A laboratory to call his own
May 19, 2016
Growing up in Hyde Park during the 1970s, internist and health economist David Meltzer, PhD'92, MD'93, saw a city in crisis. Fraught with rising gang violence, an insidious drug trade and soaring homicide rates, Chicago's South Side was just beginning to struggle with many of the problems it still faces today.
"This is my home," said Meltzer, now chief of hospital medicine at the University of Chicago Medicine. "I wanted to be able to make a difference."
For the past two decades, he's been doing exactly that, investigating how to foster better health among the city's most vulnerable patients. Renowned for his work on medical cost-effectiveness, Meltzer has made a career of challenging convention and testing new models of care with the potential to dramatically improve outcomes.
His research includes a multiyear analysis of how better continuity in the doctor-patient relationship can improve the health of frequently hospitalized older adults. The Comprehensive Care Physician (CCP) Model, which has been supported by a $6 million award from the Center for Medicare and Medicaid Innovation, is a partnership between the University of Chicago Medicine and the University of Chicago's Health Lab. The Health Lab is part of the University's Urban Labs, an interdisciplinary incubator tackling some of the city's most pressing issues in health, crime, poverty, education, and energy and environment with the goal of exporting solutions to urban areas around the globe.
Generalist or specialist?
"We need to take the science of addressing social problems every bit as seriously as we take basic biological science," said Meltzer, who directs both the Health Lab and the University of Chicago's Center for Health and the Social Sciences. For him, that means applying insights from the science of economics to examine how hospital care can be done better.
"I've been trying to understand how one organizes physicians' work to improve care for as long as I've been doing research," Meltzer said.
He first started thinking about the value of specialization while working on his MD and PhD in economics in the early 1990s. At the time, the conventional wisdom was that physicians were too specialized. Several studies had demonstrated that patients cared for by specialists had worse outcomes - and higher costs of care - than those cared for by generalists.
But the studies were flawed, Meltzer said. After all, patients don't typically get randomly assigned to physicians, a fact the research failed to take into account. "If you're very sick and you want a lot of care, you're going to go to a specialist," he said. "So we shouldn't be surprised when those patients sometimes have poorer outcomes and spend a lot along the way."
The real issue, he says, was to determine the optimal degree of specialization: What was the right balance of care?
"You really needed to do experiments," said Meltzer, who chairs the University's Committee on Clinical and Translational Science. "And there was a wonderful natural experiment going on in the hospital every day." Depending on the day a patient is admitted, different physicians - specialists and generalists - are on call. So in theory, he said, "you can study whether that makes a difference."
Meltzer did his residency at Harvard-affiliated Brigham and Women's Hospital, where there was a thriving culture of research on quality of care and cost-effectiveness. "But I missed Chicago," he said. In 1996, he returned to Hyde Park as a faculty member, bringing with him a vision to transform the University of Chicago Medicine into a quality improvement laboratory.
Meltzer's homecoming happened just as a new type of specialty, the hospitalist, was gaining traction. Trained experts in inpatient care, hospitalists now provide roughly a third of all general medical care in U.S. hospitals. At the time, UChicago had just two of these specialists, and the head of general medicine wanted someone to evaluate the program's effectiveness.
"This was the study I had originally wanted to do, only now I had a new specialty to study," said Meltzer, who heads the ongoing University of Chicago Hospitalist Project. As the field has exploded over the past 20 years - UChicago Medicine now has more than 50 hospitalists on staff - Meltzer and his students have analyzed the specialty's impact on care, interviewing more than 100,000 patients.
Their finding: Care by hospitalists doesn't make as big a difference in outcomes as people hoped. "Length of stay and costs are a little better, but not dramatically," Meltzer said. While hospitalists have the advantage of inpatient expertise, there is a significant disadvantage: no ongoing relationship with the patient.
This finding led Meltzer to his next question: If hospitalists aren't producing better outcomes, why did the specialty grow so quickly? Traditionally, primary care physicians made hospital rounds to see their own patients who had been admitted. Meltzer's research revealed why that changed: Primary care physicians are so busy meeting the growing demand for preventive care from relatively health patients that they no longer have enough patients in the hospital on a daily basis to justify the trip. As hospitalists came on board to provide inpatient care, the division of labor deepened, not necessarily because it improved care, Meltzer said, but "because it was easier for doctors."
Strengthening the care model
The shift makes sense economically, but can shortchange those most in need of care. "It's not particularly good for the sickest patients who are in and out of the hospital all the time," Meltzer said. "Patients need to tell their story to a doctor in the hospital they don't know as well and often have to make complex decisions. Then they go home to a doctor who often doesn't fully understand everything that took place in the hospital."
This problem led Meltzer to an idea: What if you had a subgroup of primary care doctors who only saw patients at high risk of hospitalization? That's the premise of the Comprehensive Care Physician (CCP) Model, an experiment designed to strengthen continuity of care.
"CCP allows the most complex patients to receive the powerful benefits of a continuing relationship between the doctor and the patient," said Meltzer, who launched the study in 2012. The model makes it more feasible for physicians to maintain clinics and still provide inpatient care. In 2014, he added an offshoot program where physicians make house calls to homebound patients.
Today, the CCP program serves more than 600 Medicare beneficiaries - many from impoverished South Side neighborhoods - who are at increased risk of hospitalization. Results of the study aren't yet public, but look "incredibly promising," Meltzer said. His team is now exploring ways to expand the model locally and nationally. Strategies include partnering with local hospitals and community health centers to develop a hub-and-spoke network where CCPs connect outpatient and inpatient care for the highest-risk patients.
"The beauty of our model is that you can get clinical integration at the patient level, and you can have a competitive market with respect to hospitals and community health centers," he said. "By creating a continuing relationship with the doctor and a well-integrated team that includes a social worker and others, we're really able to help patients address the social determinants of health."
Mentoring for the future
As he translates economic insights into improved care, Meltzer is paving the way for physician-scholars around the country to think creatively about complex systems - and pursue unconventional career paths.
Nirav Shah, JD'07, MD'08, director of the Illinois Department of Public Health, draws from Meltzer's research as he manages the state's health budget. "Individuals in my chair have an obligation to think about spending as a giant cost-effectiveness problem," he said. "This way of thinking is not really typical in public health care circles."
Innovative thinking is a trademark of Meltzer's mentorship. As head of the University's dual-degree program in Medicine, the Social Sciences and Humanities - one of the only such programs in the country - he oversees students pursuing both an MD and a doctorate in a field outside the biological and physical sciences. His Hospitalist Scholars Training Program, a two-year program he founded to give young physicians time to pursue medical education and quality improvement research, attracts young physicians from around the country.
All of these endeavors echo Meltzer's original vision to turn the University of Chicago Medicine into a laboratory - and train researchers dedicated to lasting social change. Said Shah: "David has been such a friend, mentor and sounding board to so many people. He is rare among giants in that he has influenced the field not only through his scholarship, but through his mentorship."