Chapter 2 The Pretravel Consultation Counseling & Advice for Travelers
Medical tourism is the term commonly used to describe people traveling outside their home country for medical treatment. Patients may pursue medical care abroad for a variety of reasons, such as decreased cost, a preference for care from providers from a similar culture, or to receive a procedure or therapy not available in their country of residence. In the United States, medical tourism generally refers to people traveling to less-developed countries for medical care. Medical tourism is a worldwide, multibillion-dollar phenomenon that is expected to grow substantially in the next 5–10 years. Studies have estimated that hundreds of thousands of medical tourists travel from the United States annually. Little reliable epidemiologic data on medical tourism exist, but ongoing case reports and outbreaks of infections serve as a reminder that medical tourism is not without risks.
Common categories of procedures that US travelers pursue during medical tourism trips include orthopedic surgery, cosmetic surgery, cardiology (cardiac surgery), oncologic care, and dentistry. Common destinations include Thailand, Mexico, Singapore, India, Malaysia, Cuba, Brazil, Argentina, and Costa Rica. The type of procedure and the destination need to be considered when reviewing the risk of travel for medical care.
Most medical tourists pay for their care at time of service, and rely on private companies or medical concierge services to identify foreign health care facilities. These companies may not require accreditation of foreign providers, track patient outcome data, or maintain formal medical record security policies. Some health insurance companies and large employers have formed alliances with overseas hospitals to control health care costs, and several major medical schools in the United States have developed joint initiatives with overseas providers, such as the Harvard Medical School Dubai Center, the Johns Hopkins Singapore International Medical Center, and the Duke-National University of Singapore.
RISKS ASSOCIATED WITH MEDICAL TOURISM
Medical tourism has been associated with complications, including infections caused by antibiotic-resistant strains of bacteria not commonly seen in the United States. Patients who are considering seeking medical care overseas should be aware of this risk. It is wise for travelers to bring home outer packaging and package inserts from medications they receive or purchase abroad. Health care providers should be vigilant for the possibility of resistant infections among patients who have traveled for medical procedures and take measures to control their spread in the United States.
Several outbreaks of infectious disease have been documented among medical tourists after their return to the United States. Recent examples include nontuberculous mycobacteria infections among patients who had cosmetic surgery in the Dominican Republic and Q fever among patients who received sheep cell injections in Germany. Patients who experience complications after receiving medical care overseas should inform their providers of their travel history and their medical history, but may lack adequate documentation of the care they received. Some may be reluctant to share such information if they have had complications.
PRETRAVEL ADVICE FOR MEDICAL TOURISTS
Patients who travel for medical reasons should consult a travel medicine specialist in the United States for advice tailored to individual health needs, preferably ≥4–6 weeks before travel. In addition to regular considerations for healthy travel related to their destination, medical tourists should consider the additional risks associated with surgery and travel, either while being treated or while recovering from treatment. Flying and surgery both increase the risk of blood clots and pulmonary emboli. Air pressure in most commercial aircraft is equivalent to the pressure at an altitude of approximately 6,000–8,000 ft (1,829–2,438 m). Patients should not travel for 10 days after chest or abdominal surgery to avoid risks associated with this change in pressure. The American Society of Plastic Surgeons advises people who have had cosmetic procedures of the face, eyelids, or nose, or who have had laser treatments, to wait 7–10 days before flying. Patients are also advised to avoid typical vacation activities such as sunbathing, drinking alcohol, swimming, and taking long tours or engaging in strenuous activities or exercise after surgery. The Aerospace Medical Association has published medical guidelines for airline travel that provide useful information on the risks of travel with certain medical conditions (www.asma.org/asma/media/asma/Travel-Publications/paxguidelines.pdf).
GUIDANCE FOR TRAVELERS SEEKING MEDICAL CARE ABROAD
Several professional organizations have developed guidance that includes questions useful for travelers when discussing medical or dental care abroad, either with the facility providing the care or with the group facilitating the trip. When considering a trip overseas for medical care, travelers should be aware of the guiding principles developed by the American Medical Association (Box 2-06). The American College of Surgeons (ACS) issued a similar statement on medical and surgical tourism with the additional recommendation that travelers obtain a complete set of medical records before returning home to ensure that details of their care are available to providers in the United States, which helps facilitate continuity of care and proper follow-up if needed. ACS also recommends that prospective medical tourists use facilities that are internationally accredited. Examples of accrediting entities include Joint Commission International, DNV International Accreditation for Hospitals, and the International Society for Quality in Health Care, which have lists of standards that facilities need to meet to be accredited. However, using a facility that is accredited does not guarantee a lack of complications, similar to any hospital or procedure performed in the United States. Similarly, the American Dental Association provides informational documents, including “Traveler’s Guide to Safe Dental Care,” through the Global Dental Safety Organization for Safety and Asepsis Procedures (Box 2-07). Although this guidance was not developed for medical tourists, it provides useful information for travelers to consider when selecting a facility or planning a trip for medical or dental care. These guides indicate the types of questions that people considering travel for medical care should discuss with their regular health care provider. Additional resources exist to assist both providers and prospective medical tourists (Box 2-08).
Many websites that market directly to travelers provide information on medical tourism. These sites may not include comprehensive details on the qualifications or certifications of a facility or provider. Furthermore, local standards for facility accreditation and provider certification can vary. The ACS recommends that patients considering treatment abroad seek care from providers certified in their specialties through a process that is equivalent to that established by the member boards of the American Board of Medical Specialties. ACS, American Society of Plastic Surgeons, and the International Society of Aesthetic Plastic Surgery all accredit overseas physicians. Again, however, the traveler should realize that accreditation does not ensure a good outcome, and travelers should be encouraged to do as much research as possible on a health care facility they are considering using.
Box 2-06. Guiding principles on medical tourism1
The American Medical Association advocates that employers, insurance companies, and other entities that facilitate or promote medical care outside the United States adhere to the following principles:
(a) Medical care outside the United States must be voluntary.
(b) Financial incentives to travel outside the United States for medical care should not limit the diagnostic and therapeutic alternatives that are offered to patients or restrict treatment or referral options.
(c) Patients should be referred for medical care only to institutions that have been accredited by recognized international accrediting bodies (such as the Joint Commission International or the International Society for Quality in Health Care).
(d) Before travel, local follow-up care should be coordinated and financing should be arranged to ensure continuity of care when patients return from medical care outside the United States.
(e) Coverage for travel outside the United States for medical care must include the costs of necessary follow-up care upon return to the United States.
(f) Patients should be informed of their rights and legal recourse before agreeing to travel outside the United States for medical care.
(g) Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the United States.
(h) The transfer of patient medical records to and from facilities outside the United States should be consistent with Health Insurance Portability and Accountability Action (HIPAA) guidelines.
(i) Patients choosing to travel outside the United States for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.
1From American Medical Association. New AMA Guidelines on Medical Tourism. Chicago: AMA; 2008.
Box 2-07. Patient checklist for obtaining safe dental care during international travel1
Before you leave:
- Visit your dentist for a checkup to reduce the chances you will have a dental emergency.
- See a health care provider to receive any needed vaccinations, medications, and advice related to your travel destination.
When seeking treatment for a dental emergency during your trip:
- Consult hotel staff or the American Embassy or consulate for assistance in finding a dentist.
- If possible, consider recommendations from Americans living in the area or from other trusted sources.
If the answers to any of the asterisked (*) items below are “No,” you should have reservations about the office’s infection control standards. If the answer to a two-star item (**) is “No,” consider making a swift but gracious exit.
When making the appointment, ask the following:
- Do you use new gloves for each patient?*
- Do you use an autoclave (steam sterilizer) or dry heat oven to sterilize your instruments between patients?**
- Do you sterilize your handpieces (drills)?* (If not, do you disinfect them?)**
- Do you use new needles for each patient?**
- Is sterile (or boiled) water used for surgical procedures?** (In areas where drinking water is unsafe, the water also may cause illness if used for dental treatment.)
Upon arriving at the office, observe the following:
- Is the office clean and neat?
- Do staff wash their hands, with soap, between patients?**
- Do they wear gloves for all procedures?**
- Do they clean and disinfect or use disposable covers on surfaces touched during treatment?
1Excerpt from Organization for Safety and Asepsis Procedures. Traveler’s guide to safe dental care. Annapolis, MD: Organization for Safety and Asepsis Procedures; 2001. Available from: http://www.osap.org/?page=TravelersGuide.
One of the newer and more controversial forms of medical tourism is “transplant tourism,” which is travel for the purpose of receiving an organ or stem cell purchased from an unrelated donor for transplant or receiving other biomaterial (cell, tissue) from nonhuman species (xenotransplantation). Xenotransplantation is regulated differently among countries; no scientific evidence supports its therapeutic benefit, and adverse events have been reported. Additionally, several studies of medical tourism identified potential problems that travelers and clinicians need to be aware of when considering transplantation overseas: the donor and the procedures lacked documentation, most patients received fewer immunosuppressive drugs than is current practice in the United States, and most patients did not receive antibiotic prophylaxis. In 2004, to protect vulnerable populations from becoming victims of transplant tourism, the World Health Assembly Resolution 57.18 encouraged member countries to “take measures to protect the poorest and vulnerable groups [the donors] from ‘transplant tourism’ and the sale of tissues and organs.” A meeting in 2008 in Istanbul addressed the issue of transplant tourism and organ trafficking, which resulted in a call for these activities to be prohibited. In view of those events, the World Health Organization revised the Guiding Principles on Human Cell, Tissue and Organ Transplantation and released those revised principles in March 2009. These guidelines emphasize that cells, tissues, and organs should only be donated freely without any form of financial incentive.
Box 2-08. Helpful resources on medical tourism
- Aerospace Medical Association guidelines for airline travel provide useful information on the risks of travel with certain medical conditions: www.asma.org/asma/media/asma/Travel-Publications/paxguidelines.pdf
- American Academy of Orthopaedic Surgeons Bulletin, July 2007, discusses safety issues that patients should consider: www.aaos.org/news/bulletin/jul07/cover1.asp
- American Academy of Orthopaedic Surgeons discusses liability implications of medical tourism: www.aaos.org/news/aaosnow/feb08/managing7.asp
- American College of Surgeons. Statement on medical and surgical tourism: www.facs.org/fellows_info/statements/st-65.html
- American Society for Aesthetic Plastic Surgery. Guidelines for patients seeking cosmetic procedures abroad: www.surgery.org/consumers/consumer-resources/consumer-tips/guidelines-forpatients-seeking-cosmeticprocedures-abroad
- American Society of Plastic Surgeons (ASPS). The dangers of plastic surgery tourism: www.plasticsurgery.org/patient-safety/dangers-of-plastic-surgery-tourism
- American Society of Plastic Surgeons’ Find-a-surgeon tool helps identify ASPS member surgeons in the United States and overseas: www1.plasticsurgery.org/find_a_ surgeon
- European Commission. Cross-border care policy: http://ec.europa.eu/health/cross_ border_care/policy/index_en.htm
- International Society for Aesthetic Plastic Surgery’s Find-a-surgeon tool helps identify a surgeon: www.isaps.org/find-a-surgeon
- Joint Commission International list of its accredited facilities outside of the United States: www.jointcommissioninternational.org/JCI-Accredited- Organizations/
- Organization for Safety and Asepsis Procedures. Traveler’s guide to safe dental care: www.osap.org/?page=TravelersGuide
- World Health Organization. Guiding principles on human cell, tissue and organ transplantation: www.who.int/transplantation/Guiding_PrinciplesTransplantation_ WHA63.22en.pdf
- US Department of States: Your Health Abroad https://travel.state.gov/content/passports/en/go/health.html#healthy.html
- Budiani-Saberi DA, Delmonico FL. Organ trafficking and transplant tourism: a commentary on the global realities. Am J Transplant. 2008 May;8(5): 925–9.
- Chen LH, Wilson ME. The globalization of healthcare: implications of medical tourism for the infectious disease clinician. Clin Infect Dis. 2013 Dec;57(12): 1752–9.
- Mathers AJ, Hazen KC, Carroll J, Yeh AJ, L. CH, Bonomo RA, et al. First clinical cases of OXA-48-producing carbapenem-resistant Klebsiella pneumoniae in the United States: the "menace" arrives in the new world. J Clin Microbiol. 2013 Feb;51(2):680–3.
- Merion RM, Barnes AD, Lin M, Ashby VB, McBride V, Ortiz-Rios E, et al. Transplants in foreign countries among patients removed from the US transplant waiting list. Am J Transplant. 2008 Apr;8(4 Pt 2): 988–96.
- Organ Procurement and Transplantation Network, Scientific Registry of Transplant Recipients. United States organ transplantation annual data report, 2011. Rockville (MD): US Department of Health and Human Services; 2012 [cited 2016 Sep. 22]; Available from: http://srtr.transplant.hrsa.gov/annual_reports/2011/default.aspx.
- Reed CM. Medical tourism. Med Clin North Am. 2008 Nov;92(6):1433–46, xi.
- Robyn MP, Newman AP, Amato M, Walawander M, Kothe C, Nerone JD, et al. Q Fever outbreak among travelers to Germany who received live cell therapy—United States and Canada, 2014. MMWR Morb Mortal Wkly Rep 2015 Oct;64(38):1071–3.
- Rogers BA, Aminzadeh Z, Hayashi Y, Paterson DL. Country-to-country transfer of patients and the risk of multi-resistant bacterial infection. Clin Infect Dis. 2011 Jul 1;53(1):49–56.
- Schnabel D, Gaines J, Nguyen DB, Esposito DH, Ridpath A, Yacisin K, et al. Notes from the field: rapidly growing nontuberculous Mycobacterium wound infections among medical tourists undergoing cosmetic surgeries in the Dominican Republic—multiple states, March 2013–February 2014. MMWR Morb Mortal Wkly Rep. 2014 Mar 7;63(9):201–2.
- US Department of Health and Human Services. 2007 annual report of the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: transplant data 1997–2006. Rockville, MD: US Department of Health and Human Services; 2007 [cited 2016 Sep. 22]; Available from: http://www.ustransplant.org/annual_reports/current/ar_archives.htm.
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- Page last updated: June 13, 2017
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