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Medical Tourism Karen L McClean MD FRCPC University of Saskatchewan Or, for the politically correct….. Cross Border Health Care.

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Presentation on theme: "Medical Tourism Karen L McClean MD FRCPC University of Saskatchewan Or, for the politically correct….. Cross Border Health Care."— Presentation transcript:

1 Medical Tourism Karen L McClean MD FRCPC University of Saskatchewan Or, for the politically correct….. Cross Border Health Care

2 Case …. Elderly man, osteoarthritic knee not severe enough to warrant joint replacement, advised to maximize non surgical therapy TKA done in India at a JCI accredited institution Mycobacterium fortuitum joint infection 3 months post op Required 4 surgical procedures Debridement & salvage procedure, two stage revision, open Bx Cost: > $140,000 vs patient costs for surgery in India - $8,600 Cost of arthroplasty in Australia: ~ $15,000 Frequency of infections post total knee arthroplasty: 1-2% Frequency of infection post arthroplasty tourism: unknown Denominator unknown Numerator patients present to many different clinicians

3 Whats the evidence? Data is limited Largely anecdotal reports Few case series or studies – mostly in transplant field Data is subject to bias Health care providers at destination are motivated to emphasize good outcomes to protect commercial interests Health care providers at home are more likely to see / report poor outcomes than good ones Follow-up is limited Patients stays at providing institution are brief – f/u variable Procedures are done in a variety of locations Patients return home to many different locations Ability to determine short and long term outcomes is limited

4 Definitions / Scope Medical tourism – usual use Travel to a foreign country (especially exotic locations) to obtain medical care Medical tourism – less common uses Physicians engaging in unapproved medical activities while travelling to remote locations for tourism (impromptu roadside clinics) Medical students / physicians travelling for the purposes of elective experiences, volunteer medical work

5 Terminology Alternate terms Health tourism Medical journeys Global healthcare / Cross border healthcare Medical value travel More specific terms Surgical tourism Transplant tourism Reproductive tourism Dental tourism Suicide / Euthanasia tourism

6 Medical Tourism: not a new phenomenon Renowned centres / physicians have always attracted patients from afar Healing shrines Spas Pilgrimages Wealthy citizens of countries with limited health resources travelling to access care / expertise that cannot be obtained locally Desperate patients with incurable conditions seeking miracle cures

7 So, whats new? Average citizens Range of procedures available Third world / emerging economies destinations Development of an industry catering to medical tourists Travel agencies and brokers Journals Conferences Systematic government support of industry Insurance company promotion of medical tourism

8 Why do countries promote medical tourism? Money! Boost tourism revenues Generate foreign exchange Increase gross domestic product Improve medical services Upgrade services / resources available to citizens Stem brain drain to other countries

9 Why do patients want medical tourism? Lower cost Timely alleviation of pain and disability Access to innovative procedures Exotic locations and travel mystique Privacy – particularly for some cosmetic procedures

10 Issues Clinical / Medical Financial Ethical Legal

11 Clinical Decision Making in Medical Tourism How does the commoditization of care affect clinical decision making? Potential predisposition to recommend surgical / more complex procedures over conservative Rx Potential risk of minimizing risks to avoid losing a client Potential risk of focus on visible signs of quality / luxury over medical quality assurance Are patients overly optimistic about potential benefits, and under- informed / inadequately aware of potential risks? Once patients have paid a broker fee, are they pre-disposed to opt for surgery even if this is not the most appropriate care?

12 Other Clinical concerns Are innovative techniques evidence based? Are providers properly trained and accredited? Are medical quality standards comparable to home? Complication rates? – late complication rates usually unknown Infection control / MDR pathogens Exposure to exotic / opportunistic pathogens

13 Ethical issues Islands of excellence in a sea of medical neglect Infrastructure priorities may be focused on industry rather than local needs Infrastructure costs may be passed on to local population in form of increased taxes or reduced services Emphasis on high tech care at the expense of appropriate technology Brain drain from public to private sector Special issues pertaining to transplant tourism

14 Financial / Resource issues Potential plus for uninsured patients / procedures Potential undesirable results Cost of complications is carried by home country Impact on local resources if outsourcing becomes a major source of care Potential for decreased access to specialized services Decreased training resources Development of transplant programs stunted in countries where transplant tourism is a major method of obtaining transplantation Coercive use of medical tourism by insurance companies Potential shortage of nurses / physicians if foreign trained professionals remain in their country of origin

15 Legal Issues – Medical standards Canadians protected against substandard care by: Professional licensing & credentialing Institutional policies Legal remedies Care provided in other countries may not meet Canadian legal standards Disclosure of risks, benefits, alternatives Certification of professionals training, expertise Access to legal remedies Limitations of liability awards

16 Legal Issues – Liability Brokers require clients to sign waivers absolving them of any liability for medical negligence, substandard care…. Clients may be unable to bring a case against care providers in the Canadian courts Recourse to legal remedy in country of care is variable & complex

17 Legal Issues - Transplantation In some countries it is illegal to: Sell / Buy organs for transplant India / Pakistan South Africa Provide transplants to foreigners China To enter the country (as a foreigner) for the purpose of obtaining an organ donation

18 Justifications Consumer choice Global competition in health care Supply and demand pressures on costs / prices Increased GDP for countries Bystander benefits Decreased wait times when patients remove themselves from wait lists by going out of country Economic and social spin off benefits to communities in host countries – employment, better quality health care

19 What actually happens? Does medical tourism raise the quality of care and accessibility to care for the local population? Does medical tourism widen the gap between rich and poor and decrease access to care for the local population? Either is possible…..

20 Bumrumgrad Hospital - Bangkok 554 beds, 2,600 staff International patients from 150 countries Foreign patients = 50% clientele 2003 – 1 million patients overall 2005 – 55,000 American patients First hospital in Asia to receive JCI accreditation Provides services in 26 languages Expansion plans in other Asian and Middle Eastern countries

21 Thailand Private health care in Bangkok has more Gamma knife Mamography services CT scans …….. than all of England! Does that translate into improved access for local Thais?

22 India Medical tourism is a key industry Government subsidies, fiscal Incentives and tax breaks 2003: Finance minister called for India to become a global health destination Promoted measures to improve infrastructure to support the industry Ministry of tourism promotes 45 centres of excellence: cardiac surgery, minimally invasive surgery, oncology, orthopedics and joint replacement, and holistic care

23 The context of medical tourism in India Great divide between facilities focusing on medical tourism and those providing health care to the average Indian The potential for health tourism to translate into benefits for the local population seems to be limited to increasing the wealth of the rich and has done little to improve health care for the average Indian. Bulletin of the World Health Organization. March 2007, 85 (3) 164-165

24 The context of medical tourism in India WHO – 2003 data: health expenditure Private expenditure – 75% of total Public expenditure – 25% of total Addressed health needs of the majority of Indias population Health care facilities serving the Indian poor <50% have a labour room or laboratory <20% have a phone line <33% adequately stocked with essential drugs Shortages of physicians and other health care workers Corruption and lack of funds

25 Medical Tourism in Canada 15 medical tourism companies 1 each in Manitoba and Alberta 3 each in Ontario and Quebec 7 in British Columbia And other agencies providing medical tourism services in additional to traditional travel services Clients are sent to a wide range of countries: Argentina, Brazil, China, Costa Rica, Cuba, France, Germany, India, Malaysia, Mexico, Pakistan, Poland, Russia, Singapore, South Africa, Sri Lanka, Thailand, Tunisia, Turkey, UAE, US

26 Medical Tourism Brokers / Medical Tourism agencies Middlemen Find hospitals, physicians Arrange transfer of information Buy tickets / arrange flights Reserve hotels Arrange sightseeing Do not verify credentials or licensing of facilities or physicians Make money from hotel commissions and kickbacks No licensing requirements for brokers and agencies Early developments in USA for licensing

27 Transplantation Tourism

28 Tissue and Organ Transplantation Cyclosporine and newer immunosuppressants opened the door to transplant tourism WHO estimates that 10% transplants worldwide involve developed world recipients travelling to resource limited countries to purchase organs Why? Wait times due to organ shortages Eligibility – patients declined for transplant in home country are often readily accepted for transplant in a for profit system Non evidenced based transplants Fetal tissue / cell transplants Accessibility / cost

29 Ethical issues – transplant tourism Source of transplanted organs Potential for coerced organ donation Involuntary donations – executed prisoners, kidnappings Transplant flow is overwhelmingly…. South to north Female to male Black / brown to white Poor to financially secure Association with organized crime India, Brazil and other areas

30 Recipient Risks Commercial influences on medical decision making Inappropriate transplantation Poor donor – recipient matching - to reduce wait times need for more intense immune suppression risk OIs, toxicity Exposure to drug resistant bacteria, opportunistic infections, blood borne pathogens Lack of continuity of care Pre-transplant work-up and decision making through long term care post transplant Incomplete information provided post transplant Substandard care / fraudulent transplant

31 Recipient Risks Poor donor recipient matching intense immune suppression exposes recipients to increased risks… Increased risk of rejection Increased risk of infection Increased cancer risk Increased risk of graft failure Due to rejection, drug toxicity, infection

32 Renal Transplant – Favourable Outcomes Morad et al 2000 515 Malaysian patients transplanted in China or India >90% graft and patient survival Sever et al 1997 540 Saudi patients transplanted in India 96% graft survival 89% patient survival Similar results to those transplanted in Saudi Arabia

33 Renal Transplant - Inferior Outcomes Kennedy et al 2005 16 Australian patients 66% graft survival 85% patient survival Sever et al 2001 Turkish patients 84% graft survival patient survival similar to locally transplanted patients

34 Canadian experience Canadian data - 1998-2005 20 transplanted abroad - unrelated donors 22 transplants South Asia (12), East Asia (5), Middle East (4), SE Asia (1) …….. compared to…… 175 living biologically related donors transplanted in Canada 75 living emotionally related donors transplanted in Canada

35 Canadian experience - 2 33% - no records, 77% - incomplete records 1/3 hospitalized on return, primarily for sepsis Hospital stays of 4-113 days (mean 19 +/- 36) Complications: 27% systemic sepsis 52% opportunistic infections 23% CMV 9% fungal infections 14% tuberculosis 5% cerebral and spinal abscesses 25% wound infections 38% pyelonephritis (incl. MDR E coli ) 10% each: allograph nephrectomy, wound dehiscence, lymphocele 5% each: obstructive hydronephrosis, urine leak, metastatic cancer

36 Compared to Canadian Transplants…. Inferior graft survival at 3 years 98% biologically related donors 86% emotionally related donors 62% transplanted abroad Patient survival at 3 years 100% for those transplanted in Canada 82% for transplant tourists

37 Donor Risks Exploitation Inadequate informed consent process Donors treated as organ sources not patients Safeguards ensuring free and fully informed consent are weakest in countries where most transplants occur Brokers target poor, disadvantaged Diminished health status post donation leads to further economic disadvantage that is sustained over the long term Stigma Kidney sellers in Iran suffered extreme shame in their community

38 Kidney sellers - India 305 kidney sellers in Chennai, India 71% females, at least 2 coerced by husbands 70% sold through a middleman, 30% sold direct to clinic Almost all sold their kidneys to pay off debt 47 - spouse had also sold a kidney Economic outcomes On average brokers and clinics promised ~1/3 more than they actually paid. Average payment = $1070

39 Kidney sellers - India Local conditions - significant improvements in economic status over the last 10 years Poverty decreased by 50% since 1988 Per capita income increased by 37% over 10 years Most kidney sellers reported worsened economic status Average family income declined from $660 at time of sale to $420 at time of survey Percentage of participants below the poverty line increased from 54% to 71% Of those who sold a kidney to pay off debts, 74% were still in debt Increased time since selling a kidney associated with greater decline in economic status

40 Kidney sellers - India Health consequences (5 point likert scale) 13% no change in health status 38% reported 1-2 point decline in health status 48% reported a 3-4 point decline 50% had persistent pain at nephrectomy site 33% had persistent back pain 79% would not recommend selling a kidney to others

41 Kidney sellers - India Nephrectomy was associated with decline in both economic and health status Economic decline persisted and worsened with increasing time since transplant Health decline may have contributed to economic worsening through decreased fitness Most sellers would not recommend it to others - ?was informed consent adequate

42 Risk – free donation? Transplant surgeons have disseminated an untested hypothesis of risk-free live donation in the absence of any published longitudinal studies of the effects of nephrectomy among the urban poor anywhere in the world. Live donors from shantytowns, inner cities, or prisons face extraordinary threats to their health and personal security through violence, injury, and infectious disease that can all too readily compromise the kidney of last resort. Nancy Scheper-Hughes

43 Stem cell transplants - China Tiantan Puhua Stem Cell Centre Applies stem cell treatments to a wide range of neurologic disorders Stroke, Parkinson's, cerebral palsy, hereditary degenerative conditions Unique stem cell treatments Self stem cell activation and proliferation program Stem cell delivery by lumbar puncture or stereotactically Use of autologous bone marrow stem cells (to boost the immune system) and fetal stem cells in combination Claim a high level of recovery

44 Efficacy? We are not aware of any double blind, placebo controlled trials showing benefit and safety of stem cell transplants… Improvements often slight / transient come back for another treatment cycle Long term follow-up is very limited patients dont have time to wait Treatments accompanied by intensive physiotherapy / occupational therapy / massage / accupuncture / Chinese traditional therapy to: promote improved mobility and function stimulate the new cells into becoming functional helps the cells migrate into the correct area

45 Solid Organ Transplants – China 1 million Chinese awaiting transplant Paying foreigners given priority (transplants at military hospitals) Organs derived from executed prisoners # organs transplanted exceeds number of reported executions by 41,500 (2000-2005) Organ procurement takes weeks (vs. 2.5 years in most countries) Research by David Kilgour and David Matas (Canada) documents evidence that Falun Gong practitioners under detention are being used as organ sources China has indicated that it will ban sale of organs from living donors and require consent from prisoners ….many loopholes Applies only to Ministry of Health Hospitals (not military hospitals)

46 Bottom line Medical tourism is a reality… and a growth industry Both risks and benefits exist Difficult to determine the extent of risks Quality of care is variable Buyer beware Many ethical issues Travel clinic has a role in preparing medical tourists for travel

47 What is the role of the Travel Health Provider?

48 What is the role of travel clinic? Provide usual general pre-travel advice Vaccinations Malaria prophylaxis Pre-travel counselling Make traveller aware of key issues in medical tourism Effects of commoditization of care on medical decision making Consider potential risks specific to medical tourism

49 Buyer Beware Joint Commission International accredits hospitals (US standards) List of accredited hospitals easily accessible on line Trent International Accreditation Scheme UK accreditation scheme Beginning to accredit overseas institutions Accreditation standards adjusted to reflect local standards and culture Local staff conduct accreditations No inspections Healthcare Tourism International New, non profit US group, accredits non clinical aspects of medical tourism

50 Providing Advice Consider the potential for legal complications Be aware of legal restrictions May require special visa if travel is specifically for medical care Consider the what ifs Will there be recourse to compensation if problems occur? What if there are complications? Who pays for extended hospital stays? Additional surgery? Specific medical tourism health risks Avoid sunburn – increased scar pigmentation Infection – multidrug resistant or unusual pathogens Thromboembolic disease Complications of early air travel post op - patients are typically sent home 10-14 days post op Anecdotal reports of patients being sent home within 2-3 days of surgery, with active complications

51 Possible Outcomes Quality, evidence based medical care Appropriate indications Well trained, experienced practitioners Substandard care Staff / hospital credentials Unnecessary surgical procedures Poor infection control procedures Medically questionable procedures Unproven efficacy for indication Fraudulent care Fake transplants / procedures Fake credentials


53 Israel 2001 MOH regulation allowed reimbursement for kidney transplants done abroad…. Increased competition between brokers Local physicians with little knowledge of transplantation medical advisors Non-selective referral Increased referral of older, less fit, highly sensitized patients Less selective choice of facilities Downstream effects…..

54 Israel Complications Patients required to return to Israel, presenting on arrival with complications and no medical information Reduced imperative to develop national donor programs No increase in donor rates over 10 years Poor access for non kidney transplants 2006 – New MOH regulation to limit referrals abroad to situations where absence of organ trafficking could be guaranteed, increase donations locally

55 Israel >150 Israelis obtain transplants abroad/yr 50% transplanted prior to dialysis Alternate route to obtain organs – low donor rates in Israel Ministry of Health gains by saving expense of dialysis Health insurance agencies gain by selling high priced policies covering transplants abroad Donors – living related / paid unrelated donors from Israel (travel with patient to transplant site) or paid donors at destination

56 Transplant outcomes Outcomes of United States Residents who Undergo Kidney Transplantation Overseas: Canales et al, Transplant Tourism 10 kidney transplant patients (Sept 02 – July 06) Transplanted in Pakistan (8), China (1), Iran (1) Mean age: 36.8 years Follow-up period: 0.4-3.7 years (mean 2.0) 6 serious post op (in 3 months) infections in 4 patients 1 death 1 graft failure due to acute rejection Graft survival and function – generally good High incidence of post transplant infection Inadequate communication of information – immunosuppressive regimens and perioperative information

57 Specific cases One patient presented to emergency on arrival in US with wound infection Spent 2 months in hospital Acinetobacter bacteremia Aspergillus CNS infection Died 4 months post transplant Two patients diagnosed with urosepsis on arrival home One patient had a seizure immediately prior to discharge in Pakistan, treated and allowed to fly home, second seizure on arrival Cyclosporine toxicity

58 Israel - complications post transplant 3 cases of aspergillosis 2 cases of mucormycosis 1 case of severe hepatitis C

59 Kidney Transplants - India India dubbed warehouse for kidneys and the great organ bazaar 150,000 Indians need transplants annually Only 3,500 actually performed Sale of organs illegal - Criminal act for foreigners to go to India to obtain transplants

60 Kidney Transplants - India Kidneygate - Illegal transplant ring 400-500 transplants done over past 9 years Located in residential home in wealthy suburb of Delhi Donors… Voluntary, paid donations, impoverished people from slums Migrant workers kidnapped / held at gunpoint / drugged Recipients… Wealthy Indians, Americans, Europeans, Middle Easterners Culprits… Ayurvedic doctor Amit Kumar – no MD degree Multiple physicians, nurses and hospitals involved

61 Kidney transplant - India So with all the bad press ….you would think it would be difficult to access organ transplants in India, right? Numerous websites offering surgery in India Some note the possibility of bringing a potential donor Small print – What if you have not donor….

62 Kidney Sellers - Pakistan 239 kidney sellers M:F ratio – 3.5:1 90% illiterate 69% bonded labourers 93% sold kidney for debt repayment 19% repaying debts of parents, uncles, grandparents 5% coerced by landlords to repay debts

63 Kidney Sellers - Paksitan Promised payment: $1146 - $2950 (mean $1737 +/- 262) Actual payment: $819 - $1803 (mean $1377 +/- 196) No sellers received promised amount Deductions for hospital stay and travel 88% had no economic improvement 98% had worsened health status

64 SurgeryUSA USD India USD BMTx400,00030,000 Liver Tx500,00040,000 CABG50,0005,000 Neuro-surgery29,0008,000 Knee surgery16,0004,500

65 Statistics … $60 billion / yr industry* USA 2006: >½ million people travelled overseas for care Thailand 2006: 36.4 million baht (USD: 1.15 million) Israel 2006: $40 million, 15,000 health tourists Singapore 2005: 374,000 health tourists India: 2005: >150,000 medical tourists Costa Rica 1993: (CMAJ) 14% tourists came for medical reasons 10% of hospital beds in 1 private hospital occupied by foreigners *Crone, Academic Medicine, Vol 83, No 2, Feb 2008, 117-121

66 The Transplant Map India, Pakistan Turkey Romania Moldova China Philippines Egypt

67 UAE / Oman 130 patients traveled to Mumbai for transplant Poor donor-recipient matching Suspected high level of immunosupression to compensate for poor matching increased risk of infectious complications and death 18.5% mortality (vs < 2% for other transplant pts) 8 deaths in the immediate post-operative period 16 deaths in the first 3 months post-operatively 24 patients died within 1 year of transplant, 1 patient died after the first year 56% of deaths due to infection

68 UAE / Oman Blood and body fluid borne pathogens 3 new diagnoses of hepatitis B 4 new diagnoses of HIV - previously screened negative Inappropriate transplant decisions 7 patients transplanted despite having been found ineligible for transplant in home country 1 patient suspected to have AIDS and advised against transplant but went to Mumbai and transplanted within 2 weeks, HIV confirmed on return

69 Stem Cell Transplants - China Parkinsons: Human retinal epithelial cells from adults No immunosuppression required Cells injected stereotactically into putamen Daily cocktail of drugs to fertilize the area Stem cell activation and proliferation treatment (to enhance the bodys own neural stem cells) ~20 patients treated No published RCTs

70 Stem Cell Transplants - China Stroke self stem cell activation and proliferation 50 patients treated Minor to significant improvements Cerebral plasy, Degenerative neurologic disorders, Epilepsy, Brain infections Neural (fetal) stem cells Bone marrow stem cells (autologous) Recommended because the immune system is weak Both types of cells delivered by lumbar puncture – cells are said to flow through the CSF into the brain

71 Thrombosis DVT – PE risk Post operative period = increased risk for DVTs / PE Decreased mobility Hypercoagulability High risk: orthopaedic / joint replacement surgery Prolonged air travel Economy class syndrome Convergence of risks Early post-op travel Data?

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