Quality improvement efforts in surgery have made significant progress in the past several decades. The surgical time-out, in which the operating team pauses and confirms patient identity and the surgical site, and briefing/debriefing checklists have resulted in safer surgery.1 Quality evaluation programs such as the National Surgical Quality Improvement Program have led to real clinical improvements.2 Progress to date has focused on enhancing care for patients who actually have operations. Many patients, however, do not receive operations that have been proven effective and would improve their health. In addition, many of the patients who do have operations cannot expect much gain from them, based on any evidence. In the balance of too many patients having surgical procedures they do not need, and too many not being offered operations they do need, lies the problem of inappropriate care.
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