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PubMed2005

The application of enhanced parallel gatekeeping strategies.

The parallel gatekeeping strategy proposed by Dmitrienko et al. (Statist. Med. 2003; 22:2387-2400) provides a flexible framework for the pursuit of strong control on study wise type I error rate. This paper further explores the application of the weighted Simes parallel gatekeeping procedure recommended by Dmitrienko et al. and proposes some modifications to it to better incorporate the interrelationships of different hypotheses in actual clinical trials and to achieve better power performance. We first propose a simple method to quantitatively control the impact of secondary tests on the testing of primary hypotheses. We then introduce a matched gatekeeping procedure to exemplify how to address special relationships between individual primary and secondary tests following the parallel gatekeeping framework. Our simulation study demonstrates that the enhanced gatekeeping procedures generally result in more powerful tests than the parallel gatekeeping procedure in Dmitrienko et al. whenever applicable.

Analgesics↗
PubMed2006

Gatekeeping access to community mental health teams: a qualitative study.

BACKGROUND: Gatekeeping access to services at the interface with primary care has been identified as one of the key issues that community mental health teams (CMHTs) have to confront. OBJECTIVES: The aim of this study was to develop a better understanding of the contextual influences that impact upon the outcome of gatekeeping decisions. DESIGN: An interview-based qualitative study, informed by the philosophy of critical realism. SETTING: An urban catchment area in Northern England. PARTICIPANTS: Twenty-nine interviews were conducted with gatekeeping clinicians and service managers. METHOD: A convenience sample of clinicians was initially approached to take part in a series of semi-structured interviews. This was followed up by a purposive sample of clinicians and service managers, as specific contextual influences were identified and explored in detail. The emerging analysis was then subjected to critical scrutiny by a further sample of gatekeeping clinicians. FINDINGS: A clear hierarchy of appropriateness was identified with four dimensions: severity, risk, beneficence and a moral dimension. It was suggested that the salient contextual influences that shaped the hierarchy were: (a) the need to fit in with strategic planning directives, (b) the burden of responsibility that clinicians carried, (c) the high number of referrals and the relatively slow turnover of patients on clinical caseloads, (d) the position of CMHTs in the economy of care and (e) the character of the relationship between clinicians and service managers. CONCLUSION: The findings from the study support a multi-level view of the gatekeeping process within CMHTs, which takes account of the role that key contextual influences play in shaping the range of options that are available to gatekeeping clinicians.

Attitude of Health Personnel↗
PubMed2002

Managed care gatekeeping, emergency medicine coding, and insurance reimbursement outcomes for 980 emergency department visits from four states nationwide.

STUDY OBJECTIVE: We analyzed 980 emergency department visits for 951 patients with managed care insurance to document gatekeeping interactions and compare ED coding with professional fee billing reimbursements. METHODS: A prospective cohort study was performed at 12 academic and community hospital EDs in 4 states involving consecutive ED patients with managed care insurance. The main outcomes measured were gatekeeper decisions, coding levels, and reimbursement. RESULTS: Preauthorization for payment was required from managed care gatekeepers for 876 (89%) patients. Authorization was granted for 490 (56%) of these visits and denied in 176 (20%) visits; gatekeepers were not available for 210 (24%) visits. Reimbursement was initially denied for 211 (43%) of the ED visits preapproved by managed care gatekeepers. Reimbursement was initially denied for most (634 or 65%) visits, and downcoding occurred in the other 346 (35%) visits. Appeals for 560 (57%) visits resulted in a decrease in the number of unreimbursed ED visits to 193 and an increase in the number of reimbursed ED visits to 787. CONCLUSION: Preauthorization gatekeeping is not predictive of whether managed care third-party payers will initially reimburse ED visits. Overall, almost two thirds of all ED claims were initially denied, and reimbursed claims were uniformly downcoded. On appeal, reimbursement was often reinstated or increased, although billing services only appealed about half of ED visits.

Adult↗
PubMed2001

Gatekeeping: a challenge in the management of primary care physicians.

Assesses the degree of self-reported implementation of gatekeeping in clinical practice, and gains insight into primary care physicians' attitudes toward gatekeeping and their perceptions of necessary conditions for implementation of gatekeeping in daily practice. A self-administered questionnaire was mailed to a national sample of 800 primary care physicians in Israel, with a response rate of 86 per cent. Multivariate analysis indicated that sick fund affiliation was the main predictor of self-reported implementation of gatekeeping, while specialty training predicted primary care physicians' attitude toward this role. Close communication with specialists, continuous medical education, and management support of physician decisions were identified by respondents as being important conditions for gatekeeping. Discusses strategies to gain the cooperation of primary care physicians, which is necessary for implementing an effective gatekeeping system.

Adult↗
PubMed2005

Health expenditures for privately insured adults enrolled in managed care gatekeeping vs indemnity plans.

OBJECTIVES: We assessed the ability of managed care gatekeeping strategies (i.e., requiring a designated primary care provider to authorize referrals) to control health care costs in the mid-1990s. METHODS: We analyzed expenditure data from 8195 privately insured adults sampled in the nationally representative 1996 Medical Expenditure Panel Survey. Managed care gatekeeping plan enrollees included those in health maintenance organizations and other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees. RESULTS: In 1996, total per capita annual health expenditures for adult gatekeeping enrollees were about $50 less than those of indemnity enrollees, primarily owing to lower out-of-pocket expenditures. After multivariate adjustment, mean per capita expenditures were approximately 6% lower for gatekeeping enrollees than for indemnity enrollees. CONCLUSIONS: In the private sector, gatekeeping strategies resulted in modest cost savings over indemnity plans.

Adult↗
PubMed2004

Gatekeepers in the ribosomal protein s6: thermodynamics, kinetics, and folding pathways revealed by a minimalist protein model.

We investigate the effect of structural gatekeepers on the folding of the ribosomal protein S6. Folding thermodynamics and early refolding kinetics are studied for this system utilizing computer simulations of a minimalist protein model. When gatekeepers are eliminated, the thermodynamic signature of a folding intermediate emerges, and a marked decrease in folding efficiency is observed. We explain the prerequisites that determine the "strength" of a given gatekeeper. The investigated gatekeepers are found to have distinct functions, and to guide the folding and time-dependent packing of non-overlapping secondary structure elements in the protein. Gatekeepers avoid kinetic traps during folding by favoring the formation of "productive topologies" on the way to the native state. The trends in folding rates in the presence/absence of gatekeepers observed for our minimalist model of S6 are in very good agreement with experimental data on this protein.

Computer Simulation↗
PubMed2006

The gatekeeper residue controls autoactivation of ERK2 via a pathway of intramolecular connectivity.

Studies of protein kinases have identified a "gatekeeper" residue, which confers selectivity for binding nucleotides and small-molecule inhibitors. We report that, in the MAP kinase ERK2, mutations at the gatekeeper residue unexpectedly lead to autoactivation due to enhanced autophosphorylation of regulatory Tyr and Thr sites within the activation lip that control kinase activity. This occurs through an intramolecular mechanism, indicating that the gatekeeper residue indirectly constrains flexibility at the activation lip, precluding access of the phosphoacceptor residues to the catalytic base. Other residues that interact with the gatekeeper site to form a hydrophobic cluster in the N-terminal domain also cause autoactivation when mutated. Hydrogen-exchange studies of a mutant within this cluster reveal perturbations in the conserved DFG motif, predicting a route for side chain connectivity from the hydrophobic cluster to the activation lip. Mutations of residues along this route support this model, explaining how information about the gatekeeper residue identity can be transmitted to the activation lip. Thus, an N-terminal hydrophobic cluster that includes the gatekeeper forms a novel structural unit, which functions to maintain the "off" state of ERK2 before cell signal activation.

Animals↗
PubMed2000

Who needs a gatekeeper? Patients' views of the role of the primary care physician.

BACKGROUND: The primary care physician serving as a 'gatekeeper' can make judicious decisions about the appropriate use of medical services, and thereby contribute to containing costs while improving the quality of care. However, in Israel, sick funds competing for members have not adopted this model for fear of endangering their competitive stance. The purpose of this study was to examine, for the first time, the stated preferences and actual behaviour of a national sample of members of the four Israeli sick funds regarding self-referral to specialists, and to identify the characteristics of patients who prefer the gatekeeper model. METHODS: Data were derived from a national telephone survey carried out in 1997. A random representative sample of 1084 of all adult sick fund members were interviewed, with a response rate of 81%. Bivariate analysis was conducted using over all chi-square tests, and multivariate analysis was performed using logistic regression models. RESULTS: A third of all respondents prefer self-referral to a specialist, 40% prefer their family physician to act as gatekeeper and 19% prefer the physician to co-ordinate care but to refer themselves to a specialist. Independent variables predicting preference for the gatekeeper model are: living in the periphery, sick fund membership, low level of education, being male, fair or poor health status, having a permanent family physician and being satisfied with the professional level of the family physician. A significant correlation was found between practising self-referral and preference for self-referral. CONCLUSIONS.: The findings indicate the importance of surveying patients' attitudes as an input in policy formulation. The study identified specific population groups which prefer the gatekeeper model, and explored the advantages of a flexible model of gatekeeping.

Adult↗
PubMed1997

Adverse outcomes of managed care gatekeeping.

OBJECTIVES: To determine whether telephone preauthorization for reimbursement of ED care (medical "gate-keeping") by managed care organizations (MCOs) is associated with adverse outcomes. METHODS: A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on-call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) "near miss" (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above. RESULTS: Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococal meningitis in immuno comprised host, endocarditis, incarerated inguinal hernia, meningocococemia, meninoccocal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina. CONCLUSION: Adverse outcomes occur with MCO gatekeeping, Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study.

Adolescent↗
PubMed1998

One-year outcomes of older adults referred for aging and mental health services by community gatekeepers.

One-year outcomes of older adults referred for community aging and mental health services through the Gatekeeper Model were examined in this study. Outcomes included level of social, physical, psychological, and economic isolation, physical health problems, service need, and service utilization. Findings indicate that individuals referred by gatekeepers were more likely to live alone and to be socially isolated but less likely to have physical health problems. They were also less likely to have a physician at referral, but at 1 year this difference was not found. Cognitive problems had a significant impact on the lives of clients referred by gatekeepers at referral but not after one year. At referral, those referred by gatekeepers had greater service needs, but after 1 year they did not use more services than those referred by other sources. Implications of these findings are discussed. The findings from this study indicate that the adoption of the Gatekeepers model does not result in high service utilization. The Gatekeeper model is inexpensive to implement and can benefit communities through increased collaboration among service providers.

Activities of Daily Living↗
PubMed2003

Gatekeeping strategies for clinical trials that do not require all primary effects to be significant.

In this paper we describe methods for addressing multiplicity issues arising in the analysis of clinical trials with multiple endpoints and/or multiple dose levels. Efficient 'gatekeeping strategies' for multiplicity problems of this kind are developed. One family of hypotheses (comprising the primary objectives) is treated as a 'gatekeeper', and the other family or families (comprising secondary and tertiary objectives) are tested only if one or more gatekeeper hypotheses have been rejected. We discuss methods for constructing gatekeeping testing procedures using weighted Bonferroni tests, weighted Simes tests, and weighted resampling-based tests, all within the closed testing framework. The new strategies are illustrated using an example from a clinical trial with co-primary endpoints, and using an example from a dose-finding study with multiple endpoints. Power comparisons with competing methods show the gatekeeping methods are more powerful when the primary objective of the trial must be met.

Clinical Trials as Topic↗
PubMed2001

Unlocking specialists' attitudes toward primary care gatekeepers.

OBJECTIVES: Many managed care plans rely on primary care physicians to act as gatekeepers, which may increase tension between these physicians and specialists. We surveyed specialist physicians in California to determine whether their attitudes toward primary care gatekeepers differed depending on how the specialists were paid and the settings in which they practiced. STUDY DESIGN: We performed a cross-sectional survey using a mailed questionnaire. The predictors of specialist attitudes toward gatekeepers were measured using chi-square, the t test, and regression analyses. POPULATION: A probability sample of 1492 physicians in urban counties in California in the specialties of cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, and orthopedics was used. OUTCOMES: We used questions about specialists' attitudes toward primary care physicians in the gatekeeper role. A summary score of attitudes was developed. RESULTS: A total of 979 physicians completed the survey (66%). Attitudes toward primary care physicians were mixed. Relative to nonsalaried physicians, those who were salaried had a somewhat more favorable attitude toward gatekeepers (P = .13), as did physicians with a greater percentage of practice income derived from capitation (P =.002). CONCLUSIONS: Specialists' attitudes toward the coordinating role of primary care physicians are influenced by the practice setting in which the specialists work and by financial interests that may be threatened by referral restrictions. Policies that promote alternatives to fee for service and shift specialty practice toward more organized group settings may generate a common sense of purpose among primary care physicians and specialists.

Adult↗
PubMedDate not supplied

The process of gatekeeping in health care research.

Gatekeeping in health care research is the process of permitting or denying access to a selected research site. It is a complex process that researchers should be aware of as the process of gaining the confidence of the various gatekeepers is often time-consuming. This article identifies how gatekeeping occurs at various stages of the research process and highlights the reasons why some gatekeepers may deny access to researchers. It also offers strategies to minimise any problems associated with gatekeeping.

Biomedical Research↗
PubMed1994

Primary care, financing and gatekeeping in western Europe.

Primary care in western Europe is delivered by general practitioners (GPs) but their role within the overall health system is poorly understood. The aim of this article is to present an overview of the characteristics of general practice in the context of health systems and to describe their variability and interrelationships. Data were obtained from two main sources: publications of official organizations and EC research projects. The characteristics of general practice are described and analysed with regard to three features: mode of payment, gatekeeper function and practice organization and workload. Despite their focus on general practice as the cornerstone of the health system, western European countries differ considerably in the major characteristics of primary care. There is variability in the ratio of GPs to population and in the extent to which patients relate to individual physicians. Although all countries have universal health insurance, the mode of payment of GPs differs. In some countries, the gatekeeper function of general practice is more highly developed and the use of specialist services varies accordingly. Practice characteristics such as workload, length of consultation, ordering of tests and reappointments also vary with differences in payment and gatekeeping arrangements. In particular, fee-for-service was associated with weaker physician-patient relationships, reduced attractiveness of general practice, more home visiting and longer consultations. Strong gatekeeping arrangements are not incompatible with high public satisfaction and are associated with lower visit rates. However, strong gatekeeping is not characteristic of fee-for-service arrangements. These findings suggest a need for more concerted research that could inform policy decisions concerning primary care in the USA as well as in Europe.

Adolescent↗
PubMed2005

Condom use among female sex workers in China: role of gatekeepers.

OBJECTIVE: The objective of this study was to assess the potential role of gatekeepers of establishments in promoting condom use among female sex workers (FSWs) in China. GOALS: The goals of this study were to explore FSWs' perceptions of gatekeeper attitudes and support for condom use, and to assess their association with FSWs' practice, communication, intention, proper use, knowledge of correct use, and perceptions related to condom use. STUDY: The authors conducted a cross-sectional study among 454 establishment-based FSWs in one Chinese county. RESULTS: Perceived gatekeeper support for condom use was low among FSWs. Perceived support was positively associated with condom use communication with sexual partners, condom use frequency and intention, but not associated with proper condom use among FSWs. Perceived support was significantly associated with most condom use-related perceptions (e.g., self-efficacy of condom use, barriers to condom use, and perceived peer condom use) among FSWs. CONCLUSIONS: Healthcare professionals should work with gatekeepers to create a supportive local environment for condom use in sex work establishments. Gatekeepers need to clearly articulate their support for condom use to the FSWs. Training and skill acquisition regarding correct use of condoms among FSWs will be necessary.

Adult↗
PubMed1998

The gatekeeper model: implications for social policy.

One of the most important needs of an aging population is to insure that older adults are able to live as independently and safely as possible. The question for social policymakers is how to meet this goal in an era of shrinking resources and growing numbers of older adults. The Gatekeeper Model is highlighted as a method to insure that older adults at risk of problems that impact their ability to live independently can be helped by existing systems of care. The model trains employees of community businesses and corporations who work with the public to serve as community gatekeepers by identifying and referring community-dwelling older adults who may be in need of help. A research project was conducted at Spokane Mental Health, Elder Services Division, where the model was developed. The results indicate that community-based gatekeepers found 40% of clients. Gatekeepers find a distinct population of community-dwelling older adults who are not found by more traditional referral sources. The social policy implications of the Gatekeeper Model are discussed.

Aged↗
PubMed1996

Randomized controlled trial of residents as gatekeepers.

BACKGROUND: Managed care advocates suggest that primary care gatekeepers may improve patient care and reduce costs. Training internal medicine residents in these gatekeeping functions has not been emphasized in most internal medicine programs. OBJECTIVE: To determine if residents could perform gatekeeper functions and if patient costs and satisfaction would be favorable. METHODS: Patients (n = 254) followed up by residents (n = 26) in continuity clinics at the Denver Veterans Affairs Medical Center in Denver, Colo, were divided into 2 groups. A control group of 128 was followed up by residents with no restrictions on appointments made for them. An intervention group of 126 patients were followed up by residents who had to approve all referrals made for their patients. A research nurse assisted with the approvals when the residents were rotating through other institutions. Utilization of resources, satisfaction with care, and health status were monitored over a 1-year period. RESULTS: A minor reduction of resource utilization was found in the intervention group, particularly in medication use. Significantly more visits were made to primary care providers in the intervention group (3.01 vs 2.59; P = .03). Patient satisfaction and health status were similar in both groups with a trend toward better satisfaction in the intervention group in some areas. CONCLUSIONS: Our study showed that residents can function as gatekeepers of highly complex patients and that satisfaction with care and utilization of resources does not suffer. Drug utilization and costs may be less when a gatekeeper exists.

Ambulatory Care↗
PubMedDate not supplied

[The Swiss gatekeeper system--a model for improving capacity development and economic effectiveness].

The German as well as the Swiss health care system are facing similar problems. However, in Switzerland different gatekeeper systems to improve the capacity and economic efficiency were successfully tried and tested. The main structures of gatekeeping are the HMO health centres and different GP systems. Central to this idea is the primary care physician functioning as a gatekeeper. He has to control the demands of medical services according to the patient's needs to fulfil integral, comprehensive and economic criteria. Although data processing has not yet been completed yet, first results show clear advantages of the gatekeeper system in respect of the costs and quality of health care compared with the customary Swiss health insurance. Although in Switzerland there are still relatively few persons insured according to the gatekeeper system, it is expected that particularly the family physician systems will expand considerably in the future. Reorganisation and rearrangements of the medical care providers are likely.

Adolescent↗