A more productive alternative is to change the objective from optimization to unambiguous improvement of the effectiveness and efficiency of the catheterization system (Box 1). By finding ways that will continually improve the system, one will gradually get closer to the optimal rate of catheterization in the population that one serves. An important first step would be to act on what we already know. For example, a recent analysis indicated that, despite universal health care and increases in the availability of catheterization, there were significant inequities in access to catheterization and CABG after myocardial infarction within regions of Canada related to the socioeconomic status and sex of the patient and the specialty of the attending physician.14 If such inequities are measurable in populations of hospitalized patients, they are likely magnified several fold in outpatient populations of referrals for catheterization, which are initiated in thousands of primary care practices and specialist offices across the country. Improved efficiency of the referral process for outpatients might be achieved if standardized methods were developed, validated and adopted for screening and referring people at high risk of CAD for further investigations and possible catheterization; a greater emphasis on objective criteria would potentially reduce unjustifiable variability in access, provide more rapid access for patients who are likely to gain maximal benefit, and potentially reduce the size of waiting lists and the morbidity and mortality associated with waiting.2