Our intention was simply to demonstrate that outcome evaluation is possible and reliable at the level of the hospital or hospital unit. In contrast, the factors that operate at other levels of hospital organization cannot be precisely known or sufficiently controlled, inevitably leaving persistent doubts about the accuracy of the information obtained. In this regard, RECALCAR does a magnificent job in providing dedicated hospital cardiology units with objective quality indicators; however, as Cequier et al. acknowledge, these indicators do not cover other, smaller-scale cardiology services. The point we wanted to make about the risk-standardized mortality ratio (RSMR) was that this value should always be quoted with its corresponding 95% confidence interval.

We also take this opportunity to highlight the multilevel analysis included in the EURHOBOP project. To take account of data grouping, this analysis modeled in-hospital mortality using the country of origin of each patient and the hospital as random effects variables, with other patient and hospital variables included as fixed effects.2 The EURHOBOP study also calculated the projected in-hospital mortality rate in each hospital by adjusting the models with all the patients except those admitted to the hospital being analyzed. Finally, EURHOBOP provided a software application to enable each hospital to compare its in-hospital mortality rate for patients with acute coronary syndrome with that of other hospitals with similar characteristics.

We thus fully share the RECALCAR investigators’ goal to provide tools that are useful, objective, and robust indicators of the quality of cardiology care, especially at the level of the hospital or cardiology service, and that result in improved outcomes of the treatment of cardiac conditions.