Appropriate care programs differ in the way and the extent to which they involve or collaborate with stakeholders. Here we describe the collaboration of two national appropriate care programs with gynecologists to improve the curative care of women with cervical intraepithelial neoplasia (CIN), a cervical pre-malignancy.

The present case report describes the collaboration based on project documentation.

The Appropriate Care program from the Dutch National Health Care Institute performs a systematic cyclic health technology assessment to examine the degree to which care in the insured package is provided to patients. The full cycle consists of four phases: screening, in-depth analysis, implementation, and evaluation. The results of the in-depth analysis are discussed with the stakeholders. This is followed by written agreements on multiple actions to improve healthcare from the patient perspective. For CIN these actions encompass improvements in a top-down fashion; for example, by updating guidelines to eliminate unwanted practice variation and creating tools for shared decision-making. These actions were supplemented by the development of audit and feedback information on a national and local level. The development was supported by a second national appropriate care program, Healthcare Evaluation and Appropriate Use. The results of the first production run of the audit and feedback information were disseminated by the Dutch Society of Obstetrics and Gynaecology and more than 50 healthcare institutions. This information was used to prioritize modular guideline updates and helped pinpoint the main areas of improvement of individual healthcare institutions. A future production run of audit and feedback information will facilitate the Plan-Do-Check-Act cycle on a local and national level.

In the case we present, the collaboration between appropriate care programs and healthcare professionals led to a synergy between top-down (updating and disseminating guidelines and tools for shared decision-making) and bottom-up (learning from audit and feedback information) activities to improve curative care for women with CIN.