An educational framework for triage nursing based on gatekeeping, timekeeping and decision-making processes

INTRODUCTION: The role of the triage nurse has emerged in response to growing community demand for a more accessible and efficient emergency department (ED) service. The focus of triage research has been on measuring outcomes and improving the delivery of emergency care. This has meant that the context of care, and triage processes and practices have remained concealed. Thus, little evidence about the role and ways to prepare nurses for this role is available. The aim of this study was to provide insight and understanding needed to educate and support the triage nursing role in Australian EDs. METHODS: A 12-month ethnographic study of triage nursing practice was conducted in Sydney metropolitan EDs. Data were then collected from participant observation in four EDs and interviews with 10 triage nurses. Analysis used standard content and thematic analysis techniques. FINDINGS: Findings reveal that notions of timeliness, efficiency and equity are embedded in a culture of ED care. This sustains a particular cadence of care to which triage nurses are culturally oriented. Triage nurses maintain, negotiate and restore this cadence of emergency care by using gatekeeping, timekeeping and decision-making processes. CONCLUSION: The comprehensive study of triage nursing has led to the development of an educational framework based on the processes of gatekeeping, timekeeping and decision-making.     

Competition,gatekeeping, and health care access

We study gatekeeping physicians’ referrals of patients to specialty care. We derive theoretical results when competition in the physician market intensifies. First, due to competitive pressure, physicians refer patients to specialty care more often. Second, physicians earn more by treating patients themselves, so refer patients to specialty care less often. We assess empirically the overall effect of competition with data from a 2008–2009 Norwegian survey, National Health Insurance Administration, and Statistics Norway. From the data we construct three measures of competition: the number of open primary physician practices with and without population adjustment, and the Herfindahl–Hirschman index. The empirical results suggest that competition has negligible or small positive effects on referrals overall. Our results do not support the policy claim that increasing the number of primary care physicians reduces secondary care.     

A survey of the views of palliative care healthcare professionals towards referring cancer patients to participate in randomized controlled trials in palliative care

Goals of work  Clinical trials in palliative care (PC), especially randomised controlled trials (RCTs), are notoriously difficult to complete. One perceived challenge is gatekeeping, the reluctance of some healthcare professionals (HCPs) to refer patients for research studies. This study aimed to identify the extent of gatekeeping from palliative RCTs. Materials and methods  An anonymous questionnaire was sent to 597 HCPs with an interest in PC in Australia and New Zealand to assess their willingness to refer patients for RCTs. Respondents considered key issues that might affect their decision, documented willingness to refer to RCTs of increasing complexity in a hypothetical pain situation and documented the degree of patient inconvenience considered acceptable. Demographic data were collected. Main results  One hundred ninety-eight questionnaires were returned (33%), 122 from doctors and 76 from other HCPs. Very few were willing to refer to complicated studies involving many extra tests and/or hospital visits. Non-medical HCPs were less interested than doctors in studies that involved randomisation, placebo controls or double-blind methodology. The majority would refer patients for non-pharmacological studies, but were less willing to refer for pharmacological studies with possible side effects. Non-medical HCPs were less willing than doctors to refer to trials that involved patient inconvenience. Two factors predicted for greater willingness to refer: previous research experience and male gender. Conclusion  The survey revealed an unwillingness on the part of many HCPs to refer patients for RCTs in PC. It identifies trial-related factors that may encourage or discourage referral. Gatekeeping has the potential block recruitment and introduce a selection bias.     

Multiplicity Adjustment for Clinical Trials With Two Doses of an Active Treatment and Multiple Primary and Secondary Endpoints

Frequently, two doses of an active treatment, multiple primary and secondary endpoints are simultaneously considered in Phase III confirmatory clinical trials. For these trials, many traditional multiplicity adjustment procedures do not take into account the possible dose effect on each endpoint and the priority order of the primary and secondary endpoints, and therefore may have lower power. To gain power, we consider the problem as a three-dimensional multiplicity problem: one dimension concerns the multiple doses, one dimension concerns the priority order of the primary and secondary endpoints, and another dimension concerns the multiple endpoints in each priority category. We propose procedures that consider the dose order and the priorities of the endpoints to form closed procedures and therefore control the family-wise error rate. Furthermore, we consider procedures that provide control of type I error rates in clinically relevant subfamilies of comparisons, providing a pragmatic approach to maintain study power as compared to the traditional approaches for the ultimate overall strong control. Simulation results and a real data example show that the procedures proposed in this article in general are easy to use and have improved power.     

Multiplicity Issues in Clinical Trials With Multiple Objectives

Modern clinical trials for evaluating efficacy and safety of new treatments frequently include multiple objectives with questions of varying clinical importance. Answering them generally requires performing a number of statistical tests and analyses which raise multiplicity of tests issues. These issues can be complex and multidimensional in nature. For example, one dimension may relate to the assessment of the effects of the treatment on multiple endpoints, the other to the effects of multiple doses of the treatment, and yet another to the type of the tests (e.g., superiority or noninferiority-type tests). Also, the trial may seek claims for treatment benefits either for the total patient population or for targeted subgroups. In addition, there may be interest in finding whether or not a certain consistency of results persists across certain multiple endpoints; in some situations this may be measuring different but critical features of a disorder, or in other situations may be measuring the same underlying pathophysiology of the disorder. Addressing such problems in clinical trials for the purpose of controlling the Type I error rate requires the use of advanced statistical test strategies and methods, some of which have only recently appeared. Actually, the last decade has witnessed a number of novel methods as well as innovative extensions of old methods for addressing complex multiplicity problems in clinical trials. The main purpose of this article is to present—at the conceptual level—how multiplicity issues of confirmatory clinical trials that include multiple objectives can be addressed by using some of these new statistical methods that use α-propagation and gatekeeping concepts. One additional goal of this contribution is to address some issues that often arise in the use of coprimary and composite endpoints in clinical trials.     

An enhanced mixture method for constructing gatekeeping procedures in clinical trials

ABSTRACT

It is increasingly common to encounter complex multiplicity problems with several multiplicity components in confirmatory Phase III clinical trials. These components are often based on several endpoints (primary and secondary endpoints) and several dose-control comparisons. When constructing a multiplicity adjustment in these settings, it is important to control the Type I error rate over all multiplicity components. An important class of multiple testing procedures, known as gatekeeping procedures, was derived using the mixture method that enables clinical trial sponsors to set up efficient multiplicity adjustments that account for clinically relevant logical relationships among the hypotheses of interest. An enhanced version of this mixture method is introduced in this paper to construct more powerful gatekeeping procedures for a specific type of logical relationships that rely on transitive serial restrictions. Restrictions of this kind are very common in Phase III clinical trials and the proposed method is applicable to a broad class of multiplicity problems. Several examples are provided to illustrate the new method and results of simulation trials are presented to compare the performance of gatekeeping procedures derived using this method and other available methods.     

Gatekeeping access to community mental health teams: a qualitative study

BACKGROUND: Gatekeeping access to services at the interface with primary care has been identified as one of the key issues that community mental health teams (CMHTs) have to confront. OBJECTIVES: The aim of this study was to develop a better understanding of the contextual influences that impact upon the outcome of gatekeeping decisions. DESIGN: An interview-based qualitative study, informed by the philosophy of critical realism. SETTING: An urban catchment area in Northern England. PARTICIPANTS: Twenty-nine interviews were conducted with gatekeeping clinicians and service managers. METHOD: A convenience sample of clinicians was initially approached to take part in a series of semi-structured interviews. This was followed up by a purposive sample of clinicians and service managers, as specific contextual influences were identified and explored in detail. The emerging analysis was then subjected to critical scrutiny by a further sample of gatekeeping clinicians. FINDINGS: A clear hierarchy of appropriateness was identified with four dimensions: severity, risk, beneficence and a moral dimension. It was suggested that the salient contextual influences that shaped the hierarchy were: (a) the need to fit in with strategic planning directives, (b) the burden of responsibility that clinicians carried, (c) the high number of referrals and the relatively slow turnover of patients on clinical caseloads, (d) the position of CMHTs in the economy of care and (e) the character of the relationship between clinicians and service managers. CONCLUSION: The findings from the study support a multi-level view of the gatekeeping process within CMHTs, which takes account of the role that key contextual influences play in shaping the range of options that are available to gatekeeping clinicians.     

Between iatrotropic stimulus and interiatric referral: the domain of primary care research

The “iatrotropic stimulus” is a typical example of Alvan Feinstein's terminology and his clinical way of thinking about medical research. Feinstein specified “interiatric referral” as an additional important factor affecting “the likelihood that patients will appear at the particular setting in which research is being conducted.” He emphasized these phenomena as highly relevant for clinical judgment, clinical research, and clinical epidemiology. This has stimulated the realization of original clinical research in international primary medical care. It has helped to recognize the characteristics of the spectrum of health problem and morbidity patterns presented to primary care physicians and to acknowledge the position of generalistic primary care research between open population research and clinical research in referred (specialist) care. Accordingly, primary care-specific challenges in investigating (early) diagnosis, prognosis, treatment, and referral decisions have emerged. This research supports adequate decision-making by the primary care physician, which is important for effective health care. Although Feinstein was a clinical specialist and has always lived in a country without a very strong primary care tradition, he not only recognized the value of primary care research but also substantially contributed to its development.     

Druggists and pharmacists as gatekeepers: Sales routines and compliance with sales protocols for over-the-counter naproxen 275 mg medicines in the Netherlands

Objectives

Since for the sales of over-the-counter (OTC) medicines, prescribing physicians are not involved, and written instructions on/in the medicine boxes are inefficient, druggists and pharmacists are important gatekeepers in preventing customers’ accidents. In this study we investigated the sales routines, and compliance with sales protocols, in order to evaluate that gatekeeper's function.

Methods

By means of the mystery shopping method, 228 pharmacies and drugstores in The Netherlands were visited and a naproxen 275 mg medium-risk medicine was requested for a (fictitious) patient who was suffering from severe back pains. According to the sales protocols the vendors should never sell the requested medicine, because the mystery shoppers only gave an answer to one of the four mandatory sales protocol questions. Furthermore, the requested medicine is not the right or best choice for back pains. Four different scenarios were used in a 2 × 2 design (8-year-old patient vs. 25-year-old patient, and 1 box with 12 pills vs. 3 boxes with 12 pills).

Results

Of the drugstores and pharmacies only 16.7% complied with the sales protocols and did not sell the specific (or comparable) medicine, after asking all four mandatory questions (or already after one, two or three questions). Most vendors (83.3%) did not comply and sold the requested medicine, a comparable medicine, or even a more risky medicine after no question at all (or after asking some or even all four questions). Although both score low, pharmacists show better compliance (23.9%) than druggists (10.1%).

Conclusions

When it comes to OTC medicines, druggists and pharmacists largely commit sloppy sales. The expected gatekeeping function of pharmacists and druggists is very limited, and customers might be in danger of inappropriate medicine selection, quantity and usage. We call for thorough evaluation of the over-the-counter system, improvement of the educational programs for medicine providers, and national campaigns to inform the public.     

The market for paid sick leave

In many countries, general practitioners (GPs) are assigned the task of controlling the validity of their own patients’ insurance claims. At the same time, they operate in a market where patients are customers free to choose their GP. Are these roles compatible? Can we trust that the gatekeeping decisions are untainted by private economic interests? Based on administrative registers from Norway with records on sick pay certification and GP-patient relationships, we present evidence to the contrary: GPs are more lenient gatekeepers the more competitive is the physician market, and a reputation for lenient gatekeeping increases the demand for their services.