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.

Figure 1.

Study selection flow diagram.

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.