Month: March 2019

Impact of GP gatekeeping on quality of care, health outcomes, health care use, and spending

In many health systems, primary care physicians (sometimes referred to as general practitioners or family physicians) regulate access to specialist medical services and investigations. This process is sometimes described as “gatekeeping” and is a response to a shortage of specialists and a need to control healthcare spending. In gatekeeping systems, patients are required to visit a GP or primary care physician to authorise access to specialty care. However, the effectiveness of gatekeeping remains unclear.

In a systematic review published in the British Journal of General Practice, we examined the impact of gatekeeping on areas such as the quality of health care, healthcare spending and use, and health-related and patient-related outcomes.

We found an an association between gatekeeping and better quality of care, especially in terms of preventive care, and appropriate referral for specialty care and investigation. However, we found one study that reported unfavourable outcomes of patients with cancer under gatekeeping.

Gatekeeping resulted in fewer hospitalisations and lower specialist use, but also led to more primary care visits. Gatekeeping may also lead to lower healthcare use and expenditure. Primary care clinicians have conflicting views on gatekeeping, whereas patients are often less satisfied with gatekeeping schemes, preferring health systems where they have direct access to specialists.

As with many areas of health policy, the impact of gatekeeping on key health system metrics needs further investigation to help devise more efficient and equitable health systems that improve health outcomes and lead to high patient satisfaction whilst at the same time, keeping spending on health services at sustainable levels.

Digital health: A greater focus on human factors is needed

There is growing appreciation that the success of digital health – whether digital tools, digital interventions or technology-based change strategies – is linked to the extent to which human factors are considered throughout the design, development and implementation. A shift in focus to individuals as users and consumers of digital health highlights the capacity of the field to respond to recent developments, such as the adoption of person-centred care and consumer health technologies.

In an article published in the journal BMC Medicine, we argue that this project is not only incomplete, but is fundamentally ‘uncompletable’ in the face of a highly dynamic landscape of both technological and human challenges. These challenges include the effects of consumerist, technology-supported care on care delivery, the rapid growth of digital users in low-income and middle-income countries and the impacts of machine learning.

Digital health research will create most value by retaining a clear focus on the role of human factors in maximising health benefit, by helping health systems to anticipate and understand the person-centred effects of technology changes and by advocating strongly for the autonomy, rights and safety of consumers.

Digital Education in Health Professions: The Need for Overarching Evidence Synthesis

Synthesizing evidence from randomized controlled trials of digital health education is challenging. Problems include a lack of clear categorization of digital health education in the literature; constantly evolving concepts, pedagogies, or theories; and a multitude of methods, features, technologies, or delivery settings.

The Digital Health Education Collaboration was established to evaluate the evidence on digital education in health professions; inform policymakers, educators, and students; and change the way in which these professionals learn and are taught. In a paper published in the Journal of Medical Internet Research, we presented the overarching methods we use to synthesize evidence across our digital health education reviews and to discuss challenges related to the process.

For our research, we followed Cochrane recommendations for the conduct of systematic reviews; all reviews are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. This included assembling experts in various digital health education fields; identifying gaps in the evidence base; formulating focused research questions, aims, and outcome measures; choosing appropriate search terms and databases; defining inclusion and exclusion criteria; running the searches jointly with librarians and information specialists; managing abstracts; retrieving full-text versions of papers; extracting and storing large datasets, critically appraising the quality of studies; analyzing data; discussing findings; drawing meaningful conclusions; and drafting research papers.

The approach used for synthesizing evidence from digital health education trials is the most rigorous benchmark for conducting systematic reviews. Although we acknowledge the presence of certain biases ingrained in the process, we have clearly highlighted and minimized those biases by strictly adhering to scientific rigor, methodological integrity, and standard operating procedures. our paper will be a valuable asset for researchers and methodologists undertaking systematic reviews in digital health education.

Is it getting easier to obtain antibiotics in the UK?

In the UK, antibiotics are, with very few exceptions, only prescribable by doctors or other health professionals with prescribing qualifications. This has meant that, until recently, access to antibiotics has been possible only through face-to-face medical assessment in primary or secondary care, providing a significant disincentive to seeking antibiotics unnecessarily.

Inappropriate prescribing of antibiotics in UK primary care remains of concern, but antimicrobial stewardship initiatives are having a measurable effect, with prescribing rates falling in response to interventions. However, novel routes to obtaining antibiotics, associated with either a lower threshold for prescribing or issuing of antibiotics without medical assessment, undermine these strategies and are likely to increase inappropriate use.

These issues are discussed further in an article published in the British Journal of General Practice.