In most countries, the prevalence of heart failure is rising and is associated with staggering healthcare costs with many of these costs related to hospital care.1 Each year, more than 1 million patients are hospitalised with heart failure in both Europe and the USA.2 ,3 Because of marked variations in practice and outcomes, heart failure is often targeted for hospital quality improvement efforts. Most quality improvement programmes or national policies focus on improving processes of care as a means to improve quality. These programmes’ attention towards process measures are designed to accelerate the implementation of best strategies of care or evidence-based therapeutics systematically to reduce variations in practice and ideally improve outcomes. Despite the logical relationship of some process measures to outcomes, whether such links exist is often unclear. That is, would ‘perfect’ care as measured by processes of care yield ‘perfect’ outcomes?

In their Heart publication, Bottle et al4 describe the association between six National Heart Failure Audit process of care measures and outcomes for patients hospitalised with heart failure in England from 2009 to 2012. The investigators found broad use of appropriate medical therapy …