Subspecialty Clinics Require Evidence of Efficacy

Academic health science centers use groupings of patients as one method to deliver high quality care. In pediatric gastroenterology, for example, regional centers have been developed to provide subspecialty consultative care to children with chronic inflammatory bowel diseases, with feeding and swallowing disorders, requiring home parenteral alimentation, and with chronic viral hepatitis. The advantages of such consolidation of complex tertiary care patients into areas of specialization are apparent. Health care providers are able to acquire increased knowledge about the investigation and management of difficult and unusual problems that otherwise might not be encountered on a regular basis. Such foci of care also have the potential to promote access to a variety of resources including, for example, surgeons, other pediatric subspecialists, specialized nurses, dietitians, medical social workers, and pharmacists. They also may serve as units in which clinical nurse practitioners and nurse specialists can develop focused skills and expertise. Similarly, exposure to groups of patients in one setting may be educationally valuable to a variety of learners, including physicians of the future. Some have proposed that these focused care centers also provide psychologic and social support for parents and older children and adolescents by providing the potential for interactions among families coping with similar illnesses and associated stressors. The units also can serve to promote the recruitment of subjects into clinical research trials. Although the proposed advantage of these multidisciplinary care clinics, which focuses on aspects of the practice of pediatric gastroenterology, may seem to be self evident, there are other issues that require consideration. Such units are more expensive to operate compared with consultative care and follow-up provided by a private practice practitioner of the subspecialty. In addition, the centralized nature of the units frequently requires that families travel longer distances than would be required to access consultative care from a pediatric gastroenterologist in practice. Continuity of care can also prove less than optimal in centralized referral centers. These are concerns that should be the subject of careful comparative study rather than emotional debate. The findings could have an impact of the future use of limited health care resources in providing optimal care to children requiring management by pediatric gastroenterologists. In one study that set out to evaluate the efficacy of social work support for children with long-term illnesses, there was no evidence of improved psychosocial outcomes in response to social work support and counseling (Lancet 1987;2:411–415). It should be pointed out that the children evaluated in this study did not suffer from illnesses referable to the liver or gastrointestinal tract. A subsequent cross-sectional study performed in the United Kingdom reported that both nutritional status and lung function were better in patients with cystic fibrosis who received their care in regional centers compared with patients who had not (Br Med J 1998;316:1771–1775). Although an accompanying editorial raised concerns regarding whether the findings can be generalized (Br Med J 1998;316:1775), the implications should encourage practitioners and academicians to join together to determine in a prospective, comparative manner whether multidisciplinary care clinics for children and adolescents with other illnesses within our subspecialty are beneficial to patients and their families. Only in this way can we ensure that health care resources, including the talents and energy of pediatric gastroenterologists, are used in the most effective and efficient manner.

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