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PubMed2003

Many helping hearts: an evaluation of peer gatekeeper training in suicide risk assessment.

Literature reviews on suicide prevention programs have presented conflicting results on the efficacy of school-based prevention programs. Gatekeeper training and peer helping are both recommended as part of a comprehensive school-based prevention program, yet there is no literary evidence of the systematic evaluation of gatekeeper training for peer helpers. This study evaluated the efficacy of such training with high school peer helpers using a repeated measures design. Significant gains in knowledge about suicide and skills for responding to suicidal peers were evident immediately after training and 3 months later. There was also a significant improvement in positive attitudes toward suicide intervention following training. Although there was no control group, the research offers tentative support for the efficacy of training peer helpers in suicide risk assessment and indicates the importance of additional training for peer helpers.

Adolescent↗
PubMed2005

Potential impact of myocardial perfusion scintigraphy as gatekeeper for invasive examination and treatment in patients with stable angina pectoris: observational study without post-test referral bias.

AIMS: To evaluate the impact of using myocardial perfusion scintigraphy (MPS) as gatekeeper for coronary angiography and revascularization in stable angina pectoris. METHODS AND RESULTS: A prospective series of 507 out of 972 adult patients referred to coronary angiography for known or suspected stable angina pectoris underwent clinical examination followed immediately by MPS, the result of which was not communicated. MPS showed normal perfusion in 258/507 (51%) patients, reversible defects in 201/507 (40%), and fixed defects in 48/507 (9%). Of 168 revascularized patients, 27 (16%) had normal perfusion and 13 (8%) had fixed defects. Coronary angiography was undertaken in 476 patients of whom 252 (53%) had normal findings or insignificant stenoses. The same was the case in 361 (41%) out of the 883 of the 972 consecutive patients, who had this examination. Assuming that the true rate of normal perfusion in the entire series was correspondingly lower, 48% of catheterizations and 19% of revascularizations were superfluous. CONCLUSION: The use of MPS as gatekeeper appears to make about half of catheterizations and almost one-fifth of revascularizations redundant. Even in high-risk groups, substantial savings are possible, and the risk of overlooking patients with severe disease seems negligible.

Angina Pectoris↗
PubMed2001

Balancing rationalities: gatekeeping in health care.

Physicians are increasingly confronted with the consequences of allocation policies. In several countries, physicians have been assigned a gatekeeper role for secondary health care. Many ethicists oppose this assignment for several reasons, concentrating on the harm the intrusion of societal arguments would inflict on doctor-patient relations. It is argued that these arguments rest on a distinction of spheres of values and of rationality, without taking into account the mixing of values and rationalities that takes place in everyday medical practice. If medical practice, then, does not follow a single, pure rationality, can it also incorporate the societal rationality of the gatekeeper role? Using a case from general practice, I try to show how physicians may integrate societal arguments into their practice in a morally acceptable way. A version of the model of reflective equilibrium and especially Beauchamp and Childress's safeguards, may be helpful both to analyse and teach such balancing of values and rationalities.

Anecdotes as Topic↗
PubMed2001

Gatekeepers and sentinels. Their consolidated effects on inpatient medical care.

Evaluations assessing precertification by nurse gatekeepers and onsite monitoring by nurse sentinels report inconclusive unique effects of these programs on the utilization, expense, and appropriateness of inpatient medical care. By applying the fixed- and random-effects paradigm of meta-analysis, this article consolidates the results of all relevant quasi-experiments conducted by an evaluation group of a large private insurer from 1986 to 1990. It determines the difference in effect between the target and comparison groups, reports this effect and its statistical range, and determines the pooled effect and its range. The random effects indicate that precertification will reduce admissions, and onsite, concurrent review will reduce length of stay, bed days, and inpatient ancillary expense. The precertification and onsite programs may reduce negative iatrogenic effects, thereby enhancing the patients' well-being. If applied to privately insured populations who are still served on a fee-for-service basis, the gatekeeper and sentinel effects of these programs may reduce utilization and expense; however, inference of these results to Medicare fee-for-service care remains problematical.

Concurrent Review↗
PubMed2000

Patient desire and reasons for specialist referral in a gatekeeper-model managed care plan.

OBJECTIVE: To describe patient desire and reasons for specialist referrals in a gatekeeper-model managed care plan. STUDY DESIGN: Cross-sectional prospective study. PATIENTS AND METHODS: We developed a patient questionnaire to gather demographic data and to gauge patients' desire for specialist referral and their reasons for seeking such referral. The survey was administered at 2 sites--an ambulatory care facility of a university hospital and an internal medicine clinic in a suburban ambulatory care site. Patients asked to complete the questionnaire at the university hospital site were enrolled in a gatekeeper-model managed care plan (called CU Gold); those seen at the internal medicine clinic were enrolled in a group-model health maintenance organization. Patients were asked to complete the 1-page questionnaire in the waiting room before being seen by their primary care physician. RESULTS: Among the 860 CU Gold patients who met the inclusion criteria during the 3-month study period (September to December 1997), 112 (13%) reported a definite desire to see a specialist and 274 (32%) indicated a possible desire to see a specialist at the time of their primary care visit. Compared with the CU Gold patients, significantly fewer patients in the health maintenance organization indicated a definite desire to see a specialist (3% versus 13%), but a similar percentage expressed a possible desire to see a specialist (30% versus 32%). The difference in definite desire for referral between the 2 groups could not be explained by patient or primary care physician characteristics. The principal health concerns for which patients sought referral were musculoskeletal, genitourinary or gynecologic, or dermatologic problems. Need for reassurance (cited by 67% of patients), seeing a specialist before (56%), and believing the primary care physician lacked expertise (49%) were the primary reasons patients sought referral. Seventy-four percent of patients referred by their primary care provider and 54% of those not referred agreed it was a good idea to see their primary care physician first before seeing a specialist. CONCLUSIONS: Patients have a significant desire for specialist referral, driven by their need for reassurance, previous specialist referral, and belief that their primary care physician does not have the requisite expertise. Patients' expectations for referral varied significantly, depending on the healthcare system (academic primary care clinic or health maintenance organization) in which they were enrolled.

Adult↗
PubMed1992

The "gag rule" revisited: physicians as abortion gatekeepers.

In this article, I explore this failure [of the therapeutic exception as a compromise device in federal abortion counseling regulations] with an eye toward its broader lessons about the social uses of medical discretion and the difficulty of achieving an abortion compromise in America. I begin by examining the legal underpinning beneath the widespread belief that the "gag rule" imposed a near-absolute ban on discussion of the abortion option. This conventional wisdom, I conclude, collapses on careful inspection. It fails utterly to account for the strong support to be found in the Title X regulations and their larger legal context for a therapeutic exception unconstrained by administrative or judicial definition. Next, I observe that this legal unboundedness would have empowered Title X clinic physicians (and perhaps others who do counseling) to exercise broad discretion over abortion access, under the rubric of medical indication.... By so doing, however, physicians would have become abortion gatekeepers. This would have raised difficult ethical and clinical questions about the extent to which medical judgment should be allowed to incorporate (and shield) socially-disputed moral choices. I briefly consider some of these questions, along with the countervailing appeal of preserving a measure of intimate freedom under medical cover. I then conclude by positing some connections between the moral infirmities of medical gatekeeping and the political failure of the therapeutic exception. I suggest, in essence, that this failure was ensured by a strong resonance between the exception's moral infirmities and the fears of the medical leaders, pro-choice activists, and abortion opponents who framed the public debate over the "gag rule." The potential breadth of the therapeutic exception went unrecognized and unexplored because professional and popular understanding of the abortion counseling regulations was molded by the activists who framed the debate...

Abortion, Induced↗
PubMed2001

Medical care expenditures under gatekeeper and point-of-service arrangements.

OBJECTIVE: To compare expenditures for medical care in a closed-panel gatekeeper HMO and an open-panel point-of-service (POS) plan that share the same provider network. DATA SOURCE/STUDY SETTING: The two study HMOs are distinct product lines of a single managed care organization; both plans are commercial products. We used administrative data files from the study plans for 1994-95 to assess differences in total medical care expenditures and spending for five categories of services: physician services, inpatient hospital services, outpatient hospital services, prescription drugs, and other services. STUDY DESIGN: Multivariate analyses were based on the two-part model of the demand for medical care. The dependent variables in these models were expenditures in each of the five categories of services, and the independent variables were indicator variables for plan type and visit copayments, prescription drug copayment, distance to the nearest primary care physician (PCP), demographic characteristics, chronic conditions, area characteristics, and entry/exit indicator variables. PRINCIPAL FINDINGS: Total expenditures for medical care ranged from equal in both plans to 7 percent higher in the gatekeeper HMO (p < .10), depending on the copayments for physician visits. Expenditures were not higher in the POS plan for any of the five categories of services. These findings were robust to a wide range of sensitivity analyses. CONCLUSIONS: Direct patient access to specialists in POS plans does not necessarily result in higher medical care expenditures. When POS enrollees are required to choose PCPs, patient cost sharing, physician financial incentives, and utilization review may control expenditures without constraining direct patient access to providers.

Adolescent↗
PubMed1999

Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists.

CONTEXT: Few data are available regarding how patients view the role of primary care physicians as "gatekeepers" in managed care systems. OBJECTIVE: To determine the extent to which patients value the role of their primary care physicians as first-contact care providers and coordinators of referrals, whether patients perceive that their primary care physicians impede access to specialists, and whether problems in gaining access to specialists are associated with a reduction in patients' trust and confidence in their primary care physicians. DESIGN, SETTING, AND PATIENTS: Cross-sectional survey mailed in the fall of 1997 to 12707 adult patients who were members of managed care plans and received care from 10 large physician groups in California. The response rate among eligible patients was 71%. A total of 7718 patients (mean age, 66.7 years; 32 % female) were eligible for analysis. MAIN OUTCOME MEASURES: Questionnaire items addressed 3 main topics: (1) patient attitudes toward the first-contact and coordinating role of their primary care physicians, (2) patients' ratings of their primary care physicians (trust and confidence in and satisfaction with), and (3) patient perceptions of barriers to specialty referrals. Referral barriers were analyzed as predictors of patients' ratings of their physicians. RESULTS: Almost all patients valued the role of a primary care physician as a source of first-contact care (94%) and coordinator of referrals (89%). Depending on the specific medical problem, 75% to 91% of patients preferred to seek care initially from their primary care physicians rather than specialists. Twenty-three percent reported that their primary care physicians or medical groups interfered with their ability to see specialists. Patients who had difficulty obtaining referrals were more likely to report low trust (adjusted odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2) with their primary care physicians. CONCLUSIONS: Patients value the first-contact and coordinating role of primary care physicians. However, managed care policies that emphasize primary care physicians as gatekeepers impeding access to specialists undermine patients' trust and confidence in their primary care physicians.

Aged↗
PubMed2007

Tree-structured gatekeeping tests in clinical trials with hierarchically ordered multiple objectives.

This paper discusses a new class of multiple testing procedures, tree-structured gatekeeping procedures, with clinical trial applications. These procedures arise in clinical trials with hierarchically ordered multiple objectives, for example, in the context of multiple dose-control tests with logical restrictions or analysis of multiple endpoints. The proposed approach is based on the principle of closed testing and generalizes the serial and parallel gatekeeping approaches developed by Westfall and Krishen (J. Statist. Planning Infer. 2001; 99:25-41) and Dmitrienko et al. (Statist. Med. 2003; 22:2387-2400). The proposed testing methodology is illustrated using a clinical trial with multiple endpoints (primary, secondary and tertiary) and multiple objectives (superiority and non-inferiority testing) as well as a dose-finding trial with multiple endpoints.

Antihypertensive Agents↗
PubMed2005

An educational framework for triage nursing based on gatekeeping, timekeeping and decision-making processes.

INTRODUCTION: The role of the triage nurse has emerged in response to growing community demand for a more accessible and efficient emergency department (ED) service. The focus of triage research has been on measuring outcomes and improving the delivery of emergency care. This has meant that the context of care, and triage processes and practices have remained concealed. Thus, little evidence about the role and ways to prepare nurses for this role is available. The aim of this study was to provide insight and understanding needed to educate and support the triage nursing role in Australian EDs. METHODS: A 12-month ethnographic study of triage nursing practice was conducted in Sydney metropolitan EDs. Data were then collected from participant observation in four EDs and interviews with 10 triage nurses. Analysis used standard content and thematic analysis techniques. FINDINGS: Findings reveal that notions of timeliness, efficiency and equity are embedded in a culture of ED care. This sustains a particular cadence of care to which triage nurses are culturally oriented. Triage nurses maintain, negotiate and restore this cadence of emergency care by using gatekeeping, timekeeping and decision-making processes. CONCLUSION: The comprehensive study of triage nursing has led to the development of an educational framework based on the processes of gatekeeping, timekeeping and decision-making.

Anthropology, Cultural↗
PubMed1989

Going into gatekeeping: an empirical assessment.

Purchasers of medical care in the United States have focused attention on the gatekeeping role performed by primary care physicians as a means to control expenditures while assuring access to care. This research reports on the experience of a group of Medicaid beneficiaries in Missouri whose primary care providers agreed to become formal gatekeepers to virtually all medical services for their patients enrolled in the program. The results suggest that this relationship contributed to changes in health care utilization, including reductions in use of emergency rooms, specialists, and nonphysician providers and some increase in the likelihood of obtaining care from a primary care physician. There was, however, no evidence of significant cost reductions.

Cost Control↗
PubMed1990

A survey of the attitudes of physician specialists toward capitation-based health plans with primary care gatekeepers.

A survey of 414 Washington state physicians board certified in one of seven non-primary care specialties (gastroenterology, cardiology, dermatology, otolaryngology, orthopedics, psychiatry, and general surgery) assessed physician attitudes towards capitation-based health plans with primary care gatekeepers. Responses indicated significant differences in attitude according to specialty. Negative attitudes were more prevalent among physicians in solo practices and those practicing in smaller communities and were related to quality of care provided, lack of information regarding benefits, loss of physician autonomy, and heavy administrative demands in these plans. Although most respondents disapproved of capitation-based health plans, a significant number agreed that gatekeeper-based plans serve to increase public awareness about health care costs as well as to control health care costs.

Attitude of Health Personnel↗
PubMed2003

Gatekeeper Reflux Repair System: technique, pre-clinical, and clinical experience.

The Gatekeeper Reflux Repair System is a new, promising endoscopic anti-reflux therapy. It has now been shown that it is possible to implant hydrogel prosthesis in the submucosa of the esophagus of humans. The pilot study in humans showed that it is a safe technique and no prostheses migrated into the mediastinum. With the help of endoscopic ultrasonography, each prosthesis was followed during the 6-month pilot study. After finishing this pilot study, new multi-center studies have been initiated with implantation of more prostheses to increase efficacy. One of the definite advantages over the other endoscopic treatments currently being developed is its reversibility. Regarding endoscopic anti-reflux therapy in general, it is important to stress that at this time no data are available in the literature about the comparison to medical therapy. At the same time long-term results are also unknown. For these reasons these endoscopic procedures must be considered experimental and they should be performed in a clinical research setting. Within a few years the role of the Gatekeeper Reflux Repair System will be better understood for those PPI-dependent GERD-patients who wish to stop their medication.

Acrylic Resins↗
PubMed2004

Endoscopic augmentation of the lower esophageal sphincter for the treatment of gastroesophageal reflux disease: multicenter study of the Gatekeeper Reflux Repair System.

BACKGROUND AND STUDY AIMS: The safety and effectiveness of the Gatekeeper Reflux Repair System (Medtronic Europe, Tolochenaz, Switzerland) in the treatment of gastroesophageal reflux disease (GERD) was evaluated. This new, reversible treatment modality involves the endoscopic introduction of expandable polyacrylonitrile-based hydrogel prostheses into the esophageal submucosa to augment the lower esophageal sphincter (LES). PATIENTS AND METHODS: For this study, data from two prospective, nonrandomized European multicenter trials were pooled. Sixty-nine GERD patients with heartburn and regurgitation and abnormal esophageal acid exposure (24-h pH < 4.0 for > 4 % of the total time) who had responded to proton-pump inhibitor (PPI) therapy were recruited, and 68 were treated with up to six prostheses placed at the gastroesophageal junction. Patients underwent esophageal manometry, endoscopy, 24-h pH-metry, and symptom scoring at intake and 1, 3, and 6 months after the procedure. RESULTS: A total of 77 procedures were performed in 67 patients, and a total of 270 prostheses were placed (mean 4.3 per procedure). At 1 and 6 months, 80.4 % and 70.4 % of the prostheses were retained, respectively. At 6 months, 24-h pH-metry outcomes with pH < 4.0 for > 4.0 % of the time decreased from 9.1 % to 6.1 % (n = 45; P < 0.05). Median LES pressure increased significantly from 8.8 mmHg at baseline to 13.8 mmHg at 6 months (n = 42, P < 0.01). Median GERD heartburn-related quality-of-life scores improved significantly from 24.0 to 5.0 (n = 53, P < 0.01) in patients no longer receiving PPI therapy. Two serious adverse events (3.0 %) occurred. Both patients recovered uneventfully. Prostheses were endoscopically removed from one patient without any adverse events. CONCLUSIONS: The Gatekeeper Reflux Repair System is a safe endoscopic treatment modality that significantly improves GERD symptoms and has objective effects on acid reflux.

Adult↗
PubMed1994

Influence of ambulatory care rotations on gatekeeping referral patterns of categorical medical residents.

PURPOSE: To determine whether a required ambulatory care block rotation for categorical medicine residents improved their ambulatory care skills and altered their outpatient gatekeeping referral patterns. METHOD: In 1991-92 a prospective cohort study was conducted of 39 categorical medicine residents at the University of California, San Francisco, and their continuity clinic patients. Before and after the residents participated in an ambulatory care block rotation, the residents were surveyed about their ambulatory care skills, and the frequencies and indications for referral of their continuity clinic patients were obtained. Statistical methods consisted of Student's t-test, the Wilcoxon rank-sum test, and Mantel-Haenszel analysis. RESULTS: The 39 residents reported significant improvement in ambulatory care skills. Yet the proportions of the residents' 4,276 patients referred before and after the intervention were 14.2% and 12.4%, respectively (adjusted odds ratio 1.02, p > .9). One-fourth of the referrals were for procedures both before and after the intervention (adjusted odds ratio 1.06, p > .5). CONCLUSION: Despite improvements in the ambulatory care skills of the categorical medicine residents, the residents' gatekeeping referral patterns remained unchanged. Ambulatory care curriculum changes need to be evaluated from the perspective of the trainee and from the perspective of whether these changes influence patient care.

Ambulatory Care↗
PubMed1990

The hospital ward sister: professional gatekeeper.

This study is a shortened report of research exploring ward sisters/charge nurses' perceptions of their responsibilities. (Throughout the study, the title 'ward sister' is used to refer to ward sister/charge nurse.) Using semi-structured interview technique, 10 hospital sisters from two large hospitals in the south of England were interviewed. The emergent data were analysed using grounded theory method. From the analysis, the substantive theory was developed that ward sisters act to gatekeep the professional function of the nurse. Many previous British studies have explored the role of the ward sister, reporting the powerful influence that the ward sister exerts over her environment. This study suggests that one of the reasons the ward sister is able to exert such power is because of her professional gatekeeper role. The shift in emphasis from the clinical to the managerial function of ward sister could therefore have important implications for the professional nursing function. Some possible implications are discussed and recommendations are made.

Employee Performance Appraisal↗
PubMed1997

Primary care physician access and gatekeeping: a key to reducing emergency department use.

Use of the Emergency Department (ED) for nonurgent conditions results in increased cost and discontinuous health care. This prospective study evaluated a program (KenPAC) that required 24-hour access to a primary care physician (PCP) with ED gatekeeping responsibility. Following established criteria, medical records were reviewed for appropriateness of ED use by an urban indigent pediatric population. Emergency Department visits declined (10% to 7.6% (P = 0.00005) and inappropriate visits dropped (41% to 8%) (P < 0.00001) before KenPAC and after KenPAC, respectively. Parental experience, as judged by age and number of children, played a significant role in ED use. The institution of gatekeeping activity contributed to the reduced overall and inappropriate use of the ED.

Child↗
PubMed2005

Tumor suppressor genes in breast cancer: the gatekeepers and the caretakers.

Tumor suppressor genes encode for proteins whose normal function is to inhibit cell transformation and whose inactivation is advantageous for tumor cell growth and survival. A variety of mechanisms result in the inactivation of tumor suppressor genes, including intragenic mutations, chromosomal deletions, and loss of expression by methylation-mediated transcriptional silencing or increased proteolysis. Tumor suppressor genes participate in a variety of critical and highly conserved cell functions, including regulation of the cell cycle and apoptosis, differentiation, surveillance of genomic integrity and repair of DNA errors, signal transduction, and cell adhesion. Tumor suppressor functions can be separated into 2 major categories: gatekeepers and caretakers. Gatekeepers directly inhibit tumor growth or promote tumor death. Inactivation of these genes contributes directly to cancer formation and progression. Among them, the p53 gene is the most well known. Located on chromosome band 17p13, p53 encodes a 53-kd multifunctional transcription factor that regulates the expression of genes involved in cell cycle control, apoptosis, DNA repair, and angiogenesis. In breast cancer, most studies have shown that p53 mutation or down-regulation is associated with adverse prognosis. Other tumor suppressor genes of interest in breast cancer include the retinoblastoma gene (pRb), PTEN, p16, nm23, and maspin.

AMP-Activated Protein Kinase Kinases↗