Forces from communities and from health care are pushing toward more consumer involvement in health care internationally. This article addresses the philosophies and rationales behind this trend and traces the history and development of consumer advocacy in health care.

The paper outlines the context in which patient's views have been emphasized and the evidence from survey research about the criteria users employ to evaluate health care. Evidence from qualitative research shows that users are ambivalent about modern medicine and are particularly sceptical about the value of drugs and medicine.

There are inherent limitations in using assessments of patient satisfaction to make inferences about the quality of medical care. Such evaluations tend to be subjective, subject to reporting biases, and difficult to interpret when they are being used to motivate and guide quality improvement efforts. Newer methods of eliciting both reports and ratings from consumers, such as the Consumer Assessment of Health Plans (CAHPS) project, can provide reliable, valid, interpretable, and actionable data about selected aspects of health care. The use of these methods and continued use of new qualitative methods, such as cognitive interviewing, should allow us to continue increasing the prominence of consumer-based information in quality assessment and improvement efforts.

As the International Human Genome Project nears the term of a long gestation, the ethical and social implications of complex new genetic technologies will require a new breed of clinicians for a safe delivery. Clinical genetic care has been time intensive as performed by medical specialists. Empowering individuals to take advantage of new opportunities for genetic testing to prevent disease will require clinician education and decision support in the context of individual values.

We discuss some of the issues that have arisen during the development and introduction into practice of information materials for health professionals and patients that aim to promote clinical effectiveness and informed patient participation in clinical decision making.

Policy makers, health care providers, and the general public need valid information about the benefits and harmful effects of drugs and technologies to be able to make rational choices in their acquisition, distribution, and use. Effective communication is important for quality choices of drugs and other technologies. In effective communication, the choice of messages and media must correspond to the culture and beliefs of the target groups to make them comprehend and adopt the conclusions. Messages must be presented on a regular basis. Most regulatory agencies do not have enough resources to mount effective communication programs. Private advertising agencies and other stakeholders have definite roles. Valid knowledge must be the basis of dialogues to reduce emotional disputes among various benefit groups in society.

A National Patient Library, a public/private partnership, is proposed to identify and vet information for consumers. Library staff will help tailor general information to consumers' specific needs. The library includes an electronic network. The principal focus of the library's information is controversial and experimental procedures, Pharmaceuticals, and medical devices.

The widespread implementation of rationing and priority-setting policies in health care opposes the stochastic practice of medicine induced by professional uncertainty and professional vested interests in market-oriented clinical environments. It also clashes with consumers' overly optimistic and “mythical” view of the effectiveness of medicine, which is bound to support a potentially unlimited provision of health services. Thus, for consumers and society at large, it is necessary to create conditions favorable for a more conscious demand of evidence-based health care. In pursuit of this goal, we suggest the adoption of a community-oriented strategy based upon delivery of information to the public in order a) to generate greater awareness (“healthy skepticism”) among consumers, through disclosure of data on the true effectiveness of health care interventions and on the existing variation in their utilization, and b) to provide tools to empower consumers in dealing better with both the uncertainty in their own individual patient-physician relationships and with the health policy issues to be faced in the future. Such a community-oriented strategy could also reinforce and support, through the generation of a “bottom-up” pressure from consumers toward physicians, a wider adoption of evidence-based interventions by health care professionals. This paper, using data from surveys on public opinions and attitudes toward the practice of medicine, focuses on how consumer demand for more evidence-based medical practice can be promoted.

A comparison of two assessment methods, consensus among experts and research synthesis of the scientific literature, was performed using a surgical procedure, carotid endarterectomy (CE), as an example. These two methods have been widely advocated as being scientifically valid. While the comparison revealed a number of areas of general agreement, important differences between the two methods emerged. For example, 30-day mortality for asymptomatic patients was considered an effective outcome (ranked first) by the synthesis, but only “quivocal” (ranked third) of six major indicators reported by the consensus method. The synthesis results are also consistent with other literature reviews as well as with recent large-scale randomized trial results. A number of factors that could account for differences between the two methods were examined. Overall, use of consensus panels may be appropriate early in the development of an intervention where the evidence is sparse, while quantitative research synthesis is preferable when a number of high-quality studies have been performed.

Dental amalgam—a mixture of elemental mercury and a silver-dominated metal alloy—has been the most widely used dental filling material for well over a century. Alternative materials exist but are not well suited for some important applications, and all are more expensive than amalgam. The toxic effects of occupational mercury exposure have long been known, but it was not until about 1980 that serious consideration was given to the possibility that mercury vapor escaping from amalgam fillings might be affecting health, specifically producing subtle effects on the central nervous system. Such effects have been reported among dentists and other dental personnel, whose exposures are well below industrial levels but above those from fillings alone. No large studies have been completed that examine the effects of mercury exposure from dental amalgam fillings. In the face of inadequate evidence on the possible risks of dental amalgam, countries have reacted disparately. Sweden is phasing out amalgam entirely, possibly by the end of 1997. Germany has produced guidelines for limiting its use, other countries have signaled their intention to reduce it, and others—the United States and Canada—have studied the matter but taken no action. Policy differences within Europe have made dental amalgam a test case for the European Community's new medical device regulations. Relatively little epidemiologic research has been initiated to try to answer the question of dental amalgam's possible health effects. An international effort to define and carry out a research agenda to guide public policy is called for.

Decisions relating to designing and implementing economic evaluations alongside clinical trials are dependent on a number of issues. Initial consideration should focus on whether an economic evaluation is appropriate, whether a randomized controlled trial (RCT) is a suitable vehicle, and whether the design of the specific RCT is appropriate for integration of economic evaluation. If an economic evaluation is appropriate, decisions are required on how economic data are to be collected and analyzed. This paper discusses these and other issues and, where appropriate, provides recommendations for future studies.

This study used data from a multinational phase III randomized, double-blind, vehicle-controlled trial to evaluate the cost-effectiveness of tirilazad mesylate (Freedox®) in the treatment of aneurysmal subarachnoid hemorrhage. In men, therapy with 6 mg/kg per day of tirilazad mesylate was associated with significantly increased survival, increased cost of care, and ratios of cost per death averted that compare favorably with the ratios of other life and death interventions. In women, it appeared to have no effects on costs or survival. Further clinical studies may provide additional information about the cost-effectiveness of this intervention.

Economic evaluation of quality assurance programs is often called for but rarely reported. A study was designed to estimate the cost-utility of audit of thrombolysis in four U.K. district general hospitals, using the quality-adjusted life year. Although the results obtained were imprecise, the model used could be applied in future evaluations.

The study's purpose was to estimate the potential economic benefit of the optimization of postanesthesia care units (PACUs). A simulation model was designed and used to test the economic impact of a reduction of length of stay. For the studied PACU, a reduction of 25% of length of stay is required to yield significant economic results.

Cataract is the most common reason for visual problems in old age. The introduction of intraocular lens (IOL) implantation revolutionized cataract surgery. Since the IOL technique was established in Sweden in the early 1980s, the demand for surgery has been increasing, leading to lengthy waiting lists. To shorten some of the most troublesome waiting lists, national and local governments (county councils) in Sweden introduced a maximum waiting time guarantee in 1992. The assessment of the guarantee made in this article shows that ophthalmic surgery units vary in their adoption of the guarantee, leading to different levels of goal achievement in waiting times for their patients. The less successful units could be divided into two groups: one where the units have a low operation rate, and one where the units chose not to follow the recommendations in priority setting made in the guarantee.