Helping medical tourists make informed decisions by Sharon Kleefield Parts One and Two were featured in January and February issues of MTT. The influence of regulation of healthcare quality in the USA Ernest Codman, a Boston surgeon in the 1930s, dedicated his medical career to the systematic and comprehensive study of ‘end results’ – the assessment of patient outcomes of surgery in American and later in Canadian hospitals – which eventually led to the standards and estab- lishment of what is now the Joint Commission. It was his work that established an initial system to track the outcomes of patient treatments and to identify the clinical problems as the foundation for improving the care of future patients. He believed that this information should be made public so that patients could be guided in their choice of physicians and hos- pitals. He recorded diagnostic and treatment errors and linked these errors to needed quality improvements (Millenson, 2000). Codman established the American College of Surgeons (ACS), where his ‘end result’ approach was developed by the ACS as the Minimum Standard for Hospitals – a one-page set of requirements based on which the ACS began on-site inspections of hospitals. Codman’s initiatives and the ACS led directly to the standardised assessment of outcomes of surgery in American and US hospitals. In 1950, the American College of Physicians, the American Hospital Association, the American Medical Association and the Canadian Medical Association joined with the ACS as corporate members to create the Joint Commission, an independent, not-for-profit organisation in Chicago, Illinois, whose primary purpose was to provide the standards for hospital quality (JCI, 2014). In 1965 the US federal government required all hospitals to have Joint Commission accreditation in order to be approved for reimbursement for patient services. The Joint Commission was an outgrowth of the work of Ernest Codman, promoting hospital quality improvement based on outcomes management in patient care. The JCI was established in 1998 as a private, not-for-profit affiliate of the Joint Commission. Through voluntary international accreditation, the JCI extends its mission to help improve the quality of patient care internationally. The JCI accreditation is considered a ‘seal of approval’ for medical travellers and a marker for quality. A total of 815 healthcare organisations have JCI accreditation across 100 countries. Accreditation serves as evidence that a hospital can meet high standards for the structure and processes of managing care. Hospital quality beyond accreditation In 1980, Dr Avedis Donabedian defined quality of care as ‘that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the bal- ance of expected gains and losses that attend the process of care in all its parts’ (Donabedian, 2005). In 1984, the American Medical Association defined quality of care as that ‘which consistently contributes to the improvement or maintenance of quality and/or duration of life’ (Caper, 1988). One of the most widely cited definitions of quality was formulated by the Institute of Medicine in 1990 as the ‘degree to which health services for patients increase the likelihood of desired health outcomes and are consistent with the current professional knowl- edge’ (Kohn and Donaldson, 2000). Healthcare professionals tend to define quality as the attributes and results of medical intervention – the technical definition of ‘doing the right thing right’. This constitutes mak- ing the right professional/technical decisions about care for each patient and doing it with the right skill, judgement and timeliness of execution (Blumenthal, 1996). One important change beyond the more technical definition is the growing recognition that treatment should be responsive to the preferences and values of individual patients/consumers of healthcare services and that their opinions about care are important indicators for quality. ‘Desired health outcomes’ include the extent to which it meets the ‘expectations’ of patients (Kohn and Donaldson, 2000). Patients and consumers are more interested now in the quality and safety of care when choosing a hospital. Evidence from the early 1991 Harvard Medical Practice Study was a landmark study of medical injury in the US (Brennan et al., 1991). The study was the first review of 30,121 ran- domly selected medical records from 51 randomly selected acute care hospitals in New York state. The results from this study were revealing: it showed that adverse events occurred in 4 per cent of hospitalisations, and 27.6 per cent of those adverse events were due to negligence. The study estimated that, among the 2,671,863 patients discharged from New York hospitals in 1984, there were 98,609 adverse events involving substandard management of patient care. Surgical wound infections accounted for nearly half of all surgical adverse events. Drug com- plications accounted for additional adverse events, including known and unknown allergies, wrong dosages, wrong drug or multiple drug interactions. This study revealed that most adverse events were preventable; however, errors in hospital care appeared much more common than was originally thought. The occurrence of such adverse events was a result of the interaction of the patient, the patient’s disease and a complicated, highly technical system of medical care and patient management by physicians and other support personnel (Brennan et al., 1991; Leape, 1994; Leape et al., 1991). To err is human Following the Medical Practice Study, the Institute of Medicine, an advisory group to the US Department of Health and Human Services, published the report ‘To Err is Human: Building a Safer Health Care System‘ (Kohn and Donaldson, 2000). This report precipitated major public health concerns because of the estimated 4 per cent of hospital deaths in the USA that resulted from preventable medical errors, including:
- foreign objects retained after surgery (e.g. sponges, small instruments)
- trauma and falls
- collapsed lung due to a medical treatment
- breathing failure after surgery
- postoperative pulmonary embolism/deep-vein thrombosis (dangerous blood clot)
- wound reopening post-surgery; wound infections
- accidental cuts or tears linked to medical treatment.
The more common preventable errors included post-surgical infections due to poor cleanliness, HAIs due to poor hygiene practices and errors in drug management. The publication of Making Health Care Safer II (Agency for Health Care Quality, 2012) pro- vides evidence-based patient safety practices that are strongly encouraged if hospitals are com- mitted to significant reductions in preventable harm to patients. These practices, if universally implemented, have been shown to reduce preventable errors, are measurable at the point of care and are closely linked to clinical outcomes (CDC, 2015; De Vrieset al., 2010; Haynes et al., 2009; Reames et al., 2015). Since the Institute of Medicine report and the continued research by the USA and other countries, we have a pathway for providing an initial set of ‘markers’ for reducing errors and preventing harm in hospitals. Leaders in the medical tourism industry should apply the existing evidence for creating highly reliable hospital systems that minimise preventable harm for all patients and in particular for medical tourists. For those hospitals looking to become ‘hubs’ for medical tourism, the ‘markers’ shown in Table 19.1 are consistent with those identified in Making Health Care Safe II and provide an international strategy for promoting and competing for the best and cost-effective care. They are targeted at specific hospital practices that have been associated with reducing preventable harm and achieving good patient outcomes. Successful implementation and surveillance of these markers would encourage international hospitals to improve their organisational norms and standards of care. Encouraging international hospitals to track these ‘markers’ and share these publicly will result in better-informed choices for medical tourists and facilitators and further the industry to better serve its diverse patient populations. Moving beyond choice of hospitals via the internet, social media and testimonials, the medical tourist deserves to understand and ask the questions regarding what to expect from care received. The Cleveland Clinic, with hospitals in the USA and abroad, is one of the best examples of an organisation that is committed to sharing quality data ‘with the world’. Their goal is to make the principle of transparency a practical reality and a worldwide source for learning, both by the hospitals and by the patients they serve. Patients are encouraged to be part of these efforts by asking questions and sharing their concerns. Their Patient Safety Program reports on good hand hygiene practice, HAIs, completeness of medical record keeping, reducing risk of patient harm from falls and patient satisfaction (Cleveland Clinic, 2016). A modest proposal for a deeply personal activity A colleague taught me that practising medicine is the most intimate of professions. It remains so when practised anywhere in the world. The medical tourist, when choosing a hospital in a different country and different culture, depends on the expertise and established best practices of the hospital staff and physicians. As a global consumer of healthcare, medical tourists seek information, guidance and reassurance that their care will meet ‘best practices’ and they will not come by harm. As patients, they want to know that they will be treated with dignity, compas- sion and exemplary standards of care with good outcomes. In this chapter I identified landmark studies from the past two decades that inform the practice of medicine as to how to protect patients from preventable harm and risk. There continues to be substantial progress in awareness and efforts to employ established strategies for quality and safety improvement. The opportunity in the medical tourism industry lies in helping international hospitals adopt and benchmark best practices, thus reinforcing quality and safety for all medical tourists (Bergs et al., 2014; KPMG International Cooperative, 2011). With no regulatory oversight of quality or common safety practices, medical tourists are only able to make partially informed decisions about choosing the right hospital for their treat- ment. A recent study identified a set of global measures of hospital quality. These hospital measures, extracted from administrative data of 6.5 million patient discharges, are aligned with these encouraged ‘markers’: blood incompatibility, patient falls, catheter-associated urinary tract infection, unexpected deaths of low-mortality diagnoses, HAIs, including surgical site infec- tions. The conclusion from this study was that these measures could be used to help determine whether hospitals are meeting a minimum level of safe care (Perla et al., 2015). The publication of Making Health Care Safer II (Shekelle et al., 2013) provides a list of similar safety practices and, if implemented, could significantly improve patient care internationally. These practices have been documented by earlier studies presented in this chapter, providing strong evidence for their effectiveness in reducing preventable harm at the point of care. Adding to these safety practices, a medical outcomes study identified the importance of patient evaluations as an important ‘marker’ for quality, as these reflect the patient’s own perceptions of care, in addition to clinical outcomes (Tarlov et al., 1989; Weldring and Smith, 2013). The relevance to medical tourism is the need to understand better and include the patients’ perspective and assessment of their hospital care. Patient satisfaction surveys are an international tool for measuring patient experience and all hospitals should be encouraged to measure and report patient satisfaction. With basic statistical analysis these data would provide an additional ‘generic’ patient perspective along with the intervention-specific outcomes (Black, 2013). The quality ‘markers’ presented in this chapter reflect the last decade of research that identified specific strategies for reducing preventable harm for hospitalised patients. The medical tour- ism industry, including those companies who arrange and refer patients to particular hospitals, must be ‘strongly urged’ to move this industry in the direction of maximising safety and quality of care internationally. The individual medical tourist must also be proactive and informed as to what questions to ask regarding a hospital’s best practices of care as reflected by these ‘markers’. This is a modest but important beginning to address the quality concerns of the industry and most of all to improve and protect patient safety internationally. Exercising the right to an ‘informed consent’ remains a basic ethical principle for all patients when seeking care. It is the responsibility of the medical tourism industry to understand and incorporate the evidence on preventing patient harm and to guide the medical tourist in choosing a hospital that can meet these modest but critical quality ‘markers’. This commitment by the industry will help to improve global patient quality and safety and address the absence of information about compara- tive quality. Safety is an aspiration as well as a requirement to improve the quality of care for all patients. Patients believe in this aspiration as they give us their trust and accept risks and benefits in their pursuit of healthcare as medical tourists (Vincent and Amalberti, 2016). References Agency for Health Care Quality (2012) Inpatient Quality Indicators, Rockville, MD: US Department of Health and Human Services. Allegranzi, B., Bagheri, N., Combescure, C., et al. (2011) ‘Burden of endemic health-care-related infec- tion in developing countries: systematic review and meta-analysis.’ The Lancet, 377, pp. 228-241. Beauchamp, T. L. and Childress J. F. (2001) Principles of Biomedical Ethics, Oxford: Oxford University Press. Bergs, J., Hellings, J., Cleemput, I., et al. (2014) ‘Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications’, British Journal of Surgery, 101 (3), pp. 150-158. Black, N. (2013) ‘Patient reported outcome measures could help transform health care’, BMJ, p. 346. Blumenthal, D. (1996) ‘Quality of care – what is it?’, The New England Journal of Medicine, 335, pp. 889-891. Botterill, D., Pennings, G. and Mainil, T. (eds.) (2013) Medical Tourism and Transnational Health Care, New York, NY: Palgrave Macmillan, pp. 1-9. Brennan, T. A., Leape, L. L., Laird, N., et al. (1991) ‘Incidence of adverse events and negligence in hospitalized patients: results from the Harvard Medical Practice Study I’, The New England Journal of Medicine, 324, pp. 371-376. Bumrungrad International Hospital, https://Brumrungrad.com (accessed 7th November 2015). BusLine (2016) Time of India, www.thehindubusinessline.com, January 13. Caper, P. (1988) ‘The definition of quality,’ Health Affairs, 7, pp. 49-61. Centers for Disease Control and Prevention (CDC) (2015) National Healthcare Safety Network: Surgical Site Infection (SSI) Event, http://www.cdc.gov/homeandrecreationalsafety/ (accessed 23rd February 2016). Cleveland Clinic (2016) Patient Safety Program, Quality and Patient Safety Institute, Cleveland, OH: Outcomes Books. Cohen, I. G. (2015) Patients with Passports, Oxford: Oxford University Press, pp. 41-77. Connell, J. (2013) ‘Contemporary medical tourism: conceptualization, culture and commodification,’ Tourism Management, 34, pp. 1-13. Crooks, V. A. and Snyder, J. (2010) ‘Regulating medical tourism.’ Lancet, 376, pp. 1465-1467. Crooks, V. A., Kingsbury, P., Snyder, J., et al. (2010) ‘What is known about the patient’s experience of medical tourism? A scoping review.’ BMC Health Services Research, 10, p. 266. De Vries, E. N., Prins, H. A., Crolla, R., et al. (2010) ‘SURPASS Collaborative Group, Effect of a com- prehensive surgical safety system on patient outcomes’, The New England Journal of Medicine, 363(20), pp. 1928-1937. Donabedian, A. (1980) Explorations in Quality Assessment and Monitoring, Vol. 1, The Definition of Quality and Approaches to its Assessment, Ann Arbor, MI: Health Administration Press. Donabedian, A. (2005) ‘Evaluating the quality of medical care’, Milbank Quarterly, 83(4), pp. 691-729. EIU (2011) Traveling for Health, London: Economist Intelligence Unit. Erdogan, S., Yilmaz, E. and Isletmecilgi, T. (2012) ‘Medical tourism: an assessment on Turkey’, Joint Conference of the 11th International Conference of Asia, Istanbul, Turkey. Faden, R., Beauchamp, T. and King, N. M.P. (1986) A History and Theory of Informed Consent, New York: Frost & Sullivan (2012) Rising Middle Income, Medical Tourism Create Impact for APAC Healthcare Market, http://www.frost.com/prod/servlet/press-release.pag?docid=254506089 (accessed 14th May 2016). Greenfield, D. and Pawsey, M. (2014) ‘Medical tourism raises questions that highlight the need for care and caution’, Medical Journal of Australia, 201(10), pp. 568-569. Haynes, A. B., Weiser, T. G., Berry, W. R., et al. (2009) ‘Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population,’ The New England Journal of Medicine, 360(5), pp. 491-499. Hohm, C. and Snyder, J. (2015) ‘It was the best decision of my life: a thematic content analysis of former medical tourists’ patient testimonials’, BMC Medical Ethics, 16, p. 8. International Living (2016) http://internationalliving.com/author/iladmin/ (accessed 9th July 2016). Joint Commission International (2014) Accredited Health Care Organizations, www.jointcommissioninternational.org (accessed 24th February 2016). Kohn, L. and Donaldson, M. (eds.) (2000) To Err is Human: Building a Safer Health Care System, Institute of Medicine, Washington, DC: National Academy Press. KPMG International Cooperative (2011) ‘Medical tourism gaining momentum’, Issues Monitor, 7, pp. 1-13. Labonte, R. (2013) ‘Overview: medical tourism today: what, who, why and where? Travelling well: essays in medical tourism’, in Transdisciplinary Studies in Population Health Series, Ottawa: Institute of Population Health: University of Ottawa, pp. 6-12. Leape, L. L. (1994) ‘Error in medicine’, JAMA, 272, p. 1851. Leape, L. L., Brennan, T. A., Laird, N., et al. (1991) ‘The nature of adverse events in hospitalized patients: results from the Harvard Medical Practice Study II’, The New England Journal of Medicine, 1324, pp. 377-384. Lunt, N. and Carrera, P. (2011) ‘Systematic review of websites for prospective medical tourists’, Tourism Review, 66, pp. 57-67. Lunt, L. and Mannion, R. (2014) ‘Patient mobility in the global marketplace: a multidisciplinary perspective’, International Journal of Health Policy and Management, 2 (4), pp. 155-157. Lunt, N., Hardey, M. and Mannion, R. (2010) ‘Nip, tuck and click: medical tourism and the emergence of web-based health information’, The Open Medical Informatics Journal, 4, pp. 1-11. 244 Lunt, N., Machin, L., Green, S., et al. (2011) ‘Are there implications for quality of care for patients who participate in international medical tourism?’ Expert Review of Pharmacoeconomics and Outcomes Research, 11(2), p. 133. Mattoo, A. and Rathindran, R. (2006) ‘How health insurance inhibits trade in health care’, Health Affairs, 25(2), pp. 358-368. Millenson, W. (2000) Ernest Amory Codman: The End Result of a Life in Medicine, Philadelphia: WB Saunders. NaRonong, A. and NaRanong, V. (2011) ‘The effect of medical tourism: Thailand’s experience’, Bulletin of the WHO, 89, pp. 336-344. Ozan-Rafferty, M., Johnson, J., Shah, G., et al. (2014) ‘In the words of the medical tourist: an analysis of internet narratives by health travelers to Turkey’, Journal of Medical Internet Research, 16(2), p. 43. Penney, K., Snyder, J., Crooks, V., et al. (2011) ‘Risk communication and informed consent in the medical tourism industry: a thematic content analysis of Canadian broker websites’, BMC Medical Ethics, 12, pp. 1-11. Perla, R. J., Hohmann, S. F. and Annis, K. (2015) ‘Whole-patient measure of safety: using administrative data to assess the probability of highly undesirable events during hospitalization’, Journal of Healthcare Quarterly, 35(5), pp. 20-31. Reames, B. N., Krell, R. W., Campbell, D. A., et al. (2015) ‘A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program’, JAMA Surgery, 150(3), pp. 208-215. Runnels, V. and Carrera, P. M. (2012) ‘Why do patients engage in medical tourism?’ Maturitas, 73, pp. 300-304. Satyanarayana, K. H. (2008) ‘Informed consent: an ethical obligation or legal compulsion?’, Journal of Cutaneous and Aesthetic Surgery, 1(1), pp. 33-35. Shekelle, P. G., Wachter, R. M., Pronovost, P. J., et al. (2013) ‘Making health care safe II: an updated critical anlysis of the evidence for patient safety practices’, Comparative Effectiveness Review, 211, AHRQ Publication no 13, Rockville, MD: Agency for Healthcare Research and Quality. Snyder, J., Crooks, V. A., Kingsbury, P., et al. (2011) ‘The patient’s physician one-step removed: The evolving roles of medical tourism facilitators’, Journal of Medical Ethics, 9, pp. 530-534. Tarlov, A. R., Ware, J. E., Greenfield, S., et al. (1989) ‘The Medical Outcomes Study, an application of methods for monitoring the results of medical care’, JAMA, 262(7), pp. 925-930. Turner, L. (2007) ‘First world health care at third world prices: globalization, bioethics and medical tourism’, BioSocieties, 2, pp. 303-325. Turner, L. (2011) ‘Quality in health care and globalization of health services: accreditation and regulatory oversight of medical tourism companies’, International Journal of Quality in Healthcare, 23(1), pp. 1-7. Turner, L. (2013a) ‘Ethical dimensions of global healthcare’, The Cambridge Quarterly of Healthcare Ethics, 22(2), pp. 170-180. Turner, L. (2013b) ‘Canadian medical travel companies and the globalization of health care’, in Botterill, D., Pennings, G. and Mainil, T. (eds.) Medical Tourism and Transnational Health Care, New York: Palgrave Macmillan, pp. 151-178. Vincent, C. and Amalberti, R. (2016) Progress and Challenges for Patient Safety, London: Springer Science and Business Media. Weldring, T. and Smith, S. (2013) Patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs)’, Health Services Insights, 6, pp. 61-68. Woodman, J. (2014) Patients Beyond Borders, Chapel Hill: Healthy Travel Media. Zimlichman, E., Henderson, D., Tamir, O., et al., (2013) ‘Health care-associated infections, a meta-analysis of costs and financial impact on the US health care system’, JAMA Internal Medicine, 173(22), pp. 2039-2046.