Zentner A, Velasco Garrido M, Busse R
Fachgebiet Management im Gesundheitswesen, Technische Universität Berlin.
Gesundheitswesen. 2010 Aug-Sep;72(8-9):e38-44. doi: 10.1055/s-0029-1234126. Epub 2009 Sep 30.
The aim of this systematic review was to analyse the effects of gatekeeping where primary care physicians (PCP) control access to specialist care.
Literature search in Medline, EMBASE, Cochrane Library, and a hand search were carried out.
(1) intervention: gatekeeping by PCP compared to free access to specialist care; (2) outcomes: health outcomes, health related quality of life, quality of care, utilization of care, costs, satisfaction of patients and providers; (3) design: RCT, quasi-random. CT, CBA, cohort and case control studies, ITS. Data extraction and assessment was done by two independent reviewers according to Cochrane EPOC-Group and USTFCPS.
24 included studies (1989-2007) were as follows: 1 RCT, 2 quasi-randomised CT, 3 prospective, and 12 retrospective cohort studies, 4 CBA, and 2 ITS. 67% of the studies analysed data from the USA, the remaining from CH, UK, DK and NL. Studies had relevant limitations concerning the quality of execution and publication. Overall 13 of 24 studies reported a positive and two a negative effect of gatekeeping compared to open access models; nine showed no differences. The results varied according to outcome parameters.
International evidence on effects of gatekeeping is limited by the low internal validity of studies and applicability to other contexts. It suggests that gatekeeping by PCP decreases utilization of specialist care and health care costs. Based on very few studies health outcomes and patient quality of life in gatekeeping models might be comparable with those in open access models. Evidence is inconsistent or not available concerning the quality of care, patient or provider satisfaction.
本系统评价的目的是分析初级保健医生（PCP）控制专科护理准入的守门人制度的效果。
在医学期刊数据库（Medline）、荷兰医学文摘数据库（EMBASE）、考克兰图书馆进行文献检索，并进行手工检索。
（1）干预措施：将初级保健医生的守门人制度与专科护理的自由准入进行比较；（2）结局指标：健康结局、健康相关生活质量、护理质量、护理利用情况、成本、患者及提供者满意度；（3）研究设计：随机对照试验（RCT）、半随机对照试验（quasi-random）、对照试验（CT）、成本效益分析（CBA）、队列研究和病例对照研究、中断时间序列分析（ITS）。由两名独立评审员根据考克兰有效实践和组织关怀（EPOC）小组及美国科技、功能和临床心理学协会（USTFCPS）的标准进行数据提取和评估。
纳入的24项研究（1989 - 2007年）如下：1项随机对照试验、2项半随机对照试验、3项前瞻性研究、12项回顾性队列研究、4项成本效益分析和2项中断时间序列分析。67%的研究分析了来自美国的数据，其余来自瑞士、英国、丹麦和荷兰。这些研究在实施质量和发表方面存在相关局限性。总体而言，24项研究中有13项报告了与开放准入模式相比，守门人制度有积极效果，2项报告有消极效果；9项显示无差异。结果因结局参数而异。
关于守门人制度效果的国际证据因研究的内部效度低以及对其他背景的适用性而受到限制。这表明初级保健医生的守门人制度会降低专科护理的利用率和医疗成本。基于极少的研究，守门人模式下的健康结局和患者生活质量可能与开放准入模式相当。关于护理质量、患者或提供者满意度的证据不一致或缺乏。
