medical tourism literature review

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Lunt N, Smith RD, Mannion R, et al. Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches. Southampton (UK): NIHR Journals Library; 2014 Jan. (Health Services and Delivery Research, No. 2.2.)

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

Chapter 3 systematic review: what do we know about medical tourism.

• Introduction

Medical tourism – people travelling abroad with the expressed purpose of accessing or receiving medical treatment – is a growing phenomenon associated with processes of globalisation. 40 This includes cheaper and more widely available air travel and cross-border communication through the internet, which allows medical providers from one country to market themselves to patients in another. At the same time, increased movement of health workers for education means greater consistency of care offered in origin and destination countries. This has been coupled with an increase in foreign direct investment in health-care providers in destination countries, including by private medical insurance companies. In some instances, US private insurers now allow patients to have treatment abroad. The increasing acceptance of health-care portability is evident in Europe where greater patient mobility led to a EU directive 1 on cross-border health care. Together with a rise in out-of-pocket expenditures for health in many high-income countries at a time of economic crisis, these factors (travel, communication, consistency of care, cost and an increased acceptance of the portability of health care) conspire to form a perfect storm for medical tourism.

As a consequence, even in countries with a universal public health-care system, such as the UK NHS, patients are now travelling abroad to receive medical treatment. Data from the ONS indicate that in 2010 63,000 41 people travelled abroad for medical treatment.

However, understanding of medical travel is limited. Little is known about which patients choose to travel and why. Details of the volume of patient flows and resources spent remain uncertain. This has hampered efforts to understand the economic costs to and benefits for countries experiencing inflows and outflows of patients. 8 Similarly, the medical tourism industry and the role of private providers, brokers and marketing remains a ‘black box’. 40 Although interest in the issue has grown over the past decade, the effects on patients and health systems are not fully understood. Given the emerging nature of medical travel research, the evidence base is not yet clearly mapped.

This review of the literature aims to outline the current level of knowledge on medical tourism and to better understand this phenomenon, including its impact on the UK NHS. Specific objectives are to better understand patient motivation, the medical tourism industry, the volume of medical travel and the effects of medical tourism on originating health systems. These objectives informed the search strategy and review criteria set out in Appendix 10 . The results of the literature review are reported and discussed with reference to subthemes that emerged; special attention is devoted to findings directly relevant to the NHS. Conclusions are presented on current levels of knowledge, critical gaps and future research priorities on medical travel.

The review was conducted between September and December 2011, considering all papers published by this date, and adapted the strategy employed by Smith et al. 42 The strategy was reviewed and amended by a project advisory board consisting of academics, policy-makers and practitioners. The search strategy and inclusion criteria for the review are provided in Appendix 10 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart is provided in Appendix 11 . In total, 100 papers were selected for inclusion in the review. 8 , 10 – 12 , 17 , 26 , 40 , 42 – 134

An increase in medical tourism research is evident from the prominence of the issue. In 2010 and 2011, five journals devoted special editions to medical tourism: Global Social Policy , Body and Society , Anthropology and Medicine , Tourism Review and Signs .

A rapidly expanding literature over the past 5 years (with an ‘explosion’ in 2010 and 2011) is reflected in the publication dates of papers reviewed, as evident from Appendix 12 (see Figure 9 ); 73 papers were published in 2010 and 2011. 40 , 42 – 45 , 47 , 50 – 52 , 54 – 57 , 59 – 61 , 64 , 67 – 78 , 80 – 95 , 97 , 99 , 102 – 104 , 107 – 121 , 123 , 125 – 127 , 129 – 133 This underlines the increase in medical travel and its importance as an issue in UK health-care provision.

Types of studies reviewed

Papers included in the review were classified into the following categories:

• empirical: denoting papers based on primary research, interviews, surveys, analysis of data sets, or the calculation of revenue and tourist flows, and case studies of patients
• reviews: literature, scoping and systematic reviews of medical tourism websites
• analysis: papers that, although drawing on secondary sources, provide substantive new insights or conceptualise medical tourism in a new way (a number of papers presented frameworks)
• overview articles: papers that give an introduction to the issue of medical tourism.

The results are summarised in Appendix 12 (see Figure 10 ). In total, 47 papers 17 , 43 , 44 , 47 – 49 , 51 , 57 , 62 , 65 , 66 , 68 , 71 , 76 , 78 , 81 – 83 , 85 – 87 , 93 , 94 , 96 – 100 , 103 – 106 , 110 – 114 , 116 , 118 – 120 , 124 , 126 , 127 , 132 , 133 presented findings from empirical research, 25 provided an overview of issues, 10 , 11 , 26 , 46 , 50 , 52 , 53 , 58 – 60 , 63 , 67 , 73 , 79 , 80 , 91 , 97 , 100 , 115 , 120 , 122 , 128 , 130 , 135 , 136 15 were classified as analysis 8 , 54 , 56 , 61 , 69 , 75 , 84 , 88 , 108 , 109 , 119 , 123 , 125 , 129 , 131 and 11 were reviews. 40 , 42 , 55 , 70 , 72 , 78 , 89 , 90 , 92 , 95 , 133 Of the 47 empirical studies, 19 reported findings from quantitative research 12 , 17 , 43 , 47 , 76 , 81 , 85 , 93 , 96 , 98 , 99 , 103 – 106 , 110 , 114 , 116 , 124 (in most cases a survey), 15 were qualitative studies, 44 , 57 , 62 , 68 , 71 , 74 , 82 , 87 , 94 , 112 , 113 , 116 , 118 , 120 , 132 eight reported case studies of patients 51 , 66 , 83 , 101 , 102 , 111 , 119 , 127 and a further five 48 , 49 , 65 , 86 , 93 reported the results of an experiment, cost calculation or evaluation of an intervention. In total, 32 of the empirical findings were published between 2010 and 2011, underlying the provenance of the issue.

Geographical focus

Papers were grouped according to which region the research investigated. Papers that provided a general overview that was not focused on a specific region or country were classed as global. A total of 43 papers fell into this category. 8 , 10 – 12 , 17 , 26 , 45 – 47 , 52 – 55 , 58 , 59 , 63 , 64 , 67 , 69 , 70 , 72 , 73 , 78 – 81 , 89 , 90 , 92 , 93 , 95 , 107 , 111 , 119 , 121 – 123 , 129 – 133 , 135 Europe was the focus of 27 papers, 40 , 42 , 44 , 48 – 50 , 57 , 60 – 62 , 65 , 66 , 75 , 76 , 83 , 84 , 91 , 94 , 98 , 100 – 102 , 104 – 106 , 114 , 126 with 13 explicitly focusing on the UK 42 , 57 , 62 , 65 , 66 , 76 , 83 , 94 , 98 , 101 , 102 , 104 , 114 in their study design and a further 11 papers 10 , 40 , 43 , 50 , 53 , 90 , 91 , 99 , 105 , 106 , 119 from across the entire sample referring to either UK patients or the NHS. The geographical distribution of papers is summarised in Appendix 12 (see Figure 11 ).

Evidence from studies reviewed suggests a regional dimension to medical tourism. Japanese companies send their employees to Thailand 10 or to countries in the Gulf. 43 , 116 A study of medical tourists in Tunisia found that these were from neighbouring countries. 85 Thailand, Singapore, Malaysia 109 and India 8 and others have marketed themselves as medical tourism destinations. Countries are known for specific areas of medicine: Singapore for high-end procedures, 86 Thailand for cardiac, orthopaedic and gender reassignment surgery, 11 Eastern Europe for dental tourism 108 and Spain for fertility treatment. 72

Although some destinations were recognised as being popular with UK patients, for example Budapest for dental treatment, proximity alone does not appear to explain preference for one destination over another.

Issues covered

Most papers made reference to push and pull factors determining patients’ decision to travel. These relate to cost, perceived quality, familiarity, waiting lists or delays in treatment or the lack of availability of certain treatments in the country of origin. 61 As this list demonstrates, these are often complex 57 and may vary according to the treatment for which a patient travels. A patient travelling for cosmetic surgery, for example, may enjoy the anonymity of a destination far from their country of origin, 53 whereas migrants may prefer to travel to their country of origin to feel more comfortable with the language or type of care provided. 87

A subset of papers reviewed focused on specific types of medical tourism.

Diaspora travel

A number of studies refer to a group of medical travellers classified as diaspora travellers. Studies describe this in relation to India, China, Korea and Mexico, with recent migrants returning to their ‘home’ country to access treatment that is either not available or perceived to be not available in their country of residence, or perceived to be more effective in their ‘home’ country. 43 , 71 , 87 , 94

Glinos et al. 61 developed a typology for patient motivation (availability, affordability, familiarity, perceived quality of care), cross-referenced with whether a patient has funding or not. The authors applied this typology to understand patient motivation in a range of case studies from the literature and found that diaspora patients return because of reasons of familiarity with the system, as well as affordability.

Fertility tourism

Reproductive or fertility tourism is comparatively better documented than other forms of medical tourism. 40 Sixteen papers 44 , 47 , 57 , 59 , 60 , 72 , 74 , 79 , 98 , 100 , 106 , 113 , 114 , 129 , 130 , 132 were identified for inclusion in this review; seven 59 , 74 , 79 , 113 , 129 , 130 , 132 focused on equity and ethical issues relating to fertility tourism, including the rights of women in recipient countries.

Four papers 57 , 98 , 106 , 114 specifically examined cross-border reproductive care (CBRC) in Europe. Two 106 , 114 of these papers presented findings of surveys monitoring patient flow and services accessed across Europe and a third paper 98 presented the results of the effects of such travel on patients giving birth in a central London hospital. One 57 provided a qualitative, in-depth study of UK patients and their motivations for travelling abroad.

One paper 47 presented findings from an online survey of prospective and actual tourists. Four papers 44 , 60 , 79 , 100 provided a general overview of the issues relating to fertility tourism. Hudson et al. 72 presented a review of the literature on CBRC. Results included the consistent gap in empirical research; of 54 papers reviewed only 15 were based on findings from empirical investigation. The authors note the absence of studies and knowledge about patients’ backgrounds and factors motivating their travel, and a gap in the research on the industry.

Three papers 57 , 98 , 114 explicitly explore the effects on the NHS. The study by McKelvey et al. 98 of multiple births over the past 11 years found that over one-quarter of high-order pregnancies in a UK foetal medicine unit occurred in patients who had travelled abroad to access fertility treatment. The qualitative study by Culley et al. 57 showed the complex motivations for travelling abroad, but concurred with other research that cost of treatment and the greater number of gametes available abroad or more easily accessible gametes played a part in decision-making. This was echoed by the results of a survey 114 in which UK respondents were most likely to name difficulty in accessing fertility treatment as motivation for travel.

Dental, bariatric and cosmetic tourism

A further area of medical tourism is dental tourism. 137 Three papers 101 , 105 , 122 focused on the issue of patients travelling for dental treatment. These indicated that this is likely to be an area of increasing travel by UK residents given the high cost of dentistry in the UK private sector, limited availability in the public sector and the lower cost in Eastern Europe. 101 Some countries, such as Hungary and Poland, have marketed themselves as dental centres of excellence. 137 A survey of dental clinics in Western Hungary and Budapest 105 showed the largest group of patients (20.2%) originating from the UK, with lower prices being cited as the main motivating factor.

Two papers focused in depth on issues surrounding bariatric surgery. One explored the ethical challenges 117 and the other was a case study of complications experienced by a US patient. 127

Papers by Birch et al. 134 and Miyagi et al. 102 focused on complications from cosmetic tourism in UK patients. A poll conducted amongst members of the UK public found that 92% would consider travelling abroad for cosmetic surgery. 104 The possibility of a large number of UK patients seeking cosmetic surgery abroad appears to be supported by a survey conducted by the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), 76 which found that 37% of respondents had seen patients in the NHS with complications from overseas surgery.

The issue of risks to the patient in terms of health outcomes was covered in 30 papers. 11 , 26 , 40 , 51 , 53 , 55 , 63 , 64 , 66 , 67 , 70 , 72 , 76 , 77 , 79 , 83 , 91 , 92 , 99 , 102 , 104 , 107 , 111 , 114 , 115 , 117 , 119 , 127 , 128 , 135 Perhaps surprisingly, only seven of these 51 , 64 , 83 , 91 , 99 , 102 , 111 focused exclusively on the issue; 10 studies 51 , 55 , 65 , 98 – 101 , 117 , 127 , 132 mentioned longer-term health outcomes of patients. Four papers 51 , 66 , 83 , 111 reported cases of infection that resulted from patients travelling to receive medical treatment. Three 51 , 83 , 111 described the recent outbreak of NDM-1-producing Enterobacteriaceae following patients receiving treatment in India, which highlighted some of the dangers of medical tourism and microbial resistance. The fourth 66 described an outbreak of hepatitis B in a London hospital traced to a patient recently returned from surgery in India.

Effect on recipient country health system

As summarised in Appendix 12 , 36 papers 8 , 17 , 42 , 43 , 48 , 49 , 51 , 56 , 65 , 68 , 71 , 74 , 78 , 83 , 85 – 88 , 92 , 94 , 97 , 102 , 103 , 105 , 106 , 108 , 109 , 113 – 116 , 120 , 124 , 125 , 128 , 132 focused on the effects on the recipient country health system. Issues highlighted include the potential for medical tourism to result in the retention of doctors in, or attraction of doctors to, low- and middle-income countries, thus preventing or reversing a brain drain, and to generate foreign currency. 86 Also considered is the danger of creating a two-tiered health system, resulting in increasing inequities in access and quality of health care for the local population in destination countries. 78 , 125 Explanations are twofold: first, a rise in price in countries that do not provide public health services free at the point of use and, second, the potentially greater concentration of doctors in the private sector. 103

A total of 34 papers 8 , 17 , 42 , 47 – 49 , 56 , 57 , 65 , 66 , 71 , 76 , 77 , 81 , 83 , 87 , 91 , 94 – 96 , 98 – 101 , 104 , 106 – 108 , 114 , 117 , 118 , 127 , 129 , 132 focused on potential effects on the health system of originating countries. These referred to factors leading to travel by patients, including a rise in costs. Studies documented patients returning with complications, 99 including to the NHS. 102 Research highlighted the need for regulation, the lack of quality control of overseas providers and the cost (potential or real) arising to the originating country from treating complications. Two papers 94 , 96 calculated the potential cost savings and benefits of sending patients abroad. When papers focused on the effects on the health system of originating countries, this was mainly on perceived negative consequences.

Thirty-nine of the papers reviewed 8 , 10 , 11 , 17 , 43 , 44 , 50 , 53 , 56 , 57 , 60 , 62 , 68 , 69 , 71 , 72 , 76 , 81 , 85 , 88 – 92 , 95 , 97 , 98 , 103 , 104 , 106 , 107 , 109 , 113 , 116 , 122 , 124 , 128 , 132 , 135 focused at least partly on providers of medical tourism. Less attention was paid to facilitators ( n  = 19). 47 , 50 , 56 , 57 , 59 , 70 , 77 , 81 , 89 – 92 , 104 , 113 , 117 , 118 , 132 , 133 , 135 A subset of 19 papers 8 , 50 , 56 , 62 , 68 , 69 , 76 , 81 , 88 – 90 , 92 , 95 , 107 , 109 , 118 , 124 , 132 , 133 studied the medical tourism industry in a more focused way. This included reviews of websites, 90 market analysis, 82 qualitative analysis of the role of medical tourism facilitators 118 and a more general review, 92 as well as a model for tourism development. 69 Articles examining communication materials and websites highlighted the limited information on follow-up care and redress in case of complications. 79 They also pointed to an emphasis on testimonies from patients rather than formal accreditation or qualification of clinicians and the great focus on tourism aspects of the destination and offering services ‘as good as at home’. 80 In addition, the low cost of treatment was used as a selling point.

There were two qualitative studies of medical tourism facilitators (interview samples included nine 118 and 12 82 interviewees, respectively); facilitators were presented as a heterogeneous group with a range of motivations.

Studies tended to mention regulation but only two 123 , 130 reviewed this more systematically; both pointed to a vacuum in regulation.

Many studies mentioned individual hospitals or recounted an example of a medical tourism provider at the country level to give a flavour of the industry. 53 , 82 However, only four studies 85 – 88 reported findings of a more systematic assessment of the industry and its operations. One study, 40 evaluating past experiences of EU cross-border care, examined contracting arrangements and their effects on health outcomes.

Trade in health services: revenue and volume

Medical travel – the consumption of health services abroad – is defined as a trade under the General Agreement on Trade in Services (GATS) mode 2 and the majority of papers included in this review implicitly or explicitly focused on this form of trade in health services. 8 A subset of seven papers 75 , 85 , 94 , 103 , 116 , 125 , 128 included a detailed discussion of other forms of trade in health services, including cross-border provision of services (GATS mode 1) and movement of health workers (GATS mode 4). Many overview papers mentioned the investment by US providers in Asian hospital groups without explicitly exploring this (GATS mode 3). Four papers 8 , 46 , 75 , 94 analysed policy processes and challenges to trade in health services.

The actual volume of trade (the flow of medical patients) was referred to in many papers but investigated in few. 74 , 85 , 105 , 114 , 116 Studies by the United Nations Economic and Social Commission for Asia and the Pacific 124 and Leng 88 all provided further estimates or trends. The studies by Lautier, 85 Siddiqi et al. 116 and NaRanong and NaRanong 103 were the only ones that calculated the total volume of trade in health services (for 13 countries), including the actual costs and effects on recipient country health systems. For example, NaRanong and NaRanong 103 calculate the contribution of medical tourism to the Thai gross domestic product (GDP) (0.4%), with medical tourists with their higher purchasing power likely to increase the cost of health services and lessen access in the public sector.

Most papers cited similar figures for patient flow but often sources were not accessible or figures were based on media reports or on other academic papers, which in turn quoted inaccessible sources. When sources for patient numbers were cited these have been summarised in Appendix 12 .

One of the most commonly cited sources for patient flows was other academic papers. Seven papers 67 , 81 , 92 , 93 , 108 , 129 , 131 referred directly to a report by Deloitte 17 and six 10 , 40 , 50 , 58 , 67 , 68 referred to a report by McKinsey; 12 the exact ways in which figures in these reports were calculated remain unclear. Even when these reports were not referenced, the figures cited suggest that these two reports were used as sources. For example, a paper by Nassab et al. 104 cites the Economist , stating that 750,000 US patients travelled abroad for treatment in 2007. This is the figure provided in the report from Deloitte 17 in 2008. Eight papers 85 , 88 , 103 , 105 , 106 , 114 , 116 , 124 had either generated or collected their own data on patient flows.

Perhaps the most surprising finding was the increase in number of papers presenting findings from primary research – a shortfall or gap that had been noted by the earlier literature reviews. 42 , 55 , 70 The recent publication date of many papers confirms the increasing amount of research being carried out on medical travel.

Medical tourism is a phenomenon in the private health-care market, which makes it hard to monitor and regulate patient flows. 137 Despite the rapid increase in number of publications over the past 2 years, reliable calculations of the actual volume of patient flow remain rare. This confirms findings from an earlier review, 42 which also noted the lack of information on how the figures in the reports by Deloitte Consultancy 17 and McKinsey 12 were calculated.

The body of literature focusing on medical tourism as a trade in health services indicates that further research investigating levels of such trade is needed. Data on costs and benefits of medical tourism are rare and this limits accurate assessments of its effects to inform policy decision-making. Studies are also needed to empirically observe the effects of medical tourism in practice. The definitions of trade in health services provided, 8 together with the framework for measuring its level provided by Siddiqi et al. , 116 set out a methodology for such research.

Understanding of the industry is limited. None of the research-driven papers captured the entire value chain of medical tourism. It is not evident how different industry actors (e.g. referring clinician, websites, facilitators, travel agents and receiving clinicians or hospitals) link together and how their relationships may influence patient experiences and health outcomes. Three papers referred to the role of medical tourism facilitators, drawing on small samples, demonstrating the need for further research in this area, especially to enable regulation or to address the ethical dimensions discussed in the papers reviewed. 118 , 131 , 133

Types of medical tourism

The literature reviewed clearly indicates that medical tourism is no unified phenomenon. Subthemes as distinct areas covered by research were evident from the review, such as diaspora or fertility travel or travel for bariatric surgery or dental or cosmetic work. The papers on diaspora travel highlight that medical tourism and decisions by patients to travel are not simply guided by cost considerations or even clinical outcomes. Rather, the literature points to a complex matrix of perceptions of care, waiting times, cost and other factors.

The different types of medical travel allow some inferences about patient motivation, for example cost or availability in cosmetic procedures, regulation in the case of fertility and so on. However, a lack of information about patients’ characteristics limits a deeper understanding of push and pull factors.

Impact on the NHS: lack of studies focusing on long-term health outcomes

Evidence demonstrates that patients travelling abroad to receive treatment and returning to the UK may face complications or infections requiring follow-up in the public sector. Seven papers 65 , 66 , 76 , 83 , 98 , 101 , 102 reported on patients who were treated in the NHS as a result of complications resulting from treatment abroad. Based on the literature reviewed, cosmetic procedures appear to be an area of growth for medical travel by UK patients and are likely to result in costs to the NHS from resulting complications. This underlines the need for further research to ascertain the potential impact and costs for the NHS arising from medical tourism.

In addition, little is known about the longer-term health outcomes of medical tourists beyond these incidental reports of complications. No literature on inward medical travel and its effects on the NHS was identified, pointing to a gap in knowledge.

• Conclusions

This review provides a map of current knowledge on medical tourism and identifies a series of subthemes. The reviewed papers demonstrate the multidisciplinary nature of medical tourism research. There has been an ‘explosion’ in research on medical tourism over the past 2 years. This review clearly identifies limits to current knowledge; many papers remain hypothetical and there are many areas in which further research is needed.

There is still a lack of information on the background of patients and the numbers of patients travelling abroad for treatment. This limits insights into why some patients travel and others do not and restricts evidence about the possible costs and benefits of medical travel.

The absence of information on patients’ social, economic and demographic backgrounds hampers the ability to understand patient decision-making and determinants of travel. The studies reviewed indicate that motivation is complex. Further information is needed to fully understand this decision-making process. It is especially relevant to gain insight into why patients from countries with public health-care systems such as the UK choose to travel abroad.

Little is known about the industry beyond reviews of information materials and websites. Further research, especially qualitative and survey-based research, is needed to better understand how the sector operates and what its motives are to ultimately understand how it drives or affects trade in health services and health outcomes of medical travellers.

Although case studies of patients returning from treatment abroad with complications were reported, these did not quantify the potential cost of medical travel to the patients’ ‘home’ health systems. Given the evidence of an increase in medical travel such research is urgently needed.

There is no research examining the long-term health outcomes of UK medical tourists. Further qualitative and quantitative research, beyond immediate clinical outcomes, is needed to truly understand the effect of medical travel on patients and its cost to the health system.

• Implications for the NHS
• There is a need to collect data on the number of patients who return from treatment abroad and are treated within the NHS.
• There is a need for additional surveys and quantitative research to understand more fully the volume of patients who travel abroad and their social and economic characteristics. This will enable a more accurate understanding of the scale of the issue and factors determining patient travel. These ‘push factors’ may in themselves hold valuable lessons that reflect on the NHS.
• There is a need for research to assess the long-term health outcomes of medical travellers to fully understand the effects on individual and population health.

Included under terms of UK Non-commercial Government License .

• Cite this Page Lunt N, Smith RD, Mannion R, et al. Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches. Southampton (UK): NIHR Journals Library; 2014 Jan. (Health Services and Delivery Research, No. 2.2.) Chapter 3, Systematic review: what do we know about medical tourism?
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Medical Tourism

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Lin H. Chen, Mary E. Wilson, Medical Tourism, Journal of Travel Medicine , Volume 22, Issue 3, 1 May 2015, Page 218, https://doi.org/10.1111/jtm.12190

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To the Editor in Chief:

The review by Hanefeld and colleagues nicely summarized some aspects of medical tourism based on the published literature from September 2011 to March 2012 and brings attention to an important area. 1 We would like to alert the readers to additional perspectives that are relevant to travel medicine practitioners. 2 In addition to the papers published in the medical literature, a number of recent books explore some of the broader issues related to medical tourism. 3,4

Other critical issues include cross‐border movement of infections, particularly multidrug‐resistant microorganisms, associated with medical tourism. 2 Challenges also include the lack of regulation of medical tourism companies, inconsistent accreditation of care providers, and the absence of a system to document the flow of medical tourists and to assure informed follow‐up care. 2

Medical tourism is complicated by financial, legal, and ethical issues, as well as by health‐related risks. Obtaining a medical procedure or treatment abroad that lacks scientific evidence clearly raises ethical concern. Lack of communication from providers to the medical tourist's home health care system results in fragmented care. Lack of oversight is associated with poor standards regarding patient privacy and confidentiality, suboptimal care, lack of liability/recourse for poor outcome, and low likelihood to effect improvement. Finally, medical tourists may not be sufficiently prepared for diseases that are endemic in the destination countries, for example, vaccine‐preventable diseases, travelers' diarrhea, malaria, and other vector‐borne diseases. 5,6

As Hanefeld and colleagues have illustrated, a large number of articles on medical tourism have been published in the last several years. There is clearly much interest on the topic among health care providers as well as consumers. The lower cost and ease in travel, aggressive marketing, availability of online information, and globalization of the training of the health care workforce have all contributed to its enormous growth. More research is needed to define the magnitude of this trade and its impact on individual patients, countries of patient origin, and countries providing medical services.

Finally, portability of health care in the European Union as noted by Hanefeld and colleagues supports further formalization of cross‐border medical care. Given the globalization of health care, a better integrated surveillance system that includes data about medical tourists is long overdue.

Hanefeld J Smith R Horsfall D Lunt N . What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system . J Travel Med 2014 ; 21 : 410 – 417 .

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Chen LH Wilson ME . The globalization of healthcare: implications of medical tourism for the infectious disease clinician . Clin Infect Dis 2013 ; 57 : 1752 – 1759 .

Cohen IG . Patients with passports: medical tourism, law, and ethics . New York : Oxford University Press , 2014 .

Hodges JR , Turner L , Kimball AM , eds. Risks and challenges in medical tourism: understanding the global market for health services . Santa Barbara, CA : Praeger , 2012 .

Sadlier C Bergin C Merry C . Healthcare globalization and medical tourism . Clin Infect Dis 2014 ; 58 : 1642 – 1643 .

Chen LH Wilson ME . Reply to Sadlier, Bergin, and Merry . Clin Infect Dis 2014 ; 58 : 1643 – 1644 .

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Medical Tourism and Postoperative Infections: A Systematic Literature Review of Causative Organisms and Empiric Treatment

Affiliation.

• 1 From the Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch.
• PMID: 30489537
• DOI: 10.1097/PRS.0000000000005014

Background: Medical tourism has become increasingly globalized as individuals travel abroad to receive medical care. Cosmetic patients in particular are more likely to seek surgery abroad to defray costs. Unfortunately, not all procedures performed abroad adhere to strict hygienic regulations, and bacterial flora vary. As a result, it is not uncommon for consumers to return home with difficult-to-treat postoperative infections.

Methods: A systematic literature review of PubMed, Ovid, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was performed to assess the microbiology patterns and medical management of patients with postoperative infections after undergoing elective surgery abroad.

Results: Forty-two cases of postoperative infections were reported among patients who underwent elective surgery abroad. Most cases were reported from the Dominican Republic, and the most common elective procedures were abdominoplasty, mastopexy, and liposuction. Rapidly growing mycobacteria such as Mycobacterium abscessus, Mycobacterium fortuitum, and Mycobacterium chelonae were among the most common causes of postoperative infection, with M. abscessus involving 74 percent of cases. Most cases were treated with surgical débridement and a combination of antibiotics. Clarithromycin, amikacin, and moxifloxacin were the most common drugs used for long-term treatment.

Conclusions: When encountering a patient with a history of medical tourism and treatment-refractory infection, rapidly growing mycobacteria must be considered. To increase the likelihood of yielding a diagnostic organism, multiple acid-fast bacilli cultures from fluid and débridement content should be performed. There has been reported success in treating rapidly growing mycobacterial infections with a combination of antibiotics including clarithromycin, amikacin, and moxifloxacin.

Publication types

• Systematic Review
• Anti-Bacterial Agents / therapeutic use
• Debridement / statistics & numerical data
• Drug Therapy, Combination
• Elective Surgical Procedures / adverse effects
• Medical Tourism*
• Mycobacterium Infections / drug therapy
• Mycobacterium Infections / etiology
• Mycobacterium Infections / surgery
• Reoperation / statistics & numerical data
• Risk Factors
• Surgical Wound Infection / drug therapy
• Surgical Wound Infection / etiology*
• Surgical Wound Infection / surgery
• Anti-Bacterial Agents