The editorial by González-Juanatey et al.1 is of great interest and stimulates the debate on the metrics to be used by cardiology units (CU) (services, clinical management units, institutes, etc) to assess their management results. The focus of the proposal and the 111 indicators it contains deserve joint reflection by those responsible for CUs, which could be promoted by the Spanish Society of Cardiology (SEC). The following points are offered in relation to this proposal:
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“Measure outcomes. Add value”. In line with Porter's strategy of “adding value”,2 the authors suggest that health outcome indicators should be prioritized. Although this approach is correct, only a third of the proposed indicators—many of which overlap—are outcome indicators (mortality, readmissions, complications). It is also difficult to understand the rationale underlying some of the process or activity indicators (does having a first face-to-face consultations rate higher than the national average really “add value”?). The dashboard for the CU management team should be fed with outcome indicators as well as cost indicators, but the latter are absent from the proposal.
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“Process management.” The proposal includes several elements related to an approach to health care management processes that should be debated. Establishing outcome indicators by functional unit (cardiac catheterization, levels of care, etc) within the CU gives rise to overlapping indicators, probably unnecessary, that should be measured at the end of the process rather than in each functional unit (at discharge or at 30 days). The metrics by functional unit should probably not be monitored by management, but by the head of the CU. Another debatable aspect is that, if integrated health care process indicators are really included, then most of them should refer to the hospitals as a whole and others to their geographic-population catchment area.3 It probably makes more sense to measure in-hospital or 30-day mortality due to heart failure in hospitals as a whole rather than just in CUs, given that most patients with this disease are treated in hospitals by internal medicine departments; likewise, should not “readmissions after 30 days for heart failure” be an indicator for the whole area, including primary care? If internal medicine or primary care (such as emergencies and, in many hospitals, level 2 and 3 care) are outside the scope of CU management, then they would not be “integrated” health care processes. That is, the CU would not be providing a care service that aligns in which all the health care departments involved in the process are aligned with the best scientific evidence available and in which health care managers promote collaboration between all units in the preparation, implementation, management, and assessment of health care process outcomes.
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“To compare, adjust.” The proposed indicators, such as those of INCARDIO, lack adjustment systems.4 This approach to monitoring the performance of a given CU over time may make sense, assuming that patient profiles remain stable (which is a lot to assume). However, because patients’ characteristics affect outcomes regardless of the quality of care, the indicators must be adjusted to the independent variables (age, sex, presence of comorbidities, etc) of the patients treated in each CU, if they are to be compared with each other.2,5 The need to “adjust” is applicable to the comparison of other indicators between different units, such as those relating to the frequency of unit use. These indicators should be weighted by the age and sex of the reference population.
There are many more elements in the proposal of González-Juanatey et al.1 that should be debated. These include the number of indicators, hospital mortality vs 30-day mortality, the absence of health level indicators, and other elements proposed by Porter,2 such as Patient Reported Experience (PREM) and Patient-Reported Outcome Measure (PROM), the information and data recording system itself, and so on. In fact, the list of such elements exceeds the scope of this letter, whose aim is to warmly acknowledge the editorial by González-Juanatey et al.1 and encourage the SEC to promote its debate.
CONFLICTS OF INTERESTF.J. Elola is technical director of the RECALCAR project.