Rethinking primary care’s gatekeeper role

Greenfield, Geva; Foley, Kimberley; Majeed, Azeem

doi:10.1136/bmj.i4803

Cited by 115 publications

(113 citation statements)

References 45 publications

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“…Moreover, the results of this study may be used in other countries dealing with a high incidence of BCCs and pressure on their healthcare system. This may particularly apply to countries with a GP gatekeeper system or fee‐for‐service reimbursement systems, such as most Western countries …”

Section: Discussionmentioning

confidence: 99%

Factors influencing current low‐value follow‐up care after basal cell carcinoma and suggested strategies for de‐adoption: a qualitative study

Egmond

Wakkee

Rengen³

et al. 2019

Br J Dermatol

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SummaryBackgroundProviding follow‐up to patients with low‐risk basal cell carcinoma (BCC) can be considered as low‐value care. However, dermatologists still provide substantial follow‐up care to this patient group, for reasons not well understood.ObjectivesTo identify factors influencing current BCC follow‐up practices among dermatologists and suggested strategies to de‐adopt this low‐value care. In addition, views of patients regarding follow‐up care were explored.MethodsA qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low‐risk BCC who had received dermatological care. The interviews focused on current follow‐up practices, influencing factors and suggested strategies to de‐adopt the follow‐up care. The focus groups discussed preferred follow‐up schedules and providers, as well as the content of follow‐up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software.ResultsFactors influencing current follow‐up care practices among dermatologists included complying with patients’ preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow‐up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de‐adopt the low‐value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care.ConclusionsA mixture of factors appear to contribute to current follow‐up practices after low‐risk BCC. In order to de‐adopt this low‐value care, strategies should be aimed at dermatologists and GPs, and also patients.

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Section: Discussionmentioning

confidence: 99%

Factors influencing current low‐value follow‐up care after basal cell carcinoma and suggested strategies for de‐adoption: a qualitative study

Egmond

Wakkee

Rengen³

et al. 2019

Br J Dermatol

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“…When asked to deliberate on the skill‐mix for a “core” IHC team (of which 8‐9 providers were selected on average), almost all participants agreed that a general practitioner (GP) should be an integral member. This is not surprising given that the question was set within the context of Australian primary care, of which GPs are claimed to be the cornerstone of primary care, as well as the gatekeepers of secondary and tertiary healthcare . For other “core” disciplinary groups, there was variable agreement among consumers and providers, although most supported the inclusion of a practice nurse, pharmacist, psychologist and dietician, and to a lesser extent, a naturopath, physiotherapist and dentist.…”

Section: Discussionmentioning

confidence: 99%

Health consumer and health provider preferences for an integrative healthcare service delivery model: A national cross-sectional study

et al. 2018

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“…Direct access to specialists and allied health care may increase health care costs, and potentially undermine the important coordination role we have highlighted. Recent studies in the United Kingdom and the Netherlands have underlined the importance of strengthening the stewardship by GPs of patients' access to medical specialists, and their authors have called for caution in reducing their gatekeeper role 13 , 14 …”

Section: Discussionmentioning

confidence: 99%

Administrative encounters in general practice: low value or hidden value care?

Trevena

Harrison

Britt

2018

Medical Journal of Australia

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Objective: To determine the frequency of general practice administrative encounters, and to determine whether they represent low value care. Design: Secondary analysis of data from the Bettering Evaluation and Care of Health (BEACH) dataset. Setting: 1 568 100 GP–patient encounters in Australia, 2000–01 to 2015–16. Participants: An annual nationally representative random sample of about 1000 GPs, who each recorded the details of 100 consecutive encounters with patients. Main outcome measures: Proportions of general practice encounters that were potentially low value care encounters (among the patient's reasons for the encounter was at least one administrative, medication, or referral request) and potentially low value care only encounters (such reasons were the sole reason for the encounter). For 2015–16, we also examined other health care provided by GPs at these encounters. Results: During 2015–16, 18.5% (95% CI, 17.7–19.3%) of 97 398 GP–patient encounters were potentially low value care request encounters; 7.4% (95% CI, 7.0–7.9%) were potentially low value care only encounters. Administrative work was requested at 3.8% (95% CI, 3.5–4.0%) of GP visits, 35.4% of which were for care planning and coordination, 33.5% for certification, and 31.2% for other reasons. Medication requests were made at 13.1% (95% CI, 12.4–13.7%) of encounters; other health care was provided at 57.9% of medication request encounters, counselling, advice or education at 23.4%, and pathology testing was ordered at 16.7%. Referrals were requested at 2.8% (95% CI, 1.7–3.0%) of visits, at 69.4% of which additional health care was provided. The problems managed most frequently at potentially low value care only encounters were chronic diseases. Conclusion: Most patients requested certificates, medications and referrals in the context of seeking help for other health needs. Additional health care, particularly for chronic diseases, was provided at most GP administrative encounters. The MBS Review should consider the hidden value of these encounters.

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Rethinking primary care’s gatekeeper role

Cited by 115 publications

References 45 publications

Factors influencing current low‐value follow‐up care after basal cell carcinoma and suggested strategies for de‐adoption: a qualitative study

Factors influencing current low‐value follow‐up care after basal cell carcinoma and suggested strategies for de‐adoption: a qualitative study

Health consumer and health provider preferences for an integrative healthcare service delivery model: A national cross-sectional study

Administrative encounters in general practice: low value or hidden value care?

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