The Research On The Feasibility Of Gatekeeper System

Objectives:This study aimed to analyze the difficulties of gatekeeper system in the process of implementation and to explore its core elements using theoretical study and model construcion methods. Meanwhile, we intended to explore the feasibility and impact factors according to doctors'and patients'cognitive, experience and evaluation with gatekeeper system, which could provide policy basis for future policy-making on the system.Methods:Combined with field investigation, the method of archetype feedback analysis and analysis of feedback dynamic complex were used to analyze key elements in the process of implementation of gatekeeper system based on comprehensive literatures and different kinds of Health Statistics Annuals. The detailed research protocol and first draft of questionnaires were designed according to group discussion and specialists'consultation and were revised based on the results of the pilot study. The patients'investigation was conducted in 4 Community Health Service Centers in Wuhan (patients covered Government Insurance Scheme in institutions of higher education) and 4 in Nanjing respectively (patients covered Urban Employee's Basic Medical Insurance in Nanjing), and doctors'investigation was conducted in 4 hospitals in Wuhan and general practitioners (GPs) in Community Health Service Institutions (CHIs) in Hubei province from October,2014 to November,2015. All patients were interviewed by face-to-face with trained graduate students when they visited the Community Health Service Centers. Finally,2220 patients and 1860 doctors were included in our analysis. Descriptive analysis was carried out for demographics data, patients'and doctors' cognition and evaluation of CHI and gatekeeper system. Chi-square test was used to compare the evaluation of different level doctors. Multivariate logistic regression analysis was conducted to explore the risk factors of patients'satisfaction with community health service (CHS) and their acceptance of gatekeeper system, and the relationship between familiar with CHIs, ability-evaluation of CHIs and recognition of gatekeeper system among doctors worked in hospitals. The European Patients Evaluate General/Family Practice (EUROPEP) scale was used to assess patients'satisfaction with CHS and exploratory factor analysis was used to choose the suitable model of scale for further analysis. The database was set up with Epidata3.1 by two graduate students separately. System dynamics models were built using Venple51 software, meanwhile, descriptive analysis, single factor analysis, multivariate analysis and evaluation of reliability and validity of EUROPEP scale were conducted using SPSS 18 (SPSS Inc., Chicago,111). Besides, confirmatory factor analysis was conducted with Amos 17.0 software.Results:1?The analysis of key elements in the implementation of gatekeeper system according to system dynamics models. It revealed that patient, hospital, community health service institution and health insurance policy were significant factors in the process of implementation and the cognitive and experience of doctors and patients were the key elements.2?The analysis of gatekeeper system feasibility based on doctors' cognition. A total of 907 general practitioners (GPs) in CHIs and 953 doctors in hospital were included in our analysis. Among which,63.1% and 54.7% believed that diagnosis and treat level could meet patients with common diseases respectively; 69.2% and 62.5% believed that CHIs could undertake "community gatekeeper" responsibility; 94.5%and 85.7% supported to implement gatekeeper system; 83.7% and 81.5% thought that the gatekeeper system played a positive role in guiding residents to CHIs for treatment. Compared with doctors in hospital who were unfamiliar with CHI, doctors who were familiar with CHI had a better evaluation on the diagnosis and treat level (OR?=1.584, 95%CI,1.217-2.063), medical facilities (OR=1.892,95%CI,1.451-2.469) and drugs (OR=1.531,95%CI,1.174-1.997) of CHI.3, The analysis of gatekeeper system feasibility based on patients'cognition. A total of 1058 patients from Nanjing city and 1162 patients from Wuhan city were included in the present analysis. Among the two kinds of patients,80.0%(Nanjing) and 71.8% (Wuhan) believed that diagnosis and treat level could meet their needs; 25.8% and 33.4% were not willing to accept gatekeeper system, respectively. Patients from Nanjing were most satisfied with patient-doctor-relationship (48.9%) and medical care (40.2%), and patients from Wuhan were most satisfied with the dimension of organization of care (35.4%). Both of them were least satisfied with the dimension of accessibility, and the percent were 65.2% and 69.4%, respectively.Results of impact factors of patients' acceptance:patients satisfied with reimbursement proportion were more likely to accept the gatekeeper system (Nanjing, OR=1.763,95%CI,1.295-2.400; Wuhan, OR=3.861,95%CI,2.805-5.315); patients who understood the system were more inclined to accept the system (Nanjing, OR=2.942, 95%CI,2.164-3.999; Wuhan, OR=4301,95%CI,2.987-6.193). In Nanjing, patients who thought low cost (OR=1366,95%CI,1.022-1.827) and enough drugs (OR=2.386, 95%CI,1.518-3.748) in CHIs were more inclined to accept the system. And in Wuhan, patients who cared for medical cost were less likely to accept the system (OR=0.705, 95%C7,0.511-0.972), while patients who were satisfied with diagnosis and treat level were more incJined to accept the system (OR=1.914,95%CI,1.207-3.035).Results of influencing factors of patients'satisfaction:among the evaluation of five dimensions of EUROPEP scale, patients, who believed diagnosis and treat level could meet patients with common diseases or were willing to accept the system, were more satisfied with all dimensions in Nanjing (P<0.05) and four dimensions in Wuhan (P<0.05).Conclusions:In summary, the recognition and acceptance of doctors and patients were important indexes about the research on the feasibility of gatekeeper system. At present, the implementation condition of gatekeeper system has been formed preliminarily, and both doctors and patients have a relatively high degree of recognition and acceptance on the system, thus, the system is practicable. But patients'experience remains to be further improved, in addition, improving the health care system, especially the reimbursement system, strengthening the cooperation and communication between hospitals and CHIs, improving the level of CHIs and the service awareness of GPs, and improving patients' understanding of the connotation of gatekeeper system will be important approaches to promote the implementation of gatekeeper system continuously in China.Strengths and limitationsAt present, studies about gatekeeper system mainly focus on its necessity, importance and implement approach, however, study about its feasibility was scarce and most of them just limited on the policy or international experience, which lack of systematic demonstrability and investigation materials. Gatekeeper system is the core of medical grading system, but it is controversial to implement it mandatory in China. In terms of the topic, our study focused on the blind spot of gatekeeper system researches, and directly linked to the top of health policy design;as to the content, it was the first study to investigate patients in functional community (patients covered Government Insurance Scheme in institutions of higher education); with respect to the methods, it was also the first time to analyze the relationship between gatekeeper system and the development of health service, and to explore key elements in the implementation of the system by using system dynamics models, futhermore, the EUROPEP scale was used to assess patients' satisfaction with CHS, which is more scientific than that with self-designed satisfaction questionnaire.The limitations of our study should also be acknowledged, which mainly focus on two aspects. First, although it is important to study the feasibility of gatekeeper system based on recognition and acceptance with the system of supply and demand parties, other factors such as health insurance policy and its management mechanism, are also important implementing conditions of gatekeeper system, but we could not conduct specialized research with the limitation of time and manpower in the thesis, which may be an important research direction in the future. Second, the investigation was conducted in Hubei Province and Nanjing City, which was well representative, but it still needed to be conducted in more areas for increasing the strength of the evidence.