CASE 15

Irma Matos

A 66-year-old Ecuadorian woman with type 2 diabetes and hypertension

Edgar Maldonado, MD, and Debbie Salas-Lopez, MD, MPH, FACP

Lehigh Valley Hospital and Health Network, Allentown, PA, USA

Educational Objectives

TACCT Domains: 1, 2, 4

Case Summary, Questions and Answers

Irma Matos is a 66-year-old Hispanic woman from Ecuador who comes to her primary care physician (PCP), Dr. Bowman, for a routine visit. Mrs. Matos immigrated to the U.S. 15 years ago to join her husband who had already been established in the U.S. for several years. She became a legal resident during this time but continues to enjoy frequent visits to Ecuador to spend time with her two children and five grandchildren. She has a history of well-controlled type 2 diabetes and hypertension, managed with an oral hypoglycemic and an angiotensin converting enzyme (ACE) inhibitor. She also suffers from chronic lower back pain and major depression, which are treated with an anti-inflammatory (as needed) and a selective serotonin reuptake inhibitor. She worked as a housekeeper in a large hotel for 10 years, but as a result of her back pain and chronic depression, she has retired. She currently receives Medicare health care coverage.

1 How does this patient’s social situation impact the care provided by Dr. Bowman?

Mrs. Matos’ social situation is that she wants to spend time in Ecuador but enjoys the quality of health care provided in the U.S., which includes Medicare. Her depression may be related to the need to see her grandchildren, her chronic medical conditions, lack of acculturation, and her inability to work due to chronic back pain. Permanent resident aliens or naturalized American citizens divide their time between the United States and their country of birth. This is due in part to the ability to access a variety of health care services in the U.S. that are typically not available in their native country. In many Latin American countries, particularly Ecuador, many residents do not have health insurance and many receive health care via the public health care system, which is typically free or at low cost. However, due to the deficiencies in the public system, the services provided may not always be adequate. Consequently residents opt for private clinics or prepaid medicine that various companies in Ecuador offer with higher quality standards. In comparison to the U.S., access to doctor visits, diagnostic tests, and medications are relatively inexpensive and somewhat unregulated in Latin American countries. This allows travelers and residents to obtain diagnostic testing and medications without a doctor’s prescription.

2.What additional social history is needed about Mrs. Matos’ travel schedule to best manage her medical condition?

Many elderly patients from those parts of the United States that experience cold winters will spend the winter months in Southern states such as Florida. Similarly, patients originally from warm weather climates, such as South America, the Caribbean, and Mexico, will frequently spend the entire winter season living in their native country. By anticipating and considering this pattern, the physician can incorporate their travel plans into their plan of care. This will also help identify, in a proactive manner, potential problems that patients may encounter and will improve continuity of care. These include running out of medications, inability to adhere to prescribed or recommended diets, or decline in self-management skills. Questions to ask patients about traveling are shown in Table 15.1.

Table 15.1 Questions to ask patients about traveling

Source: Edgar Maldonado, MD, Lehigh Valley Hospital, 2009. Used with permission

• What is nature of your traveling? (Depending on your relationship with the patient, he/she might or might not let you know.)
• What is your planned duration or length of stay?
• Who will you be staying with?
• Do you have a primary care doctor there in case of an emergency?
• What kind of activities will you be involved in? (especially if touring or walking long distances. This is very important for patients who may not recognize their physical limitations, are at risk for falls, or are on insulin that may need adjusting.)
• Are you preparing the meals? Will you have access to a supermarket?
• What kinds of problems or barriers might be encountered that would lead to interruption of your usual care plan?
• Is there a knowledgeable caregiver or contact who may assist with medications, management of medical conditions, and continuation of care plan during your visit?
• Do you have a plan in place to obtain medication refills?
• Have you obtained travel information on outbreaks and endemic diseases, and did you receive the necessary vaccinations or prophylaxis as recommended by the CDC (http://www.cdc/gov/travel)?

Three months later, Mrs. Matos returns to her PCP, Dr. Bowman. She explains that she returned from Ecuador last week but ran out of her diabetes and hypertension medications during the last 2 weeks of her trip. At this visit, she presents with polydypsia, polyuria, blurred vision, and fatigue, and her prescriptions are renewed. Her blood pressure is also noted to be elevated and, on review of systems, she is positive for multiple vegetative signs of depression. She was scheduled to see her mental health care provider last month but missed her appointment because she was out of the country. She is encouraged to reschedule this appointment. Mrs. Matos also informs Dr. Bowman that she “felt ill” at the beginning of her vacation and visited the local “policlinic.” For unknown reasons, the physician requested that she have a repeat colonoscopy, ultrasound of kidneys and gallbladder, ECG, and some blood tests. She tells Dr. Bowman that she thought she needed a CT scan of the brain because she was having headaches. Mrs. Matos shows Dr. Bowman these reports, which are in Spanish, and asks her to review and interpret the results because “no one had explained the results to her.”

3 What might be done to prevent Mrs. Matos from running out of her medications during future trips to Ecuador?

Medicare/Medicaid generally provide for a 1-month supply of medications at one time, unless the patient is on vacation. Only then will they provide up to a 60-day supply, but only one time per year. Therefore, as part of travel planning, the physician needs to make sure that the patient has a process in place in the U.S. to obtain his/her medication refills in a timely manner. The best approach that seems to work for many patients is having a friend or relative obtain the refills and medical supplies (test strips, lancets, etc.) and mail them promptly to the patient. Keep in mind that, with many prescription plans, patients can only get refills 7 days before they are due, and it may take up to 10 or more days for medications to reach their destination in foreign countries. Timing is therefore extremely important when medications are life-sustaining and require special handling, such as insulin which requires refrigeration. Another way is to use mail-order scripts that provide a 90-day supply of medications. During travel, airport security restrictions apply and medications should only be stored in a carry-on bag in labeled bottles to avoid treatment interruption, if and when, checked luggage is lost or delayed.

4 What are some of the reasons for why these tests may have been ordered?

Many patients who return from Latin American countries with test results tell their physicians that they initiated the request because they were concerned about their health, or were advised by a family member to get further evaluation. In addition, this may also be a manifestation of a dissatisfaction or skepticism over the recommendations or care provided by the U.S. physician. The self-initiation of testing or treatment also in part reflects the culture and how health care is organized in some parts of Latin America. In Ecuador, for those who can afford it, there is the cultural expectation that comprehensive evaluations will always be undertaken, even for common ailments. In addition, studies such as CT scans and ultrasounds can be done there without a physician referral and paid for with U.S. currency. Further, in some Latin American countries, medical care, diagnostic tests, and surgical procedures are less expensive than in the U.S. and are readily accessible for travelers. This may cause visiting patients to perceive that healthcare is more affordable and easier to access in some of these countries. Added to all of this is the fact that in some parts of Ecuador many physicians generate income from the variety of tests offered at their medical centers or “policlinics”. These entities sometimes compete and market to the consumer, promoting early detection of various diseases which some patients may not be at risk for. Websites for diagnostic centers may state “No one is exempt from becoming ill. Early disease detection is the best way to save your life”. Clinics offer packages, such as “Paquete de examenes de prevencion general” translated as “general prevention packet”, which includes a battery of blood tests, x-rays, ultrasound, EKG, pap smear, urine and stool analysis for a fraction of the cost in the U.S. This was certainly the case for Mrs. Matos on this visit to Ecuador. Given all this, it is not surprising that when patients such as Mrs. Matos return to the United States, they will have with them the results of several diagnostic tests that may not have been indicated.

With respect to Mrs. Matos, when she complained of headaches, her daughter advised her to get a CT scan of the brain “to make sure she did not have a brain tumor.” And although she had had a normal screening colonoscopy a year ago, she had a repeat study in Ecuador since it was offered for a very affordable price.

5 What might Dr. Bowman do to minimize the likelihood that Mrs. Matos will seek unnecessary diagnostic studies while abroad?

Having had these experiences with Mrs. Matos, it would be important for Dr. Bowman at a visit to question Mrs. Matos about any upcoming, extended visits to Ecuador. If a trip is planned then the following should be done:

This is an ideal time to identify and anticipate any potential problems, to emphasize the importance of adherence to their medical plan, and to answer questions in regard to management of potential complications during travel.

6 How do changes in the diet and lifestyle of Mrs. Matos while in Ecuador affect her diabetes and hypertension management?

Patients who spend a significant amount of time in their native country often revert back to their preexisting diet and lifestyle patterns. This may or may not be an advantage, depending on where they live, what they do, and who is preparing the meals. Patients sometimes get caught up with festivities and family gatherings, especially during holidays. This could lead to excess caloric, carbohydrate, or salt intake and alcohol consumption. Some will also stop medications if they are planning to consume alcohol, which could result in acute complications. An interesting paradox is that some patients might actually lose weight as they feel more comfortable and at ease walking in warmer climates and to known local destinations (internal tourism), in contrast to an often more sedentary lifestyle in the U.S.

The Ecuadorian diet or cuisine varies from region to region, but like many Latin American countries, Ecuador’s daily diet is based on rice, soups, corn, and bananas. Meals on the coast will have a great variety of seafood which, if poorly prepared in their signature dish “ceviche,” could be a source of food-borne illness. Natural juices made from exotic fruits like passion fruit, tree tomato, guanabana, blackberry, and papaya are very popular. This often results in elevated blood sugar in diabetics. When on vacation, many look forward to these foods, particularly the fruit drinks. It is very challenging to change their diet especially when on vacation, as many of them do not have control over how meals are prepared. They do have control over portion size, which in the absence of calorie counting is a good way to maintain a balanced diet, yet still sample the food.

One month later, Mrs. Matos returns to the clinic and tells Dr. Bowman that she has been taking her medications but that her blood sugar still seems to be high when she tests it in the morning. She explains to Dr. Bowman that her sister, who has osteoarthritis, gave her a medication that makes her back feel better. She shows Dr. Bowman the pill and asks her to prescribe this medication today and says she finds it convenient when her family, friends, and local pharmacist give her medications without a doctor’s prescription. Dr. Bowman identifies this medication as a steroid/anti-inflammatory combination medication, which partially explains why her diabetes is uncontrolled despite taking her oral hypoglycemic medication.

7 How should Dr. Bowman approach Mrs. Matos’ request to prescribe a steroid combination pill for her back pain which she self-prescribed in Ecuador?

It is not uncommon for patients traveling to Latin America to have unrestricted access to prescription drugs. Many countries have their own pharmaceutical companies that make medications and combinations not found or dispensed in the U.S. The relatively high proportion of drugs dispensed without a medical prescription that nevertheless require medical follow-up, such as diabetes medications, probably reflects limited access to medical care. In many cases, these combination drugs are generics used to treat chronic conditions like diabetes, arthritis, and high blood pressure. These medications are inexpensive and can be obtained at street markets or pharmacies without a prescription.

Unlike the U.S., in Ecuador and many other Latin American countries, it is legally permissable for pharmacists to diagnose and give medical treatment without a physician’s prescription. Sharing medications among family members is a common practice in the U.S. as well as in many Latin America countries and is usually done by an adult maternal figure or community member that the family trusts for medical advice. Many times this person has several chronic conditions him/herself and therefore has access to medications and household remedies and has more experience with health care than other members of the household or community.

Table 15.2 Travel chart summary items

Source: Edgar Maldonado, MD, Lehigh Valley Hospital, 2009. Used with permission.

• Patient demographics
• Emergency contact in the U.S. and the visiting country
• Allergies
• Active medical problems
• Inactive medical problems
• Medications
• Immunization record
• Pharmacy information
• Primary care physician contact information, including after-hours number

8 How can the medical care of patients living in the U.S. and abroad, such as Mrs. Matos, be improved?

First and foremost, patient education and self-management training should include travel planning and cover self-prescribing practices. Physicians need information and understanding about their patients’ culture and health beliefs and the health care system in their native country. A reasonable way to improve the medical care for “dual-residents” is to incorporate their travel plans and travel health into their plan of care. A multidisciplinary approach (case managers, patient navigators, or nursing staff) with input from the physician is an effective strategy to use. Patients would benefit from an understanding that, although they might see it as an extended vacation, they still need to adhere to their nutrition regimen as well as medical treatment. A process for obtaining medication refills should be in place if traveling for more than 30 days. Patients should travel with a summary of medical conditions, allergies, vaccinations, and an updated medication list with dosing information (as shown in Table 15.2).

References: Case 15

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Centers for Disease Control and Prevention. Travelers’ health. Available at: http://www.cdc.gov/travel/.

Drug Utilization Research Group, Latin America. Multicenter study on self-medication and self-prescription in six Latin American countries. Clin Pharmacol Therapeut 1997;61(4):488–93.

Fleitas I. The quality of radiology services in five Latin American countries. Rev Panam Salud Publica 2006;20(2-3):113–24.

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World Health Organization. Guidelines for the regulatory assessment of medicinal products for use in self-medication. World Health Organization, Geneva, 2000:9.