Impact of the medical home model on the quality of primary care: the Belgian experience.

BACKGROUND: The Belgium medical home (MH) model, which has been garnering support of late, resembles its US counterpart in that it aims at improving the quality of health care while containing costs. OBJECTIVES: To compare the quality of care offered by MHs with that offered by traditional individual practices (IPs) in Belgium in terms of the extent of their adherence to clinical practice guidelines in antibiotherapy, cervical-cancer screening, influenza vaccination, and the management of diabetes. RESEARCH DESIGN: This is a retrospective study using public insurance claims data. Data consisted of a random sample of patients using the services of MHs and IPs who were previously matched according to sex, age category, location, disability, and socioeconomic status. We applied the McNemar test, the t test, or the Wilcoxon test, depending on the type of variable being compared. SUBJECTS: The final sample comprised 43,678 patients in the year 2004. MEASURES: On the basis of a review of the literature, we selected 4 themes, corresponding to 25 indicators: antibiotherapy, cervical-cancer screening, influenza vaccination, and the management of diabetes. RESULTS: MHs were more likely than IPs to adhere to evidence-based clinical practice guidelines. They prescribed less and more appropriate antibiotherapy, provided wider influenza-vaccination coverage for target groups, and provided a better follow-up for diabetics than did IPs. In regard to cervical-cancer screening, no significant differences were found. CONCLUSIONS: MHs, as they combine a greater adherence to guidelines and savings in secondary care, are a cost-effective alternative to traditional IPs and therefore should be encouraged.

Pneumonia and influenza, and respiratory and circulatory hospital admissions in Belgium: a retrospective database study.

BACKGROUND: Influenza infections can lead to viral pneumonia, upper respiratory tract infection or facilitate co-infection by other pathogens. Influenza is associated with the exacerbation of chronic conditions like diabetes and cardiovascular disease and consequently, these result in acute hospitalizations. This study estimated the number, proportions and costs from a payer perspective of hospital admissions related to severe acute respiratory infections. METHODS: We analyzed retrospectively, a database of all acute inpatient stays from a non-random sample of eleven hospitals using the Belgian Minimal Hospital Summary Data. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification was used to identify and diagnose cases of pneumonia and influenza (PI), respiratory and circulatory (RC), and the related complications. RESULTS: During 2002-2007, we estimated relative hospital admission rates of 1.69% (20960/1237517) and 21.79% (269634/1237517) due to primary PI and RC, respectively. The highest numbers of hospital admissions with primary diagnosis as PI were reported for the elderly patient group (n = 10184) followed by for children below five years of age (n = 3451). Of the total primary PI and RC hospital admissions, 56.14% (11768/20960) and 63.48% (171172/269634) of cases had at least one possible influenza-related complication with the highest incidence of complications reported for the elderly patient group. Overall mortality rate in patients with PI and RC were 9.25% (1938/20960) and 5.51% (14859/269634), respectively. Average lengths of hospital stay for PI was 11.6 ± 12.3 days whereas for RC it was 9.1 ± 12.7 days. Annual average costs were 20.2 and 274.6 million Euros for PI and RC hospitalizations. Average cost per hospitalization for PI and RC were 5779 and 6111 Euros (2007), respectively. These costs increased with the presence of complications (PI: 7159, RC: 7549 Euros). CONCLUSION: The clinical and economic burden of primary influenza hospitalizations in Belgium is substantial. The elderly patient group together with children aged <18 years were attributed with the majority of all primary PI and RC hospitalizations. TRIAL REGISTRATION: Not applicable.

Medical homes versus individual practice in primary care: impact on health care expenditures.

BACKGROUND: The medical home (MH) model has prompted increasing attention given its potential to improve quality of care while reducing health expenditures. OBJECTIVES: We compare overall and specific health care expenditures in Belgium, from the third-party payer perspective (compulsory social insurance), between patients treated at individual practices (IP) and at MHs. We compare the sociodemographic profile of MH and IP users. RESEARCH DESIGN: This is a retrospective study using public insurance claims data. Generalized linear models estimate the impact on health expenditures of being treated at a MH versus IP, controlling for individual, and area-based sociodemographic characteristics. The choice of primary care setting is modeled using logistic regressions. SUBJECTS: A random sample of 43,678 persons followed during the year 2004. MEASURES: Third-party payer expenditures for primary care, secondary care consultations, pharmaceuticals, laboratory tests, acute and long-term inpatient care. RESULTS: Overall third-party payer expenditures do not differ significantly between MH and IP users (€+27). Third-party payer primary care expenditures are higher for MH than for IP users (€+129), but this difference is offset by lower expenditures for secondary care consultations (€-11), drugs (€-40), laboratory tests (€-5) and acute and long-term inpatient care (€-53). MHs attract younger and more underprivileged populations. CONCLUSIONS: MHs induce a shift in expenditures from secondary care, drugs, and laboratory tests to primary care, while treating a less economically favored population. Combined with positive results regarding quality, MH structures are a promising way to tackle the challenges of primary care.

Cost-effectiveness analysis of FDG PET-CT in the management of pulmonary metastases from malignant melanoma.

OBJECTIVES: Most guidelines consider FDG PET-CT to detect occult extra-pulmonary disease prior to lung metastasectomy. A cost-effectiveness analysis, using a Markov model over a 10 year period, was performed to compare two different surveillance programs, either PET-CT or whole-body CT, in patients with suspected pulmonary metastasised melanoma. METHODS: Data from published studies provided probabilities for the model. Complication and care costs were obtained from standardised administrative databases from 19 hospitals identified by DRG codes (reported in 2009 Euros). For the cost calculation of PET-CT we performed a microcosting analysis. All costs and benefits were yearly discounted at respectively 3% and 1.5%. Outcomes included life-months gained (LMG) and the number of futile surgeries avoided. Cost-effectiveness ratios were in Euros per LMG. Univariate and probabilistic sensitivity analyses addressed uncertainty in all model parameters. RESULTS: The PET-CT strategy provided 86.29 LMG (95% CI: 81.50-90.88 LMG) at a discounted cost of euro3,974 (95% CI: euro1,339-12,303), while the conventional strategy provided 86.08 LMG (95% CI: 81.37-90.68 LMG) at a discounted cost of euro5,022 (95% CI: euro1,378-16,018). This PET-CT strategy resulted in a net saving of euro1,048 with a gain of 0.2 LMG. Based on PET-CT findings, 20% of futile surgeries could be avoided. CONCLUSION: Integrating PET-CT in the management of patients with high risk MM appears to be less costly and more accurate by avoiding futile thoracotomies in one of five patients as well as by providing a small survival benefit at 10 years.