title: The effect of primary care gatekeepers on the management of patients with chest pain.
abstract: OBJECTIVE
  To determine whether patients with chest pain referred to a cardiologist from a gatekeeper managed care organization differ from those referred from an open-access managed care organization.
  
  
  METHODS
  Retrospective study using clinical and claims data from a cardiac network database.
  
  
  METHODS
  We reviewed data from 1414 patients with chest pain or angina who were referred to a cardiologist between January 1, 1995, and June 30, 1996. We examined baseline clinical characteristics and subsequent physician practice patterns for these patients, who were referred from either a primary care gatekeeper model (n = 490) or an open-access model (n = 924).
  
  
  RESULTS
  Although twice as many open-access patients were referred to a cardiologist, there were no differences in patient demographics or clinical characteristics at the time of referral. Cardiologists ordered similar diagnostic tests for patients from both types of managed care plans, and gatekeeper patients did not have a higher rate of abnormal tests. Rates of cardiac catheterization, coronary angioplasty, myocardial infarction, and hospitalization were similar in both groups. A significantly higher percentage of gatekeeper patients received a cardiac catheterization on the day of referral (7% versus 1%; P = .05). Open-access patients were significantly more likely to continue to be seen by a cardiologist (44% versus 28%; P < .01). Cardiology professional charges per patient were lower among gatekeeper patients ($972 +/- 1398 versus $1187 +/- 1897; P = .06), and total cardiology professional charges were significantly lower for the gatekeeper group because of the smaller number of patients seen.
  
  
  CONCLUSIONS
  The type of cardiology services provided to patients with chest pain was not affected by the primary care administrative structure of the managed care organization, but the higher volume of patient referrals from the open-access plan may be an important consideration for cardiology practices participating in capitated contracts. The lower volume of referrals and coordination of care suggest potential cost advantages for the gatekeeper model.
authors.affiliation: Emory University Center for Clinical Evaluation Sciences, Rollins School of Public Health, Atlanta, GA 30322, USA. krask@emory.edu
authors.forename: K J
authors.initials: KJ
authors.lastname: Rask
authors.forename: C
authors.initials: C
authors.lastname: Deaton
authors.forename: S D
authors.initials: SD
authors.lastname: Culler
authors.forename: S A
authors.initials: SA
authors.lastname: Kohler
authors.forename: D C
authors.initials: DC
authors.lastname: Morris
authors.forename: W A
authors.initials: WA
authors.lastname: Alexander
authors.forename: R G
authors.initials: RG
authors.lastname: Pope
authors.forename: W S
authors.initials: WS
authors.lastname: Weintraub
mesh_terms: D000328:Adult; D000368:Aged; D002309:Cardiology; D002637:Chest Pain / Q000209:etiology / Q000628:therapy*; D003266:Continuity of Patient Care; D005260:Female; D020793:Gatekeeping; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000706:statistics & numerical data*; D008875:Middle Aged; D012017:Referral and Consultation; D012189:Retrospective Studies; D014481:United States