Medical tourism: a cost or benefit to the NHS?

Foreign patients and multicultural challenges in pediatric oncology: The experience of the Istituto Nazionale dei Tumori in Milan

This paper describes the complexity of the clinical management of foreign minors suffering from cancer, through the clinical experience of an Italian referral center. The study includes 50 patients less than 18 years (22% of the patients admitted to the unit in 2023), 32 foreigners who were Italian resident and 18 who had come to Italy specifically to receive cancer treatment. Patients who migrate for healthcare reasons often arrive at the referral center with advanced disease or relapse. Numerous socio-cultural issues were reported. To address them, specific strategies were implemented to ensure equal and high-quality care for all patients, respecting their needs.

Understanding and comparing the medical tourism cancer patient with the locally managed patient: A case control study

Introduction

Medical tourism is characterized by people seeking treatment abroad for various medical conditions due to varied reasons, many of whom benefit from specialized care for non-communicable diseases. Conversely, there are associated negative effects such as medical complications and weakened health systems. Currently, there is paucity of scientific evidence on patient-related factors influencing seeking treatment benefits abroad. This study sought to compare patient-related factors associated with choice of cancer treatment center locally or abroad, to understand reasons for seeking treatment outside Kenya.

Materials and methods

As a case-control study, 254 cancer patients were randomly sampled to compare responses from those who chose to receive initial treatment abroad or in Kenya. The cases were recruited from Ministry of Health while the controls from Kenyatta National Hospital and Texas Cancer Center. Data was analyzed using SPSS Software Version 21. Descriptive statistics, bivariate and multiple logistic regression analysis was carried out. Level of significance was set at 5%.

Results

Out of 254 respondents, 174 (69.5%) were treated for cancer in Kenya and 80 (31.5%) in India. We found that cost effectiveness was a significant factor for over 73% of all respondents. The study revealed independent predictors for seeking treatment in India were: monthly income higher than US$ 250; every additional month from when disclosure to patients was done increased likelihood by 1.16 times; physician advice (Odds Ratio(OR) 66; 95% Confidence Interval(CI) 7.9–552.9); friends and family (OR 42; 95% CI 7.07–248.6); and perception of better quality of care (OR 22.5; 95% CI 2.2–230.6).

Conclusion

Reasons patients with cancer sought treatment in India are multifactorial. Several of these can be addressed to reverse out-ward bound medical tourism and contribute to improving the in-country cancer healthcare. It will require strengthening the health system accordingly and sensitizing the medical fraternity and general public on the same.

Outbound medical tourists: The interplay of perceived quality, length of stay, group-size, post-visit destination image and revisit intention

Using halo effect as the underlying theory, we examined how perceived quality of medical care influenced components of post-visit destination image (infrastructure, attraction, value for money, and enjoyment) and how each component influenced Bangladeshi outbound medical tourists’ revisit intentions. Additionally, we examined how these relationships varied based on their length of stay (LOS) and travel-group size (TGS). Results showed a significant positive effect of the perceived quality of medical care on all four components of the post-visit destination image. Except for enjoyment, all three components had a significant positive influence on revisit intentions. All the proposed relationships were supported for medical tourists with higher LOS and TGS. However, for medical tourists with low LOS, the perceived quality of medical care did not influence value for money. Furthermore, value for money and enjoyment did not significantly influence revisit intentions for medical tourists with low LOS and TGS.

Dental tourists: treat, re-treat or do not treat?

Many UK patients in the search for their perfect smile have now decided to have their dental treatment abroad, the main reasons being that they believe they can have the same treatment but at a much lower price. With many overseas clinics offering treatment packages that also include a holiday, dental tourism seems an opportunity not to be missed. Although not always the case, some treatments unfortunately do not go to plan, often leaving distraught patients and their apprehensive dentists in a difficult situation. This article will discuss the reasons behind dental tourism and if the health system has contributed to the increasing demand for dental tourism. We will touch on the impact dental tourism has had on UK dentistry and if the NHS should be responsible for handling the consequences of any failed or incomplete dental treatment carried out abroad. It will also put the spotlight on dentists' responsibilities and to what extent they should treat these patients, as these cases can leave clinicians in primary and secondary care in a challenging predicament, not only clinically but also ethically and medico-legally.

Relationship between international tourism and concentrations of PM 2.5: an ecological study based on WHO data

Tourism is regarded as a major global industry. Given the importance of identifying factors affecting the tourism industry and attracting international tourists, the present ecological study explored the impact of environmental pollution on the number of international tourists arrival using concentrations of PM_2.5 (particulate matter 2.5 μm or less in size) in a multivariate framework under the context of 190 countries. Using panel data from 190 countries, the author explored the data on the number of international tourists arriving in countries in 2017 extracted from the World Bank (WB) website, and obtained the information about the concentrations of PM_2.5 from the World Health Organization (WHO) website. Pearson's correlation coefficient and linear regression analysis were used to examine the correlation of the number of tourists with the variables of daily concentrations of PM_2.5, societal safety, international conflict, and the relationship of tourist arrival with the studied variables, respectively. The number of countries with low, moderate, and high concentrations of PM_2.5 in urban areas was 33, 116, and 41, respectively. This numbers for rural areas was 47, 102, and 42 countries, respectively. The mean concentrations of PM_2.5 in the surveyed countries was 23.90 ± 15.81 and 25.69 ± 16.76 for rural and urban areas, respectively. The estimation results revealed that there was a significant correlation between the number of tourists with the concentrations of PM_2.5 in the rural areas (p = 0.01). There was also a significant relationship between the human development index (HDI) and the concentration of PM_2.5. A significant relationship was observed in the results of univariate linear regression analysis between tourist arrival with rural concentrations of PM_2.5 (p = 0.02) and societal safety (p = 0.003). After adjusting the effect of societal safety variables, domestic and international conflict, the relationship between tourist arrivals and concentrations of PM_{2.5 in} rural area remained significant (p = 0.02). The results imply that by reducing the concentration of PM_2.5 the positive attitude of tourists for traveling to countries with healthy air can be earned.

Where is the policy? A bibliometric analysis of the state of policy research on medical tourism

Background

It is imperative that researchers studying medical tourism connect their work with policy, so that its real-world challenges can be better understood, and more effectively addressed. This article gauges the scope and evolution of policy thinking in medical tourism research through a bibliometric review of published academic literature, to establish the extent to which researchers apply public policy theories and frameworks in their investigation of medical tourism, or consider the policy imperatives of their work.

Methods

A Boolean search of the Web of Science (WoS) Core Collection was performed to identify policy-related publications on medical tourism. We analyzed the results using bibliometrics and a data visualization software called VOSviewer to identify patterns in knowledge production and underlying network linkages in policy research on the subject.

Results

Our findings suggest that only a small proportion of medical tourism research explicitly addresses policy issues or applies policy paradigms in their study approach. Field-specialized journals serving practitioners publish less research as compared to interdisciplinary social and health policy journals. Moreover, there are significant geographical and disciplinary disparities in the policy-orientation of research, and a predilection towards select policy areas such as reproductive and transplant tourism to the neglect of more holistic governance and health system considerations.

Conclusion

This article is a call to action for greater engagement by policy scholars on medical tourism, and for health researchers to more explicitly consider how their research might contribute to the understanding and resolution of contemporary policy challenges of medical tourism. Failure to clearly and consistently make the policy connection is a lost opportunity for researchers to frame the public debate, and influence policy thinking on medical tourism.

The north-south policy divide in transnational healthcare: a comparative review of policy research on medical tourism in source and destination countries

Medical tourism occupies different spaces within national policy frameworks depending on which side of the transnational paradigm countries belong to, and how they seek to leverage it towards their developmental goals. This article draws attention to this policy divide in transnational healthcare through a comparative bibliometric review of policy research on medical tourism in select source (Canada, United States and United Kingdom) and destination countries (Mexico, India, Thailand, Malaysia and Singapore), using a systematic search of the Web of Science (WoS) database and review of grey literature. We assess cross-national differences in policy and policy research on medical tourism against contextual policy landscapes and challenges, and examine the convergence between research and policy. Our findings indicate major disparities in development agendas and national policy concerns, both between and among source and destination countries. Further, we find that research on medical tourism does not always address prevailing policy challenges, just as the policy discourse oftentimes neglects relevant policy research on the subject. Based on our review, we highlight the limited application of theoretical policy paradigms in current medical tourism research and make the case for a comparative policy research agenda for the field.

Cosmetic Tourism: a Costly Filler Within the National Health Service Budget or a Missed Financial Opportunity? A Local Cost Analysis and Examination of the Literature

BACKGROUND

Cosmetic tourism is a global commodity, but patients seeking treatment for complications of international cosmetic tourism appear to be on the rise. We calculate the financial burden to a single NHS trust and summarise the literature, reviewing the implications of cosmetic tourism and summarising available guidance to assist surgeons in this ethically challenging, but expanding, field.

METHODS

Hospital episodes for patients with complications from cosmetic tourism between January 2016 and March 2017 were retrieved using the patient management system. The coding department provided the episode costs. A literature search was conducted using Medline, EMBASE and HBE identifying 273 English abstracts. The abstracts were reviewed for relevance followed by assessment of the 48 selected full articles by all authors and 17 papers contained relevant, new information.

RESULTS

Eleven patients underwent management for complications of cosmetic surgery, most commonly infection, with a sum of 29 inpatient episodes and total cost of £259,732.

DISCUSSION

Our study illustrates the management of complications of cosmetic surgery carries a high cost. This is not an experience limited to just this trust in the UK. Internationally, healthcare systems are evolving to raise the safety profile for cosmetic tourists, some going the extra mile to accommodate healthcare tourists, reaping the financial reward. Following the examination of the literature, we query whether NHS trusts should heighten their presence as providers of private services on the international market, eliminating numerous medical-ethic concerns associated with substandard cosmetic tourism.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Complications of Cosmetic Surgery Abroad - Cost Analysis and Patient Perception

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Background:

Cosmetic surgery tourism is rapidly becoming more prevalent in the United Kingdom. We aim to identify the motivational factors underlying patients’ decisions to go abroad for their treatment and gather information about the ensuing complications.

Methods:

A retrospective review (January 2013–August 2017) was conducted of patients seen at a single major trauma center for complications from cosmetic surgery performed overseas. Cost analysis was performed based on national tariffs. Complications were grouped based on Clavien-Dindo classification and the Clinical Commissioning Group cost. A telephone survey was conducted to evaluate reasons for travel, details of complications, and impression of healthcare at home and abroad.

Results:

A total of 20 patients (one male, 19 females) with a mean age 36 years (23–59 years) were included. Lower cost was the most popular reason for travel, followed by lack of expertise and friend’s recommendation. Abdominoplasty (n = 9) had the highest number of complications followed by gluteal augmentation (n = 7). All major complications were due to gluteal augmentation (n = 4). The cost was for minor (n = 8, £3,448), intermediate (n = 8, £18,271), and major (n = 4, £42,083.59) complications.

Conclusions:

We raise serious concerns about the lack of regulation in cosmetic tourism and the absence of patient follow-up abroad. A particular concern was all gluteal augmentation cases had major complications. An international consensus to regulate surgical practice abroad is crucial to protect patients’ interests and promote safe cosmetic surgery.

The upside of trade in health services

Cross border movement of patients and health workers is often portrayed negatively but Johanna Hanefeld and Richard Smith discuss how it can benefit both source and recipient countries as long as the risks are properly managed

Report on Current Experience of ASAPS Membership and Management of Cosmetic Tourism Complications

Background

Cosmetic tourism is an expanding industry with increasing scrutiny in the public domain of complications and patient safety issues. The health and financial implications for patients are large and deserve further investigation.

Objectives

The aim of this study was to understand the experience of the American Society for Aesthetic Plastic Surgery (ASAPS) members treating medical tourism patients with complications who returned to the United States for secondary management.

Methods

A 20-question survey was administered electronically in August 2018 to ASAPS members with voluntary participation. Questions about surgeon experience, the nature of complications, type of initial surgery, and subsequent management were asked. Responses were tabulated and percentages of response choices were calculated and reported.

Results

Ninety-three responses were received from the 1611 physician ASAPS members (5.8% response rate). More than half of respondents had seen 2 to 5 patients in the last 12 months with a complication from cosmetic tourism. The most common procedure that patients had done abroad was abdominoplasty. The most common complication was infection caused by Gram-positive organisms, managed on an outpatient basis without surgical intervention. Involvement of an ASAPS member led to successful resolution of complications in the vast majority of patients. Estimated costs out of pocket for management of complications were most commonly between $1001 and 5000.

Conclusions

While the experience of ASAPS members is as varied as the complications faced by cosmetic tourism patients, the vast majority of complications is infectious and can be managed on an outpatient basis successfully with the involvement of an ASAPS member. Further collaborative efforts both domestically and internationally can help improve patient safety for cosmetic tourism patients.

Cosmetic Surgery: Regulatory Challenges in a Global Beauty Market

The market for cosmetic surgery tourism is growing with an increase in people travelling abroad for cosmetic surgery. While the reasons for seeking cosmetic surgery abroad may vary the most common reason is financial, but does cheaper surgery abroad carry greater risks? We explore the risks of poorly regulated cosmetic surgery to society generally before discussing how harm might be magnified in the context of cosmetic tourism, where the demand for cheaper surgery drives the market and makes surgery accessible for increasing numbers of people. This contributes to the normalisation of surgical enhancement, creating unhealthy cultural pressure to undergo invasive and risky procedures in the name of beauty. In addressing the harms of poorly regulated surgery, a number of organisations purport to provide a register of safe and ethical plastic surgeons, yet this arguably achieves little and in the absence of improved regulation the risks are likely to grow as the global market expands to meet demand. While the evidence suggests that global regulation is needed, the paper concludes that since a global regulatory response is unlikely, more robust domestic regulation may be the best approach. While domestic regulation may increase the drive towards foreign providers it may also have a symbolic effect which will reduce this drive by making people more aware of the dangers of surgery, both to society and individual physical wellbeing.

Government roles in regulating medical tourism: evidence from Guatemala

Background

Regulation of the medical tourism and public health sectors overlap in many instances, raising questions of how patient safety, economic growth, and health equity can be protected. The case of Guatemala is used to explore how the regulatory challenges posed by medical tourism should be dealt with in countries seeking to grow this sector.

Methods

We conducted a qualitative case study of the medical tourism sector in Guatemala, through reviews and analyses of policy documents and media reports, key informant interviews (n = 50), and facility site-visits.

Results

Key informants were critical of the absence of effective public regulation of the emerging medical tourism sector, noting several regulatory gaps and the importance of filling them. These informants specifically expressed that: 1) The government should regulate medical tourism in Guatemala, thought there was disagreement as to which government sector should do so and how; 2) The government has not at this time regulated the medical tourism sector nor shown great interest in doing so; and 3) International accreditation could be used to augment domestic regulation.

Conclusions

The intersection of domestic and international regulation of medical tourism has been largely unexplored. This case study advances new research in this area. It highlights the need for and dearth of regulatory protections in Guatemala and lessons for other, similarly situated countries. National regulatory models from Israel and Barbados could be adapted to the Guatemalan context. Global governance could help to protect national governments from any competitive disadvantages created by regulation. Underlying the concerns over growth in medical tourism, however, is how it contributes to the ongoing privatization of health care facilities worldwide. This trend risks undermining efforts to reach targets for Universal Health Coverage and exacerbating existing inequities in the global distribution of health and wealth.

Financial Implications of Atypical Mycobacterial Infections After Cosmetic Tourism: Is It Worth the Risk?

BACKGROUND

Cosmetic tourism has become increasingly popular despite many associated risks. The economic impact of atypical mycobacterial infections in cosmetic tourism is poorly defined in the literature. We sought to investigate the costs and clinical course of patients with these infections.

METHODS

A retrospective review of all patients managed by the Plastic Surgery Division at Columbia University Medical Center from 2013 to 2014 with atypical mycobacterial surgical site infections after cosmetic surgery outside the United States was performed. Data including patient demographics, procedure costs, clinical course, impact on daily life, and costs associated with complications were collected using hospital billing information, patient questionnaires, telephone interviews, and clinical charts. Cost analysis was done to identify the personal and societal costs of these complications.

RESULTS

Data from 10 patients were collected and analyzed. Management of mycobacterial infections cost an average of $98,835.09 in medical charges. The indirect cost of these infections was $24,401 with a mean return to work time of 6.7 months. Total patient savings from cosmetic tourism was $3419. The total cost of a mycobacterial infection was greater than $123,236.47. Although the incidence of mycobacterial infection abroad is unknown, the potential cost of an infection alone outweighs the financial benefits of cosmetic tourism if the risk exceeds 2.77%.

CONCLUSIONS

Atypical mycobacterial infections as a result of cosmetic tourism come at considerable cost to patients and the health care system. When our results are taken into consideration with other risks of cosmetic tourism, the financial risks likely far outweigh the benefits.

Medical tourism and national health care systems: an institutionalist research agenda

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for national health care systems, the comparative scholarship on the topic remains too limited in scope. In this article, we draw on the existing literature to discuss a comparative research agenda on medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, we claim that such characteristics shape the demand for medical tourism in each country. On the other hand, the institutional characteristics of each national health care system can shape the very nature of the impact of medical tourism on that particular country. Using the examples of Canada and the United States, this article formulates a systematic institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus with a view to informing future policy work in this field.

Understanding medical travel from a source country perspective: a cross sectional study of the experiences of medical travelers from the Maldives

BACKGROUND

The resolution adopted in 2006 by the World Health Organization on international trade and health urges Member States to understand the implications of international trade and trade agreements for health and to address any challenges arising through policies and regulations. The government of Maldives is an importer of health services (with outgoing medical travelers), through offering a comprehensive universal health care package for its people that includes subsidized treatment abroad for services unavailable in the country. By the end of the first year of the scheme approximately US$11.6 m had been spent by the government of Maldives to treat patients abroad. In this study, affordability, continuity and quality of this care were assessed from the perspective of the medical traveler to provide recommendations for safer and more cost effective medical travel policy.

RESULTS

Despite universal health care, a substantial proportion of Maldivian travelers have not accessed the government subsidy, and a third reported not having sufficient funds for the treatment episode abroad. Among the five most visited hospitals in this study, none were JCI accredited at the time of the study period and only three from India had undergone the National Accreditation Board for Hospitals (NABH) in India. Satisfaction with treatment received was high amongst travelers but concern for the continuity of care was very high, and more than a third of the patients had experienced complications arising from the treatment overseas.

CONCLUSION

Source countries can use their bargaining power in the trade of health services to offer a more comprehensive package for medical travelers. Source countries with largely public funded health systems need to ensure that medical travel is truly affordable and universal, with measures for quality control such as the use of accredited foreign hospitals to make it safer and to impose measures that ensure the continuity of care for travelers.

Colorectal Cancer Screening among Korean Americans in Chicago: Does It Matter Whether They had the Screening in Korea or the US?

Background:

Colorectal cancer (CRC) is one of the most common cancers in Korean Americans (KAs) and CRC screening can detect CRC early and may reduce the incidence of CRC by leading to removal of precancerous polyps. Many KAs in the US leave the country, primarily to travel to Korea, for health screening. The aim of this study was to (a) assess CRC screening rates, including fecal occult blood test (FOBT), flexible sigmoidoscopy, and colonoscopy and (b) explore factors related to these tests among KAs by location of CRC screening.

Methods:

Descriptive and correlational research design with cross-sectional surveys was used with 210 KAs. Socio-demographics (age, gender, years in the US, marital status, education, employment, household income, and proficiency in spoken English), access to health care (health insurance and usual source of health care), and location of CRC screening utilization (Korea, the US, or both Korea and US) were measured and analyzed using descriptive statistics and multinominal logistic regression.

Results:

Out of 133 KA participants who had had lifetime CRC screening (i.e., had ever had FOBT, flexible sigmoidoscopy, or colonoscopy), 19% had visited Korea and undergone CRC screening in their lifetimes. Among socio-demographic factors and access to health care factors, having a usual source of health care in the US (OR=8.45) was significantly associated with having undergone lifetime CRC screening in the US. Having health insurance in the US and having had lifetime CRC screening in the US were marginally significant (OR=2.54).

Conclusion:

Access to health care in the US is important for KAs to have CRC screening in the US. As medical tourism has been increasing globally, the location of CRC screening utilization must be considered in research on cancer screening to determine correlates of CRC screening.

Achieving universal health coverage in small island states: could importing health services provide a solution?

Background

Universal health coverage (UHC) is difficult to achieve in settings short of medicines, health workers and health facilities. These characteristics define the majority of the small island developing states (SIDS), where population size negates the benefits of economies of scale. One option to alleviate this constraint is to import health services, rather than focus on domestic production. This paper provides empirical analysis of the potential impact of this option.

Methods

Analysis was based on publicly accessible data for 14 SIDS, covering health-related travel and health indicators for the period 2003–2013, together with in-depth review of medical travel schemes for the two highest importing SIDS—the Maldives and Tuvalu.

Findings

Medical travel from SIDS is accelerating. The SIDS studied generally lacked health infrastructure and technologies, and the majority of them had lower than the recommended number of physicians in a country, which limits their capacity for achieving UHC. Tuvalu and the Maldives were the highest importers of healthcare and notably have public schemes that facilitate medical travel and help lower the out-of-pocket expenditure on medical travel. Although different in approach, design and performance, the medical travel schemes in Tuvalu and the Maldives are both examples of measures used to increase access to health services that cannot feasibly be provided in SIDS.

Interpretation

Our findings suggest that importing health services (through schemes to facilitate medical travel) is a potential mechanism to help achieve universal healthcare for SIDS but requires due diligence over cost, equity and quality control.

South-South cross-border patient travel to South Africa

This paper explores intra-regional South-South cross-border patient travel within the context of Southern Africa. South Africa, in particular, has been widely touted as one of the emerging destinations of high-end patients from the Global North alongside other destinations such as Brazil, India, Costa Rica and Thailand. Using South Africa as a case study, the paper demonstrates that South-South cross-border patient travel is far more significant than North-South patient travel both in numerical and financial terms. Every year, thousands of patients from neighbouring countries travel to South Africa in search of medical treatment for procedures that are not offered in their own countries. Despite its size and importance, the South-South flow of patients in Southern Africa is not fully understood and requires further scholarly research.

Hospital Costs of Foreign Non-Resident Patients: A Comparative Analysis in Catalonia, Spain

Although patient mobility has increased over the world, in Europe there is a lack of empirical studies. The aim of the study was to compare foreign non-resident patients versus domestic patients for the particular Catalan case, focusing on patient characteristics, hospitalisation costs and differences in costs depending on the typology of the hospital they are treated. We used data from the 2012 Minimum Basic Data Set-Acute Care hospitals (CMBD-HA) in Catalonia. We matched two case-control groups: first, foreign non-resident patients versus domestic patients and, second, foreign non-resident patients treated by Regional Public Hospitals versus other type of hospitals. Hospitalisation costs were modelled using a GLM Gamma with a log-link. Our results show that foreign non-resident patients were significantly less costly than domestic patients (12% cheaper). Our findings also suggested differences in the characteristics of foreign non-resident patients using Regional Public Hospitals or other kinds of hospitals although we did not observe significant differences in the healthcare costs. Nevertheless, women, 15-24 and 35-44 years old patients and the days of stay were less costly in Regional Public Hospitals. In general, acute hospitalizations of foreign non-resident patients while they are on holiday cost substantially less than domestic patients. The typology of hospital is not found to be a relevant factor influencing costs.

Trade is central to achieving the sustainable development goals: a case study of antimicrobial resistance

Johanna Hanefeld and colleagues highlight the links between trade and health and argue for greater consideration of trade agreements in actions to meet the sustainable development goals

"Ensure that you are well aware of the risks you are taking…": actions and activities medical tourists' informal caregivers can undertake to protect their health and safety

Background

When seeking care at international hospitals and clinics, medical tourists are often accompanied by family members, friends, or other caregivers. Such caregiver-companions assume a variety of roles and responsibilities and typically offer physical assistance, provide emotional support, and aid in decision-making and record keeping as medical tourists navigate unfamiliar environments. While traveling abroad, medical tourists’ caregiver-companions can find themselves confronted with challenging communication barriers, financial pressures, emotional strain, and unsafe environments.

Methods

To better understand what actions and activities medical tourists’ informal caregivers can undertake to protect their health and safety, 20 interviews were conducted with Canadians who had experienced accompanying a medical tourist to an international health care facility for surgery. Interview transcripts were subsequently used to identify inductive and deductive themes central to the advice research participants offered to prospective caregiver-companions.

Results

Advice offered to future caregiver-companions spanned the following actions and activities to protect health and safety: become an informed health care consumer; assess and avoid exposure to identifiable risks; anticipate the care needs of medical tourists and thereby attempt to guard against caregiver burden; become familiar with important logistics related to travel and anticipated recovery timelines; and take practical measures to protect one’s own health.

Conclusion

Given that a key feature of public health is to use research findings to develop interventions and policies intended to promote health and reduce risks to individuals and populations, the paper draws upon major points of advice offered by study participants to take the first steps toward the development of an informational intervention designed specifically for the health and safety needs of medical tourists’ caregiver companions. While additional research is required to finalize the content and form of such an intervention, this study provides insight into what practical advice former caregiver-companions state should be shared with individuals considering assuming these roles and responsibilities in the future. In addition, this research draws attention to the importance of ensuring that such an intervention is web-based and readily accessible by prospective caregiver-companions.

Radiologist income, receipts, and academic performance: an analysis of many nations

Background Considerable interest exists in comparison between healthcare systems across multiple countries, especially where cost enters the discussion. Purpose To evaluate the relationship between radiologists' income, receipts for studies, and academic performance across multiple countries. Material and Methods The annual income of radiologists and receipts for computed tomography (CT) and magnetic resonance imaging (MRI) were obtained based on a survey sent to expert radiologists practicing in 23 countries of varying developmental status. Articles published in generalist radiology journals determined the academic performance of each country. Results Among the developed countries, Canada has the highest estimated annual income for both private ($700,000/year) and university radiologists ($600,000/year) while Spain has the lowest income for private practice ($68,000/year) and Portugal has the lowest income for university practice ($57,300/year). Among the developing countries, Saudi Arabia has the highest incomes for both private ($210,000/year) and university ($140,000/year) radiologists and Vietnam has the lowest incomes for both private ($30,000/year) and university ($6,000/year) radiologists. Total receipts for CT and MRI studies ranged from $80/study (Portugal) to $1000/study (USA) in developed countries, and ranged from $30/study (Egypt) to $700/study (Saudi Arabia) in developing countries. A moderate correlation ( r = 0.482) was seen between radiologist's income and the receipts for combined practice in all countries. The radiology journal academic quotient was highest in The Netherlands among developed countries, and Turkey among developing countries. Conclusion A relatively broad range of radiologists' income is observed among developed and developing countries, which shows correlation with the receipts for advanced imaging studies. Countries with an acceptable compromise between income, receipts, and academic performance, may be the best models for other countries to emulate.

National Health Service Principles as Experienced by Vulnerable London Migrants in "Austerity Britain": A Qualitative Study of Rights, Entitlements, and Civil-Society Advocacy

BACKGROUND

Recent British National Health Service (NHS) reforms, in response to austerity and alleged 'health tourism,' could impose additional barriers to healthcare access for non-European Economic Area (EEA) migrants. This study explores policy reform challenges and implications, using excerpts from the perspectives of non-EEA migrants and health advocates in London.

METHODS

A qualitative study design was selected. Data were collected through document review and 22 in-depth interviews with non-EEA migrants and civil-society organisation representatives. Data were analysed thematically using the NHS principles.

RESULTS

The experiences of those 'vulnerable migrants' (ie, defined as adult non-EEA asylum-seekers, refugees, undocumented, low-skilled, and trafficked migrants susceptible to marginalised healthcare access) able to access health services were positive, with healthcare professionals generally demonstrating caring attitudes. However, general confusion existed about entitlements due to recent NHS changes, controversy over 'health tourism,' and challenges registering for health services or accessing secondary facilities. Factors requiring greater clarity or improvement included accessibility, communication, and clarity on general practitioner (GP) responsibilities and migrant entitlements.

CONCLUSION

Legislation to restrict access to healthcare based on immigration status could further compromise the health of vulnerable individuals in Britain. This study highlights current challenges in health services policy and practice and the role of non-governmental organizations (NGOs) in healthcare advocacy (eg, helping the voices of the most vulnerable reach policy-makers). Thus, it contributes to broadening national discussions and enabling more nuanced interpretation of ongoing global debates on immigration and health.

A Study of Tourism Dynamics in Three Italian Regions Using a Nonautonomous Integrable Lotka-Volterra Model

This article is a first application of an integrable nonautonomous Lotka–Volterra (LV) model to the study of tourism dynamics. In particular, we analyze the interaction in terms of touristic flows among three Italian regions. Confirming an hypothesis advanced by recent theoretical works, we find that these regions not only compete against each other, but at times they also proceed in mutualism. Moreover, the kind and the intensity of the interaction changes over time, suggesting that dynamic models can play a vital role in the study of touristic flows.

Global Health Policy and Access to Care: Investigating Patient Choice on an International Level Using Social Media

BACKGROUND

Increased access to transportation and information has led to the emergence of more diverse patient choice and new forms of health care consumption, such as medical travel. In order for health care providers to effectively attract patients, more knowledge is needed on the mechanisms underlying decision-making of potential travelers from different countries. A particularly promising method of studying the travelers' motives is collecting data on social media.

OBJECTIVES

The aim of this study was to test what factors influence decision-making of potential medical travelers and how these factors interact. Based on existing literature, the factors analyzed included quality, cost, and waiting time for 2 procedures varying in invasiveness across 12 different destination countries.

METHODS

Decision-making patterns were examined using a pilot questionnaire that generated a large amount of data from over 800 participants in 40 countries. Participants indicated their willingness to travel given different scenarios. Each scenario consisted of a combination of several factors. Additionally, participants were asked to indicate the reasons for their choice.

RESULTS

Individuals display high willingness to travel for medical care when combining all participants and scenarios, travel for care was chosen 66.9% of the time. Among the factors influencing their decisions, quality of the medical procedure abroad was considered most important, and cost was least important as shown by chi-square tests and corresponding odds ratios. Log-linear analyses revealed an interaction between time waiting in the local health care system and type of procedure, whereby time pressure increased the odds of agreeing to travel for the more invasive procedure. The odds of traveling to Europe and the USA were by far the highest, although participants indicated that under certain conditions they might be willing to travel to other medical destinations, such as Asia.

CONCLUSION

Our measurements yielded several reliable insights into the factors driving medical decision-making. An essential next step would be to expand these findings with a more encompassing sample and more elaborate statistical modeling.

Medical tourism in Thailand: a cross-sectional study

Objective

To investigate the magnitude and characteristics of medical tourism in Thailand and the impact of such tourism on the Thai health system and economy.

Methods

In 2010, we checked the records of all visits to five private hospitals that are estimated to cover 63% of all foreign patients. We reviewed hospital records of foreign patients and obtained data on their countries of origin, diagnoses and interventions. We surveyed 293 medical tourists to collect demographic characteristics and information on their expenditure and travelling companions. To help understand the impact of medical tourism on the Thai health system, we also interviewed 15 hospital executives and 28 service providers from the private hospitals.

Findings

We obtained 911 913 records of hospital visits, of which 324 906 came from 104 830 medical tourists. We estimated that there were 167 000 medical tourists in Thailand in 2010. Of the medical tourists who attended our study hospitals, 67 987 (64.8%) came from the eastern Mediterranean region or Asia and 109 509 (34%) of them were treated for simple and uncomplicated conditions – i.e. general check-ups and medical consultations. The mean self-reported non-medical expenditure was 2750 United States dollars. According to the hospital staff interviewed, medical tourism in 2010 brought benefits to – and apparently had no negative impacts on – the Thai health system and economy.

Conclusion

We estimate that the total number of medical tourists visiting Thailand is about 10% of previous national government estimates of 1.2 million. Such tourists appear to bring economic benefits to Thailand and to have negligible effects on the health system.

Evidence on global medical travel

The potential benefits of travelling across national borders to obtain medical treatment include improved care, decreased costs and reduced waiting times. However, medical travel involves additional risks, compared to obtaining treatment domestically. We review the publicly-available evidence on medical travel. We suggest that medical travel needs to be understood in terms of its potential risks and benefits so that it can be evaluated against alternatives by patients who are seeking care. We propose three domains –quality standards, informed decision-making, economic and legal protection – in which better evidence could support the development of medical travel policies.

Trends and structural shifts in health tourism: evidence from seasonal time-series data on health-related travel spending by Canada during 1970-2010

There has been a growing interest in better understanding the trends and determinants of health tourism activities. While much of the expanding literature on health tourism offers theoretical or qualitative discussion, empirical evidences has been lacking. This study employs Canada's outbound health tourism activities as an example to examine the trends in health tourism and its association with changing domestic health care market characteristics. A time-series model that accounts for potential structural changes in the trend is employed to analyze the quarterly health-related travel spending series reported in the Balance of Payments Statistics (BOPS) during 1970-2010 (n = 156). We identified a structural shift point which marks the start of an accelerated growth of health tourism and a flattened seasonality in such activities. We found that the health tourism activities of Canadian consumers increase when the private investment in medical facilities declines or when the private MPI increases during the years following the structural-change. We discussed the possible linkage of the structural shift to the General Agreement on Trade in Services (GATS), which went into effect in January, 1995.

Spectrum of neurosurgical complications following medical tourism: challenges of patients without borders

BACKGROUND AND OBJECTIVES

The cost of medical care and availability of resources (human and facilities) which differs from nation to nation are amongst others, factors driving medical tourism (MT) despite its potential drawbacks. The aim of the study was to analyse all patients that presented with neurosurgical complications following MT.

METHODS

A single institution prospective study was carried out. Data which included patients' demographics, diagnosis, Glasgow coma scale score at admission, type of complication, and outcome were collected over a 3 year period and analysed.

RESULTS

A total of 23 neurosurgical cases were seen during the study period with a median age of 42 years (17-70 years). India is the most common country visited by Nigerian patients. Nine patients died from various complications on arrival in Nigeria. There was no significant statistical difference between the outcome and patients clinical status prior to travel (p=0.107), country where the surgery was done (p=0.776), admission GCS in Nigeria (p=0.169), and redo surgery in Nigeria (0.181).

CONCLUSION

Government in different nations should have legislations to ensure that medical tourists' receive appropriate care abroad, proper follow-up care upon their return, and also promulgate laws to regulate quasi and organised MT agencies that are operating in a regulatory vacuum.

"You don't want to lose that trust that you've built with this patient...": (dis)trust, medical tourism, and the Canadian family physician-patient relationship

Background

Recent trends document growth in medical tourism, the private pursuit of medical interventions abroad. Medical tourism introduces challenges to decision-making that impact and are impacted by the physician-patient trust relationship—a relationship on which the foundation of beneficent health care lies. The objective of the study is to examine the views of Canadian family physicians about the roles that trust plays in decision-making about medical tourism, and the impact of medical tourism on the therapeutic relationship.

Methods

We conducted six focus groups with 22 family physicians in the Canadian province of British Columbia. Data were analyzed thematically using deductive and inductive codes that captured key concepts across the narratives of participants.

Results

Family physicians indicated that they trust their patients to act as the lead decision-makers about medical tourism, but are conflicted when the information they are managing contradicts the best interests of the patients. They reported that patients distrust local health care systems when they experience insufficiencies in access to care and that this can prompt patients to consider going abroad for care. Trust fractures in the physician-patient relationship can arise from shame, fear and secrecy about medical tourism.

Conclusions

Family physicians face diverse tensions about medical tourism as they must balance their roles in: (1) providing information about medical tourism within a context of information deficits; (2) supporting decision-making while distancing themselves from patients’ decisions to engage in medical tourism; and (3) acting both as agents of the patient and of the domestic health care system. These tensions highlight the ongoing need for reliable third-party informational resources about medical tourism and the development of responsive policy.

Experiences among undocumented migrants accessing primary care in the United Kingdom: a qualitative study

Immigration is a key political issue in the United Kingdom. The 2014 Immigration Act includes a number of measures intended to reduce net immigration, including removing the right of non-European Economic Area migrants to access free health care. This change risks widening existing health and social inequalities. This study explored the experiences of undocumented migrants trying to access primary care in the United Kingdom, their perspectives on proposed access restrictions, and suggestions for policymakers. Semi-structured interviews were conducted with 16 undocumented migrants and four volunteer staff at a charity clinic in London. Inductive thematic analysis drew out major themes. Many undocumented migrants already faced challenges accessing primary care. None of the migrants interviewed said that they would be able to afford charges to access primary care and most said they would have to wait until they were much more unwell and access care through Accident & Emergency (A&E) services. The consequences of limiting access to primary care, including threats to individual and public health consequences and the additional burden on the National Health Service, need to be fully considered by policymakers. The authors argue that an evidence-based approach would avoid legislation that targets vulnerable groups and provides no obvious economic or societal benefit.

Multidrug-resistant Gram-negative bacteria: a product of globalization

Global trade and mobility of people has increased rapidly over the last 20 years. This has had profound consequences for the evolution and the movement of antibiotic resistance genes. There is increasing exposure of populations all around the world to resistant bacteria arising in the emerging economies. Arguably the most important development of the last two decades in the field of antibiotic resistance is the emergence and spread of extended-spectrum β-lactamases (ESBLs) of the CTX-M group. A consequence of the very high rates of ESBL production among Enterobacteriaceae in Asian countries is that there is a substantial use of carbapenem antibiotics, resulting in the emergence of plasmid-mediated resistance to carbapenems. This article reviews the emergence and spread of multidrug-resistant Gram-negative bacteria, focuses on three particular carbapenemases--imipenem carbapenemases, Klebsiella pneumoniae carbapenemase, and New Delhi metallo-β-lactamase--and highlights the importance of control of antibiotic use.

"Best care on home ground" versus "elitist healthcare": concerns and competing expectations for medical tourism development in Barbados

Introduction

Many countries have demonstrated interest in expanding their medical tourism sectors because of its potential economic and health system benefits. However, medical tourism poses challenges to the equitable distribution of health resources between international and local patients and private and public medical facilities. Currently, very little is known about how medical tourism is perceived among front line workers and users of health systems in medical tourism ‘destinations’. Barbados is one such country currently seeking to expand its medical tourism sector. Barbadian nurses and health care users were consulted about the challenges and benefits posed by ongoing medical tourism development there.

Methods

Focus groups were held with two stakeholder groups in May, 2013. Nine (n = 9) citizens who use the public health system participated in the first focus group and seven (n = 7) nurses participated in the second. Each focus group ran for 1.5 hours and was digitally recorded. Following transcription, thematic analysis of the digitally coded focus group data was conducted to identify cross-cutting themes and issues.

Results

Three core concerns regarding medical tourism’s health equity impacts were raised; its potential to 1) incentivize migration of health workers from public to private facilities, 2) burden Barbados’ lone tertiary health care centre, and 3) produce different tiers of quality of care within the same health system. These concerns were informed and tempered by the existing a) health system structure that incorporates both universal public healthcare and a significant private medical sector, b) international mobility among patients and health workers, and c) Barbados’ large recreational tourism sector, which served as the main reference in discussions about medical tourism’s impacts. Incorporating these concerns and contextual influences, participants’ shared their expectations of how medical tourism should locally develop and operate.

Conclusions

By engaging with local health workers and users, we begin to unpack how potential health equity impacts of medical tourism in an emerging destination are understood by local stakeholders who are not directing sector development. This further outlines how these groups employ knowledge from their home context to ground and reconcile their hopes and concerns for the impacts posed by medical tourism.

Why do medical tourists travel to where they do? The role of networks in determining medical travel

Evidence on medical tourism, including patient motivation, is increasing. Existing studies have focused on identifying push and pull factors across different types of treatment, for example cosmetic or bariatric surgery, or on groups, such as diaspora patients returning 'home' for treatment. Less attention has been on why individuals travel to specific locations or providers and on how this decision is made. The paper focused on the role of networks, defined as linkages - formal and informal - between individual providers, patients and facilitators to explain why and where patients travel. Findings are based on a recently completed, two year research project, which examined the effects of medical tourism on the UK NHS. Research included in-depth interviews with 77 returning medical tourists and over sixty managers, medical travel facilitators, clinicians and providers of medical tourism in recipient countries to understand the medical tourism industry. Interviews were conducted between 2011 and 2012, recorded and transcribed, or documented through note taking. Authors undertook a thematic analysis of interviews to identify treatment pathways by patients, and professional linkages between clinicians and facilitators to understand choice of treatment destination. The results highlight that across a large sample of patients travelling for a variety of conditions from dental treatment, cosmetic and bariatric surgery, through to specialist care the role of networks is critical to understand choice of treatment, provider and destination. While distance, costs, expertise and availability of treatment all were factors influencing patients' decision to travel, choice of destination and provider was largely the result of informal networks, including web fora, personal recommendations and support groups. Where patients were referred by UK clinicians or facilitators these followed informal networks. In conclusion, investigating medical travel through focus on networks of patients and providers opens up novel conception of medical tourism, deepening understanding of patterns of travel by combining investigation of industry with patient motivation.

South-South medical tourism and the quest for health in Southern Africa

Intra-regional South-South medical tourism is a vastly understudied subject despite its significance in many parts of the Global South. This paper takes issue with the conventional notion of South Africa purely as a high-end "surgeon and safari" destination for medical tourists from the Global North. It argues that South-South movement to South Africa for medical treatment is far more significant, numerically and financially, than North-South movement. The general lack of access to medical diagnosis and treatment in SADC countries has led to a growing temporary movement of people across borders to seek help at South African institutions in border towns and in the major cities. These movements are both formal (institutional) and informal (individual) in nature. In some cases, patients go to South Africa for procedures that are not offered in their own countries. In others, patients are referred by doctors and hospitals to South African facilities. But the majority of the movement is motivated by lack of access to basic healthcare at home. The high demand and large informal flow of patients from countries neighbouring South Africa has prompted the South African government to try and formalise arrangements for medical travel to its public hospitals and clinics through inter-country agreements in order to recover the cost of treating non-residents. The danger, for 'disenfranchised' medical tourists who fall outside these agreements, is that medical xenophobia in South Africa may lead to increasing exclusion and denial of treatment. Medical tourism in this region and South-South medical tourism in general are areas that require much additional research.

UK medical tourists in Thailand: they are not who you think they are

Background

Travel for medical treatment is an aspect of globalization and health that is comparatively less understood. Little is known about volume, characteristic and motivation of medical tourists, limiting understanding of effects on health systems and patients. Thailand is amongst a handful of countries that have positioned themselves as medical tourism destination. This paper examines in unprecedented detail volume and characteristics of medical tourists who travel from the UK to Thailand for treatment.

Methods

As part of a wider medical tourism study, authors gained access to over 4000 patient records from the five largest private hospitals in Thailand. These included information on country of origin, gender, age, arrival month, hospitalization, diagnosis, procedures, length of stay, medical expenditure and type of payment. Patient records were analysed to understand who travels and findings were triangulated with data from the UK International Passenger Survey (IPS).

Results

104,830 medical tourists visited these hospitals in Thailand in 2010. While patients originate all over the world, UK medical tourists represent the largest group amongst Europeans. The majority UK medical tourists (60%) have comparatively small, elective procedures, costing less than USD 500. A significant minority of patients travel for more serious orthopedic and cardiothoracic procedures. Data of individual patient records from Thailand shows a higher number of UK patients traveled to Thailand than indicated by the IPS.

Conclusions

Thailand is attracting a large number of medical tourists including larger numbers of UK patients than previously estimated. However, as many patients travel for comparatively minor procedures treatment may not be their primary motivation for travel. The small but significant proportion of older UK residents traveling for complex procedures may point to challenges within the NHS.