Time is money: general practitioners' reflections on the fee-for-service system.

BACKGROUND: Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions. METHODS: We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis. RESULTS: We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees. CONCLUSIONS: GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification.

BACKGROUND: General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. METHODS: Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach. RESULTS: Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. CONCLUSION: Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.

Attributing practice variation by its sources: the case of varicose veins treatments in the Netherlands.

BACKGROUND: Unwarranted practice variation refers to regional differences in treatments that are not driven by patients' medical needs or preferences. Although it is the subject of numerous studies, most research focuses on variation at the end stage of treatment, i.e. the stage of the treating specialist, disregarding variation stemming from other sources (e.g. patient preferences, general practitioner referral patterns). In the present paper, we introduce a method that allows us to measure regional variation at different stages of the patient journey leading up to treatment. METHODS: A series of logit regressions estimating the probability of (1) initial visit with the physician and (2) treatment correcting for patient needs and patient preferences. Calculating the coefficient of variation (CVU) at each stage of the patient journey. RESULTS: Our findings show large regional variations in the probability of receiving an initial visit, The CVU, or the measure of dispersion, in the regional probability of an initial visit with a specialist was significantly larger (0.87-0.96) than at the point of treatment both conditional (0.14-0.25) and unconditional on an initial visit (0.65-0.74), suggesting that practice variation was present before the patient reached the specialist. CONCLUSIONS: We present a new approach to attribute practice variation to different stages in the patient journey. We demonstrate our method using the clinically-relevant segment of varicose veins treatments. Our findings demonstrate that irrespective of the gatekeeping role of general practitioners (GPs), a large share of practice variation in the treatment of varicose veins is attributable to regional variation in primary care referrals. Contrary to expectation, specialists' decisions meaningfully diminish rather than increase the amount of regional variation.

HK2: Gatekeeping microglial activity by tuning glucose metabolism and mitochondrial functions.

Hexokinase 2 (HK2) plays a multifaceted role in the regulation of cellular activities. A new study by Hu et al.1 delineated a critical role of HK2 in governing glycolytic flux and mitochondrial activity, thereby modulating microglial functions in maladaptive inflammation in brain diseases.

Development of the Pharm-SAVES educational module for gatekeeper suicide prevention training for community pharmacy staff.

INTRODUCTION: Pharmacists are one of the most accessible health professionals in the United States, who, with training, may serve as gatekeepers who recognize suicide warning signs and refer at-risk individuals to care. Our objective was to codesign a 30-min online gatekeeper training module (Pharm-SAVES) specifically for community pharmacy staff. METHODS: Over a period of 8 months, a nine-member pharmacy staff stakeholder panel and the Finger Lakes (New York) Veterans Research Engagement Review Board each worked with the study team to codesign Pharm-SAVES. Formative data from previous interviews with community pharmacists were presented to the panels and guided website development. RESULTS: Four key topics were identified for brief skills-based modules that could be delivered asynchronously online. To help pharmacy staff understand their opportunities as gatekeepers in suicide prevention, statistics and statements from the Joint Commission and pharmacy professional organizations were highlighted in Module 1 ('Why Me?'). Module 2 ('What can I do?') presents the five gatekeeping steps (SAVES): (1) Recognize suicide warning Signs, (2) Ask if someone is considering suicide, (3) Validate feelings, (4) Expedite referral, and (5) Set a reminder to follow-up. Module 3 ('How does it work?') provides three video scenarios modeling SAVES steps and two interactive video cases for participant practice. Module 3 demonstrates use of the 24/7 National Suicide Prevention Lifeline, including the DOD/VA Crisis Line. Module 4 (Resources) includes links to national resources and a searchable zip code-based provider directory. Pharm-SAVES was codesigned with pharmacy and veteran stakeholders to deliver brief, skills-focused, video-based interactive training that is feasible to implement in busy community pharmacy settings. CONCLUSION: Pharm-SAVES is a brief, online suicide prevention gatekeeper training program codesigned by researchers, community pharmacy and veteran stakeholders. By actively engaging stakeholders at each stage of the design process, we were able to create training content that was not only realistic but more relevant to the needs of pharmacy staff. Currently, Pharm-SAVES is being evaluated in a pilot randomized controlled trial for changes in pharmacy staff suicide prevention communication behaviors. PATIENT OR PUBLIC CONTRIBUTION: Stakeholder engagement was purposefully structured to engage pharmacy staff and pharmacy consumers, with multiple opportunities for study contribution. Likewise, the involvement of patient/public contribution was paramount in study design and overall development of our study team.

Moving Beyond Psychiatric Gatekeeping for Gender-Affirming Surgery.

This Viewpoint describes gatekeeping in gender-affirming care and provides recommendations to improve access to gender-affirming surgery for transgender people.

Introducing a gatekeeping system for amyloid status assessment in mild cognitive impairment.

BACKGROUND: In patients with mild cognitive impairment (MCI), enhanced cerebral amyloid-ß plaque burden is a high-risk factor to develop dementia with Alzheimer's disease (AD). Not all patients have immediate access to the assessment of amyloid status (A-status) via gold standard methods. It may therefore be of interest to find suitable biomarkers to preselect patients benefitting most from additional workup of the A-status. In this study, we propose a machine learning-based gatekeeping system for the prediction of A-status on the grounds of pre-existing information on APOE-genotype 18F-FDG PET, age, and sex. METHODS: Three hundred and forty-two MCI patients were used to train different machine learning classifiers to predict A-status majority classes among APOE-ε4 non-carriers (APOE4-nc; majority class: amyloid negative (Aß-)) and carriers (APOE4-c; majority class: amyloid positive (Aß +)) from 18F-FDG-PET, age, and sex. Classifiers were tested on two different datasets. Finally, frequencies of progression to dementia were compared between gold standard and predicted A-status. RESULTS: Aß- in APOE4-nc and Aß + in APOE4-c were predicted with a precision of 87% and a recall of 79% and 51%, respectively. Predicted A-status and gold standard A-status were at least equally indicative of risk of progression to dementia. CONCLUSION: We developed an algorithm allowing approximation of A-status in MCI with good reliability using APOE-genotype, 18F-FDG PET, age, and sex information. The algorithm could enable better estimation of individual risk for developing AD based on existing biomarker information, and support efficient selection of patients who would benefit most from further etiological clarification. Further potential utility in clinical routine and clinical trials is discussed.

Gatekeeping astrocyte identity.

New findings cast doubt on whether suppressing the RNA-binding protein PTBP1 can force astrocytes to become dopaminergic neurons.

"Mental Readiness" and Gatekeeping in Trans Healthcare.

Gatekeeping refers to clinicians' strict application of eligibility criteria to determine a trans patient's "fitness" to engage in medical transition, resulting in significant barriers to gender-affirming care. Gatekeeping often uses "mental readiness" as a prerequisite to medical transition, which contributes to patient distress and systemic discrimination. Changing international trans health guidelines (the new World Professional Association for Transgender Health Standards of Care version 8) recommends clinicians shift from a gatekeeping model towards an informed consent model, which improves access to care. This commentary offers recommendations on how clinicians can reconsider existing "mental readiness" frameworks around medical transition to facilitate improved access to care.

Managing multiplicity in clinical vaccine studies - A case study using a gatekeeping testing strategy.

BACKGROUND: Multiplicity issues are increasingly common in vaccine clinical studies. Common causes include multi-valent combinations/co-administrations requiring separate evaluation of each antigen; numerous efficacy endpoints; requests from regulatory authorities for inclusion of specific powered endpoints into registration studies; interim analyses to support early decision-making. In a Phase III study to evaluate safety and immunogenicity of the 4-component Neisseria meningitidis serogroup B vaccine (4CMenB) when co-administered with 13-valent pneumococcal conjugate vaccine (PCV13) to healthy infants, a total of 49 statistical hypotheses were identified for the primary objectives as requested by the health authority. We designed a sequential testing strategy with visualization using a graphical gatekeeping procedure. METHODS: The 49 immunogenicity objectives related to evaluation of the sufficiency of the 4CMenB immune response; and demonstration of non-inferiority of PCV13 and 4CMenB when co-administered versus administration alone. We used a graphical shortcut display for closed families assuming that the multiple testing procedure is consonant and hypotheses that are rejected by a closed testing procedure are also rejected within the graphical short-cut. The 49 hypotheses were grouped into 10 families and distributed over 4 sequential steps following the clinical and statistical logical relationships agreed with the clinical team. Test decisions within the first 8 families will be made based on p-values with alpha propagation to subsequent families according to the tree structure. RESULTS: This tailored strategy allowed evaluation of all 49 statistical hypotheses individually, and more efficiently. The method avoided a rigid all-or-nothing approach whereby all endpoints fail if one or more null hypotheses cannot be rejected. Clinical input and agreement are critical for designing an efficient and fit-for-purpose strategy. Our experience could encourage more application of such strategies in increasingly complex clinical trials.

Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study.

BACKGROUND: Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor-patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed. OBJECTIVE: To explore Norwegian GPs' perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider 'unreasonable'. METHODS: A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation. RESULTS: The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an 'unreasonable' patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs' gatekeeping role among peers and from authorities. CONCLUSION: Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required.

Breve reflexão sobre a aferição de temperatura em ambientes públicos para controle da COVID-19 / Notes on temperature measurement in public environments for COVID-19 control / Breve reflexión sobre medición de temperatura en ambientes públicos para el control de COVID-19

A Covid-19 é uma doença causada pelo betacoronavírus SARS-CoV-2. O vírus é transmitido pelo contato interpessoal próximo, por meio de gotículas respiratórias. Dentre as medidas de prevenção contra contágio e disseminação da doença, é recomendado a higienização das mãos com água e sabão e/ou álcool em gel e o afastamento social, uso de máscaras de pano e a aferição da temperatura utilizando termômetro digital infravermelho para o controle de acesso nos ambientes públicos, a fim de impedir possíveis portadores sintomáticos do vírus. Temos por objetivo, refletir sobre a eficácia da aferição da temperatura em ambientes públicos utilizando termômetro digital com sensor de infravermelho. Baseado nos conhecimentos da fisiologia da temperatura corporal e processos febris, apresentados na literatura especializada, e na experiência da identificação de portadores utilizando o procedimento de aferição de temperatura descrito, é evidente a necessidade de uma elaboração de políticas públicas de combate à pandemia mais abrangente, que enfatize a necessidade do conjunto das medidas sanitárias. Aliado a isso, é necessário um programa de testagem contínuo e em massa, permitindo o mapeamento e a busca por auxílio e orientação médica especializada, bem como um programa de educação e conscientização da população para a necessidade de quarentena e isolamento social em casos suspeitos que apresentem sintomas de pirexia.

Covid-19 is a disease caused by the betacoronavirus SARS-CoV-2, which is transmitted through close interpersonal contact through respiratory droplets. Among the preventive measures against contagion and dissemination, the guidelines recommend hand hygiene with water and soap or hand sanitizer, social withdrawal, use of cloth masks and temperature measurement using digital infrared thermometer for access control in public environments to prevent possible symptomatic carriers. This study sought to reflect on the effectiveness of measuring temperature in public environments using a digital infrared thermometer. Based on specialized literature on body temperature physiology and febrile response, as well as on the practice of carrier identification by temperature measurement, the research point to the need of elaborating more comprehensive public policies to combat the pandemic, emphasizing a combination of health measures. Moreover, a continuous and mass testing program is needed, allowing the mapping and search for specialized medical help, as well as an education and awareness program on the need for quarantine and social isolation is symptomatic carriers.

Covid-19 es la enfermedad causada por el betacoronavirus SARS-CoV-2. El virus se transmite por contacto interpersonal cercano, a través de gotitas respiratorias. Entre las medidas preventivas contra el contagio y propagación de la enfermedad, se recomiendan la higiene de manos con agua y jabón y / o gel de alcohol y el retraimiento social, el uso de mascarillas de tela y la medición de la temperatura mediante un termómetro digital infrarrojo para su control. para prevenir posibles portadores sintomáticos del virus. Nuestro objetivo es reflexionar sobre la efectividad de medir la temperatura en entornos públicos utilizando un termómetro digital con sensor de infrarrojos. Con base en el conocimiento de la fisiología de la temperatura corporal y los procesos febriles, presentado en la literatura especializada, y en la experiencia de identificación de portadores mediante el procedimiento de medición de temperatura descrito, se evidencia la necesidad de la elaboración de una política pública más integral para combatir la pandemia., que enfatiza la necesidad de todas las medidas sanitarias. A ello se suma un programa de pruebas continuas y masivas, que permitan el mapeo y búsqueda de asistencia y orientación médica especializada, así como un programa de educación y sensibilización de la población sobre la necesidad de cuarentena y aislamiento social en casos sospechosos, que presentan síntomas del pirexia.

Challenges of Clinical Research Administration During the COVID-19 Pandemic.

In early 2020, clinicians and researchers rushed to understand the SARS-CoV-2 virus and how to go about treating and preventing it. Caring for patients while simultaneously learning about a disease not seen before created challenges on several levels. Much of the spotlight was on the researchers doing this critical work; however, these narratives remind us of the enormous effort and commitment shown by IRB members and research administrators responsible for research infrastructure. Despite the sense of urgency and obligation to plan and conduct clinical research during the pandemic, IRBs guaranteed that researchers still adhered to the core ethical principles that protect the rights and welfare of human subjects so that critical research could continue. Many themes emerge in these stories, including the need for flexibility in processes for both staff and research participants and the perception that IRB members serve as "research gatekeepers." With approaches to clinical research evolving, the SARS-CoV-2 pandemic may be the catalyst needed to make sustainable improvements to our research processes, roles, and goals.

Patient Choice and Willingness Toward Gatekeepers as First-Contact Medical Institutions in Chinese Tiered Healthcare Delivery System: A Cross-Sectional Study.

Introduction: Gatekeeping mechanism of primary care institutions (PCIs) is essential in promoting tiered healthcare delivery system in China. However, patients seeking for higher-level institutions instead of gatekeepers as their first contact has persisted in the past decade. This study aims to explain patients' choice and willingness and to provide potential solutions. Methods: A survey was conducted among residents who had received medical care within the previous 14 days. Patients' choice and willingness of PCIs for first contact together with influencing factors were analyzed using binary logistic regression. Results: Of 728 sampled patients in Hubei, 55.22% chose PCIs for first contact. Patients who are older, less educated, with lower family income, not living near non-PCIs, with better self-perceived health status, only buying medicines, and living in rural instead of urban area had significantly higher probability of choosing PCIs. As of willingness, over 90% of the patients inclined to have the same choice for their first contact under similar health conditions. Service capability was the primary reason limiting patients' choice of PCIs. Conclusions: The gatekeeper system did not achieve its goal which was 70% of PCIs among all kinds of institutions for first contact. Future measures should aim to improve gate-keepers' capability.

Barriers and Facilitators to Adolescent and Young Adult Cancer Trial Enrollment: NCORP Site Perspectives.

Background: Although it is well documented that adolescents and young adults (AYAs) with cancer have low participation in cancer clinical trials (CCTs), the underlying reasons are not well understood. We used the National Cancer Institute Community Oncology Research Program (NCORP) network to identify barriers and facilitators to AYA CCT enrollment, and strategies to improve enrollment at community-based and minority and/or underserved sites. Methods: We performed one-on-one semistructured qualitative interviews with stakeholders (NCORP site principle investigators, NCORP administrators, physicians involved in enrollment, lead clinical research associates or clinical research nurses, nurse navigators, regulatory research associates, patient advocates) in the AYA CCT enrollment process. NCORP sites that included high and low AYA-enrolling affiliate sites and were diverse in geography and department representation (eg, pediatrics, medical oncology) were invited to participate. All interviews were recorded and transcribed. Themes related to barriers and facilitators and strategies to improve enrollment were identified. Results: We conducted 43 interviews across 10 NCORP sites. Eleven barriers and 13 facilitators to AYA enrollment were identified. Main barriers included perceived limited trial availability and eligibility, physician gatekeeping, lack of provider and research staff time, and financial constraints. Main facilitators and strategies to improve AYA enrollment included having a patient screening process, physician endorsement of trials, an "AYA champion" on site, and strong communication between medical and pediatric oncology. Conclusions: Stakeholders identified several opportunities to address barriers contributing to low AYA CCT enrollment at community-based and minority and/or underserved sites. Results of this study will inform development and implementation of targeted interventions to increase AYA CCT enrollment.

Recommending no further treatment: Gatekeeping work of generalists at a Japanese university hospital.

In medical decision-making, doctors have to take into consideration whether patients' expectations can be satisfied while appropriately allocating medical resources. This study explores how recommendations for no further treatment, or gate-closing recommendations, are resisted by patients and how doctors react to resistance in outpatient consultations at a university hospital in Japan. We show how the type of patient resistance shapes doctors' reactions. Problem-focused resistance problematizes the doctor's understanding of the patient's problem or the treatment itself without focusing on the gate-closing aspect of a recommendation, and is met with doctors' persuasion through diagnosis-based accounts. Provider-focused resistance focuses on the gate-closing aspect of a recommendation, and leads doctors to manage their dual roles as patient advocate and resource steward. Two subtypes of provider-focused resistance further shape this work differently. Unwillingness-focused resistance is met with persuasion mainly through institution-based accounts. Unavailability-focused resistance is met with a concession. Doctors systematically respond to patients' resistance in order to reach an agreement during decision-making. They take measures to reconcile their dual roles, and orient themselves toward the implicit rationale of gatekeeping, which has a moral nature.

Phone triage nurses' assessment of respiratory tract infections - the tightrope walk between gatekeeping and service providing. A qualitative study.

BACKGROUND: Phone nurses triage callers to Norwegian out-of-hours cooperatives to estimate the appropriate urgency and level of care for the caller. Many callers with mild symptoms of respiratory tract infections receive a doctor's consultation, which may lead to busy sessions and in turn impair clinical decisions. OBJECTIVE: This study explores how phone triage nurses assess callers with mild-to-moderate symptoms of respiratory tract infections and their views and experiences on triaging and counselling these callers. METHODS: We conducted four focus groups with 22 nurses (five men and 17 women aged 24-66 years) in three different locations in Norway. The interviews were transcribed verbatim and analysed by systematic text condensation. RESULTS: The informants were reluctant to call themselves gatekeepers. However, their description of their work indicates that they practice such a role. When nurses and callers disagreed about the right level of care, the informants sought consensus through strategies and negotiations. The informants described external factors such as organisational or financial issues as decisive for the population's use of out-of-hours services. They also described callers' characteristics, such as language deficiency and poor ability to describe symptoms, as determining their own clinical assessments. CONCLUSIONS: Nurses perceive assessments of callers with respiratory tract infections as challenging. They need skills and time to reach a consensus with the callers and guide them to the right level of health care. This should be considered when planning nurse training and staffing of out-of-hours cooperatives.KEY-POINTSPhone triage nurses assess callers to the out-of-hours service and estimate the level of urgencyThis study explores how phone triage nurses assess callers with respiratory tract infections and their views and experiences on this taskThe nurses describe their professional role as a tightrope walk between gatekeeping and service providingThe nurses seek consensus with callers through strategies and negotiations.

Delayed healthcare access among victims of sexual abuse, understood through internal and external gatekeeping mechanisms.

BACKGROUND: Sexual abuse is associated with severe health consequences, and the European Union has, through the Istanbul Convention, urged its member countries to provide specialist care for victims of sexual abuse. AIM: This aim of this study was to investigate patient- and abuse-related characteristics among patients seeking help at a specialist clinic in Sweden, with focus on disclosure, mental health and appropriate healthcare access. METHODS: This is a descriptive study where journal data from 100 consecutive patients January 2017 to February 2018 were analyzed. All adult individuals (women n = 80, men n = 8) who had taken part in the standardized semi-structured intake interview at the clinic were included (n = 88). RESULTS: At admission, mean age was 40.3 (SD 11.9), mean number of psychiatric diagnoses 6.3 (2.6), and 93% of the patients scored above cut-off (≥34) on IES-R for PTSD. A majority of the patients (87%) had been exposed to childhood sexual abuse (CSA), and mean time to first disclosure was 15.9 (SD 15.3) years. In total, 82% of the patients had, despite disclosure, experienced difficulties accessing appropriate healthcare before coming to the specialist clinic. CONCLUSION: Adult victims of sexual abuse have difficulties accessing appropriate healthcare. This constitutes a gender-based equality problem. A model of gatekeeping mechanisms with two dimensions (external and internal) and three categories (Competence related, Organizational and Emotional) is proposed to understand these difficulties.

Effectiveness of primary care gatekeeping: difference-in-differences evaluation of a pilot scheme in China.

INTRODUCTION: This paper evaluates the effectiveness of a gatekeeping pilot in shifting resources and patient visits from hospitals to primary care facilities under the Chinese New Rural Cooperative Medical Scheme. METHODS: We applied a difference-in-differences regression analysis using claims data from a pilot district in northern China. The study covered 200 685 enrollees in 17 townships in 2012 and followed-up the townships over 12 year-quarters until the end of 2014. RESULTS: The gatekeeping pilot led to significantly more patients visiting primary care facilities (55.3%, p=0.001), but there was little evidence of increased ambulatory spending on primary care (1.6%, p=0.884). The pilot reduced hospital visits by 23.9% (p=0.048) and ambulatory spending at the hospitals by 22.4% (p=0.011). CONCLUSIONS: This first impact evaluation of gatekeeping outside high-income countries found that gatekeeping policy did not seem to have expanded the care provided by primary care facilities, despite an increased volume of claimed visits. Although claimed patient visits and expenditure at hospitals reduced, we suspect this may have been because patients found it either cumbersome or difficult to obtain reimbursement for their care.

Using ex-ante economic evaluation to inform research priorities in pesticide self-poisoning prevention: the case of a shop-based gatekeeper training programme in rural Sri Lanka.

OBJECTIVES: Suicide by pesticide self-poisoning is a major public health challenge in low- and middle-income countries. While effectiveness studies are required to test alternative prevention approaches, economic evidence is lacking to inform decision-making in research priority setting. Therefore, this study aimed to estimate the costs of a shop-based gatekeeper training programme for pesticide vendors seeking to prevent pesticide self-poisoning in rural Sri Lanka and assess its potential for cost-effectiveness. METHODS: Ex-ante cost and cost-effectiveness threshold (CET) analyses were performed from a governmental perspective based on a three-year analytic horizon, using 'no programme' as a comparator. A programme model targeting all 535 pesticide shops in the North Central Province and border areas was applied. Total programme costs (TPC) were estimated in 2019 USD using an ingredients approach and 3% annual discounting. The Sri Lankan gross domestic product per capita and life years saved were used as CET and effectiveness measure, respectively. Sensitivity analyses were performed. RESULTS: TPC were estimated at 31 603.03 USD. TPC were sensitive to cost changes of training material and equipment and the programme lifetime. The programme needs to prevent an estimated 0.23 fatal pesticide self-poisoning cases over three years to be considered cost-effective. In the sensitivity analyses, the highest number of fatal cases needed to be prevented to obtain cost-effectiveness was 4.55 over three years. CONCLUSIONS: From an economic perspective, the programme has a very high potential to be cost-effective. Research assessing its effectiveness should therefore be completed, and research analysing its transferability to other settings prioritised.

OBJECTIFS: Le suicide par auto-intoxication par les pesticides est un défi majeur de santé publique dans les pays à revenu faible ou intermédiaire. Bien que des études d'efficacité soient nécessaires pour tester d'autres approches de prévention, les données économiques manquent pour informer la prise de décision dans les priorités de recherche. Par conséquent, cette étude visait à estimer les coûts d'un programme de formation des vendeurs dans les magasins de pesticides visant à prévenir l'auto-intoxication par les pesticides dans les régions rurales du Sri Lanka et à évaluer son potentiel de rentabilité. MÉTHODES: Les analyses ex-ante des coûts et des seuils de rentabilité (SR) ont été réalisées dans une perspective gouvernementale sur la base d'un horizon analytique de trois ans, en utilisant «l'absence de programme¼ comme comparateur. Un modèle de programme ciblant les 535 magasins de pesticides de la province du Centre-Nord et des zones frontalières a été appliqué. Les coûts totaux du programme (CTP) ont été estimés en USD 2019 en utilisant une approche d'ingrédients et une remise annuelle de 3%. Le produit intérieur brut sri-lankais par habitant et les années de vie sauvées ont été utilisés comme SR et mesure d'efficacité, respectivement. Des analyses de sensibilité ont été effectuées. RÉSULTATS: le CTP a été estimé à 31.603,03 USD. Le CTP était sensible aux changements de coût du matériel et de l'équipement de formation et de la durée de vie du programme. Le programme devrait prévenir environ 0,23 cas d'auto-intoxication mortelle par des pesticide sur trois ans pour être considéré comme rentable. Dans les analyses de sensibilité, le plus grand nombre de cas mortels à prévenir pour obtenir une rentabilité était de 4,55 sur trois ans. CONCLUSIONS: D'un point de vue économique, le programme a un potentiel très élevé pour être rentable. La recherche évaluant son efficacité doit donc être complétée et la recherche analysant sa transférabilité à d'autres contextes doit être priorisée.