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Context In the past 50 years, individual patient involvement at the clinical consultation level has received considerable attention. More recently, patients and the public have increasingly been involved in collective decisions concerning the improvement of health care and policymaking. However, rigorous evaluation guiding the development and implementation of effective public involvement interventions is lacking. This article describes those key ingredients likely to affect public members' ability to deliberate productively with professionals and influence collective health care choices. Method We conducted a trial process evaluation of public involvement in setting priorities for health care improvement. In all, 172 participants (including 83 patients and public members and 89 professionals) from 6 Health and Social Services Centers in Canada participated in the trial. We videorecorded 14 one-day meetings, and 2 nonparticipant observers took structured notes. Using qualitative analysis, we show how public members influenced health care improvement priorities. Findings Legitimacy, credibility, and power explain the variations in the public members' influence. Their credibility was supported by their personal experience as patients and caregivers, the provision of a structured preparation meeting, and access to population-based data from their community. Legitimacy was fostered by the recruitment of a balanced group of participants and by the public members' opportunities to draw from one another's experience. The combination of small-group deliberations, wider public consultation, and a moderation style focused on effective group process helped level out the power differences between professionals and the public. The engagement of key stakeholders in the intervention design and implementation helped build policy support for public involvement. Conclusions A number of interacting active ingredients structure and foster the public's legitimacy, credibility, and power. By paying greater attention to them, policymakers could develop and implement more effective public involvement interventions. [ABSTRACT FROM AUTHOR]

There are serious problems associated with the underuse, overuse, and misuse of health care. Part of the solution involves changing practicing physicians' competence and performance, but this proves to be a difficult task. People differ widely in their views of how the behavior of physicians can be effectively changed. Some approaches focus on improving the knowledge, skills, or attitudes of professionals, whereas others believe in changing the social interaction and collaboration within teams or changing the organizational or political context. Some believe in self-motivation and regulation by those who need to change, whereas others emphasize external stimuli, pressure, or control. However, systematic reviews show that no current approach is superior for all purposes and target groups and that we may need them all, well integrated, to achieve effective improvements in patient care. Educational activities for professionals are not sufficient and should be combined with activities and measures at other levels. Those wishing to improve the competence and performance of physicians must be aware of the limitations of educational approaches and know how to integrate these with approaches that focus on teams, organizations, or the political or economic context. Teachers of physicians need to develop their knowledge and skills in these areas to be successful. [ABSTRACT FROM AUTHOR]

Objectives: To identify predictors of high-quality clinical practice guidelines., Methods: A total of 86 guidelines from 11 countries were assessed by four independent appraisers per guideline using the AGREE instrument (23 items). Six aspects of guideline development were considered to explain the variation in quality scores: care level (primary/secondary care), scope (diagnosis/treatment), type of guideline (new/update), year of publication, type of agency (governmental/professional), and whether the guideline was produced within a structured and coordinated program., Results: Guidelines produced within a guideline program and by governmental agencies had higher scores than their counterparts. Differences in the applicability of the guidelines could not be explained by the variables studied., Conclusion: To ensure high quality, clinical guidelines should be produced within a structured and coordinated program. Professional organizations or specialist societies that aim to develop guidelines may adopt quality criteria from leading guideline agencies.

Objective: To compare guidelines on diabetes from different countries in order to examine whether differences in recommendations could be explained by use of different research evidence., Research Design and Methods: We analyzed 15 clinical guidelines on type 2 diabetes from 13 countries using qualitative methods to compare the recommendations and bibliometric methods to measure the extent of overlap in citations used by different guidelines. A further qualitative analysis of recommendations and cited evidence for two specific issues in diabetes care explored the apparent discrepancy between recommendations and evidence., Results: The recommendations made in the guidelines were in agreement about the general management of type 2 diabetes, with some important differences in treatment details. There was little overlap in evidence cited by the guidelines, with 18% (185/1,033) of citations shared with any other guideline, and only 10 studies (1%) appearing in six or more guidelines. The measurable overlap in evidence between guidelines increases if multiple publications from the same study and the use of reviews are taken into account. Research originating from the U.S. predominated (40% of citations); however, nearly all (11/12) guidelines were significantly more likely to cite evidence originating from their own countries., Conclusions: Despite the variation in cited evidence and preferential citation of evidence from a guideline's country of origin, we found a high degree of international consensus in recommendations made for the clinical care of type 2 diabetes. The influence of professional bodies such as the American Diabetes Association may be an important factor in explaining international consensus. Globalization of recommended management of diabetes is not a simple consequence of the globalization of research evidence.