Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists

CONTEXT

Few data are available regarding how patients view the role of primary care physicians as "gatekeepers" in managed care systems.

OBJECTIVE

To determine the extent to which patients value the role of their primary care physicians as first-contact care providers and coordinators of referrals, whether patients perceive that their primary care physicians impede access to specialists, and whether problems in gaining access to specialists are associated with a reduction in patients' trust and confidence in their primary care physicians.

DESIGN, SETTING, AND PATIENTS

Cross-sectional survey mailed in the fall of 1997 to 12707 adult patients who were members of managed care plans and received care from 10 large physician groups in California. The response rate among eligible patients was 71%. A total of 7718 patients (mean age, 66.7 years; 32 % female) were eligible for analysis.

MAIN OUTCOME MEASURES

Questionnaire items addressed 3 main topics: (1) patient attitudes toward the first-contact and coordinating role of their primary care physicians, (2) patients' ratings of their primary care physicians (trust and confidence in and satisfaction with), and (3) patient perceptions of barriers to specialty referrals. Referral barriers were analyzed as predictors of patients' ratings of their physicians.

RESULTS

Almost all patients valued the role of a primary care physician as a source of first-contact care (94%) and coordinator of referrals (89%). Depending on the specific medical problem, 75% to 91% of patients preferred to seek care initially from their primary care physicians rather than specialists. Twenty-three percent reported that their primary care physicians or medical groups interfered with their ability to see specialists. Patients who had difficulty obtaining referrals were more likely to report low trust (adjusted odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2) with their primary care physicians.

CONCLUSIONS

Patients value the first-contact and coordinating role of primary care physicians. However, managed care policies that emphasize primary care physicians as gatekeepers impeding access to specialists undermine patients' trust and confidence in their primary care physicians.

Adducts with haemoglobin and with DNA in epichlorohydrin-exposed rats

Epichlorohydrin (1-chloro-2,3-epoxypropane; ECH) is an important industrial chemical and a carcinogen in experimental animals. The main aims of the present study were to characterize the adduct formation in female Wistar rats and to identify adducts that could potentially be used in human biomonitoring studies. The total binding of radioactivity to haemoglobin in rats administered 0, 0. 11, 0.22, 0.43, or 0.97 mmol [3H]ECH/kg body weight by i.p. injection, and sacrificed 24 h after treatment, was linearly related to a dose up to 0.43 mmol/kg body weight. The binding at the highest dose was higher than predicted by extrapolation from lower doses, indicating saturation of a metabolic process for elimination of ECH. Ion-exchange chromatography of a globin hydrolysate showed one major radioactivity peak corresponding to S-(3-chloro-2-hydroxypropyl)cysteine. The half-life of this adduct was estimated as about 4 days by analysis of globin from rats administered 0.43 mmol/kg body weight and sacrificed after 1, 2 and 9 days. Crosslinking of the adduct, presumably with glutathione, appeared to be the predominant secondary reaction. Hydrolysis of N-(3-chloro-2-hydroxypropyl)valine, the primary reaction product of ECH with N-terminal valine, would give N-(2,3-dihydroxypropyl)valine. A sensitive gas chromatography/mass spectrometry method for the dihydroxypropyl adduct was used to follow its formation and removal after administration of nonlabelled ECH (0.11 mmol/kg body weight). The level of this adduct reached a maximum of about 20 pmol/g globin after a few weeks, corresponding to about 0.1% of the initial binding of ECH to globin. N-7-(3-Chloro-2-hydroxypropyl)guanine was detected in rats administered 0.97 mmol [3H]ECH/kg body weight and sacrificed 6 h after treatment. The adduct levels in haemoglobin and DNA were compared with previously reported adduct levels in male Fischer 344 rats exposed to propylene oxide. Despite its higher chemical reactivity, the capacity of ECH to alkylate macromolecules in vivo was found to be somewhat lower than that of propylene oxide.

Synthesis of an N-methyldehydroalanine-containing fragment of microcystin by combination of solid phase peptide synthesis and beta-elimination in solution

A new method for the synthesis of dehydroalanine (delta Ala)-containing peptides has been developed by combining solid phase peptide synthesis (tert-butyloxycarbonyl/HF-chemistry) with solution synthesis. A sequence from cyanobacterial hepatotoxin microcystin, Ac-D-gamma-Glu-[N-Me-delta Ala]-D-Ala-Leu amide was chosen as a model peptide. The precursor for the synthesis of the dehydroalanine-containing peptide, Ac-D-gamma-Glu-[N,S-diMeCys]-D-Ala-Leu, was synthesized on a solid phase followed by sulfonium salt formation on the resin. The resulting S,S-dimethylated peptide was cleaved from the resin with liquid HF. The HPLC-purified S,S-dimethylated cysteine-containing precursor peptide was subjected to beta-elimination in solution catalysed by DBU (1,8-diazabicyclo[5.4.0]undec-7-ene) in methanol. The final product, Ac-D-gamma-Glu-[N-Me-delta Ala]-D-Ala-Leu amide, was purified by HPLC, and analysed by mass spectrometry and 1H NMR spectroscopy. The stability of the model peptide under acidic, neutral and basic conditions has been studied.

Rationing or rationalizing children's medical care: comparison of a Medicaid HMO with fee-for-service care

OBJECTIVES

This paper examines how medical care obtained by children enrolled in a Medicaid health maintenance organization (HMO) differs from that obtained by similar children who receive care from fee-for-service Medicaid providers.

METHODS

In a randomized trial, some Medicaid households were assigned to remain in a traditional fee-for-service arrangement and others were randomly selected to join a Medicaid prepaid plan (an HMO). Participating households recorded data on children's health status and use of medical care.

RESULTS

The prepaid plan members and the fee-for-service recipients received equivalent numbers of checkup visits, but the children in the prepaid plan made significantly fewer acute care visits. This plan appeared to target its services to children with the greatest health care needs. However, the content of health visits in the two systems did not differ, nor did prepaid and fee-for-service enrollees use the emergency room differently.

CONCLUSIONS

It is possible to design a Medicaid HMO that achieves financial savings without reducing services to the most vulnerable patients. However, these findings alone do not provide a basis for widespread policy change in the direction of Medicaid HMOs. Further research is needed to establish whether the children treated in the HMO differed in health outcomes from those treated by fee-for-service care.

Characterization of the lipid and protein contents of myelin bodies isolated from the renal cortex of gentamicin-treated rats

Myelin bodies were isolated from the renal cortex of gentamicin-treated rats (100 mg/kg body weight, twice daily for 3 days, i.p.) employing an initial pelleting by differential centrifugation and subsequent flotation on a discontinuous sucrose gradient. These structures were found to contain almost twice as much protein as phospholipid and SDS-polyacrylamide gel electrophoresis revealed the presence of many different polypeptides. All the major phospholipids are present, although myelin bodies contain a considerably higher proportion of phosphatidylinositol, somewhat more phosphatidylcholine and considerably lower percentages of phosphatidylserine and sphingomyelin than do normal renal phospholipids. The fatty acids of myelin body phospholipids are highly saturated (67.3-87.9%) and a striking feature is the occurrence of relatively large amounts of 22:1, presumably erucic acid, especially in sphingomyelin. Myelin bodies contain small amounts of unesterified cholesterol, unesterified dolichol and coenzymes Q9 and Q10.

A midcourse review of the nation's health agenda

In the fall of 1979, a group of experts were convened under the auspices of the U.S. Public Health Service to craft a national health strategy that would reduce preventable death and disease among Americans by 1990. Derived from this consensus-building activity were a set of measurable healthy objectives, guideposts for the nation to pursue in quest of better health for all (Preventing Disease/Promoting Health: Objectives for the Nation). A call to action subsequently was issued to all sectors and levels of society--including business and industry--to improve health status and reduce risks to health through preventive interventions and the adoption of positive health behaviors. This initiated a process, by which a national prevention agenda could be addressed.