Garrido, M. V., Zentner, A., & Busse, R. (2011). The effects of gatekeeping: A systematic review of the literature. Scandinavian Journal of Primary Health Care, 29(1), 28-38. doi:10.3109/02813432.2010.537015 This article reviewing the literature on the role of gatekeepers on health-care utilization looked at 32 studies on gatekeepers, mostly in the US (26 of 32 studies). The evidence generally suggests that there is less utilization of health care when there is a gatekeeper and there are cost savings – but there is no evidence on either patient satisfaction or health outcomes. The research on gatekeeping, to be convincing, needs to begin to respond to these larger questions about what happens when insurance companies or other bodies limit use of healthcare.
Fenton, J. J., Jerant, A. F., Bertakis, K. D., & Franks, P. (2012). The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Archives of Internal Medicine, 172, 405-411. Although client satisfaction is often thought to be a good thing – and in some ways it is – in this prospective study (N = 36-52,000, depending on the year of the study), greater client satisfaction was associated with more inpatient hospitalizations, greater total medical expenditures (medications and otherwise), and increased mortality. The authors speculate that the most satisfied patients had doctors who gave in to patient requests for medication, tests, and other services, which put them at greater risk of negative medical outcomes. Because this was a prospective study, it was possible to draw causal conclusions from the study's correlational data. This study is another in a series of articles from different fields suggesting difficulties in the idea of client satisfaction, at least suggesting that agencies should be concerned about relying only on client satisfaction as an outcome without also considering other metrics.