The hospital emigration to another region in the light of the environmental, social and governance model in Italy during the period 2004-2021

The following article presents an analysis of the impact of the Environmental, Social and Governance-ESG determinants on Hospital Emigration to Another Region-HEAR in the Italian regions in the period 2004-2021. The data are analysed using Panel Data with Random Effects, Panel Data with Fixed Effects, Pooled Ordinary Least Squares-OLS, Weighted Least Squares-WLS, and Dynamic Panel at 1 Stage. Furthermore, to control endogeneity we also created instrumental variable models for each component of the ESG model. Results show that HEAR is negatively associated to the E, S and G component within the ESG model. The data were subjected to clustering with a k-Means algorithm optimized with the Silhouette coefficient. The optimal clustering with k=2 is compared to the sub-optimal cluster with k=3. The results suggest a negative relationship between the resident population and hospital emigration at regional level. Finally, a prediction is proposed with machine learning algorithms classified based on statistical performance. The results show that the Artificial Neural Network-ANN algorithm is the best predictor. The ANN predictions are critically analyzed in light of health economic policy directions.

Demographics and Trends for Inbound Medical Tourism in Germany for Orthopedic Patients before and during the COVID-19 Pandemic

Medical tourism is a rapidly growing sector of economic growth and diversification. However, data on the demographics and characteristics of the traveling patients are sparse. In this study, we analyzed the common demographic properties and characteristics of the inbound medical tourists seeking orthopedic medical care in Germany for the years 2010 to 2019 compared to a domestic group. At the same time, we examined how the COVID-19 pandemic outbreak of 2020 changed the field of medical tourism in Germany. Calculations were performed using administrative hospital data provided by the Federal Statistical Department of Germany. Data were analyzed from the years 2010 to 2020. A total of six elective orthopedic surgery codes (bone biopsy, knee arthroplasty, foot surgery, osteotomy, hardware removal, and arthrodesis) were identified as key service indicators for medical tourism and further analyzed. Factors including residence, sex, year, and type of elective surgery were modeled using linear regression analysis. Age and sex distributions were compared between patients living inside Germany (DE) or outside Germany (non-DE). Between 2010 and 2020, 6,261,801 orthopedic procedures were coded for the DE group and 27,420 key procedures were identified for the non-DE group. Medical tourists were predominantly male and significantly younger than the domestic population. The linear regression analysis of the OPS codes over the past years showed a significantly different slope between the DE and non-DE groups only for the OPS code "hardware removal". With the COVID-19 pandemic, an overall decline in performed orthopedic procedures was observed for the non-DE and the DE group. A significant reduction below the 95% prediction bands for the year 2020 could be shown for hardware removal and foot surgery (for DE), and for hardware removal, knee arthroplasty, foot surgery, and osteotomy (for non-DE). This study is the first to quantify inbound medical tourism in elective orthopedic surgery in Germany. The COVID-19 pandemic negatively affected many-but not all-areas of orthopedic surgery. It has to be seen how this negative trend will develop in the future.

Stakeholder perspectives on ‘Swiss quality’ healthcare in the context of inbound medical tourism to Switzerland: An exploratory qualitative study

Background

Global literature on medical travel focuses on patients from high-income countries traveling to middle-income countries reputed for providing high quality care at significantly lower costs. However, little is known about the movement of wealthy foreign patients to high-income countries such as the USA, the UK or Switzerland.

Objective

In this paper, we focus on Swiss medical tourism stakeholders and their strategies to attract a niche of self-paying foreign patients to undergo medical treatment in Switzerland. We describes how they harness the label of ‘Swiss quality’ healthcare to promote Switzerland in global medical travel industry.

Methods

We conducted semi-structured, in-depth interviews with 30 medical tourism stakeholders including 15 healthcare professionals (HCPs) treating self-paying foreign patients in publicly funded and privately owned hospitals in French- and German-speaking regions of Switzerland. The data were inductively coded using thematic analysis.

Results

We present their views on ‘Swiss quality’ healthcare under three themes: health-related human resources, Swiss medical infrastructure, and foreign patients’ perceived trust in the ‘Swiss quality’ label. Participants equated Switzerland's global image and ‘Swiss quality’ as a ‘brand’ and believed that foreign patients’ trust in ‘Swiss quality’ is a unique selling point of Swiss healthcare system.

Conclusion

By problematizing the use of ‘Swiss quality’ label to attract wealthy patients to Switzerland, we highlight a few ethical questions that deserve further scrutiny.

Destination brand equity and tourist's revisit intention towards health tourism: an empirical study

Purpose

This paper aims to investigate the relationship between destination brand equity and tourist's revisit intention towards health tourism destinations. The study also examines the mediating effect of destination brand association between destination-based brand equity and travellers' revisit intention for health tourism destinations.

Design/methodology/approach

A survey instrument is used to examine the relationships in the proposed model using the co-variance-based structural equation modelling (SEM) technique. The collected primary data from two hundred forty-six respondents (n = 246) are analysed to test the relationship amongst exogenous, mediating, moderating and endogenous constructs articulated in the proposed structural model.

Findings

Empirical findings reveal that destination brand equity influences the revisit intention of a traveller for health tourism via destination brand association. The perceived trust, reliability and soft issues of a traveller moderate the relationship between destination brand equity and destination brand association. Enduring travel involvement also proves a significant moderation effect on the relationship between destination brand association and the revisit intention of a traveller for a health tourism destination.

Practical implications

This paper is an initial attempt to develop and empirically examine a conceptual model of the intention of a traveller to revisit a health tourism destination in a dynamic process of information search using the data collected from current travellers after medical tourism-related trips. Results suggest that stakeholders must focus on hedonic and utilitarian factors of the destination that are recognised by travellers to encourage revisit for medical tourism.

Originality/value

Although there have been numerous studies on health tourism. However, to the best of the authors' knowledge, this research is a pioneer in the healthcare tourism literature that links destination brand equity, brand association and revisit intention of a traveller for health tourism. These findings extend the knowledge of how healthcare tourism that is embedded with destination brand equity and destination brand association. The study findings potentially benefit the marketers for gaining competitive advantages through considering the experience of a traveller.

Inbound and outbound medical travel in Austria

Purpose

The purpose of this paper is twofold: First, it analyzes demand and supply-side factors that influence patient flows to and from Austria. Second, building on the empirical research and existing conceptualizations, the study offers a general extended framework to guide future comparative analysis.

Design/methodology/approach

The paper draws on multiple data sources including a literature review, secondary data, website analysis and semi-structured interviews with patients and health providers. Content analysis was carried out to identify common motives for seeking care abroad and providers' orientation towards medical travel.

Findings

Outbound medical travel is largely determined by factors of access, affordability and vicinity, while inbound medical travel is predominately driven by a lack of adequate medical infrastructure in source countries and quality, both in terms of medical and service quality. Providers distinguish themselves according to the extent they take part in medical travel.

Research limitations/implications

The findings emerging from a single country case study approach cannot be generalized across settings and contexts, albeit contributing to a better understanding of current medical travel patterns in Europe.

Originality/value

Unlike most recent contributions, this study focuses both on inbound and outbound medical travel in Austria and investigates patient flows for distinctive treatments and drivers. While analysis of the supply-side of medical travel is often limited to tourism studies, this study provides a critical insight into developments in Europe from a health policy perspective, acknowledging that diverse medical travel patterns in Europe coexist.

Knowledge management orientation and operational performance relationship in medical tourism (overview of the model performance in the COVID-19 pandemic and post-pandemic era)

Despite the considerable growth of interest in medical tourism in the last decade, there is no standard procedure to measure the pivotal factors in medical tourism destinations. Medical tourism is a rising global phenomenon that is strongly dependent on innovation and knowledge management. Being both innovative and systematic in medical tourism requires thought enrichment in knowledge management in hospitals. By applying a quantitative method, "knowledge management-oriented innovation" items have been used in this study to analyze new products or services related to active hospitals in medical tourism in Iran. This study presents the positive effects of the most essential knowledge management areas such as time, cost, and quality management orientation, on operational performance through the mediating role of innovation speed. In the current study, hospitals of Iran that are active in the medical tourism area have been considered as the final destination. Additionaly, because this study coincides with the coronavirus COVID-19 pandemic as the global health crisis which has a considerable effect on medical tourism, the managerial implications have been developed to help managers and decision-makers in order to apply the obtained findings during the pandemic and post-pandemic period.

The patient-doctor relationship in the transnational healthcare context

Moving away from paternalism to more equal forms of interaction in the patient-doctor relationship has been seen in positive light by policymakers, patients' rights advocates and scholars alike. Nonetheless, against the background of commercialisation and consumerism, empirical research showcases how reduced asymmetries bring in tensions and friction between patients and doctors (Greenfield et al. 2012). This paper contributes to the discussion through the examination of the patient-doctor relationship in the niche setting of private transnational healthcare markets which involve patients travelling overseas for care and where commodification, consumerism and care go hand-in-hand. It is geographically focused on two large cities in South-Eastern Europe as settings where health care is provided to foreign patients - Athens and Istanbul - and empirically draws on qualitative interviews with doctors who run small/medium practices. The findings highlight that, despite excessive consumerism, power asymmetries are not mitigated but patient vulnerability shapes the patient-doctor relationship. In the transnational context, the patient faces an additional source of vulnerability: a condition of foreignness. As such, the findings stress that one relationship model (the consumerist) does not, per se, replace an older one (e.g. the Parsonian). Instead, the consumer-provider dimension co-exists with the client-expert, patient-doctor and, finally, host-guest relation.

Cross-border-assisted reproduction: a qualitative account of UK travellers' experiences

Surveys on patients' experiences of cross-border fertility treatment have reported a range of positive and challenging features. However, the number of such studies is limited, and there is no detailed qualitative account of the experiences of UK patients who travel overseas for fertility treatment. The present study used a cross-sectional, qualitative design and in-depth interviews. Fifty-one participants (41 women and 10 men, representing 41 treatment 'cases') participated in semi-structured interviews. The experiences reported were broadly positive with a large proportion of participants (39 cases, 95%) citing a favourable overall experience with only two cases (5%) reporting a more negative experience. Thematic analysis revealed 6 major categories and 20 sub-categories, which described the positive and challenging aspects of cross-border fertility travel. The positive aspects were represented by the categories: 'access', 'control' and 'care and respect'. The more challenging aspects were categorized as 'logistics and coordination of care', 'uncertainty' and 'cultural dissonance'. The study confirms findings from others that despite some challenges, there is a relatively high level of patient satisfaction with cross-border treatment with participants able to extend the boundaries of their fertility-seeking trajectories and in some cases, regain a sense of control over their treatment.

A measure of medical tourism destination brand equity

Purpose

Given the increasing dominance of medical tourism on the service economy of some of the developing nations, as a pioneering attempt, this study aims to develop a consumer-based brand equity (CBBE) measurement scale for the medical tourist destinations (city/hospital).

Design/methodology/approach

Following the traditional marketing construct development process (qualitative study, purification study and validation study), in the present study, two sets of large and independent samples were assessed to judge the dimensionality of the measure.

Findings

A well-validated measurement scale was developed as an amalgamation of four dimensions, namely, awareness, perceived quality, brand loyalty and authenticity to assess CBBE of medical destinations.

Practical implications

To reduce the financial and physical risk associated with the purchase of treatment, the customers may rely on “authenticity” of the service providers to select a treatment destination. The outcomes would help medical administrators/managers to focus more on developing “assurance” by increased reliability, responsiveness and tangibles to attract the medical tourists to a large extent.

Originality/value

The study is a pioneering attempt to develop a scale for measuring CBBE for medical tourist destinations. The study aligns with earlier CBBE scales in terms of the first three elements, namely, brand awareness, loyalty and perceived quality. However, based on predictive validity, the study puts forth five interrelated first order attributes, namely, “trust”, “value for money”, “quality of residents”, reliability and soft issues (like friendliness and ease of process) as contributing factors to a so far unexplored dimension, “brand authenticity”.

Patient mobility in the global marketplace: a multidisciplinary perspective

There is a growing global market in healthcare and patients. And while there is a small body of evidence emerging around this phenomenon commonly known as medical tourism there remain significant unanswered policy and research questions which need to be addressed. We outline some of the key issues set against the six key disciplinary preoccupations of the journal: epidemiology, health economics, health policy ethics, politics of health, health management, and health policy.

Transnational healthcare practices of Romanian migrants in Ireland: inequalities of access and the privatisation of healthcare services in Europe

This article deals with the transnational healthcare practices of Central and Eastern European migrants in Europe, taking the case of Romanian migrants in Ireland. It explores the implications of migrants' transnational healthcare practices for the transformation of citizenship in Europe, more particularly in terms of access to free public healthcare. The article places these practices in the larger perspective of global care chains, seen as including transnational flows of healthcare seekers and healthcare workers that link distant healthcare systems in an emerging European healthcare assemblage. The study adopted a holistic perspective, taking into account both formal and informal practices, as well as the use of healthcare services in both the host and the origin countries of migrants. These were explored during multi-sited fieldwork in Romania and Ireland, conducted between 2012 and 2013, and combining a variety of sources and methods (semi-structured interviews, informal conversations, documentary analysis, etc.). The article explores the links between migrants' transnational healthcare practices and two other important processes: 1) inequalities in access to healthcare services in migrants' countries of origin and of destination; and 2) the contribution of healthcare privatisation to these inequalities. It shows that Romanian migrants' transnational healthcare practices function as strategies of social mobility for migrants, while also reflecting the increasing privatisation of healthcare services in Ireland and Romania. The article argues that these processes are far from specific to Ireland, Romania, and the migration flows uniting them. Rather, they draw our attention to the rise of an unevenly developed European healthcare assemblage and citizenship regime in which patients' movements across borders are closely interlinked with diminishing and increasingly unequal access to public healthcare services.

Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches

Background

The study examined the implications of inward and outward flows of private patients for the NHS across a range of specialties and services.

Objectives

To generate a comprehensive documentary review; to better understand information, marketing and advertising practices; examine the magnitude and economic and health-related consequences of travel; understand decision-making frames and assessments of risk; understand treatment experience; elicit the perspectives of key stakeholder groups; and map out medical tourism development within the UK.

Design and participants

The study integrated policy analysis, desk-based work, economic analysis to estimate preliminary costs, savings and NHS revenue, and treatment case studies. The case studies involved synthesising data sources around bariatric, fertility, cosmetic, dental and diaspora examples. Overall, we drew on a mixed-methods approach of qualitative and quantitative data collection. The study was underpinned by a systematic overview and a legal and policy review. In-depth interviews were carried out with those representing professional associations, those with clinical interests and representative bodies (n = 16); businesses and employees within medical tourism (n = 18); NHS managers (n = 23); and overseas providers. We spoke to outward medical travellers (46 people across four treatment case studies: bariatric, fertility, dental and cosmetic) and also 31 individuals from UK-resident Somali and Gujarati populations.

Results

The study found that the past decade has seen an increase in both inward and outward medical travel. Europe is both a key source of travellers to the UK and a destination for UK residents who travel for medical treatment. Inward travel often involves either expatriates or people from nations with historic ties to the UK. The economic implications of medical tourism for the NHS are not uniform. The medical tourism industry is almost entirely unregulated and this has potential risks for those travelling out of the UK. Existing information regarding medical tourism is variable and there is no authoritative and trustworthy single source of information. Those who travel for treatment are a heterogeneous group, with people of all ages spread across a range of sociodemographic groups. Medical tourists do not appear to inform their decision-making with hard information and consequently often do not consider all risks. They make use of extensive informal networks such as treatment-based or cultural groups. Motivations to travel are in line with the findings of other studies. Notably, cost is never a sole motivator and often not the primary motivation for seeking treatment abroad.

Limitations

One major limitation of the study was the abandonment of a survey of medical tourists. We sought to avoid an extremely small survey, which offers no real insight. Instead we redirected our resources to a deeper analysis of qualitative interviews, which proved remarkably fruitful. In a similar vein, the economic analysis proved more difficult and time consuming than anticipated. Data were incomplete and this inhibited the modelling of some important elements.

Conclusions

In 2010 at least 63,000 residents of the UK travelled abroad for medical treatment and at least 52,000 residents of foreign countries travelled to the UK for treatment. Inward referral and flows of international patients are shaped by clinical networks and longstanding relationships that are fostered between clinicians within sender countries and their NHS counterparts. Our research demonstrated a range of different models that providers market and by which patients travel to receive treatment. There are clearly legal uncertainties at the interface of these and clinical provision. Patients are now travelling to further or ‘new’ markets in medical tourism. Future research should: seek to better understand the medium- and long-term health and social outcomes of treatment for those who travel from the UK for medical treatment; generate more robust data that better capture the size and flows of medical travel; seek to better understand inward flows of medical travellers; gather a greater level of information on patients, including their origins, procedures and outcomes, to allow for the development of better economic costing; explore further the issues of clinical relationships and networks; and consider the importance of the NHS brand.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A Unifying Framework of the Demand for Transnational Medical Travel

Transnational medical travel has gained attention recently as a strategy for patients to obtain care that is higher quality, costs less, or offers improved access relative to care provided within their home countries. This article examines institutional environments in the European Union and United States that influence transnational medical travel, describes the conceptual model of demand for medical travel, and illustrates individual dimensions in the conceptual model of medical travel using a series of case studies. The conceptual model of medical travel is predicated on Andersen's behavioral model of health services. Transnational medical travel is a heterogeneous phenomenon that is influenced by a number of patient-related factors and by the institutional environment in which the patient resides. While cost, access, and quality are commonly cited factors that influence a patient's decision regarding where to seek care, multiple factors may simultaneously influence the decision about the destination for care, including culture, social factors, and the institutional environment. The conceptual framework addresses the patient-related factors that influence where a patient seeks care. This framework can help researchers and regulatory bodies to evaluate the opportunities and the risks of transnational medical travel and help providers and governments to develop international patient programs.

Use of medical tourism for hip and knee surgery in osteoarthritis: a qualitative examination of distinctive attitudinal characteristics among Canadian patients

Background

Medical tourism is the term that describes patients’ international travel with the intention of seeking medical treatment. Some medical tourists go abroad for orthopaedic surgeries, including hip and knee resurfacing and replacement. In this article we examine the findings of interviews with Canadian medical tourists who went abroad for such surgeries to determine what is distinctive about their attitudes when compared to existing qualitative research findings about patients’ decision-making in and experiences of these same procedures in their home countries.

Methods

Fourteen Canadian medical tourists participated in semi-structured phone interviews, all of whom had gone abroad for hip or knee surgery to treat osteoarthritis. Transcripts were coded and thematically analysed, which involved comparing emerging findings to those in the existing qualitative literature on hip and knee surgery.

Results

Three distinctive attitudinal characteristics among participants were identified when interview themes were compared to findings in the existing qualitative research on hip and knee surgery in osteoarthritis. These attitudinal characteristics were that the medical tourists we spoke with were: (1) comfortable health-related decision-makers; (2) unwavering in their views about procedure necessity and urgency; and (3) firm in their desires to maintain active lives.

Conclusions

Compared to other patients reported on in the existing qualitative hip and knee surgery literature, medical tourists are less likely to question their need for surgery and are particularly active in their pursuit of surgical intervention. They are also comfortable with taking control of health-related decisions. Future research is needed to identify motivators behind patients’ pursuit of care abroad, determine if the attitudinal characteristics identified here hold true for other patient groups, and ascertain the impact of these attitudinal characteristics on surgical outcomes. Arthritis care providers can use the attitudinal characteristics identified here to better advise osteoarthritis patients who are considering seeking care abroad.

Why do patients engage in medical tourism?

Medical tourism is commonly perceived and popularly depicted as an economic issue, both at the system and individual levels. The decision to engage in medical tourism, however, is more complex, driven by patients' unmet need, the nature of services sought and the manner by which treatment is accessed. In order to beneficially employ the opportunities medical tourism offers, and address and contain possible threats and harms, an informed decision is crucial. This paper aims to enhance the current knowledge on medical tourism by isolating the focal content of the decisions that patients make. Based on the existing literature, it proposes a sequential decision-making process in opting for or against medical care abroad, and engaging in medical tourism, including considerations of the required treatments, location of treatment, and quality and safety issues attendant to seeking care. Accordingly, it comments on the imperative of access to health information and the current regulatory environment which impact on this increasingly popular and complex form of accessing and providing medical care.

Risk communication and informed consent in the medical tourism industry: a thematic content analysis of Canadian broker websites

BACKGROUND

Medical tourism, thought of as patients seeking non-emergency medical care outside of their home countries, is a growing industry worldwide. Canadians are amongst those engaging in medical tourism, and many are helped in the process of accessing care abroad by medical tourism brokers - agents who specialize in making international medical care arrangements for patients. As a key source of information for these patients, brokers are likely to play an important role in communicating the risks and benefits of undergoing surgery or other procedures abroad to their clientele. This raises important ethical concerns regarding processes such as informed consent and the liability of brokers in the event that complications arise from procedures. The purpose of this article is to examine the language, information, and online marketing of Canadian medical tourism brokers' websites in light of such ethical concerns.

METHODS

An exhaustive online search using multiple search engines and keywords was performed to compile a comprehensive directory of English-language Canadian medical tourism brokerage websites. These websites were examined using thematic content analysis, which included identifying informational themes, generating frequency counts of these themes, and comparing trends in these counts to the established literature.

RESULTS

Seventeen websites were identified for inclusion in this study. It was found that Canadian medical tourism broker websites varied widely in scope, content, professionalism and depth of information. Three themes emerged from the thematic content analysis: training and accreditation, risk communication, and business dimensions. Third party accreditation bodies of debatable regulatory value were regularly mentioned on the reviewed websites, and discussion of surgical risk was absent on 47% of the websites reviewed, with limited discussion of risk on the remaining ones. Terminology describing brokers' roles was somewhat inconsistent across the websites. Finally, brokers' roles in follow up care, their prices, and the speed of surgery were the most commonly included business dimensions on the reviewed websites.

CONCLUSION

Canadian medical tourism brokers currently lack a common standard of care and accreditation, and are widely lacking in providing adequate risk communication for potential medical tourists. This has implications for the informed consent and consequent safety of Canadian medical tourists.