202750 Addressing Barriers to Care Using Patient Advocacy, Financial Assistance, and Electronic Medical Record Database Referral System: Experience in Rural El Salvador

Wednesday, November 11, 2009

Jennifer Kasper, MD, MPH , Doctors for Global Health, Decatur, GA
Joel Sawady, MD , Doctors for Global Health, Decatur, GA
Maggie Newburger, MD , Doctors for Global Health, Decatur, GA
Michael Tang, MD , Boston Combined Residency Program, Boston, MA
Don Lassus , Doctors for Global Health, Decatur, GA
Caitlin Polley , Doctors for Global Health, Decatur, GA
Etelvina Umana , Asociacion Campesina para el Desarrollo Humano, Morazan, El Salvador
Jose Ramiro Cortez Argueta , Asociacion Campesina para el Desarrollo Humano, Morazan, El Salvador
Judith S. Palfrey, MD , Division of General Pediatrics, Children's Hospital Boston, Boston, MA

Although rudimentary primary care infrastructure exists in rural communities in northeast El Salvador, access to specialty care and diagnostic tests is extremely limited. We designed and implemented a system to help poor, rural patients overcome barriers to accessing this care.


In January 2007 we implemented system of intensive advocacy and coordination of care for patients seen in rural clinic and referred for specialty care and diagnostic testing. We also provided funds for travel to receive care and for some diagnostic services and treatment. In September 2008 we implemented custom-designed database to monitor patient care and use of funds. We report on the time period since database implementation.

Preliminary Results

During 1491 patient encounters, 390 (26%) referrals were made, of which 35% were men and 23% were children < 18 years of age. The total amount of money spent was $1363USD with the two major expenses being medications (45%) and transportation (36%). An average of $3.50USD was spent for each referral. 10% of referrals were for emergency care, 57% for specialist consultation, and 33% for diagnostic testing. The most common subspecialty referrals were ophthalmology (28%), orthopedics (9%), general surgery (8%), gynecology (7%), dentistry (6%), and cardiology (6%). The most common barrier to care identified was money for transportation.

Conclusions and Next Steps

Using a triad of systematic advocacy, patient counseling and coordination of care, and modest financial assistance we are facilitating specialty care, diagnostic testing, and treatment for population that has previously been unable to access that care.

Learning Objectives:
1. To understand barriers to specialty care and diagnostic tests for people with little to no economic means in rural El Salvador 2. To describe and evaluate the design and implementation of a comprehensive referral system to overcome those barriers. 3. To highlight the challenges (e.g. follow-up, ongoing care) of providing primary and subspecialty care in rural El Salvador

Keywords: Access to Care, International Health

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a physician who has been working with Doctors for Global Health in rural El Salvador since 1996.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.