Diagnostic management by gatekeepers is not cost effective for neuro-ophthalmology

To determine whether the "gatekeeper physician system" for evaluating neuro-ophthalmologic problems is cost effective.

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.

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.

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.