Implementing coordinated ambulatory cardiology care in southern Germany: a mixed-methods study

Abstract

Abstract Background In 2009 health insurers AOK and Bosch BKK introduced the “FacharztProgramm Kardiologie” - a program for coordinated ambulatory cardiology care in the German state of Baden-Württemberg. It aims for efficient, medical guideline-oriented cardiology care to reduce avoidable hospitalizations as well as costs of care. A high number of cardiologists participate and the program has served as blueprint for programs in other medical fields. With many prerequisites and conditions involved, its implementation cannot be expected to be self-directed. Still, only little data on the actual implementation exists. We aimed to determine to what extent medical specialists and cooperating general practitioners implemented the program, which components they adapted, and which contextual factors they deemed relevant. Methods We collected data from primary care practices of medical specialists and general practitioners within Baden-Württemberg. Qualitative data was obtained through structured telephone interviews with participating and non-participating medical specialists as well as general practitioners cooperating with the program and general practitioners not cooperating. Interviews were analyzed through content-structuring qualitative content analyses via MAXQDA. Quantitative data was obtained using anonymous written questionnaires completed by participating and non-participating medical specialists as well as general practitioners cooperating with the program. Analyses were performed using SPSS Statistics, mainly with regard to differences within and between groups of physicians. Results Most components of the program regarding medical care were well implemented. However, access to medical care was not completely as intended due to high numbers of patients participating in the program and prioritization by physicians. Procedures for communication and cooperation between medical specialists and general practitioners were only partially adhered to and standardized communication was not implemented. A range of regional and practice-related contextual factors influenced implementation and outcomes. Conclusions Implementation of this program was mixed. Contextual factors posed individual challenges to participating physicians which can’t be captured by an encompassing program. Both control mechanisms and tailoring of the program to medical care seem needed. Trial registration Though not a clinical study, we deemed registration appropriate to ensure transparency. The study has been registered as a non-interventional observation study at the German Clinical Trials Register under ID: DRKS00013070.

Keywords

• Cardiology
• Managed care
• Selective contract
• Implementation
• Mixed-methods
• Ambulatory