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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

In the United States, health care expenditures account for nearly 16% of the gross domestic product and are continuing to rise.1 Although many technologic and therapeutic advances are worthy of praise, the quality of care delivered is nowhere near the level expected or desired from our investment.2-4 Cardiovascular medicine, in particular, has benefitted enormously from the investment in scientific discovery and clinical research5; yet the timely, systematic translation of new knowledge into clinical practice remains a challenge. To advance evidence-based practice and to reduce the variability in the quality of cardiovascular care, three key tools—clinical guidelines, performance measures, and appropriate use criteria—have been developed and promoted for quality assessment and improvement. This chapter provides an overview of these tools in the context of accepted frameworks to maximize quality and safety, after briefly reviewing the need for continual assessment and improvement of the quality of health care in the United States.

The United States invests an estimated $2.4 trillion dollars in health care, with a projected annual growth rate of 6.2% over the next 10 years.1 For a country that spends more money than any other nation in the world,6 however, the United States ranks poorly on most standardized health indices7 and quality metrics.4,8 In the United States, cardiovascular disease (CVD) remains the leading cause of death and disability, with an estimated annual total cost of $475.3 billion.9 Such a magnitude of disease burden necessitates and demands careful scrutiny of the quality of care being delivered.

Progress in Cardiovascular Care

Cardiovascular medicine in the United States has benefitted enormously from the investment in scientific discovery and clinical research, leading to many advances in the knowledge and treatment of the disease process. Importantly, the last 3 decades have witnessed substantial improvements in age-adjusted mortality rates due to CVD, coronary artery disease (CAD), and stroke (Fig. 3–1),5 a likely reflection of the successful adoption of primary and secondary prevention, coupled with improved treatments for acute cardiac conditions. Data from large population studies support these findings with marked reductions observed in the age- and race-adjusted rates of sudden death due to CAD,10 as well as in the incidence, case fatality rates, and mortality associated with CVD between 1971-1982 and 1982-1992.11a-11c


Percent decline in age-adjusted mortality rates for (A) cardiovascular disease (reference year: 1979), (B) coronary artery disease (reference year: 1970), and (C) stroke ...

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