Part Two: Choosing the Good Hospital’ Helping medical tourists make informed decisions by Sharon Kleefield Part One was featured in January’s issue of MTT. The business case Medical tourism offers business opportunities for entrepreneurs and governments to increase revenues from tourism. For example, Thailand made an early entry into medical tourism when the government launched a campaign to promote it as the medical hub of Asia’, advertising high-tech, high-quality and lower-cost medical care. Bumrungrad International Hospital has generated an estimated US$2 billion in medical tourism, or 0.4per cent of their GDP, showing that these efforts have paid off for the Thai government (Lunt and Mannion, 2014). Limited by its own population to finance what is needed for high-tech medical care, Malaysia established the government-industry partnership under the Ministry of Health, increasing the number of international patients with a target of 1 million medical tourists. The Indian government adopted a policy in 2002 to support medical tourism by subsidising the effort through tax and land concessions, duty and tax concessions on various imports and special M visas for medical tourists. With the growing medical tourism industry, the global patient and the physician are no longer restricted by geographical boundaries or local restrictions (Labonte, 2013). There are approximately 11,000 medical tourism brokers and facilitator companies who advertise their services on the internet and social media (Lunt et al., 2010; Turner, 2007). Facilitator companies are mediators’ between hospitals or clinics and medical tourists, but the service and advice they provide remain unregulated, so it is difficult to verify what they advertise and how they manage referrals. Facilitators provide information on locations and costs and many actually arrange the package’ for care, including flights, visas, hotels and physician/ hospital referrals. They are likely to receive a monetary return from specific referrals. The consumer may not have this knowledge and its potential conflict of interest for facilitators. Facilitators often have built-in clauses for contracting services that do not take responsibility for patient outcomes and protect them from malpractice (Snyder et al., 2011). Choosing an international hospital Little is known about how patients actually utilise these resources to decide on where to travel, but two recent studies conducted via telephone interviews provide some insight. Telephone interviews were conducted with 32 Canadians who travelled abroad for care. The goal of the study was to understand better why they travelled, how they understood the risks and how they gathered information from other patients who travelled abroad. Crooks et al. (2010) conclude that we have much to learn about patients’ experiences as medical tourists, specifically how they access and evaluate information from sources before deciding where to travel (Crooks and Snyder, 2010; Lunt et al., 2011). Lunt et al. suggest this gap in understanding and identifies patient decision making as a priority for medical tourism research, especially related to continuity of care, patient health and safety and the commodification of care. We have very limited knowledge about the process of patients’ medical travel from start to completion’ (Lunt et al., 2010). Canadians, for example, use facilitators for arranging travel, visas, hotels and referrals to inter- national hospitals. While the number of Canadian medical tourists is small compared to other countries, they do travel for dental and cosmetic surgery that is typically not covered by their healthcare system; they also travel for orthopaedic procedures because of long waiting times and ineligibility due to age. In choosing a destination, several patients said that the major deciding factor was the reputa- tion of the surgeon whom they had found online and/or through social networks (Hohm and Snyder, 2015). Length of stay and time to recuperate were also factors influencing their choice. As affordability was a factor, neither the USA nor the UK were viable options. Anecdotal reports from other medical tourists, such as testimonials and support from family members, were also factors in choosing the destination. Their local family physician did not typically provide advice and often was not asked for an opinion, as many patients anticipated that the general practitioner would not be supportive about them leaving their own communities. There were a few physicians who offered to speak directly with the surgeon abroad and who said they would provide follow-up care if needed. Participants stated that medical tourism facilitators and clinics abroad provided most of the support in their decision making. Some had direct communication with the surgeon via phone or email, where they could ask questions about the potential risks of the surgery, likely outcomes and if they were appropriate candidates for the procedure. While waiting time was part of their decision to go abroad, the availability of certain procedures was more important for those who sought alternative procedures, such as hip resurfacing, an alternative to a total hip replacement or a vertical sleeve gastrectomy, a form of gastric bypass surgery. All participants expected that the surgery would improve their qual- ity of life. The specific destination was less important than what they understood to be the expertise of the surgeon and reputation of the facility. The Canadians who were interviewed (Penney et al., 2011) highlighted issues similar to other medical tourists who are exposed to the same internet sites, advertisements and testimo- nials, regardless of specific regulatory or legal issues within their home country. This study of 32 Canadian medical tourists who sought surgery abroad confirms other accounts of medical tourism that attribute its growth to the influence of the internet (and social media) in connect- ing appropriate expectations and needs. Information from other medical tourists also influenced these decisions, although there is limited reporting regarding effectiveness and outcomes, both short- and long-term (Penney et al., 2011; Turner, 2013a). A similar study of medical tourists (Ozan-Rafferty et al., 2014) who travelled to Turkey is another example of how the internet is used to access information. Turkey has invested sig- nificant resources to become a hub’ for international patients. The study included 36 medical tourists from 13 different countries who had 47 procedures in Turkey between 2007 and 2012. They were predominantly from the USA and Europe and decided on treatment in Turkey because of lower costs and availability of treatment options. Like the Canadian study, patient reports via the internet, blogs and other discussion posts provided limited information on patients’ experiences when travelling abroad for care. Turkey was reported as a top destination between 2008 and 2011. These patient narratives reported sat- isfaction with their outcomes of care in Turkey (75 per cent). The few negative reports included postoperative infections, negative outcomes after IVF and unsuccessful hair transplants. Most of the feedback about the physicians was positive and noted that follow-up was available via email, Skype or telephone. Facilitators provided the necessary logistics of travel. Hospital accreditation was mentioned, but did not appear to be a significant factor in their decision making. It was not clear that they understood that some facilitator companies may have had a financial incentive for these referrals (Erdogan et al., 2012; Ozan-Rafferty et al., 2014). Both studies of patient narratives, albeit limited, identify the main pathways for learning about medical tourism as word-of-mouth’, internet searches, media stories and direct hospital- to-patient advertising (Hohm and Snyder, 2015). Medical tourism facilitators often emphasise the benefits of such travel while there is little to no information on comparative quality, safety and risks. There are thousands of websites with very attractive pictures, personal testimonials, credentials of physicians and their experience. Common to most websites is the lack of discussion regarding safety and risks of procedures, while some minimise potential questions about the quality of care at a particular facility. Clinical outcomes are presented with very general descrip- tions. Due to privacy issues for the specifics of care, there is little public clinical information about postoperative complications, lapses in safety, infection and any questionable professional or business practices. The importance of informed consent: a first principle of medical treatment Informed consent is a first principle of the ethics of medicine. The principle of consent was already evident during Greek and Roman civilisations, with evidence that the doctor’s inter- vention had to be, in some way, first approved by the patient. Plato had foreseen the problems, the procedures and the modes of information that are at the root of the modern principle of informed consent: the only guarantee for the patient should be derived from a fundamen- tal principle of medicine at all times: In disease, focus on two aims, to improve and not to cause damage’ (Plato, law IV). The Hippocratic oath suggests the awareness of precautions and preventive information. From the Hippocratic oath, the relationship between the doctor and patient was based upon two criteria: by the professional duty of the physician to do what is best for the patient and the duty of the patient to completely understand and consent to the physi- cian’s decisions and interventions. The obligation and certainty that the physician acted in the interest of the patient’s best interests have been passed down for centuries as the ethical standard that bestows professional authority upon physicians. During the twentieth century, informed consent was defined by more specific criteria: the fundamental autonomy of the patient to decide, as part of one’s personal rights and also the essential objective element of having information necessary for consent to a medical interven- tion. A truly informed consent is said to be given based upon a clear articulation and under- standing of the facts, implications and consequences of a medical intervention. To give an informed consent means that the individual has and understands all the relevant facts – possible complications, potential risks and benefits, duration and cost of treatment, as well as expected outcomes and follow-up. In providing informed consent, a patient agrees and gives explicit and written permission to an intervention (Satyanarayana, 2008). Patients have the moral right to an informed decision when choosing their care, whether at home or abroad (Beauchamp and Childress, 2001; Faden et al., 1986). Physicians (and hospitals) have the moral obligation to provide such information as the foundation for their trust and mutual agreement. In the UK, Malaysia and Singapore, informed consent for medical procedures requires proof of the current standard of care locally. This is referred to as sufficient consent’. Medicine in the USA, Australia and Canada takes a more patient-focused approach, requiring doctors to disclose significant risks and benefits to the individual patient. In some of the Mediterranean and Arab countries, informed consent is approached more on the context of the delivery of information, with the emphasis more on who is saying it and where, when and how it is being said, rather than what is said, which is relatively more important in Western countries. Optimal’ establishment of an informed consent requires an understanding of relevant cultural or other individual factors of the patient; however, the moral and technical requirements for informed consent should rest on the Western definition. With no regulatory oversight internationally, the requirements for an informed consent should have the same ethical conviction and requirement as defined by the World Health Organization (www.who.int/). The medical professionals at the World Bank’s Health Services Department developed the following criteria for choosing surgical procedures abroad: (1) only surgery for a non-acute condition; (2) the patient is able to travel without major pain; (3) the surgery is commonly performed with acceptable volumes, with minimal rates of postoperative complications; (4) the surgery requires minimal follow-up treatment on site; (5) the surgery requires minimal laboratory and pathology reports; and (6) the surgery results in minimal post-procedure immo- bility. In applying these criteria, medical tourists could initially understand their general risks and benefits for the most commonly performed procedures (Agency for Health Care Quality, 2012) and communicate to surgeons abroad as to their expectations for quality and outcomes. Quality and safety risks for medical tourists The Economist Intelligence Unit published its first study on the medical tourism market, Traveling for Health (EIU, 2011). The report highlights the fact that developing markets are becoming more pronounced’ because of the continued rise of medical costs in the USA and Europe and the increasing number of baby boomers’ moving toward retirement age, causing additional strain on healthcare systems in the West; however, identifying hospitals and physi- cians who provide the best care remains challenging (Connell, 2013). What are the risks faced by medical tourists and what information do we have on com- parative quality and safety of facilities and providers abroad (Greenfield and Pawsey, 2014)? In the USA, there are many regulatory mechanisms designed to protect patients in the health- care setting. The USA requires accreditation for all hospitals, certification and professional self- regulation of physicians, nurses and other ancillary staff. Malpractice suits are reported in a National Malpractice Database that is accessible publicly; a government agency, the Department of Health and Human Services, requires hospitals to report a robust list of quality measures that are used for payment. The overabundance’ of required reporting has led to improvement across the best hospitals. As Lunt et al. (2011) reported, evidence of clinical outcomes for medical tourists is sparse and reports are difficult to verify. Turner observes that, without data, there is no viable way to track the movement of patients, clinical outcomes, surgical complications, infections and other hospital-related events. There is no information, for example, on improperly performed procedures, disease transmission and spread of infections from inbound and outbound medi- cal travellers. When medical tourists return home with less than satisfactory outcomes, that knowledge is not available unless through testimonials and social media (Turner, 2007, 2013b). Many destination countries have infectious diseases of global concern, such as tuberculosis, polio, malaria and other mosquito-borne infections. Medical tourists can be exposed to circu- lating infectious diseases as soon as they come in contact with other patients and staff in the hospital. There are also nosocomial infections – hospital-acquired infections (HAIs) – from contaminated water, food, devices (catheters and ventilators) and contact with healthcare team members who may be delinquent in required hand hygiene practices. In developed countries, including the USA, urinary tract infections are the most common HAIs. In the USA, the annual costs of the major HAIs in hospitals (central line-associated blood stream infections, ventilator- associated pneumonia, surgical site infections and catheter-associated urinary tract infections) totalled $9.8 billion – a significant cost to the healthcare budget (Zimlichman et al., 2013). On average, 10-15per cent of all hospitalised patients in lower-income countries will acquire HAIs. Blood safety presents additional risks, with 39 of the 164 countries responding to a 2008 World Health Organization (WHO) survey on blood safety (www.who.int/), indicating that they do not follow the WHO guidelines for screening donated blood for HIV, hepatitis B and C and syphilis. Rates of HAIs in developing countries are recognisd to be higher than those in developed countries (Allegranzi et al., 2011). One identifying marker of a good-quality hospital is a JCI accreditation or an equivalent accreditation identified by the International Society for Quality in Healthcare. Another marker is foreign-trained physicians who have been deemed qualified to practise in the USA or UK. A third is that the hospital engages in collaborations with prestigious US medical centres (Cohen, 2015). While these considerations can identify positive characteristics of a hospital, there is limited available evidence that these are correlated with the best patient outcomes. Quality of care remains the most frequently cited concern for medical travel abroad. The medical tourist typically has this information, if guided properly, but too often these data are under-reported by hospitals and by specific procedures (Cohen, 2015; Lunt et al., 2010: 11; Snyder et al., 2011; Turner, 2011). Patients may not know what questions to ask regarding their exposure to risk and safety in a foreign country, for example infections, especially across many different cultures and local professional variations in comparable standards of care. Stay tuned for Part Three, which will appear in March’s issue of MTT.