Frequently hospitalized patients may benefit from new medical specialty focused on their needs

The model defining the role of hospitalists, who practice only in hospitals, was first identified in a 1996 article in the New England Journal of Medicine, said David O. Meltzer, an associate professor of medicine and director of the University of Chicago's Center for Health and the Social Sciences.

"Since that time, hospitalists have become the fastest-growing medical specialty in the United States, providing more than one-third of all general medical care in the United States," Meltzer wrote in the paper, "Coordination, Switching Costs and the Division of Labor in General Medicine: An Economic Explanation for the Emergence of Hospitalists in the United States," published by the National Bureau of Economic Research.

Meltzer discussed the growth of the field as well as the potential need for a new specialty -- the comprehensive care physician, who would specialize in care of the seriously ill on April 29 at a conference organized by the Milton Friedman Institute at the University of Chicago. The conference, "Individuals and Institutions in the Health Care Sector," also will look at issues such as technology and insurance.

The hospitalist specialty developed in response to the growing needs of severely ill patients, combined with reduced hospitalization of patients by general care or ambulatory physicians, Meltzer argues. As their number of hospitalized patients declined, general care physicians saw their travel costs loom large compared to the small number of hospitalized patients, Meltzer points out.

The use of hospitalists also has grown as hospitals have changed how they are reimbursed for their services, Meltzer contends. "Though the evidence that hospitalists produce savings is not consistent, it is clear that the growth of hospitalists accelerated as evidence to support cost-savings began to appear in the mid-1990s," he said.

The use of hospitalists has the potential of creating communication problems, however, as these specialists do not always know the full medical histories of their patients as well as those patients' general care physicians. The establishment of a specialty called the comprehensive care physician, or comprehensivist, could overcome that problem, Meltzer contends. The comprehensivist would work both in a hospital and an attached clinic and attend to those at greatest risk of hospitalization.

"Congestive heart failure, end-stage renal disease or liver disease, sickle cell disease or chronic-obstructive pulmonary disease might all be reasonable models for such care, especially if cases could be collected into centers of excellence with sufficient volume to support such degrees of specialization," he said.

Although the comprehensivist model has yet to be introduced in the United States, it is similar to other approaches in Canada, the United Kingdom, Australia and New Zealand, he said.