The effect of primary care gatekeepers on the management of patients with chest pain

Objective: To determine whether patients with chest pain referred to a card iologist from a gatekeeper managed care organization differ from those refe rred from an open-access managed care organization. Study Design: Retrospective study using clinical and claims data from a car diac network database. Patients and Methods: We reviewed data from 1414 patients with chest pain o r angina who were referred to a cardiologist between January 1, 1995, and J une 30, 1996. We examined baseline clinical characteristics and subsequent physician practice patterns for these patients, who were referred from eith er a primary care gatekeeper model (n = 490) or an open-access model (n = 9 24). Results: Although twice as many open-access patients were referred to a car diologist, there were no differences in patient demographics or clinical ch aracteristics at the time of referral. Cardiologists ordered similar diagno stic tests for patients from both types of managed care plans, and gatekeep er patients did not have a higher rate of abnormal tests. Rates of cardiac catheterization, coronary angioplasty, myocardial infarction, and hospitali zation were similar in both groups. A significantly higher percentage of ga tekeeper patients received a cardiac catheterization on the day of referral (7% versus 1%; P=.05). Open-access patients were significantly more likely to continue to be seen by a cardiologist (44% versus 28%; P<.01). Cardiolo gy professional charges per patient were lower among gatekeeper patients ($ 972 +/- 1398 versus $1187 +/- 1897; P=.06), and total cardiology profession al charges were significantly lower for the gatekeeper group because of the smaller number of patients seen. Conclusions: The type of cardiology services provided to patients with ches t pain was not affected by the primary care administrative structure of the managed care organization, but the higher volume of patient referrals from the open-access plan may be an important consideration for cardiology prac tices participating in capitated contracts. The lower volume of referrals a nd coordination of care suggest potential cost advantages for the gatekeepe r model.