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Cost Effectiveness of Diagnostic Management by Gatekeepers
Letters to the Editor
Cost Effectiveness of Diagnostic Management by Gatekeepers The fo//owing letters address an article that appeared in the September 1994 issue of the Journal: Diagnostic Management by Gatekeepers Is Not Cost Effective for Neuro-ophthalmology (Ophthalmology 1994;101:1627-30) Dear Editor: I read with interest the article by Dillon et al. I congratulate them for nicely outlining the negative financial impact of the gatekeeper system for neuro-ophthalmic problems. As part of a plan to generate outcomes data and practice guidelines at our institution, we have reviewed the charts of patients referred with the diagnosis of Adie tonic pupil. Of ten patients, two (20%) were "overtested" using the criteria outlined by Dillon et al. One patient had magnetic resonance imaging at a cost of $1007.00 and the second patient had both magnetic resonance imaging and magnetic resonance angiography at a cost of$1509.00. In the remaining eight patients, who did not undergo neuroimaging, no changes were disclosed in the original diagnosis of the Adie tonic pupil syndrome during follow-up over several months to years. We are attempting to perform a similar analysis for other diagnoses at our institution to generate outcomes data to promote the concept advocated by Dillon et al that prompt subspecialty evaluation is not only a cost-effective strategy but also good medicine. ANDREW G. LEE, MD Houston. Texas
Authors' reply
Dear Editor: We were pleased to learn that Dr. Lee has begun a similar cost-effective study for other neuro-ophthalmologic diagnoses and look forward to the results of his independent analysis. We also share his belief that appropriate and prompt subspecialty evaluation is cost effective and good medicine. We hope that Dr. Lee's work and our study will stimulate additional investigations in all areas of ophthalmology and other medical subspecialties. EDWARD C. DILLON, MD ROBERT C. SERGOTT, MD PETER J. SAVINO, MD THOMAS M. BOSLEY, MD Philadelphia. Pennsylvania
Dear Editor: I read with great interest the article by Dillon et al. I applaud the authors for their efforts. This type of study provides the information needed to make informed decisions regarding health care delivery and to make heaIthcare as rational, efficient, and cost effective as possible. The authors justifiably question the widely used "gatekeeper" system that may place excessive burdens on primary care providers by penalizing referrals, encouraging these physicians to manage patients with conditions unfamiliar to the gatekeeper's prior training and experience. It is imperative that we not shy away from judging ourselves and our systems to expose and correct our weaknesses. However, authors who publish articles that explicitly or implicitly indict fellow physicians of providing substandard Care tread on sensitive, treacherous ground. Our professional ethics demand that we judge fairly. We are obligated to demonstrate that the standard of care used is generally accepted, and includes any reasonable approach that has not been demonstrated harmful or useless. Equally important, the characteristics of the physicians that fall short of the professional standard must be defined as precisely.as possible to draw any meaningful conclusions-conclusions that can lead to improved healthcare delivery by addressing the characteristics associated with poor physician performance. Dillon et al report that "gatekeeper" physicians and optometrists subjected many patients with optic neuropathy, diplopia, ptosis, and proptosis to unnecessary and potentially dangerous tests, concluding that all patients with these common neurologic disorders should be managed by fellowship-trained neuro-ophthalmologists. Did the authors meet their obligations? The common neuroophthalmic conditions they chose have generally accepted algorithms for diagnostic management, absolutely. What characteristics of the offending "gatekeeper" physicians are provided that the authors conclude led to their shortcomings? That these providers were not fellowship-trained neuro-ophthalmologists. According to the article, the "gatekeepers" included family practitioners, internists, neurologists, ophthalmologists, and optometrists, a group so diverse that the lack of fellowship training in neuroophthalmology is nearly the only characteristic they have in common. It is not reasonable to assume that these different practitioners, with vastly different levels of training and experience with neuro-ophthalmologic disorders, can be lumped successfully into a single group to be judged unable to provide adequate care to patients with neuroophthalmologic disorders. Because the authors chose to critique such a diverse group, they should have provided results separately for each specialty of gatekeeper. I would expect (or at least hope) that the probability of an ophthalmologist ordering unnecessary tests for these common disorders. seen many 1257
Cost Effectiveness of Diagnostic Management by Gatekeepers The fo//owing letters address an article that appeared in the September 1994 issue of the Journal: Diagnostic Management by Gatekeepers Is Not Cost Effective for Neuro-ophthalmology (Ophthalmology 1994;101:1627-30) Dear Editor: I read with interest the article by Dillon et al. I congratulate them for nicely outlining the negative financial impact of the gatekeeper system for neuro-ophthalmic problems. As part of a plan to generate outcomes data and practice guidelines at our institution, we have reviewed the charts of patients referred with the diagnosis of Adie tonic pupil. Of ten patients, two (20%) were "overtested" using the criteria outlined by Dillon et al. One patient had magnetic resonance imaging at a cost of $1007.00 and the second patient had both magnetic resonance imaging and magnetic resonance angiography at a cost of$1509.00. In the remaining eight patients, who did not undergo neuroimaging, no changes were disclosed in the original diagnosis of the Adie tonic pupil syndrome during follow-up over several months to years. We are attempting to perform a similar analysis for other diagnoses at our institution to generate outcomes data to promote the concept advocated by Dillon et al that prompt subspecialty evaluation is not only a cost-effective strategy but also good medicine. ANDREW G. LEE, MD Houston. Texas
Authors' reply
Dear Editor: We were pleased to learn that Dr. Lee has begun a similar cost-effective study for other neuro-ophthalmologic diagnoses and look forward to the results of his independent analysis. We also share his belief that appropriate and prompt subspecialty evaluation is cost effective and good medicine. We hope that Dr. Lee's work and our study will stimulate additional investigations in all areas of ophthalmology and other medical subspecialties. EDWARD C. DILLON, MD ROBERT C. SERGOTT, MD PETER J. SAVINO, MD THOMAS M. BOSLEY, MD Philadelphia. Pennsylvania
Dear Editor: I read with great interest the article by Dillon et al. I applaud the authors for their efforts. This type of study provides the information needed to make informed decisions regarding health care delivery and to make heaIthcare as rational, efficient, and cost effective as possible. The authors justifiably question the widely used "gatekeeper" system that may place excessive burdens on primary care providers by penalizing referrals, encouraging these physicians to manage patients with conditions unfamiliar to the gatekeeper's prior training and experience. It is imperative that we not shy away from judging ourselves and our systems to expose and correct our weaknesses. However, authors who publish articles that explicitly or implicitly indict fellow physicians of providing substandard Care tread on sensitive, treacherous ground. Our professional ethics demand that we judge fairly. We are obligated to demonstrate that the standard of care used is generally accepted, and includes any reasonable approach that has not been demonstrated harmful or useless. Equally important, the characteristics of the physicians that fall short of the professional standard must be defined as precisely.as possible to draw any meaningful conclusions-conclusions that can lead to improved healthcare delivery by addressing the characteristics associated with poor physician performance. Dillon et al report that "gatekeeper" physicians and optometrists subjected many patients with optic neuropathy, diplopia, ptosis, and proptosis to unnecessary and potentially dangerous tests, concluding that all patients with these common neurologic disorders should be managed by fellowship-trained neuro-ophthalmologists. Did the authors meet their obligations? The common neuroophthalmic conditions they chose have generally accepted algorithms for diagnostic management, absolutely. What characteristics of the offending "gatekeeper" physicians are provided that the authors conclude led to their shortcomings? That these providers were not fellowship-trained neuro-ophthalmologists. According to the article, the "gatekeepers" included family practitioners, internists, neurologists, ophthalmologists, and optometrists, a group so diverse that the lack of fellowship training in neuroophthalmology is nearly the only characteristic they have in common. It is not reasonable to assume that these different practitioners, with vastly different levels of training and experience with neuro-ophthalmologic disorders, can be lumped successfully into a single group to be judged unable to provide adequate care to patients with neuroophthalmologic disorders. Because the authors chose to critique such a diverse group, they should have provided results separately for each specialty of gatekeeper. I would expect (or at least hope) that the probability of an ophthalmologist ordering unnecessary tests for these common disorders. seen many 1257