The effects of gatekeeping: A systematic review of the literature

Abstract

Objective. To assess the effects of physician-centred gatekeeping on health, health care utilization, and costs by conducting a systematic review of the literature. Methods. Systematic search in PubMed (MEDLINE and Pre-MEDLINE), EMBASE, and the Cochrane Library, from the databases' respective inception dates up to January 2010, using the search words “gatekeeping”, “gatekeeper*”, “first contact”, and “self-referral”. We included RCTs, CCTs, cohort studies, CBAs, and interrupted time-series. We included only studies in which the gatekeeper function was exercised by a physician and that reported health and patient-related outcomes including quality of life and satisfaction, quality of care, health care utilization, and/or economic outcomes (e.g. expenditures or efficiency). Selection was made independently by two reviewers and discrepancies were solved by consensus after discussion. Data on target population, intervention, additional interventions, study results, and methodological quality were extracted. Methodological quality was assessed independently by two reviewers following the previously defined criteria. Discrepancies were solved by consensus after discussion. Results. This review includes 26 studies in 32 publications. The majority of studies (62%) reported data from the United States and in most gatekeeping was associated with lower utilization of health services (up to −78%) and lower expenditures (up to −80%). However, there was great variability in the magnitude and direction of the differences. Conclusion. Overall, the evidence regarding the effects of gatekeeping is of limited quality. Many studies are available regarding the effects on health care utilisation and expenditures, whereas effects on health and patient-related outcomes have been studied only exceptionally and are inconclusive.

Key Words::

• Gatekeeping
• health care costs
• health care utilization
• primary health care
• systematic review

Acknowledgements

The authors would like to thank Matthew D. Gaskins and Mary K. Renaud for copy-editing the manuscript. They would also like to thank Karen Hofmann for her support in retrieving the publications.

Conflict of interest

The authors do not have any conflicts of interest.

Sources of support

This review originated in the authors' work for the German Advisory Council on the Assessment of Developments in the Health Care System for its report “Coordination and Integration: Health Care in a Society of Longer Living”. The Council did not have any influence on the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

Prior presentation

Results of this review were presented as a poster at the 7th Annual Meeting of HTAi in June 2010. An abridged and previous German-language version of this systematic review covered publications only up to 2007 [44].