Consensus methods are being used increasingly to solve problems in medicine and health. Their main purpose is to define levels of agreement on controversial subjects. Advocates suggest that, when properly employed, consensus strategies can create structured environments in which experts are given the best available information, allowing their solutions to problems to be more justifiable and credible than otherwise. This paper surveys the characteristics of several major methods (Delphi, Nominal Group,

The standard way to assess medical technologies is to conduct a randomized clinical trial. Patients are randomly assigned to groups receiving alternative treatments, and outcomes are monitored over a long period of time. For example, some victims of left main coronary artery disease may undergo coronary artery bypass surgery, and others may receive medical treatment with nitroglycerine and beta blockers. Comparison of five-year mortality and morbidity in the two groups helps to determine the relative appropriateness of the two procedures. In addition, information about quality of life and cost can also be collected and compared.

N THE LAST DECADE, THERE HAS BEEN heightened awareness of the extent to which children personally witness or experience violence. [1][2][3] Public health officials have responded by identifying violence as one of the most significant US public health issues. [4][5][6] Large numbers of US children experience such violence, and an even greater number may experience symptoms of distress after personally witnessing violence directed at others. 2,7-9 For many children, personally experiencing or directly witnessing multiple incidents of violence is the norm. 3,10,11 Violence affects all racial, ethnic, and socioeconomic groups, but its burden falls disproportionately on urban, 5,12 poor, and minority populations. 13,14 Several studies have found that the majority of children exposed to violence, defined as personally witnessing or directly experiencing a violent event, display symptoms of posttraumatic stress disorder (PTSD), 15,16 and a substantial minority develop clinically significant PTSD. [17][18][19] However, the harmful effects of violence extend beyond symptoms of PTSD. Exposure to violence is associated with depression 20 and behav-Author Affilations are listed at the end of this article.

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We measured geographic differences in the use of medical and surgical services during 1981 by Medicare beneficiaries (age greater than or equal to 65) in 13 large areas of the United States. The average number of Medicare beneficiaries per site was 340,000. We found large and significant differences in the use of services provided by all medical and surgical specialties. Of 123 procedures studied, 67 showed at least threefold differences between sites with the highest and lowest rates of use. Use rates were not consistently high in one site, but rates for procedures used to diagnose and treat a specific disease varied together, as did alternative treatments for the same condition. These results cannot be explained by the actions of a small number of physicians. We do not know whether physicians in high-use areas performed too many procedures, whether physicians in low-use areas performed too few, or whether neither or both of these explanations are accurate. However, we do know that the differences are too large to ignore and that unless they are understood at a clinical level, uninformed policy decisions that have adverse effects on the health of the elderly may be made.