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INTRODUCTION

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The Trustees of Hospitals should see to it that an effort is made to follow up each patient they treat, long enough to determine whether treatment given has permanently relieved the condition or symptom complained of … A layman could not enter authoritatively into the details … but he could insist that the End Results System should be used.— Ernest A. Codman

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Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.—Willa A. Foster

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For more than a century, there has been growing recognition of both the importance of, and rigor required to improve, the quality of health care. In the United States, health-care expenditure accounted for nearly 17.5% of the gross domestic product in 2014 and is expected to reach 19.6% by 2024. 1 In a recent report, the US health system ranked lowest among 11 countries with respect to access, equity, quality, efficiency, and healthy lives, 2 despite spending the most on health care. 3 Although there has been some improvement in the quality of health care in the United States over the past decade, it is nowhere near the level desired or expected, thus creating a critical challenge to the profession to provide higher value care to Americans. 4,5,6 Despite many technologic and therapeutic advances, particularly in the cardiovascular field, the timely, systematic translation of new knowledge into clinical practice remains a challenge, 7 as an ideal health-care system should be able to rapidly deploy new knowledge to improve the value of health care.

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It is often thought that high-quality health care is dependent on the increased discovery and delivery of novel diagnostic and therapeutic interventions. However, prior studies suggested that more use of expensive medical care was actually associated with worse quality and outcomes. 8,9 Woolf and Johnson 10 have extended this concept to mathematically quantify the trade-off between the development of new interventions and the more consistent delivery of known therapies. They argue that despite tremendous scientific and technologic advancements, the failure to consistently deliver proven therapies dilutes and reduces the overall quality of a health-care system. Thus, money spent on improving this actual delivery of care may be equally or even more critical than money spent on improving technology to result in improved quality of both routine and specialized health care. By using a mathematical nomogram, it has been shown that it is easier to save lives by improving the delivery of care to all patients than by improving the efficacy of care through further technologic advances. 10 For example, a new drug must yield dramatic, often unrealistic, increases in efficacy to do more good than could be accomplished by improving the delivery of care to all patients in need—the break-even point. 10 In addition, such new therapeutic choices are usually more expensive than ...

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