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.

journal_name

Plast Reconstr Surg

authors

Hartzell TL,Shahbazian JH,Pandey A,Girson LA,Rubinstein R,Bojovic B,Bernthal N,Azari KK,Benhaim P

doi

10.1097/PRS.0b013e31829acc74

subject

Has Abstract

pub_date

2013-09-01 00:00:00

pages

381e-386e

issue

3

eissn

0032-1052

issn

1529-4242

pii

00006534-201309000-00019

journal_volume

132

pub_type

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