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Published on: February 17, 2018
Does the gatekeeper model work in hand surgery?
Tristan L Hartzell1, Jonathan H Shahbazian, Amit Pandey
1Norfolk, 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.
Insights
Most patients with hand problems see a primary care provider first, but many receive incorrect diagnoses and unnecessary treatments. This suggests the current referral system may not be the most efficient for hand care.
Area of Science:
- Orthopedics
- Hand Surgery
- Health Services Research
Background:
- Managed care plans often use a physician "gatekeeper" model for referrals.
- The effectiveness of this gatekeeper system for upper extremity complaints is largely unevaluated.
- Prior management of patients with elective hand disorders has not been systematically assessed.
Purpose of the Study:
- To evaluate the prior management of patients with elective hand disorders presenting to a hand surgery clinic.
- To assess the accuracy of diagnoses and appropriateness of treatments initiated before specialist referral.
Main Methods:
- Prospective enrollment of new patients at a tertiary academic medical center.
- Evaluation of prior provider, diagnosis, treatment, and complications for 125 patients.
- Independent determination of actual diagnosis and appropriate treatment by two experienced hand examiners.
Main Results:
- 98% of patients saw a primary care provider, but only 34% received the correct diagnosis.
- Nerve compression syndromes were diagnosed accurately 64% of the time; stenosing tenosynovitis only 15%.
- 74% of patients had prior interventions, 70% deemed unnecessary; 90% of advanced imaging was unwarranted.
Conclusions:
- Primary care providers unfamiliar with hand anatomy frequently misdiagnose and mistreat common hand conditions.
- The current referral system may be inefficient for delivering care for elective hand conditions.
- Delays in diagnosis and unnecessary interventions led to complications in 17% of patients.
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.
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