Table 2.

Extracted outcomes from included studies

StudyFavouring gatekeepingFavouring direct access
Phillips et al (2004)13Female patients in gatekeeper plans were more likely to receive mammography screening (77% versus 71%), clinical breast examination (87% versus 80%), and cervical screening (84% versus 74%). All comparisons, P<0.001
Mitchell and Keenan (2008)14A correct provisional diagnosis was stated in 43.6% of primary care diagnoses
Vedsted and Olesen (2011)15Relative 1-year survival was higher compared with gatekeeper system (gatekeeper = 67.8, without gatekeeper = 73.4; P = 0.004)
Hartzell et al (2013)16The correct diagnosis was made 31% of the time when the patient had been seen by only a primary care provider (P= 0.4)
Ferris et al (2002)17Children visited a primary care physician an average of 2.16 times (95% CI = 2.12 to 2.19) per 6-month period before the removal of gatekeeping and 2.05 times (95% CI = 2.01 to 2.08) per 6-month period after the removal of gatekeeping.
After a stable baseline period, the percentages of all visits to eligible specialists averaged 10.8% during the year before removal of gatekeeping and 11.0% during the year after removal of gatekeeping (P = 0.29)
Pati et al (2005)2For gatekeeping enrolees, mean annual total expenditures were US$1791 (SE = 140) compared with US$1834 (SE = 90) for those non-gatekeeping plans (P = 0.81)
If both groups had similar characteristics, total mean per capita expenditures would have been US$1835 (SE = 18) for gatekeeping enrolees versus US$1959 (SE = 19) for indemnity enrolees
Adults enrolled in managed care gatekeeping plans on average paid about US$110 less out of pocket than indemnity enrolees (P<0.05)
Median per capita expenditures were higher for managed-care gatekeeping enrolees at US$561 (SE = 21) versus US$492 (SE = 22) for indemnity enrolees (not statistically significant)
For outpatient expenditures, the proportion of adults with any ambulatory care expenditure was higher among care gatekeeping enrolees than among indemnity enrolees (76% versus 70%; P<0.05)
Third-party payments for ambulatory services were about US$65 greater for gatekeeping enrolees than for indemnity enrolees (P<0.05)
Ferris et al (2001)18Adults visited a PCP an average of 1.21 times per 6-month period before the removal of gatekeeping and 1.19 times per 6-month period after the removal of gatekeeping (P = 0.05)
After a stable baseline period, the average proportion of visits to eligible specialists as a percentage of all visits was 29.0% before the removal of gatekeeping and 29.6% during the year afterward (P = 0.39)
Rates of visits to specialists were stable over the baseline period and did not change with the removal of gatekeeping
Escarce et al (2001)19About 83% of enrolees in the gatekeeper plan used physician services annually, compared with 74% of enrolees in the POS plan (P<0.001)
About 5.7% of gatekeeper HMO members and 4.5% of POS plan members had inpatient hospital stays each year (P<0.001)
87% of enrolees in the gatekeeper HMO used some type of medical care annually, compared with 78% of enrolees in the POS plan (P<0.001)
Gatekeeper enrolees had 25% higher expenditures for physician services (P<0.001), 23% higher inpatient hospital expenditures (P<0.01), 30% higher outpatient hospital expenditures (P<0.001), 43% prescription drug expenditures (P<0.001), and 41% higher expenditures for other services (P<0.001) than people in the POS plan
Total medical care expenditures were 29% higher in the gatekeeper HMO (P<0.001)
Tye et al (2004)20Female patients in gatekeeper plans were more likely to report receiving mammography (77% versus 72%; P<0.001). The adjusted OR = 1.18 (95% CI = 1.03 to 1.36)
Linden et al (2003)21At 3 months’ follow-up, the average total number of contacts between the enrolled patients and any other physicians in Germany was 4.56 per patient compared with 3.49 in the NetherlandsAt the 12-month follow-up, hospital admissions were reported less often in Germany (15.7%) than in the Netherlands (25.4%; P<0.005)
Psychiatric medication is given twice as often in Germany as in the Netherlands (16% versus 7%)
Ferris et al (2001)22Mean total expenditures for children in the gatekeeping group decreased 53% from US$486 before switching to gatekeeping to US$180 in 1994
Visits to subspecialists also declined dramatically in the gatekeeping group after the switch to gatekeeping (1.6/year in 1991 and 1992 to 0.5/year in 1994) (P<0.001 for difference)
Mean annual subspecialty expenditures decreased 6% in the indemnity group and 59% in the gatekeeping group (P<0.001 for difference)
Mean visits to subspecialists for children with chronic conditions decreased 57% in the gatekeeping group while increasing 31% in the indemnity group (P<0.005 for difference)
Outpatient expenditures for primary care physician services declined for both the indemnity (5%) and gatekeeping (53%) groups over the period of the study (P<0.004 for difference)
Velasco Garrido et al (2011)4For quality of life, the study showed results favouring gatekeeping in single items (pain and role limitations), but no statistically significant differences in overall quality of life
The studies with greater suitability suggest fewer hospitalisations under gatekeeping
Overall, the results suggest lower use of specialist care under gatekeeping
Most observations suggest 6–80% lower expenditures under gatekeeping
The studies showed decreased satisfaction under the gatekeeping plan
The diagnosis of melanoma was made without delay significantly more frequently in patients with free access, which, however, did not lead to any differences in the tumour stage at diagnosis
Haggstrom et al (2004)23Female patients in gatekeeper plans were more likely to receive screening mammography (77% versus 71%; P<0.001) and cervical screening (84% versus 74%; P<0.001)
Joyce et al (2000)24Gatekeeper HMO members had 35% more PCP visits, 28% more specialist visits, and 33% more total visits than people in the POS plan
Schneider et al (2016)25Averaging over age, the total difference per patient was −€ 9.65 (95% CI = −11.64 to −7.67), indicating lower costs for the gatekeeping model
The prescription of psychotropic medication, measured in terms of cost, was lower in the coordinated group with total difference per patient = −€20.31 (95% CI = −26.43 to −14.46) in favour of coordinated care for these patients
Kroneman et al (2006)26Countries with more providers directly accessible for patients showed a higher patient satisfaction with GP services (Pearson’s r= 0.54; P = 0.05)
Pati et al (2003)27If gatekeeping and indemnity plan enrolees had similar characteristics, total mean per capita expenditures would have been approximately 4% lower for children in gatekeeping plans at US$646 (SE 11) versus US$673 (SE 10) for indemnity plan enrolees
Families of children enrolled in gatekeeping plans on average paid US$62 less out-of-pocket than indemnity plan enrolees (P<0.05)
The proportion of children with any ambulatory care expenditures was higher among gatekeeping plan enrolees compared with indemnity plan enrolees (78% versus 74%; P<0.05)
Mean total per capita annual expenditures for children in gatekeeping versus indemnity plans differed by <1% (US$887 versus US$881, respectively)
Third-party expenditures for ambulatory services were on average US$45 greater for children enrolled in gatekeeping plans than for those in indemnity plans (P<0.05)
Delnoij et al (2000)28On average, per capita health spending is lower in gatekeeping systems than in non-gatekeeping systems
In countries with gatekeeping GPs, ambulatory care expenditure has increased less than in non-gatekeeping systems
Schwenkglenks et al (2006)29Generally, health expenditure in gatekeeping group was lower than fee-for-service plans (but not statistically significant)
Kapur et al (2000)30Expenditures tended to be higher in the gatekeeper HMO than in the POS plan, although covariate adjustment considerably narrowed the gaps observed in the unadjusted data (711 versus 564)
Expenditures for PCPs’ services were significantly higher in the gatekeeper HMO (P<0.001)
Total physician expenditures were 4% higher in the gatekeeper HMO (P<0.05)
Total physician expenditures were 9% higher in the gatekeeper plan with US$10 co-payments for PCP and PCP-referred specialist visits than in the POS plan with US$10 and US$15 co-payments (P<0.01)
Rask et al (1999)31The cardiology visit rate was significantly higher in the open-access group (5.8 per 1000 open-access members versus 3.3 per 1000 gatekeeper members; P<0.01) and lower rate of echocardiograms among the gatekeeper patients (21% versus 29%; P<0.01)
Gatekeeper patients with known coronary atherosclerotic heart disease were more likely to receive cardiac catheterisations (33% versus 19%; P<0.01)
Gatekeeper patients as a group received cardiac catheterisation significantly sooner than did open-access patients (P = 0.05)
Schillinger et al (2000)32Patients in an intervention group had 0.14 fewer hospitalisations per year than a control group (P = 0.02, 95% CI = −0.26 to −0.03), representing approximately 29% fewer hospitalisations
Patients in an intervention group decreased their specialty use by 0.57 visits per year more than a control group (P = 0.04, 95% CI = −1.05 to −0.01)
Regarding coordination of care among ED patients (n= 734), a greater percentage of patients in an experimental group returned to general medicine clinic within a month of an ED visit, when compared with control patients (61% versus 52%; P<0.01)
Halm et al (1997)33Gatekeeping had a positive impact on preventive care (26% positive versus 10% negative), and knowledge over patients’ overall care (33% positive versus 8% negative) (P≤0.01). The overall cost of care was favourably affected by gatekeeping (P<0.001)Quality of care judged to be impacted negatively (20% negative versus 6% positive; P<0.001)
Gatekeeping was judged to have a negative effect on the appropriate use of hospitalisation (−0.33), laboratory tests (−0.22), specialists (−0.45), and medication choice (−0.45) (P<0.001)
Forrest et al (2002)34There is a significant difference in choice of PCP satisfaction between with and without authorisation requirement (67.1% versus 70.8%, difference = −3.7; P>0.001)
Franco et al (1997)35There was a significant reduction of ED visits compared with 10.1% (283/2798) of clinic registrants who visited the ED during an analogous period before the intervention (P <0.001)
92% of ED visits were appropriate compared with 59% before the intervention (P<0.001)
  • ED = emergency department. HMO = health maintenance organisation. OR = odds ratio. CI = confidence interval. PCP = primary care physician. POS = point of service. SE = standard error.