Short-term medical relief trips from the United States to destinations in developing countries are common, with an estimated hundreds of trips traveling from the United States yearly [
Since 2006, the Virginia Commonwealth University (VCU) Department of Internal Medicine has been sending a team of internists to rural Honduras to provide medical services, largely emphasizing the treatment of acute illnesses. Since 2008, our group has focused its efforts on two communities in the Department of Yoro area of Northern Honduras; a remote, mountainous area in and around the town of La Hicaca, and several communities near the more developed city of Olanchito (Coyoles).
Our group created the Adult Health Initiative (AHI) in 2009 to help optimize and standardize the care provided by the relief team, as well as to begin addressing chronic illness [
During the first part of the June 2010 brigade (in the area in and around La Hicaca) the traditional “one patient one provider” encounter mechanism was used. Under the individual provider system, each physician was responsible for addressing all of the elements on the clinical encounter form, including assessment for diabetes, osteoarthritis, gastrointestinal illness, and candidacy for antihelminthic therapy and multivitamins. In Coyoles, the new “team-based” encounter mechanism was employed. With the team-based approach, four stations were established (Figure
Team-based encounter mechanism.
Clinical encounter form.
We examined the effectiveness of the traditional versus the team-based clinical encounter methods. Outcomes of interest included provider compliance with screening for diabetes, gastrointestinal and dermatologic conditions, along with assessment for candidacy of antihelminthics and multivitamins. We also examined differences in other measures of care, including the proportion of patients diagnosed with osteoarthritis, gastrointestinal illnesses, diabetes and physical therapy education, and medications prescribed.
Two clinical encounter mechanisms, the “traditional” one patient to one physician model versus the “team-based” encounter method were compared, respectively, between La Hicaca and Coyoles (Table
Comparison of clinical encounter methods.
Variable | Team based | Traditional | Team based versus traditional |
---|---|---|---|
Compliance with diabetes screen | 311 (99%) | 61 (39%) | |
Blood glucose value checked | 132 (42%) | 9 (5.9%) | |
Diabetes education handout given | 14 (4.5%) | 2 (1.3%) |
*
|
Compliance with antihelminthic therapy candidacy screen | 304 (96.8%) | 139 (90.8%) | |
Diagnosis of osteoarthritis | 72 (22.9%) | 27 (17.6%) | |
Home PT handout given | 29 (9.2%) | 12 (7.8%) | |
Prescribed an analgesic | 287 (91.4%) | 123 (80.4%) | |
Prescribed acetaminophen | 263 (83.3%) | 86 (56.2%) | |
Prescribed ibuprophen | 55 (17.5%) | 40 (26.1%) | |
Diagnosis of dyspepsia | 23 (7.3%) | 14 (9.2%) | |
Diagnosis of GERD | 191 (60.8%) | 34 (22.2%) | |
Prescribed an H2/PPI | 152 (48.4) | 44 (28.8%) | |
Prescribed an MVI | 297 (94.6%) | 120 (78.4%) | |
Women of childbearing age prescribed an MVI | 150 (87.2%) | 93 (92.1%) | |
Prescribed topical antifungals | 52 (16.6%) | 15 (9.8%) |
*Fisher’s exact test.
There were 338 patients interviewed at the Coyoles site, and 153 patients interviewed at La Hicaca. Twenty-four patients at Coyoles were not interviewed using the team-approach, and so they were excluded from the method analysis. This left a total of 314 patients interviewed and treated using the team-based approach, and 153 patients interviewed using the traditional method (Table
The team-based encounter mechanism resulted in increased adherence with clinical evaluation elements. For diabetes screening, Chi-square analysis revealed a significant difference between methods, with 311 (99%) patients screened with the team-based method and 61 (39%) patients screened with the traditional method,
No statistically significant difference was observed for compliance with diabetes education, with 14 (4.5%) patients receiving a diabetes education handout through the team model and 2 (1.3%) patients receiving diabetes education handouts through the traditional approach,
Medical relief work in developing countries is common. The VCU Honduras program consists of a team of physicians, residents, students, and pharmacists. Over the years, the VCU Honduras relief effort has provided direct medical care for acute and chronic conditions to the same rural Honduran communities [
The AHI project was designed to help lay the groundwork to better assess and address other noninfectious chronic illnesses of public health significance, including diabetes, hypertension, and obesity. The Pan American Health Organization’s report on Health in the Americas stated that 36% of the adult population of Tegucigalpa was overweight and another 23% were obese. This same report found the prevalence of diabetes in this population at 7.8%, nearly half of whom were unaware of their diagnosis. In 2004 the incidence of diabetes was 593 per 100,000 people [
Recognizing that care across providers on relief trips is often inconsistent, the novel team-based encounter mechanism was developed in an attempt to increase physician uniformity and adherence to health screening as specified in the encounter form. The traditional clinical encounter mechanism involves one practitioner completing the entire form with each patient. The team-based approach divides the encounter across four separate stations and providers. We believe that this method increases compliance by creating a more focused, goal-oriented encounter at each station, allowing for better, less fragmented and more thorough patient care.
Based on our experience, when different providers are expected to complete an entire encounter form per patient, discrepancies in information obtained and varying levels of completeness are observed. Any number of factors can affect this, from communication difficulties with the patient to provider fatigue. Incomplete data hinders our efforts to best tailor our medical relief program to the public health needs of the population.
We documented a significant improvement in compliance with many aspects of patient evaluation, favoring the team-based encounter mechanism over the traditional method. Under a team-based encounter approach, screening for diabetes, osteoarthritis, dermatologic conditions, and antihelminthic therapy was more successful. These were all performed prior to the final clinical and summary encounter with a physician. This format also led to increased frequency of GERD diagnosis, and a greater number of medication prescriptions written for analgesics and MVIs.
A potential disadvantage of the new team-based method is the loss of continuity between patient and provider during a single encounter. By rotating through stations, the patient meets with a minimum of four different physicians during one encounter. This system could disrupt the flow of the visit and be uncomfortable or distracting for the patient. It may also give the impression that patients are being processed through the medical equivalence of an assembly line. In this way the traditional approach is better at supporting patient-provider continuity during an encounter.
A total of 338 patients were examined at Coyoles, and 153 patients were examined in La Hicaca. On average, 84 patients were interviewed per day over the 4 days in Coyoles while 51 patients were interviewed per day in La Hicaca over 3 days. We believe that the team-based encounter mechanism did not adversely affect patient throughput during the clinic sessions. Although subject to a standardized, more structured approach, the stations likely allowed for quicker and more focused data collection without compromising clinical care and face-to-face time with a physician.
The utilization of a structured, team-based clinical encounter mechanism allowed us to more thoroughly and methodically assess both acute and chronic illnesses of public health concern, such as antihelminthic candidacy screening, obesity, diabetes, dermatologic infections, and osteoarthritis. This approach is of benefit to the patients as the spectrum of their medical concerns is fully addressed during the course of a structured, station-based encounter.
There is a paucity of data on the optimal clinical encounter mechanism for medical relief trips to developing countries, and this study adds to the small body of literature as an example of how to better structure a medical relief brigade in this environment.
Our study has several strengths. The same team of physicians traveled to both sites, allowing for consistent interview personnel regardless of which approach was used. Also, the data used to compare methods was collected on the same medical relief trip, eliminating change in population over time as a confounder. A major limitation of our study is that patients were not randomized to either encounter method group. Rather, the traditional model and the team-based models were employed in two different towns. While both are poor and have limited access to healthcare, nuanced differences may exist in demography and health status. La Hicaca, where the traditional method was used, is a rural, mountainous region located 75 kilometers from the nearest city and medical center. However, Coyoles, where the new team-based approach was employed, is in a flatter, more urbanized setting about 15 kilometers from a metropolitan center. It is possible that health differences in these populations may exist owing to different environments and to differing levels of healthcare access. These differences may have affected the disparities in diagnoses and prescription patterns observed between the two encounter methods. Of note, the community with the greatest poverty and isolation (La Hicaca), evaluated by the traditional encounter method, had a smaller proportion of patients with GERD, and received less H2/PPI medications. This may be a reflection of missed diagnostic and therapeutic opportunities by the traditional encounter or a marker of better health status.
These findings have important implications for future medical relief trips, including a more efficient restructuring of clinical workflow and a better ability to assess and address chronic disease. By better addressing chronic illness and optimizing various aspects of our public health focus, the data from the AHI project will allow us to more effectively address the health needs of select communities in Northern Honduras.
The authors thank Reena Hemrajani, M. D., Daniel Markley, D. O., and Kara Elam, M. P. H.