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PubMedDate not supplied

Gatekeeping in child welfare: a comparative study of intake decisionmaking by social workers in Canada and Sweden.

This article details findings from social workers in Sweden and Canada, illuminating similarities and differences in gatekeeping in child welfare and child protection. Analysis revealed different patterns of inclusion and exclusion. Swedish child welfare includes a greater readiness to intervene with more resources and measures. Gatekeeping is assessment driven and focused on family preservation. In Canada, only the most needy children are eligible for a limited range of services. Gatekeeping is structure driven and narrowly focused on protection. Analyses of evidence-based research to improve outcomes for children and families must include comparisons of how different structural orientations influence management of referrals at intake. The authors discuss the implications of these findings.

Adult↗
PubMed1999

Primary care physicians should be coordinators, not gatekeepers.

Primary care gatekeeping, in which the goal of the primary care physician (PCP) is to reduce patient referrals to specialists and thereby reduce costs, is not an adequate system in which to practice medicine. However, returning to the pre-managed care model of uncoordinated open access to specialists is a poor solution. The primary care model should be retained, but PCPs should be transformed from gatekeepers into coordinators of care, in which the goal of the PCP is to integrate both primary and specialty care to improve quality. Changes in the PCP's daily work process, as well as the referral and payment processes, need to be implemented to reach this goal. This model would eliminate the requirement that referrals to specialists be authorized by the primary care physician or managed care organization. Financial incentives would be needed, eg, to encourage PCPs to provide management of complex cases and discourage both over-referral and underreferral to specialists. Budgeting specialists should control excess costs that might be created by the elimination of the primary care gatekeeper. Pilot projects are needed to test and refine this model of PCP as coordinator of care.

Case Management↗
PubMed1984

Assessing a CMHC's impact: resident and gatekeeper awareness of center services.

One accessible measure of the impact a community mental health center has on the community it serves is the awareness levels of both residents and gatekeeper groups regarding the center's existence and services. This broad-based study was conducted with university students at no cost to the center and included 436 residents and 175 gatekeepers. The results indicated that awareness levels for community residents and gatekeeper groups were 34% and 53%, respectively, but varied dramatically as a function of how the awareness questions were phrased. The overall awareness findings generally supported those of other studies and were discussed in light of potential normative levels, methods for conducting surveys of this nature, response rates, and the increasing need to justify existence given the diminishing funding situation.

Analysis of Variance↗
PubMedDate not supplied

Gatekeeping procedures in dose-response clinical trials based on the Dunnett test.

This paper discusses multiple testing procedures in dose-response clinical trials with primary and secondary endpoints. A general gatekeeping framework for constructing multiple tests is proposed, which extends the Dunnett test [Journal of the American Statistical Association 1955; 50: 1096-1121] and Bonferroni-based gatekeeping tests developed by Dmitrienko et al. [Statistics in Medicine 2003; 22:2387-2400]. The proposed procedure accounts for the hierarchical structure of the testing problem; for example, it restricts testing of secondary endpoints to the doses for which the primary endpoint is significant. The multiple testing approach is illustrated using a dose-response clinical trial in patients with diabetes. Monte-Carlo simulations demonstrate that the proposed procedure provides a power advantage over the Bonferroni gatekeeping procedure. The power gain generally increases with increasing correlation among the endpoints, especially when all primary dose-control comparisons are significant.

Clinical Trials as Topic↗
PubMed2006

RN as gatekeeper: student understanding of the RN buddy role in clinical practice experience.

Students may be informally buddied with registered nurses (RNs), during their clinical experience. This paper describes one component of a larger phenomenographic study that explored the qualitatively different ways students understand the RN buddy role during clinical experience and the implications of this understanding for student learning. The perception of the RN as gatekeeper was an unexpected finding and is the focus of this report. Phenomenography is a field of descriptive research concerned with the variation in ways people experience and understand similar phenomena. This approach was used to identify the variation in experience and understanding of students with buddy RNs. Individual semi-structured interviews were conducted with a purposive sample of 24 students from one university in Queensland, Australia. The two variations in understanding of the role discussed in this paper are: understanding as an expectation, and RN as gatekeeper: gatekeeping as access. The research highlights that the various ways RNs promote or block access for students influence the quality of the learning experience. Formal recognition of the complexity of the RN role is essential to ensure RNs have adequate preparation for their role with students.

Attitude of Health Personnel↗
PubMed1994

Diagnostic management by gatekeepers is not cost effective for neuro-ophthalmology.

PURPOSE: To determine whether the "gatekeeper physician system" for evaluating neuro-ophthalmologic problems is cost effective. METHODS: The authors retrospectively reviewed the records of 588 patients referred for neuro-ophthalmologic evaluation between July and December 1989 to determine the frequency and cost of unnecessary diagnostic testing ordered by "gatekeeper physicians." Pre-referral diagnostic testing costs were compared with the cost of neurophthalmologic consultation for four common problems: (1) optic neuropathy; (2) diplopia; (3) ptosis; and (4) proptosis. RESULTS: Between 16% and 26% of patients in the first three diagnostic categories were subjected to overtesting, resulting in $57,900 of excessive costs, a 724% overcharge. Although the evaluation of proptosis was performed correctly, the quality of 10 of the 18 neuro-imaging procedures was substandard. CONCLUSIONS: The gatekeeper system managed by primary care physicians for these four neuro-ophthalmologic problems not only did not conserve healthcare dollars but also had a negative impact on cost control. For neuro-ophthalmologic disorders, prompt subspecialty evaluation and examination appear to be a cost-effective strategy.

Blepharoptosis↗
PubMed2006

Selective transmission of CCR5-utilizing HIV-1: the 'gatekeeper' problem resolved?

Understanding the mechanisms of HIV-1 transmission is crucial for the development of effective preventive microbicides and vaccine strategies, and remains one of the main goals of HIV research. Over the past decade, many studies have focused on trying to identify the 'gatekeeping' mechanism that restricts the transmission of CXCR4-utilizing HIV-1 more efficiently than CCR5-utilizing HIV-1. However, to date, no study has explained the almost perfect negative selection of the former in vivo. Here, we propose that there is no single gatekeeper and that, instead, the selective transmission of R5 HIV-1 depends on the superimposition of multiple imperfect gatekeepers.

HIV Infections↗
PubMed2003

UVB-induced mutations in human key gatekeeper genes governing signalling pathways and consequences for skin tumourigenesis.

The UVB component of the solar spectrum induces DNA lesions that, in the absence of error-free DNA repair, may give rise during DNA replication to mutations in caretaker and gatekeeper genes. The DNA repair genes are the best candidates for caretaker genes as exemplified by the human hereditary xeroderma pigmentosum (XP) syndrome. Cultured XP cells are hypermutable after UVB irradiation. This increased mutation frequency is also found in gatekeeper genes, which govern signalling pathways implicated in the control of cellular proliferation, differentiation and survival of human epidermal keratinocytes. We describe and discuss the role of mutated gatekeeper genes in five specific signalling pathways which have been implicated in skin carcinogenesis. The pathways we focus on in this review are: (i) P16(INK4A)-CDK4/6-RB; (ii) P14(ARF)-HDM2-P53; (iii) Sonic hedgehog (SHH)/GLI; (iv) WNT/beta-catenin; and (v) Bone Morphogenetic Protein (BMP)/SMAD. 70-80% of XP skin cancers exhibit one or several mutations in the P53, PTCH-1, SMO or CDKN2A genes, the type and frequency of mutated genes being different between squamous cell (SCCs) and basal cell carcinomas (BCCs). In XP cancers, the typically UVB-induced CC to TT tandem transitions represent approximately 60% of total mutations compared to 10-15% in skin tumours from DNA repair-proficient patients. Acquired activation of the pathways described herein can alter proliferation and differentiation of keratinocytes, allowing a damaged cell to replicate and give rise to mutated daughter cells, then eventually to the development of the carcinogenic process following clonal selection.

Cocarcinogenesis↗
PubMed2000

Gatekeeping access to services at the primary/secondary care interface.

This paper examines the role that mental health clinicians play in gatekeeping access to services at the primary/secondary care interface. Layder's research map is used to explore the factors that influence gatekeeping decisions at four interrelated levels of social organization; self, situated activity, setting and context, plus a historical dimension that permeates each level. The main theme that emerges from the analysis is that the dilemmas that arise from attempting to control the demand for care are difficult to resolve for policy makers, managers or clinicians alike. A combination of factors make it difficult to establish consistent priorities including: the uneven distribution of specialist services, the lack of a consensus definition of severe mental illness and the difficulty of weighing the potential benefits of care for the individual against the need to ensure that resources are distributed fairly. It is suggested that there are no easy answers to these dilemmas because gatekeeping is a socially contested process, in which there will be winners and losers.

Community Mental Health Services↗
PubMed1989

Importance of the characteristics of gatekeepers in the design of effective alcohol education programs.

Community "gatekeepers" (N = 53) participated in an alcohol education workshop designed to increase identification, intervention, and referral of women with alcohol problems. Participants completed questionnaires before and after the workshop and, participated in a six-month follow-up. Results suggest that the higher the educational level and more salient the topic of alcoholism in women, as suggested by greater percent of women clients, the greater the actual gain in knowledge. Gatekeepers with no prior alcoholism training perceived themselves as having less knowledge about alcoholism before the workshop and showed greater pains in perceived knowledge as a result of the workshop than gatekeepers with prior training.

Alcoholism↗
PubMed1996

The gatekeeper effect on managing acute medical conditions.

This study was designed to analyze whether the gatekeeper approach, by itself, is effective in changing physicians' practice patterns. The effect of the gatekeeper could be isolated, because a 95% overlap existed between contracted physicians in the PPO plan and the POS plan used in the study. In treating low-to-moderately resource-intensive conditions, the results of this episode-of-care study showed that the POS system of care (gate-keeper in place) was no more efficient than the PPO system of care (no gatekeeper mechanism) in terms of overall medical costs.

Acute Disease↗
PubMed1986

Gatekeeping--clinical and administrative issues.

Most gatekeeper-based models of health care delivery utilize primary care physicians for authorizing services, screening referrals, managing cases and monitoring costs. Issues in four major areas related to gatekeeping have arisen in such systems: those affecting patients primarily, those affecting physicians primarily, those related to administering the gatekeeping function and, finally, those issues related to the health care system as a whole.

Adult↗
PubMed1983

Primary care gatekeepers in HMOs.

The most pressing issue in health care delivery today is inflationary cost increases. The gatekeeping role of primary care physicians, particularly family physicians, may lower health care costs through a more judicious use of specialty referrals, expensive tests, and hospitalization. The study of such an impact is most readily carried out in the practice setting of health maintenance organizations (HMOs), where there is a defined patient population. Incomplete data and lack of sensitive indicators of the gatekeeping effect are limitations of this preliminary study. The results show, however, that the internal organization of an HMO does not influence hospital and ambulatory care utilization rates, with the exception that HMOs staffed by a group of salaried physicians (staff HMOs) reported higher ambulatory care utilization. No significant differences were demonstrated in hospital or ambulatory care utilization rates among the HMOs using more primary care physicians or family physicians than others. The results indicate that ambulatory care utilization rates are proportional to the number of physicians per 1,000 members. The results also suggest that there may be an inverse relationship between hospital utilization rates and the number of primary care physicians, especially if they are family physicians. Further studies need more specific indicators to evaluate the effect of the gatekeeping role in health care delivery.

Ambulatory Care↗
PubMedDate not supplied

Are gatekeepers necessary?

Primary care physicians, acting as gatekeepers, are being used in an attempt to better control rising healthcare costs. However, the success of gatekeepers is difficult to measure because of the lack of data. The purpose of this article is to outline the function of gatekeepers, address the complications in measuring the benefits, and propose methods for further studies. In addition, we hope to foster a sense of responsibility and emphasize the importance of sharing data among organizations involved in the delivery of healthcare.

Cost-Benefit Analysis↗
PubMed1997

[Prerequisites to successful conversion to the Swiss model managed care-gatekeeper systems in Germany].

In Switzerland different gatekeeper-systems to improve the capacity and economic efficiency were successfully tried and tested. The systems show clear advantages of the gatekeeper-system concerning the costs and quality of health care over the customary Swiss health insurances. The German as well as the Swiss health care system are facing similar problems. The introduction of the Swiss gatekeeper-system in Germany would offer a promising opportunity to achieve economic efficiency and quality in German Statutory Health Insurance. Thus, greater flexibility is imperative in the subjects of legal conditions, especially the contract, incentive and information systems.

Cost-Benefit Analysis↗
PubMed2006

Gatekeeping in health care.

We study the competitive effects of restricting direct access to secondary care by gatekeeping, focusing on the informational role of general practitioners (GPs). In the secondary care market there are two hospitals choosing quality and specialization. Patients, who are ex ante uninformed, can consult a GP to receive an (imperfect) diagnosis and obtain information about the secondary care market. We show that hospital competition is amplified by higher GP attendance but dampened by improved diagnosing accuracy. Therefore, compulsory gatekeeping may result in excessive quality competition and too much specialization, unless the mismatch costs and the diagnosing accuracy are sufficiently high. Second-best price regulation makes direct regulation of GP consultation redundant, but will generally not implement first-best.

Delivery of Health Care↗
PubMed2005

Addressing telehealth's foremost barrier: provider as initial gatekeeper.

OBJECTIVES: During the past decade, telehealth has enjoyed a plethora of public funding and publication outlets around the world. Yet, rhetoric appears to be outpacing the actual diffusion and utilization of telehealth technologies for patient care. Several barriers, such as reimbursement and legal/regulatory issues, are commonly cited as impeding the successful deployment of this innovation. However, two separate studies carried out in Michigan that controlled for these barriers point out a more significant initial gatekeeper to the deployment of telehealth, namely providers. METHODS: Multiple data collection strategies were used in both the telehospice and telepsychiatry projects, including utilization logs, surveys, telehospice nursing notes, cost frame data collection, patient interviews, caregiver interviews and focus groups, and videotaped visits. RESULTS: This study summarizes data from the two studies to support the hypothesis that the provider is the most important initial gatekeeper for telemedicine. CONCLUSIONS: The implications from this conclusion have important consequences for health system deployment strategies. Specifically, telemedicine project managers must keep providers' needs (ease of use and incentives) in mind when designing a telemedicine system.

Data Collection↗
PubMedDate not supplied

The experience of gatekeeping: a psychiatric nurse in an emergency department.

Emergency departments are increasingly identified as the entry point to mental health services. In the hope of facilitating the flow of psychiatric patients through a general hospital's emergency department, experienced psychiatric nurses were asked to participate in a pilot project in a general hospital in Canada. This paper is a reflection of one emergency psychiatric nurse's (EPN) experience of her role being transformed into that of a gatekeeper. The notion of "gatekeeper" as a metaphor highlights "keeping psychiatric patients out" of an already strained emergency system. As a means to balance fiscal demands with patient care, the EPN inadvertently served to obscure entry for patients with mental illness who were seeking emergency services.

Attitude of Health Personnel↗