title: Does the gatekeeper model work in hand surgery?
abstract: BACKGROUND
  Most managed care plans use a physician "gatekeeper" to control referrals to hand surgeons. The appropriateness of this model for upper extremity complaints has never been challenged. The purpose of this study was to evaluate the prior management of patients with elective hand disorders who present to a hand surgery clinic.
  
  
  METHODS
  All patients presenting to a tertiary, academic medical center for a new-patient hand surgery evaluation from February 3, 2011, to June 15, 2011, were prospectively enrolled. Patients were evaluated for prior provider, diagnosis, treatment, and complications. Actual diagnosis, recommended workup, and appropriate treatment were determined independently by two experienced hand examiners. Traumatic injuries and surgeon disagreements in diagnosis and treatment were excluded, leaving 125 patients.
  
  
  RESULTS
  Ninety-eight percent of patients had been evaluated by a primary care provider. Overall, the correct diagnosis was established 34 percent of the time. Nerve compression syndromes were diagnosed with the greatest accuracy (64 percent), whereas stenosing tenosynovitis was diagnosed correctly only 15 percent of the time. Before presentation, 74 percent of patients had undergone a study or intervention. On review, 70 percent of studies/interventions were deemed unnecessary. Advanced imaging was unwarranted in 90 percent of patients who received it. Seventeen percent of patients experienced a complication. Most (67 percent) were caused by a delay in diagnosis, whereas 33 percent resulted from an intervention.
  
  
  CONCLUSIONS
  Health care providers less familiar with an examination of the hand often misdiagnose and mistreat common problems. A referral system may not be the most efficient means of delivering care to patients with elective hand maladies.
authors.affiliation: Norfolk, Neb.; Los Angeles, Calif.; and Baltimore, Md. From the Department of Surgery, Faith Regional Health Service; the Department of Orthopedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles; the University of Southern California; and the Department of Surgery, University of Maryland Medical Center.
authors.forename: Tristan L
authors.initials: TL
authors.lastname: Hartzell
authors.forename: Jonathan H
authors.initials: JH
authors.lastname: Shahbazian
authors.forename: Amit
authors.initials: A
authors.lastname: Pandey
authors.forename: Lily A
authors.initials: LA
authors.lastname: Girson
authors.forename: Roee
authors.initials: R
authors.lastname: Rubinstein
authors.forename: Branko
authors.initials: B
authors.lastname: Bojovic
authors.forename: Nicholas
authors.initials: N
authors.lastname: Bernthal
authors.forename: Kodi K
authors.initials: KK
authors.lastname: Azari
authors.forename: Prosper
authors.initials: P
authors.lastname: Benhaim
mesh_terms: D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D004387:Dupuytren Contracture / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D006225:Hand / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D009329:Nebraska; D009408:Nerve Compression Syndromes / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D010003:Osteoarthritis / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D011320:Primary Health Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D011859:Radiography; D012017:Referral and Consultation / Q000706:statistics & numerical data; D013717:Tenosynovitis / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*