“What is not defined cannot be measured. What is not measured cannot be improved.
What is not improved always deteriorates.”
Lord Kelvin

“What is not measured cannot be managed.”
Peter Drucker

Three cardiologists from an imaginary world-whom I shall call Sergio Nonrich, Mirza Ten and Mario Halcón-discuss the future of cardiovascular health in Argentina. They wonder why issues related to the healthcare system, with the exception of those linked to doctors’ financial circumstances, do not generate the same level of interest as many aspects strictly related to the individualized treatment of various clinical syndromes. In this regard, they consider how to highlight opportunities to improve patient-focused medical processes using an appropriate methodology that is amenable to external evaluation. This would be not only a management tool but also a patient’s right to receive safe care in accordance with quality standards that reflect technical and human expectations.

From the healthcare system perspective, having access to quality indicators is essential for assessing the current status of various prevalent cardiovascular conditions. In this regard, for example, the “National Survey on Acute Myocardial Infarction” provided information on reperfusion status in cases of ST-segment elevation myocardial infarction. The results highlight treatment delays and the different areas requiring improvement, and suggest “that the implementation of medical education programs and supportive healthcare policies that consider regional characteristics and the cost-benefit ratio of reperfusion strategies in practice may help reduce the time to reperfusion, for both thrombolytic therapy and for primary percutaneous coronary intervention.” (1)

In this regard, the Argentine Society of Cardiology will embark on a process aimed at defining quality indicators to evaluate and improve medical care, with a particular focus on cardiovascular diseases and, mainly, a patient-centered approach. “Measuring to heal” is likely an ambitious title given the national healthcare reality and the system’s tendency to resort to bureaucratic constraints. Furthermore, we wonder where the patient’s decision-making lies when required to accept treatment in healthcare centers with high morbidity and mortality rates. This aspect is not merely a technical assessment on the quantification of processes and their outcomes. It reflects a compassionate, patient-centered approach to care and a refusal to be complicit in the system’s shortcomings. We are dealing with a human and social issue, not merely medical and technical aspects. While we await decisions from the relevant health authorities, we could begin to design a system to measure outcomes in cardiology services. This would highlight the strengths and weaknesses of cardiovascular healthcare, following the model of international societies. (2-5)

The European Society of Cardiology proposes a structured four-step method that involves defining target populations and validating data to ensure that the metrics are both scientifically sound and feasible. (6) The texts emphasize the importance of using these data to improve clinical performance and transparency, thereby enabling the comparison of outcomes across different healthcare centers. The success of these systems depends on multidisciplinary collaboration involving medical professionals, managers, and patient representatives.

Quantifying quality in healthcare provision has become an indispensable tool for identifying gaps in care and promoting continuous improvement. There is a growing recognition that optimizing clinical outcomes requires tools that allow the performance of healthcare providers to be assessed and compared. Measuring quality is not an end in itself, but it is a means of bridging the “gap between evidence and practice” that ensures that science-based treatments are effectively translated into daily clinical practice. (7)

In this regard, it is important to assess outcomes at center level rather than just by region or country. For instance, in the meta-analysis of outcomes of transcatheter aortic valve implantation in South America, Boissonnet et al. reported significant variability in terms of procedural success, the need for a permanent pacemaker, and the presence of significant residual aortic regurgitation. These findings provide a basis for evaluating the performance of the technique and serve as a catalyst for future clinical optimization initiatives. (8)

THE IMPORTANCE OF MEASURING QUALITY FOR IMPROVEMENT

The measurement and public reporting of healthcare processes and outcomes are key catalysts for quality improvement initiatives. Performance measurement serves to: (9)

  1. Foster evidence-based medicine: quality indicators act as mechanisms to support care delivery aligned with clinical practice guidelines.

  2. Facilitate benchmarking: comparisons across providers motivate learning and the adoption of best practices.

  3. Identify disparities and variations: substantial variation in care delivery has been documented, reflected in unequal outcomes across regions and centers. Systematic measurement brings these disparities to light for targeted intervention.

  4. Ensure accountability and transparency: the use of indicators engages multiple stakeholders, including health authorities, payers and the public, facilitating pay-for-performance programs and greater transparency.

  5. Improve patient outcomes: the implementation of structural and process measures has been consistently associated with reduced mortality and improved outcomes in critical conditions, such as acute myocardial infarction.

However, measurement alone does not improve quality; it should be regarded as a tool within a broader quality improvement strategy that incorporates cycles of learning and adaptation.

For indicators to be useful, they must be developed following a structured process that ensures their scientific validity and practical applicability: (10, 11)

  1. Identification of key domains of care. The first step is to construct a conceptual framework that defines the dimensions of measurement. The Donabedian model is recommended, which classifies indicators into three types: (12)

    • Structural: These describe organizational aspects such as > facilities, human resources and available protocols.

    • Process: These capture actions taken by providers or patients, > such as adherence to recommended therapies.

    • Outcome: These relate to the effects of care on patients’ health > and well-being, including mortality and patient-reported > outcome measures (PROMs).

  2. Development of candidate indicators. This is carried out through a systematic review of the literature and existing clinical practice guidelines to identify gaps in care where improvement is possible. (13)

  3. Selection of the final set of indicators. To ensure acceptance and reliability, consensus should be achieved among experts and stakeholders (clinicians, researchers, managers and patient representatives). (14, 15)

  4. Feasibility assessment. An indicator is only valuable if it can be implemented with reasonable effort and cost. (16)

QUALITY CRITERIA FOR THE SELECTED INDICATORS

For an indicator to be considered robust, it must meet the following criteria: (15)

  • Importance: it must address a clinical area with a high burden of disease or disparities in care.

  • Validity: it must accurately measure what it is intended to measure and distinguish between high- and low-quality care.

  • Reliability: it must be reproducible and yield consistent results when measured by different people.

  • Actionability: results must be interpretable by healthcare providers and professionals to enable corrective action.

  • “Less is more”: prioritizing a limited number of robust indicators avoids measurement fatigue and ensures a clear focus on improvement priorities.

CONCLUSION

Systematic quality measurement represents the essential first step towards a high-performing healthcare system. By employing rigorous and transparent methodologies to construct indicators that are both scientifically valid and feasible in practice, healthcare organizations can identify critical gaps, reduce unwarranted variability and ultimately improve patient survival and quality of life. The Argentine Society of Cardiology will move into the lead in defining a minimum set of indicators that can make a real contribution. The key lies in selecting “few but high-quality” indicators, thus ensuring that each measure serves as a genuine driver of positive change rather than merely an administrative burden”.

Sergio Baratta MTSAC ORCID logo 
President of the Argentine Society of Cardiology

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