Shared decision making between patient and GP about referrals from primary care: Does gatekeeping make a difference?

Abstract

Primary care faces challenging times in many countries, mainly caused by an ageing population. The GPs’ role to match patients’ demand with medical need becomes increasingly complex with the growing multiple conditions population. Shared decision-making (SDM) is recognized as ideal to the treatment decision making process. Understanding GPs’ perception on SDM about patient referrals and whether patients’ preferences are considered, becomes increasingly important for improving health outcomes and patient satisfaction. This study aims to 1) understand whether countries vary in how GPs perceive SDM, in patients’ referral, 2) describe to what extent SDM in GPs’ referrals differ between gatekeeping and non-gatekeeping systems, and 3) identify what factors GPs consider when referring to specialists and describing how this differs between gatekeeping and non-gatekeeping systems. Data were collected between October 2011 and December 2013 in 32 countries through the QUALICOPC study (Quality and Costs of Primary Care in Europe). The first question was answered by assessing GPs’ perception on who takes the referral decision. For the second question, a multilevel logistic model was applied. For the third question we analysed the GPs’ responses on what patient logistics and need arguments they consider in the referral process. We found: 1) variation in GPs reported SDM– 90% to 35%, 2) a negative correlation between gatekeeper systems and SDM—however, some countries strongly deviate and 3) GPs in gatekeeper systems more often consider patient interests, whereas in non-gatekeeping countries the GP’s value more own experience with specialists and benchmarking information. Our findings imply that GPs in gatekeeper systems seem to be less inclined to SDM than GPs in a non-gatekeeping system. The relation between gatekeeping/non-gatekeeping and SDM is not straightforward. A more contextualized approach is needed to understand the relation between gatekeeping as a system design feature and its relation with and/or impact on SDM.

Healthcare utilization and management of actinic keratosis in primary and secondary care: a complementary database analysis

“…However, in many Western countries, primary care is the point of entry in the healthcare system for patients, and in many countries, some level of a gatekeeping system is applied. 45,52 Therefore, we believe that our observations could be applied to other countries as well. Regardless of the type of healthcare system, AK is a high-volume condition and therefore comparable issues should be evaluated in other countries to improve the efficiency of care.…”

“…Finally, some aspects may be specific to the Dutch healthcare system, and this may raise some concerns about the generalizability of our results. However, in many Western countries, primary care is the point of entry in the healthcare system for patients, and in many countries, some level of a gatekeeping system is applied . Therefore, we believe that our observations could be applied to other countries as well.…”

“…Given these large numbers of patients with AK, AK being managed rather than cured, and overburdening in secondary care, both national and international guidelines support the concept that the majority of patients with AK could and should be managed in primary care . Many countries including the Netherlands, have some level of gatekeeping in access to specialists, although the extent varies widely between countries . However, with skin cancer GP education being side‐lined in both a national and an international perspective, successful AK management (and thus efficient gatekeeping) is compromised .…”

“…2,19,28,29 Many countries including the Netherlands, have some level of gatekeeping in access to specialists, although the extent varies widely between countries. [42][43][44][45] However, with skin cancer GP education being side-lined in both a national and an international perspective, successful AK management (and thus efficient gatekeeping) is compromised. [32][33][34][37][38][39]46,47 Increasing the familiarity of GPs with AK management by extending dermatology training for GPs may increase the likelihood of treating the condition themselves, reducing the use of nonindicated treatments (e.g.…”

Comparison of patient perceptions of primary care quality across healthcare facilities in Korea: A cross-sectional study

“…[2] Countries with a strong primary care sector have better population health outcomes, care qualities, and user satisfaction at lower costs and with a more equitable distribution of resources than countries with specialist-oriented systems. [4][5][6][7][8][9][10] Despite the evidence for primary care, however, resource allocation in most countries is still skewed toward hospitals and specialist care. [6,[11][12][13] The Korean health system has developed very rapidly in a short period, especially after the introduction of National Health Insurance in 1989-a universal coverage system compulsory for all citizens.…”