Staff specialized in HF, day hospital, and telemonitoring do indeed require institutional investment, whether in dedicated training, physical space, or technology. But a significant portion of our program’s components do not depend on that type of investment: management based on critical pathways, structured discharge checklist, education with written guidelines, administrative coordination of appointments and follow-up, and multidisciplinary case conferences for complex decision-making are not merely ancillary elements of the program; rather, the available evidence suggests that they account for a significant portion of its clinical effect, and their implementation depends on systematization and organizational discipline, not on the facility’s level of complexity.

This is consistent with the meta-analysis by McAlister et al., which showed that multidisciplinary strategies involving active follow-up by trained staff and access to specialized consultations reduce all-cause mortality and hospitalizations, whereas models of scheduled consultations without structured follow-up show a considerably smaller benefit. (1) Similarly, the meta-analysis by Feltner et al. on transitional care in HF showed that programs focused on discharge education, follow-up coordination and early post-discharge contact—rather than isolated technological interventions—were the ones that significantly reduced readmissions. (2)

Something similar can be said regarding the day hospital. Its rationale does not lie in the availability of a dedicated space, but preferably in a protocol for intensive outpatient treatment and follow-up that helps prevent avoidable hospitalizations in selected low-risk patients. Strictly speaking, it is a way of working—involving explicit selection criteria, a standardized diuretic regimen, and closely spaced follow-up appointments—rather than a physical structure. In our own experience, the day hospital operated for many years using general inpatient beds, without a dedicated physical space, and it was not until 2023—toward the end of the consolidation period analyzed—that a dedicated area became available. This reinforces the fact that the protocolized approach preceded, and largely explains, the observed benefit, regardless of the infrastructure available at any given time.

It should also be noted that, within our own cohort, components such as telemonitoring were gradually incorporated only in the final years of the consolidation period, whereas the most pronounced decline in length of stay was already evident in earlier stages, limiting the ability of these technological components alone to explain the sustained improvement observed throughout the decade. This point is significant when considering local historical evidence: the DIAL study, conducted in Argentina two decades ago, showed that an intervention as simple as structured telephone follow-up by trained nurses—without any technological support—significantly reduced mortality and hospitalizations due to HF in outpatients. (3) The fact that a low-cost strategy without a technological component has demonstrated a benefit of this magnitude reinforces the idea that the critical factor is the consistency and quality of contact with the patient—and not necessarily the sophistication of the tool used to achieve it.

In short, we agree with the author that identifying the relative importance of each component is the central challenge in the future, and that the proposed coefficient of variation could be a useful tool for that assessment.

Our interpretation of the evidence suggests that these results are based on organizational components and structured follow-up—which do not require a high-complexity center for implementation—rather than on the incorporation of technology. Ultimately, we believe that a HF unit is not a matter of technological sophistication or exceptional resources, but rather of maintaining a systematic, patient-centered approach to care. It is, above all, an institutional decision: a project that relies on widely available or low-cost resources, whose true challenge lies not in availability but in sustainability—consistently applying these protocols with a care team whose goal is the continuous improvement of the quality of care for patients with HF. Standardizing care—rather than any specific resource—is what explains the observed results and what expands, instead of restricting, the real possibilities for adapting the model to other centers in the region.