Objective To develop a set of quality criteria for patient decision support technologies (decision aids). Design and setting Two stage web based Delphi process using online rating process to enable international collaboration. Participants Individuals from four stakeholder groups (researchers, practitioners, patients, policy makers) representing 14 countries reviewed evidence summaries and rated the importance of 80 criteria in 12 quality domains on a 1 to 9 scale. Second round participants received feedback from the first round and repeated their assessment of the 80 criteria plus three new ones. Main outcome measure Aggregate ratings for each criterion calculated using medians weighted to compensate for different numbers in stakeholder groups; criteria rated between 7 and 9 were retained. Results 212 nominated people were invited to participate. Of those invited, 122 participated in the first round (77 researchers, 21 patients, 10 practitioners, 14 policy makers); 104/122 (85%) participated in the second round. 74 of 83 criteria were retained in the following domains: systematic development process (9/9 criteria); providing information about options (13/13); presenting probabilities (11/13); clarifying and expressing values (3/3); using patient stories (2/5); guiding/coaching (3/5); disclosing conflicts of interest (5/5); providing internet access (6/6); balanced presentation of options (3/3); using plain language (4/6); basing information on up to date evidence (7/7); and establishing effectiveness (8/8). Conclusions Criteria were given the highest ratings where evidence existed, and these were retained. Gaps in research were highlighted. Developers, users, and purchasers of patient decision aids now have a checklist for appraising quality. An instrument for measuring quality of decision aids is being developed.

Proton pump inhibitors (PPIs) are a class of medications used to suppress production of gastric acid, and indications for their use include the treatment of dyspepsia, gastroesophageal reflux disease, and gastric and duodenal ulcers. Proton pump inhibitors are also recommended for hospitalized patients in intensive care unit settings for prophylaxis of stress ulcers. In the short term, PPIs are quite effective at symptom relief and treatment of these acid-related conditions; however, no recommendations have been made for the frequently observed prophylactic use of PPIs in nonintensive medical and surgical inpatient settings. Although indications exist for long-term therapy (eg, hypersecretory states), longterm use is often not warranted.

The phenomenon of practice variation draws attention to the need for better management of clinical decision making as a means of ensuring quality. Different policies to address variations, including guidelines and measures of appropriateness, have had little demonstrable impact on variation itself or on the underlying quality problems. Variations in rates of interventions raise questions about the patient-centeredness of decisions that determine what care is provided to whom. Policies that support the development and routine use of measures of decision quality will provide opportunities to measurably improve the quality of decisions, thereby leading to more patient-centered and efficient health care. S t r i k i n g va r i at i o n s i n r at e s of common surgical procedures among seemingly similar populations have been documented for more than sixty years. Variation is greatest when there is legitimate discretion about the best course of action. 1 Sometimes this discretion exists because of inadequate research and the resulting collective professional uncertainty about the effectiveness of an intervention. Sometimes research is adequate but is variably interpreted or disseminated, which results in individual professional uncertainty. In some cases, two or more interventions may be equally effective. Under these circumstances, local conventional wisdom shaped by the beliefs of local medical opinion leaders can take over, masking uncertainty and driving procedure rates in one direction or the other. The result is often an idiosyncratic pattern of rates that John Wennberg has labeled the "surgical signature" of a particular geographic area. 2 The cost and quality implications of these geographic differences are too great to be ignored. 3 One response of policymakers to practice variation has been to urge professional organizations and researchers to develop clinical practice guidelines to as-VA R -5 4 7 O c t o b e r 2 0 0 4

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