International Perspectives on General Internal Medicine
International Perspectives on General Internal Medicine
Jessica Greene ) 1
Mitchell D. Feldman
0 Division of General Internal Medicine, Department of Medicine, University of California, San Francisco , San Francisco, CA , USA
1 Marxe School of Public and International Affairs, Baruch College, City University of New York , New York, NY , USA
T Perspectives on General Internal Medicine features a
his inaugural theme issue of JGIM on International
collection of empirical papers from across the globe. In spite of
the heterogeneity of nations represented, these papers share a
remarkably consistent focus— examining innovative
strategies to ensure that patients have access to medical care and
related supports that they need to manage their health. The
research was conducted in countries that differ markedly in
terms of resources and health care infrastructure—from
highincome countries with universal health care coverage to a
country with a per capita annual income of less than $1500.
Despite these differences, the strategies discussed in these
studies push the boundaries of how to improve access to
medical care, particularly for vulnerable patients.
Three studies describe proactive efforts to make health care
available to patients in the community rather than requiring
them to go to the health care setting. In rural Kenya, Pastakia
and colleagues1 tested a model of integrating chronic disease
education and treatment into community-based microfinance
groups. This not only enabled participants to access health
care locally and in a supportive environment, but the
microfinance connection enabled participants to earn money
to pay for their health care. This study’s results were
promising; a relatively high percentage of those who screened
positive for hypertension or diabetes participated in the program
(72%), retention rates were high among those who participated
(70%), and the investigators observed meaningful declines in
participants’ blood pressure.
In Switzerland, where health insurance coverage is
universal, Bodenmann and colleagues2 sought to reduce reliance on
the emergency department (ED) by frequent ED users. They
provided patients with case management for social issues,
including income entitlements and housing; care coordination
counseling; and referrals to mental health services and
substance abuse treatment. The case management team had an
Bopen door policy,^ providing study participants with the
team’s phone number and address. The vast majority of those
randomized to receive case management proactively reached
out to the team (86%), as compared to not one of the patients in
the control group, who were also given the team’s contact
information but had no prior interaction with the team. The
intervention group also had a trend of fewer ED visits over 12
months compared with the ‘usual care’ control group.
Uittenbroek and colleagues’3 research focused on caring for
an aging population, a topic of concern in many countries.
Specifically, the authors sought to improve the care provided
to older adults in The Netherlands, living in the community, by
providing integrated health and social services. They varied
the intensity of the intervention based upon the patients’ risk
profile. For those assessed as being frail or having complex
health care needs, the care team conducted home visits once or
twice a month to address patients’ health and social concerns.
Patients receiving home visits reported an improvement in the
quality of care that they received, and health care providers
also reported substantial improvements in how integrated the
care for older adults had become.
Two additional studies examined approaches to removing
barriers to accessing care. In 2010, the Australian Government
reduced medication copayments for Indigenous Australians
with chronic conditions. First, Trivedi and colleagues4 found
that in areas with higher registration for the copayment
reduction program, the rates of chronic disease-related
hospitalization among Indigenous Australians declined by over 40
percent. This finding suggests that medication copayments were a
substantial barrier to accessing chronic care medication for this
vulnerable population and that reduced medication access may
have resulted in cascading impacts on health and utilization.
Second, Bahadin and colleagues5 sought to reduce barriers to
chronic care check-up visits for patients in Singapore. In
government clinics, patients with chronic conditions have quarterly
check-ups, which require patients to take a half day off from
work or other responsibilities. The study explored the feasibility
of replacing physician office visits with a check-up at an
unmanned health care kiosk for patients whose chronic conditions
were well controlled. The kiosk, which queried patients about
recent symptoms, took blood pressure measurements, and was
integrated with the electronic health record, showed promise for
providing flexible, reliable, and lower cost care to patients.
Almost all patients who piloted it found the kiosk easy to use
and were satisfied with using it rather than seeing the doctor.
While the approaches described in these studies showed
encouraging results, it is clear that substantial health and social
services system problems remain. Several articles highlight
racial, ethnic, and socioeconomic-based disparities in health
outcomes and health care utilization: from Indigenous
Australians experiencing 3–4-fold higher rates of
hospitalizations for chronic conditions compared with non-Indigenous
Australians to complex social issues resulting in higher rates of
ED use in Switzerland.
Another health concern highlighted in this issue is tobacco
use, which continues to be a significant cause of disability and
premature mortality worldwide. Unlike in the US, many
physicians in low- and middle-income countries continue to
smoke tobacco products, setting a negative example for their
patients and endangering their own health. Salgado and
colleagues6 report on a survey of current medical students and
recent graduates of the University of Buenos Aires in
Argentina. They found that over a quarter of these medical students
and junior physicians were smokers, a rate similar to that of the
general population, and only approximately half believed that
doctors should be an example to their patients by not smoking.
Many of the interventions, and components of the
interventions, evaluated in this issue are transferable to the US,
including open-door policies for case management teams, automated
check-ups for people with controlled chronic conditions,
integration of medical care and social services, reducing cost
sharing to vulnerable populations, and even integrating
chronic condition education and treatment into community-based
events in underserved areas. These ideas, in fact, seem to echo
Donald Berwick’s 1999 call for a system of care available to
patients B24/7/365,^ without barriers, limits, or controls.7
Almost 20 years after he articulated his vision, however, the US
is far from reaching this ideal. In fact, a recent study of
patients’ care experiences in 11 countries underscored the poor
access to care many experience in the US, several years after
the Affordable Care Act was implemented.8 The study con
cluded that the US was a negative Boutlier among high-income
countries in ensuring access to health care.^ Given the very
real possibility that the Affordable Care Act and other public
insurance programs may be weakened or eliminated, access to
care in the US may be even more compromised in the near
future. Looking outside the US to generate ideas for improving
access to care in the US has typically been an under-utilized
strategy. It may be more important than ever to do so.
1. Pastakia SD , Manyara SM , Vedanthan R , et al. Impact of bridging income generation with group integrated care (BIGPIC) on hypertension and diabetes in rural Western Kenya . J Gen Inter Med . 2016 . doi:10.1007/ s11606- 016 - 3918 -5.
2. Bodenmann P , Velonaki VS , Griffin JL , et al. Case management may reduce emergency department frequent use in a universal health coverage system: a randomized controlled trial . J Gen Intern Med . 2016 . doi:10. 1007/s11606- 016 - 3789 -9.
3. Uittenbroek RJ , Kremer HPH , Spoorenberg SLW . Integrated care for older adults improves perceived quality of care: results of a randomized controlled trial of embrace . J Gen Intern Med . 2016 . doi:10.1007/s11606- 016 - 3742 -y.
4. Trivedi AN , Bailie R , Bailie J , et al. Hospitalizations for chronic conditions among indigenous australians after medication copayment reductions: the closing the gap copayment incentive . J Gen Intern Med . 2016 . doi:10.1007/s11606- 016 - 3912 -y.
5. Bahadin J , Shum E , Ng G , et al. Follow-up consultation through a healthcare kiosk for patients with stable chronic disease in a primary care setting: a prospective study . J Gen Intern Med . 2016 . doi:10.1007/ s11606- 016 - 3931 -8.
6. Salgado MV , Mejía RM , Kaplan CP , et al. Smoking-related attitudes and knowledge among medical students and recent graduates in argentina: a cross-sectional study . J Gen Intern Med . 2016 . doi:10.1007/s11606- 016 - 3890 -0.
7. Berwick D. Escape fire: lessons for the future of health care . New York : The Commonwealth Fund ; 2002 . http://www.commonwealthfund. org/usr_ doc/berwick_escapefire_563 .pdf.
8. Osborn R , Squires D , Doty MM , Sarnak DO , Schneider EC. New survey of eleven countries, US adults still struggle with access to and affordability of health care . Health Aff (Millwood). 2016 . doi:10.1377/hlthaff.2016. 1088.