The effects of gatekeeping: A systematic review of the literature

Figures & data

Figure 1. Study selection flow diagram.

Table I. Overview of included studies.

	Population				Gatekeeping^d
Study	Country^a	Age Group	Conditions^b	n^c	Enrol.	Co-pay.	Study design^e	Observation length^f	Data sources^g	Adjustment	Parameters studied^h	Assessment of study quality
Anderson 1996 [23]	USA	16–64 yrs	acute	nr	+	+	RC	18 mo	Ad	nr	U, E	III-1-poor
Escarce 2001 [24–26]	USA	working age	all	55 000*	+	+	RC	2 yrs	Ad	good	U, E	III-1-good
Etter 1997 [11]	CH	18–44 yrs	all	636	+	−	CBA	12 mo	Qu	poor	U	II-3-poor
Etter 1998 [10]	CH	adults	all	4 959	+	−	CBA	12 mo	Ad	poor	E	II-3-poor
Ferris 2001 [29]	USA	< 18 yrs	all	1 839	+	+	CBA	2 yrs	Ad	good	U, E	II-3-fair
Ferris 2001a [27]	USA	> 18 yrs	all	89 996	nr	nr	ITS	18 mo	Ad	poor	U	III-3-poor
Ferris 2002 [28]	USA	< 18 yrs	all	89 940	nr	nr	ITS	18 mo	Ad	poor	U	III-3-poor
Forrest 1999 [41]	USA	children	all	27 104	nr	nr	PC	10 d	Ad, Cl	fair	U	II-2-poor
Holdsworth 2007 [17–20]	UK	> 16 yrs	physiotherapy	2 985**	nr	nr	PC	12 mo#	Qu	nr	H, U, E	II-2-poor
Hurley 1989 [36]	USA	adults	all	800	+	nr	RC	3 mo	Su	fair	U	III-1-poor
Hurley 1991 [37,38]	USA	all ages	all	24 866	+	nr	CBA	12 mo	Ad	poor	U	II-3-poor
Laditka 2001 [39]	USA	nr	all	415 279	+	+	RC	12 mo	Ad	poor	U, E	III-1-poor
Leemrijse 2008 [21]	NL	all ages	physiotherapy	10 510	+	nr	RC	LT	Ad, Cl	fair	H	III-1-poor
Linden 2003 [22]	D, NL	adults	all	1 140	+	nr	PC	12 mo	Su	nr	U	II-2-poor
Martin 1989 [30]	USA	< 65 yrs	all	2 827	+	+	RCT	12 mo	Ad, Qu	nr	H, U	I-poor
Meyer 1996 [31]	USA	adults	all	254	+	−	CCT	12 mo	Ad, Qu	poor	H, U, E	II-1-poor
Olivarius 1994 [15]	DK	all ages	all	4 210 737	+	−	RC	12 mo	Ad	nr	U, E	III-1-poor
Ose 2008 [16]	D	adults	all	472 442	+	−	PC	24 mo	Ad	good	U	II-2-fair
Paone 1995 [32]	USA	adults	CHD–surg	794	nr	nr	RC	HS	Ad, Cl	nr	H, Q,U	III-1-poor
Perneger 1996 [12]	CH	adults	all	814	+	−	CBA	12 mo	Qu	poor	H	II-3-poor
Rask 1999 [33]	USA	> 30 yrs	chest pain	1 414	nr	nr	RC	12 mo	Ad, Cl	fair	H, Q, U, E	III 1 fair
Schillinger 2000 [34]	USA	adults	all	2 293	nr	nr	CCT	12 mo	Ad, Qu	poor	H, Q,U	II-1-poor
Schwenkglenks 2006 [13]	CH	> 18 yrs	all	710	+	nr	RC	12 mo	Ad, Cl	good	U, E	III-1-good
Shatin 1998 [40]	USA	< 18 yrs	chronic	8 510	nr	−	RC	2 yr	Ad	poor	U	III-1-poor
Swetter 2007 [35]	USA	adults	CM	234	nr	nr	RC	nr	Cl	nr	H,Q	III-1-poor
Werblow 2005 [14]	CH	all ages	all	nr	nr	nr	RC	3 yrs	Ad	poor	E	III-1-poor

Notes: ^aCH: Switzerland, D: Germany, DK: Denmark, NL:The Netherlands, UK: United Kingdom, USA: United States of America; ^bacute: acute conditions in primary care, all: any conditions presenting to primary care, CHD-Surg: Patients with coronary heart disease with surgery indication; chronic: asthma, attention deficit disorder/attention deficit hyperactivity disorder, epilepsy, diabetes, sickle-cell anaemia, CM: cutaneous melanoma, physiotherapy: conditions requiring physiotherapy treatment; ^cn: number of study participants, *inconsistency across publications: 55 954/55 011;**n = 2177 for outcome satisfaction; ^dEnrol.: Enrolment with primary care physician +: required, −: not required, nr: not reported, Co-pay.: co-payments +:yes, −: no, nr: not reported; ^eCBA: controlled before-after study; CCT: controlled clinical trial; ITS: interrupted time-series; PC: prospective cohort; RC: retrospective cohort; RCT: randomized controlled trial; ^fHS: hospital stay, LT: length of therapy, nr: not reported; ^gAd: routine administrative data, Cl: routine clinical data, Pr-Ad/Cl: primary administrative/clinical data; Qu: satisfaction questionnaire, Su: survey, #4 wks for outcome satisfaction; ^hH: health and patient-related; Q: quality of care; U: utilization, E: economic.

Figure 2. Percentage difference in gatekeeping arrangements (vs. free access) for health- and patient-related outcomes (symptoms, fatalities, quality of life, satisfaction).

Notes: Dark grey bars indicate statistically significant results, grey bars indicate results that are not statistically significant, and white bars indicate that the study did not report significance. A lack of bars indicates that there was no difference. Studies are grouped according to level of evidence (GS: greatest suitability; MS: moderate suitability), and labelled with their quality assessment. $: Study reported “no significant differences” but no data were provided to calculate percentage difference. PTCA: percutaneous transluminal coronary angiography; CABG: coronary artery bypass graft; MI: myocardial infarction.

Figure 3. Percentage difference in gatekeeping arrangements (vs. free access) for quality of care parameters.

Notes: Dark grey bars indicate statistically significant results, grey bars not statistically significant results, and white bars indicate the study did not report significance. Lack of bars indicates no difference at all. Studies are grouped according to level of evidence (GS: greatest suitability; MS: moderate suitability) and labelled with their quality assessment.

Figure 4. Percentage difference in gatekeeping arrangements (vs. free access) for length of stay and hospitalizations.

Notes: Dark grey bars indicate statistically significant results, grey bars indicate not statistically significant results, and white bars indicate the study did not report significance. Studies are grouped according to level of evidence (GS: greatest suitability; MS: moderate suitability) and labelled with their quality assessment. $: Study reported “length of stay remained stable in both cohorts” but no data were provided to calculate percentage difference. Multiple segments within a bar indicate results for subgroups, which may differ in their direction, magnitude and statistical significance.

Figure 5. Percentage difference in gatekeeping arrangements (vs. free access) for visits to primary care physicians, to specialist physicians, and to the emergency department.

Notes: Dark grey bars indicate statistically significant results, grey bars indicate not statistically significant results, and white bars indicate the study did not report significance. Lack of bars indicates no difference at all. Studies are grouped according to level of evidence (GS: greatest suitability; MS: moderate suitability) and labelled with their quality assessment. PCP: Primary care physician. Multiple segments within a bar indicate results for subgroups, which may differ in their direction, magnitude, and statistical significance.

Figure 6. Percentage difference in gatekeeping arrangements (vs. free access) for expenditures (overall expenditures, hospitalization costs, expenditures for ambulatory specialist care, and drug expenditures).

Notes: Dark grey bars indicate statistically significant results, grey bars indicate not statistically significant results, and white bars indicate the study did not report significance. Studies are grouped according to level of evidence (GS: greatest suitability; MS: moderate suitability) and labelled with their quality assessment. Multiple segments within a bar indicate results for subgroups, which may differ in their direction, magnitude, and statistical significance.

Anderson S, Cave D. The gatekeeper effect on managing acute medical conditions. Med Interface 1996;9:122–9.

 PubMedGoogle Scholar

Etter JF, Perneger TV. Introducing managed care in Switzerland: Impact on use of health services. Public Health 1997;111:417–22.

 PubMed Web of Science ®Google Scholar

Etter JF, Perneger TV. Health care expenditures after introduction of a gatekeeper and a global budget in a Swiss health insurance plan. J Epidemiol Community Health 1998;52:370–6.

 PubMed Web of Science ®Google Scholar

Ferris TG, Perrin JM, Manganello JA, . Switching to gatekeeping: Changes in expenditures and utilisation for children. Pediatrics 2001;108:283–90.

 PubMed Web of Science ®Google Scholar

Ferris TG, Chang Y, Blumenthal D, . Leaving gatekeeping behind: Effects of opening access to specialists for adults in a health maintenance organization. N Engl J Med 2001;345:1312–7.

 PubMed Web of Science ®Google Scholar

Ferris TG, Chang Y, Perrin JM, . Effects of removing gatekeeping on specialist utilisation by children in a health maintenance organization. Arch Pediatr Adolesc Med 2002;156:574–9.

 PubMedGoogle Scholar

Forrest CB, Glade GB, Starfield B, . Gatekeeping and referral of children and adolescents to specialty care. Pediatrics 1999;104:28–34.

 PubMed Web of Science ®Google Scholar

Hurley RE, Freund DA, Taylor DE. Gatekeeping the emergency department: Impact of a Medicaid primary care case management program. Health Care Manage Rev 1989;14:63–71.

 PubMedGoogle Scholar

Hurley RE, Freund DA, Taylor DE. Emergency room use and primary care case management: Evidence from four Medicaid demonstration programs. Am J Public Health 1989;79:843–6.

 PubMed Web of Science ®Google Scholar

Hurley RE, Freund DA, Gage BJ. Gatekeeper effects on patterns of physician use. J Fam Pract 1991;32:167–74.

 PubMed Web of Science ®Google Scholar

Laditka SB, Laditka JN. Utilization, costs, and access to primary care in fee-for-service and managed care plans. J Health Soc Policy 2001;13:21–39.

 PubMedGoogle Scholar

Leemrijse CJ, Swinkels ICS, Veenhof C. Direct access to physical therapy in the Netherlands: Results from the first year in community-based physical therapy. Phys Ther 2008;88:936–46.

 PubMed Web of Science ®Google Scholar

Linden M, Gothe H, Ormel J. Pathways to care and psychological problems of general practice patients in a “gate keeper” and an “open access” health care system: a comparison of Germany and the Netherlands. Soc Psychiatry Psychiatr Epidemiol 2003;38:690–7.

 PubMed Web of Science ®Google Scholar

Martin DP, Diehr P, Price KF, . Effect of a gatekeeper plan on health services use and charges: A randomized trial. Am J Public Health 1989;79:1628–32.

 PubMed Web of Science ®Google Scholar

Meyer TJ, Prochazka AV, Hannaford M, . Randomized controlled trial of residents as gatekeepers. Arch Intern Med 1996;156:2483–7.

 PubMedGoogle Scholar

Olivarius ND, Jensen FI, Gannik D; . Self-referral and self-payment in Danish primary care. Health Policy 1994;28:15–22.

 PubMed Web of Science ®Google Scholar

Ose D, Broge B, Riens B, Szecsenyi. Mit Überweisung vm Hausarzt zum Spezialisten – Haben Verträge zur Hausarztzentrierten Versorgung (HZV) einen Einfluss? [Contacts with specialists with referrals by GP – Do GP Centred Health Care (HZV) contracts have an impact?] (English summary). Z Allg Med 2008;84:321–6.

 Google Scholar

Paone GH, Higgins RS, Spencer T, . Enrollment in the health alliance plan: HMO is not an independent risk factor for coronary artery bypass graft surgery. Circulation 1995;92:II69–72.

 PubMed Web of Science ®Google Scholar

Perneger TV, Etter JF, Rougemont A. Switching Swiss enrollees from indemnity health insurance to managed care: The effect on health status and satisfaction with care. Am J Public Health 1996;86:388–93.

 PubMed Web of Science ®Google Scholar

Rask KJ, Deaton C, Culler SD, . The effect of primary care gatekeepers on the management of patients with chest pain. Am J Manag Care 1999;5:1274–82.

 PubMed Web of Science ®Google Scholar

Schillinger D, Bibbins-Domingo K, Vranizan K, . Effects of primary care coordination on public hospital patients. J Gen Intern Med 2000;15:329–36.

 PubMed Web of Science ®Google Scholar

Schwenkglenks M, Preiswerk G, Lehner R, . Economic efficiency of gate-keeping compared with fee for service plans: A Swiss example. J Epidemiol Community Health 2006;60:24–30.

 PubMed Web of Science ®Google Scholar

Shatin D, Levin R, Ireys HT, . Health care utilisation by children with chronic illnesses: A comparison of Medicaid and employer insured managed care. Pediatrics 1998;102: E44.

 PubMed Web of Science ®Google Scholar

Swetter SM, Soon S, Harrington CR, . Effect of health care delivery models on melanoma thickness and stage in a university-based referral center: An observational pilot study. Arch Dermatol 2007;143:30–6.

 PubMedGoogle Scholar

Werblow A. [Efficiency of general practice in Switzerland]. Gesundheitswesen 2005;67:107–11.

 PubMed Web of Science ®Google Scholar