CTSA Program Researchers Aim to Improve Health Care from All Sides

January 7, 2019

Primary care doctors often used to spend their mornings visiting hospitalized patients, seeing patients in the office in the afternoons. In the 1990s, a new kind of doctor appeared in many hospitals—a general practitioner known as a hospitalist—who sees patients only in the hospital. David Meltzer, M.D., Ph.D., led the effort to establish the new specialty at the University of Chicago and to study how the introduction of hospitalists affected patient health.

Today, Meltzer has grown that initial study into a thriving framework for conducting research on how health care is delivered. During the past two decades, Meltzer’s team has enrolled more than 100,000 patients and conducted dozens of studies on topics ranging from prostate cancer treatment to how a language barrier affects a patient’s health after release from the hospital. The research framework is integrated into University of Chicago Medicine’s electronic health record (EHR) system, and a team member discusses potential studies to join with every patient who is admitted to the hospital for illness.

With support from NCATS’ Clinical and Translational Science Awards Program, the initiative includes funding for students to learn about research while enrolling patients in the studies. Meltzer leads the Learning Healthcare Systems Core at the Institute for Translational Medicine (ITM), a CTSA Program hub at the University of Chicago.

The Shift to Hospitalists

Today, hospitalists are standard across the country, but Meltzer’s early research showed that their introduction brought about only minimal improvements in patient outcomes—not enough of a change to justify the huge shift in how health care is delivered. Through further research, he and his colleagues found that hospitalists have become so common because doctors are busier now and have a much larger volume of patients.

"There has been an incredible increase during the past 20 years for things like cholesterol checks, mammograms—good preventive care," Meltzer said. "It’s not a bad thing; we just were not as attentive to those things in the past."

Turning some of the work over to hospitalists made sense, but studies have suggested that the relationship between a primary care doctor and a patient is important to health; Meltzer and other researchers suspect that something was lost in the shift to hospitalists.

Studying the Doctor-Patient Relationship

Now Meltzer is studying the value of returning to the way things used to be, with an idea called comprehensive care practice (CCP). In CCP, the same primary care doctor sees patients in or out of the hospital. Each doctor cares for only 200 patients, much less than the usual load, and the doctors are on call all the time. Through this approach, the doctors get to know each of their patients well.

Meltzer’s Ph.D. is in economics, and he calls this model for health care "basic social science," similar to the approach to basic biomedical research that is conducted in a laboratory.

"It was a fundamental insight into a mechanism," he explained. "The question now is how to translate that into practice." The study of CCP represents that next step.

The research team enrolls only very unhealthy people covered by Medicare. Each participant is assigned randomly either to receive standard care, involving hospitalists, or to have a CCP doctor. Preliminary results from the first 5 years of the study show that patients are happier and healthier if the same doctor cares for them all the time. On average, CCP patients also are hospitalized fewer times, which shows that they are managing their health better, thus resulting in significant savings for the hospital and for Medicare.

Meltzer and his colleagues are focusing on disseminating the work—another step in the translational process. They have funding from Medicare to work with other institutions on ideas for caring for very sick patients. Two other institutions have tried the program with their sickest patients, and like the University of Chicago, those institutions also have seen a decrease in hospitalizations. The New York Times recently published a story about CCP.

Recruiting Patients for a Wide Range of Studies

Throughout the 20 years of building his study framework, Meltzer has worked with a variety of collaborators at ITM institutions and organizations across the country to carry out studies on health care topics, such as how patients and providers communicate about health care costs; the risk of social isolation when an elderly patient is hospitalized; and whether text messages could help people manage their heart failure after they leave the hospital.

The heart of the framework is a fleet of undergraduate students who speak with every patient who is admitted to the hospital for illness. Each student has a list of patients to approach and a list of studies in which each patient might be eligible to participate. If a patient is interested, they receive consent forms for the studies and are asked to give permission for researchers to review their EHRs.

Meltzer noted that the trainees are integral to conducting the research.

"Our suite is full of students who are busy recruiting patients in the hospital and doing interviews and follow-up," he said. In addition to undergraduates, the trainees include high-school students, medical students, and CTSA Program Clinical Research KL2 Scholars. Many of them go on to lead similar research studies independently.

Training the Next Generation of Researchers

David Meltzer, M.D., Ph.D., is all smiles in clinic with Comprehensive Care Practice team members (left to right) Shermeka Wilson, L.P.N.; Nicole Gier, L.C.S.W.; and Anitra Thomas, R.N. (Photo by Kathleen Ferraro/Chicago ITM)

One of those former trainees is Micah Prochaska, M.D. Now an assistant professor at the University of Chicago, Prochaska first became interested in clinical research in 2002 when he started working for Meltzer as an undergraduate.

"Many undergrads were really interested in doing clinical research, and David realized he could organize that interest to collect data," Prochaska said. "In return, students get this incredible experience working with patients, learning how to administer a survey, and then publishing manuscripts and talking about it in medical school interviews."

Now, Prochaska is collaborating with Meltzer to study blood transfusion and fatigue. Patients are sometimes given a blood transfusion if their levels of hemoglobin, a protein that helps transport oxygen in the bloodstream, are too low. What matters to the patients, however, is not the numbers but how they feel after the transfusion. His current study is about finding better ways to measure fatigue.

Recruiting enough patients for a study is a key bottleneck for most clinical research, but Prochaska does not expect that to be a problem. In his grant application, he was able to show how efficiently Meltzer’s framework can recruit people to join studies. When awarding the grant, reviewers from NIH’s National Heart, Lung, and Blood Institute noted that they were confident that Prochaska would be able to find enough participants to accomplish his study’s goals.

Meltzer thinks his framework points the way to a learning health system in which investigators can continually learn from experience, grow, and change. The hospital’s EHRs provide a huge volume of data that, if patients give their consent, can be used to find new ways to improve.

Initiatives like CCP that strengthen the doctor-patient relationship also could increase research participation, according to Meltzer. "I think that restructuring care produces a real increase in trust," he explained. "Not only can we improve care, but we also can engage patients in the generation of much-needed knowledge."