title: Diagnostic management by gatekeepers is not cost effective for neuro-ophthalmology.
abstract: OBJECTIVE
  To determine whether the "gatekeeper physician system" for evaluating neuro-ophthalmologic problems is cost effective.
  
  
  METHODS
  The authors retrospectively reviewed the records of 588 patients referred for neuro-ophthalmologic evaluation between July and December 1989 to determine the frequency and cost of unnecessary diagnostic testing ordered by "gatekeeper physicians." Pre-referral diagnostic testing costs were compared with the cost of neurophthalmologic consultation for four common problems: (1) optic neuropathy; (2) diplopia; (3) ptosis; and (4) proptosis.
  
  
  RESULTS
  Between 16% and 26% of patients in the first three diagnostic categories were subjected to overtesting, resulting in $57,900 of excessive costs, a 724% overcharge. Although the evaluation of proptosis was performed correctly, the quality of 10 of the 18 neuro-imaging procedures was substandard.
  
  
  CONCLUSIONS
  The gatekeeper system managed by primary care physicians for these four neuro-ophthalmologic problems not only did not conserve healthcare dollars but also had a negative impact on cost control. For neuro-ophthalmologic disorders, prompt subspecialty evaluation and examination appear to be a cost-effective strategy.
authors.affiliation: Wills Eye Hospital, Neuro-Ophthalmology Service, Philadelphia, PA 19107.
authors.forename: E C
authors.initials: EC
authors.lastname: Dillon
authors.forename: R C
authors.initials: RC
authors.lastname: Sergott
authors.forename: P J
authors.initials: PJ
authors.lastname: Savino
authors.forename: T M
authors.initials: TM
authors.lastname: Bosley
mesh_terms: D001763:Blepharoptosis / Q000175:diagnosis / Q000191:economics; D003362:Cost-Benefit Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics*; D004172:Diplopia / Q000175:diagnosis / Q000191:economics; D005094:Exophthalmos / Q000175:diagnosis / Q000191:economics; D005128:Eye Diseases / Q000175:diagnosis / Q000191:economics*; D006801:Humans; D008329:Managed Care Programs; D009885:Ophthalmology; D009901:Optic Nerve Diseases / Q000175:diagnosis / Q000191:economics; D011320:Primary Health Care; D012017:Referral and Consultation / Q000191:economics; D012189:Retrospective Studies; D014481:United States