Current health care trends include movements toward general health care reform and rapidly evolving changes affecting treatment of vascular disease. Government-sponsored programs and private coalitions increasingly influence practice management and patient care. Emerging organizational influences derive from public perceptions, policies, laws, and regulations intended to make health care safe, effective, patient centered, timely, efficient, and equitable. These trends energized methods of quality assessment, cost containment, and practice protocols over individual judgments and seek to exert increasing direction over clinical practice. Some evolving measures are good, some controversial, and some, without deliberate intent, may be harmful. This review considers evolving initiatives in the context of ethics of practice and practicalities of managing patients with vascular disease. Key issues include compliance with purely process-based measures, pay for performance, and assessment of quality outcomes. Strengths, weaknesses, opportunities, and potential threats to vascular practice are outlined.