We thank Dr Kisloff for his comments on our recent article describing efficiency metrics for endoscopy.1Gellad Z.F. et al.Clin Gastroenterol Hepatol. 2013; 11: 1046-1049Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar We agree entirely with Dr Kisloff that an exploration of overuse in gastrointestinal endoscopy is important and would be a valuable contribution to the literature. Multiple studies have highlighted potential overuse in colonoscopy,2Schoen R.E. et al.Gastroenterology. 2010; 138: 73-81Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar, 3Goodwin J.S. et al.Arch Intern Med. 2011; 171: 1335-1343Crossref PubMed Scopus (157) Google Scholar and recent practice guidelines from the American College of Physicians have noted risks of overuse of upper endoscopy in evaluating reflux.4Shaheen N.J. et al.Ann Intern Med. 2012; 157: 808-816Crossref PubMed Scopus (130) Google Scholar Unraveling the reasons for overuse and mechanisms to curb overuse are much more complex undertakings, but promising work has begun. We would point to the recent editorial by Naik et al5Naik A.D. et al.Clin Gastroenterol Hepatol. 2013; 11: 753-755Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar in this journal as such an example. The importance of endoscopy utilization notwithstanding, we continue to believe that efficiency at the operational level remains an important and understudied area of health care quality. As Jim Kim, president of the World Bank, wrote in a recent editorial, the American health care system has an “inexplicably high tolerance for poor execution…that has compromised health care in the United States.”6Kim J.Y. Healthcare. 2013; 1: 3Crossref Scopus (2) Google Scholar Rather than being used for “fiscal legerdemain,” efficiency metrics should be used to support the delivery of high-value, patient-centered endoscopy services. As Dr Kisloff points out, however, we would be remiss if we did not also emphasize that efficiency metrics should not be used in isolation but rather in conjunction with similarly robust measures of quality such as post-discharge adverse outcomes. Finally, in regard to Dr Kisloff's frustration regarding the absence of detailed information on the Donabedian paradigm, we regret the difficulty in accessing referenced material. Donabedian is a classic conceptual model, and we chose to reference the original article. A more recent reprint is available.7Donabedian A. Milbank Quarterly. 2005; 83: 691-729Crossref PubMed Scopus (1276) Google Scholar We hope this provides easier access to additional information. Quality RedefinedClinical Gastroenterology and HepatologyVol. 12Issue 3PreviewIn perusing the contents of my September 2013 issue of Clinical Gastroenterology and Hepatology, I was immediately enticed by the prospect of learning about Donabedian analysis in your “Practice Management: The Road Ahead” section.1 One can only imagine my disappointment at discovering that I would need to go to a supplementary table in an almost half-century-old reference to familiarize myself with the intellectual underpinnings of this section. My frustration was further compounded when I learned from the article of “…the absence of measures that have been evaluated rigorously in the context of the AHRQ [Agency for Healthcare Research and Quality] criteria of scientific soundness…” Finally, as I read Table 1 of the section, I could not find any mention of post-discharge measures as regards “Endoscopy Unit Efficiency Measures.” The aforementioned table provides an ample roadmap to the expeditious dispatching of a patient, with seemingly no regard to possible post-discharge adverse outcomes. Full-Text PDF