Are there implications for quality of care for patients who participate in international medical tourism?

Keywords::

• medical tourism
• medical travel
• quality
• risk
• safety

Medical tourism is now an established feature of the international healthcare landscape and is a burgeoning commercial industry attracting increasing numbers of people willing to fund their own treatment overseas. Although medical tourism spans the full spectrum of health services, most travel is restricted to a limited range of medical procedures, including cosmetic surgery, dental procedures, orthopedic surgery, cardiac surgery, fertility treatment, and organ and cellular transplantation [1,2].

Currently, there are no precise figures available on the numbers of UK medical tourists, although it has been estimated that approximately 50,000 patients fund their own travel and treatment overseas each year [3,4]. Research has not kept up to date with the apparent growth of medical tourism, but discussion and some evidence on the quality, processes and outcomes of particular treatments are beginning to emerge, including fertility services [5–7], cosmetic treatments [8,9] and knee surgery [10]. The UK media attention has focused on the poor management, organization and delivery of healthcare provided to medical tourists abroad. In particular, recent coverage has considered the implications that can arise from accessing treatment overseas for both individuals receiving treatment and the UK National Health Service (NHS), which has to accept the cost of addressing any complications arising from poor quality of care delivered by overseas providers [101].

Medical tourism in context

Medical tourism can be considered as a form of patient mobility [1,11]. A key factor when classifying medical tourism is that individuals can identify their own healthcare needs and can select an appropriate provider to meet these needs at a given cost. Consequently, a medical tourist can be distinguished from a patient traveling overseas as part of formal bilateral agreements, such as those patients ‘outsourced’ to French and German providers by the NHS in the early 2000s in order to reduce waiting lists at home [12]. Furthermore, medical tourism does not cover those patients requiring immediate medical treatment due to illness occurring incidentally on holiday or long-term residents of a country that is not their country of origin. Nor should medical tourism, as defined here, be confused with the rights of EU citizens to access healthcare in another member state and have the costs paid by their own public health system. As the medical tourist is likely to be shouldering the main financial burden for the treatment overseas, they are perhaps best cast as a ‘consumer’ of healthcare rather than a ‘citizen’ claiming rights to healthcare provision.

The attraction of traveling overseas for treatment can be explained by the interaction of several ‘push’ and ‘pull’ factors. The lack of access to specific services at home owing to strict eligibility criteria (e.g., age and other restrictions relating to fertility treatment; one author [Green] is aware of cases where patients who are HIV-infected have travelled overseas in order to access fertility treatment that are either inaccessible or expensive in the UK), quicker treatment (perhaps owing to long waiting lists at home), and greater privacy and confidentiality for sensitive treatments (e.g., drug rehabilitation or gender reassignment) have been thought to encourage medical tourism [13]. Conversely, much cheaper treatment costs and the ‘pleasures’ generally associated with overseas travel, including visits to cultural and tourist attractions, climate and food, can entice people abroad for treatment [14]. In some cases, the perceived quality of the treatment abroad is an attraction owing to the perceived reputation of the healthcare provider [11].

The business sector has responded quickly to the growing global market in healthcare services. Several countries, most notably India, Singapore and Thailand, are investing heavily in their healthcare facilities, and recruiting and training healthcare professionals to deliver high-quality care, while a developed European market is also in existence [15,16]. Commercial agencies have also emerged to service this lucrative market. These provide a ‘brokerage’ service to prospective medical tourists and offer assistance and advice on travel arrangements, the selection of providers and even individual surgeons [13]. Within the market for medical tourism, there is clearly a potential for supplier-induced demand, whereby the supplier determines both the need for the service, as well as being funded for delivering the service. That said, we know relatively little about the development of European and international industries, and markets trading in medical tourism. As the review of patient mobility in Europe noted, there are a lack of data around mobility in general, which is compounded by a dearth of commercial information [17].

Given the many projections that indicate that medical tourism will continue to grow in the coming years, it is relevant to review the key issues arising from medical tourism. The quality of care that individuals receive when traveling abroad for treatment, and the associated concerns around safety and risk, are sketched out in this article, and the areas needing further research in this field are highlighted.

Outcomes

When medical treatment is sought from abroad, the normal continuum of care may be interrupted. Perhaps not surprisingly, given commercial imperatives, evidence of outcomes for medical tourist treatments is limited and reports are difficult to obtain and verify. Little is known about the relative clinical outcomes for particular treatments, providers, clinicians and localities. There is scant evidence on long- or short-term follow-up of medical tourists who return to their home countries following treatments at a range of destinations [1].

Experiences: traveling time, effort & comfort

As with all medical treatments, an element of risk can exist to the patient’s health, which is mitigated and outweighed by the benefits resulting from the surgery. Medical tourism adds a new dynamic to this element of risk, owing to the overseas travel involved. Traveling when unwell can lead to further health complications, including the possibility of deep-vein thrombosis [13,18]. The journey home can be difficult and painful, especially following surgery. A study of Norwegian patients found that this was perceived as the most negative aspect of visiting overseas providers [19].

Information, linguistic & cultural problems or misunderstandings

Unlike other forms of patient mobility where decisions are made by an expert clinician, medical tourism involves individuals acting as a consumer and making their own decisions regarding their personal medical needs, how these can be best treated and the most appropriate provider. However, there is currently very little evidence on the processes of decision making and how these decisions are influenced and shaped by external marketing sources and information provided via commercial websites [20,21]. This has raised concerns over the provenance and veracity of information provided to prospective medical tourists. Calls have been made for the information that is available to tourists to be better regulated [2]. A systematic review of 50 medical tourism websites that market treatments and services in mainland Europe found that only nine stated explicitly that English-speaking/fluent staff were employed. Indeed, on a small number of sites, grammar and spelling were both poor, giving little confidence in the clinic’s English proficiency and communication ability [22]. This is particularly significant when considering the informed consent process when having medical treatment.

In the UK, signed informed consent prior to an elective procedure is considered best practice and a standard requirement. This ensures that patients are fully informed as to the benefits and adverse effects of a procedure or treatment they are being advised to undergo, and they also have the opportunity to ask questions and seek answers [102]. This may not be available every time in the medical tourism setting, and it is possible that medical tourists may come to regret this if there are failings in professional or clinical practice [23,24].

Overseas providers & staff: reputation, trust, competence & professionalism

Concerns for the quality and safety of the medical care provided overseas has also emerged due to the lack of robust clinical governance procedures in provider organizations intended to safeguard the quality of care provided to tourists [25]. There have also been questions over the training, qualifications and competence of healthcare professionals. In response to these concerns, a range of independent holistic accreditation schemes have been introduced with the aim of assuring the care of medical tourists in a way that avoids potential conflicts of interest. Groups such as the Joint Commission International from the USA and Quality Healthcare Advice Trent Accreditation in the UK, for example, have accredited a number of health provider centers around the world.

Infection

Instances of infection outbreak arising from treatment at overseas ‘medical tourist’ facilities have been reported within the literature [26]. While there is evidence regarding the occurrence of adverse events in UK hospitals, there are no comparative overseas data and few safeguards. Anecdotally, one author (Green) is aware of cases where hepatitis B was acquired during cardiac surgery in Pakistan and renal transplantation in India. A study of medical tourists undergoing kidney transplants by Canales et al. concludes there was inadequate communication of information regarding preoperative information and postoperative immunosuppressive regimens [18].

Cross-border spread of antimicrobial resistance & dangerous pathogens

The public health aspects of medical tourism have not been adequately studied. Of significance is the potential for hazardous microorganisms transferring between hospitals located in different parts of the world on the body of a medical tourist [27]. These could include antimicrobial resistance, such as the potential for Clostridium difficile, vancomycin-resistant Staphylococcus aureus[103] or extensively drug-resistant tuberculosis [104], or a dangerous pathogen, such as SARS or Congo–Crimean hemorrhagic fever, with potentially fatal implications for hospital staff [28]. The rapid spread of North American swine flu out of the USA and Mexico to the rest of the world in 2009 and beyond has amply illustrated the ease with which microorganisms can be transported across borders.

Regulation & reporting

Ideally, a common regulatory platform and reporting system should serve as the basis of an assessment of quality of care. This would allow for a comparison of indicators as facilitated by international accreditation and certification. Presently, there are a lack of comparative quality and safety data, and knowledge of infection rates for overseas institutions and reporting of adverse events is also lacking. Importantly, bodies such as the WHO have yet to publish any firm guidelines on this.

Conclusion

Two points emerge from our overview of quality of care issues for medical tourists who travel overseas to access treatment. First, as with all healthcare, there are quality and safety concerns surrounding the provision of services to medical tourists. Second, such issues have not yet been the subject of sustained academic study and debate. To quote Toral, “Quality, liability, aftercare – medical tourism must nail down these three areas of concern in order to thrive” [29]. It is virtually impossible to argue with this statement and strengthening the knowledge base will be one important step forward. To this end, the UK National Institute for Health Research has recently commissioned research on the implications for the NHS of inward and outward medical tourism, and it is hoped that the evidence generated from this study will help inform the development of future policy and practice in this area [105].

Disclaimer

The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the NIHR HSR program or the Department of Health.

Financial & competing interests disclosure

This project is funded by the National Institute for Health Research Health Services Research Program (project number HSR: 09/2001/21). Steve Green is the Director and Company Secretary of Quality Healthcare Advice Trent. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.