Gatekeepers and Sentinels

Evaluations assessing precertification by nurse gatekeepers and onsite monitoring by nurse sentinels report inconclusive unique effects of these programs on the utilization, expense, and appropriateness of inpatient medical care. By applying the fixed- and random-effects paradigm of meta-analysis, this article consolidates the results of all relevant quasi-experiments conducted by an evaluation group of a large private insurer from 1986 to 1990. It determines the difference in effect between the target and comparison groups, reports this effect and its statistical range, and determines the pooled effect and its range. The random effects indicate that precertification will reduce admissions, and onsite, concurrent review will reduce length of stay, bed days, and inpatient ancillary expense. The precertification and onsite programs may reduce negative iatrogenic effects, thereby enhancing the patients' well-being. If applied to privately insured populations who are still served on a fee-for-service basis, the gatekeeper and sentinel effects of these programs may reduce utilization and expense; however, inference of these results to Medicare fee-for-service care remains problematical.