Continuity in Gatekeepers: Quantifying the Impact of Care Fragmentation

Publication Date



Operational systems increasingly rely upon specialized experts who can provide high-quality service. However, these experts, by definition, only address one part of an overall problem and so individuals are needed to coordinate the overall service provision. In many services, this coordination responsibility may be shared across multiple parties serving in the role of a gatekeeper. In this paper, we explore the operational consequences of continuity or fragmentation in the role of a gatekeeper. We use a unique and comprehensive dataset from the Veterans Health Administration, the largest integrated healthcare delivery system in the United States to analyze over half a million patients over six years that suffer from a chronic disease, diabetes, whose successful management requires well-coordinated care. We examine how the continuity of care with their primary care physicians (PCPs), the gatekeeper in this environment, affects patients' health outcomes. Using an instrumental variables approach, we find that continuity of care is related to improvements in three important health outcomes: inpatient visits, length of stay, and readmission rate. In addition, we find that care continuity is even more important for patients suffering from more complex conditions. Finally, we investigate the intervening processes and find that continuity of care leads to a more efficient provision of effort and time, as measured by diagnostic tests ordered and time to see a specialist, respectively. Our results have important implications for both the theory and practice of operations management, in general, and healthcare, in particular.

Document Type



Gatekeepers, Coordination, Continuity of Care, Healthcare Operations, Empirical Operations


Business Administration, Management, and Operations




SMU Cox: IT & Operations Management (Topic)