Best medical practice in The Netherlands: a decision analyst's view

Opinions over what is bad, good and best medical practice have varied through time. In older days, medicine aimed exclusively at maximum effectiveness through an aggressive diagnostic and therapeutic approach, irrespective of cost considerations. Budget constraints in health care have put limits on this exhaustive form of medicine. Consequently, considerations regarding the ratio between the quality and the cost of medical care are becoming more and more important in the definition of 'best medical practice'. Quality standards in medicine thus should not be based exclusively on medical considerations, but should also take cost considerations into account. This balanced integration of quality and cost represents a new challenge in medicine. It demands an active interest and participation of the medical profession in budget affairs, and close cooperation between health care professionals, health economists, and health care administrators. If this integration is done explicitly and quantitatively, it requires the use of decision analysis and cost-effectiveness analysis techniques. Recent experiments at the department of Surgery at the Leiden University Hospital have demonstrated the feasibility of this approach. Quality standards were set by means of explicit outcome criteria, and policy changes were executed on the basis of cost-effectiveness analysis. Quality of care could be maintained at the same or higher levels while cost savings of up to 60% were realized. The advance of 'best medical practice' in the present and future requires a multidisciplinary approach to medicine, that is best realized by the use of explicit and quantitative quality standards. This approach can only be successful if close cooperation between professionals, administrators, economists and politicians in health care can be realized.