[Family doctor-centred care in Baden-Wuerttemberg: concept and results of a controlled evaluation study].

BACKGROUND AND RESEARCH QUESTION: Pursuant to Section 73b, volume V of the German Social Security Code (SGB V), the agreement on family doctor-centred care (HzV), which went into effect in Baden-Wuerttemberg on July 1, 2008, provides for spatially inclusive and comprehensive medical coverage. The most important elements of the agreement are: the voluntary registration of family practices and patients, the strengthening of the coordinative function of family practices, the fulfilment of certain training, quality and qualification requirements, the standardised remuneration system and the use of specified practice software for billing and the prescription of drugs. The aim of this complex intervention is to strengthen family medicine, improve health care, in particular for patients with chronic disease, and to limit primary health care costs while improving its quality wherever possible. This first controlled nationwide evaluation examines the question whether these objectives were met in the early phase (2008 to 2011) and, if so, to what extent.

METHOD: Four work packages were defined: 1. differences in health care processes (utilisation, contact to specialists, hospitalisations, drug prescriptions); 2. developments in practice teams and of patient satisfaction; 3. deployment of specially trained health care assistants in family practices (VERAH); 4. implementation of the DEGAM (German Society of General Practice and Family Medicine) heart failure guideline. To the extent that it was possible to use the statutory health insurance company AOK Baden-Wuerttemberg's routine data, an adjusted comparison of the target variables was made for HzV- and non-HzV-insured patients between the first and second or between the third and fourth quarters of 2008, and between the first and second or third and fourth quarters of 2010.

RESULTS: HzV participants were older, had a higher disease burden (Charlson Index 1.45 vs. 1.19), and were attended to more intensively than patients receiving routine care (1.7 more contacts with the family doctor per half-year). The number of non-referred contacts to specialists fell by 12.5 %. An increase in the number of referrals and hospitalisations was not observed. Participation in structured treatment programmes was substantially higher, e.g. 15 % vs. 7.5 % (non-HzV) in DMP diabetes mellitus Type 2. In the HzV, the rise in medication costs due to family physician prescriptions (ignoring the effect of discount agreements) was lower by 2.5 %, and the me-too rate was significantly lower. Higher remuneration contributed to greater satisfaction among HzV physicians despite the perceived increase in the workload. In a survey of 2,535 patients HzV participants showed a high rate of patient satisfaction overall, and physical examinations and services aimed at preventing illness were regarded particularly favourably. A survey of 294 VERAH showed that they more often accepted patient-related tasks such as home visits, geriatric assessments, patient training, and vaccination and preventive management. Family physicians were prepared to delegate responsibilities and, as a result, felt disburdened. In accordance with the latest DEGAM guideline patients with heart failure enjoyed an improvement to an overall high level in their drug therapies with ACE inhibitors, AT1 antagonists and beta blockers. Further improvement resulting from medical quality circles and training was not observed.

DISCUSSION AND CONCLUSIONS: The results confirm the findings of international studies: in particular, HzV benefits patients with chronic disease, and patients receive improved health care when they participate in the Baden-Wuerttemberg HzV. All four evaluation modules reveal that changes towards the intended direction are taking place. Family doctors assumed more responsibility for coordination. These findings reflect the early start-up phase and the development phase of HzV in Baden-Wuerttemberg. These effects, together with those of other prioritised topics, will be continuously monitored as part of an accompanying evaluation process.