The risks of US domestic medical tourism may lead to a rethink

Promoters of domestic medical tourism in the USA often mention potential cost benefits although as yet nobody has produced any figures to show if it is actually increasing as claimed.

But the potential pitfalls have been ignored until a new study by the University of Utah illustrates the problems where people have to keep travelling to hospitals far from home.

Up to 22% of US surgical patients experience unexpected complications and must be readmitted for post-operative care. A study led by the University of Utah suggests that returning to the same hospital is important for recovery. Readmission to a different hospital is associated with a 26% increased risk of dying within 90 days.

The results, published in The Lancet, have implications for patients who take part in employer or self pay domestic medical tourism.

A handful of the nation’s largest businesses encourage employees to travel to large US medical centres for complex elective surgical procedures. As part of these medical travel programmes, companies negotiate lower prices for patients to receive high-quality surgical care at some of the nation’s top hospitals.

Employers save money, as do employees, but it is the employee that may have to travel long distances – sometimes hundreds of miles from home – to reach destination hospitals.

Large employers and their insurers tend to be risk averse so the study may make some look again at the benefits and risks of domestic medical tourism-which until now has only been considered on a cost benefit basis.

A hospital hundreds of miles away makes it difficult to return should complications arise. Employers, agencies, and hospitals promote the idea that such complications are unusual, but the study disagrees.

Study leader Benjamin Brooke at the University of Utah School of Medicine explains, “This is not a small issue. Between 5$ to 22% of patients were readmitted in our study, depending on the type of surgery. Our work suggests that striving to maintain continuity of care in the same hospital, and by the same medical team when possible, is critical to achieve the best outcomes should complications arise after surgery.”

Returning to the place where the original operation was done is associated with improved survival regardless of whether it is a large teaching hospital or smaller community hospital. Patients fare slightly better when also treated by the same surgical team. The trends hold true for patients on a wide range of common operations including neurosurgery, coronary bypass and hernia repair.

Brooke recommends having operations done close to home when possible. Or if travelling to a destination hospital, planning to stay in the area during recovery- “If a patient is readmitted to an outside hospital every effort should be made to transfer surgical patients back within 24 hours to their original hospital for post-operative management.”

What makes this study important for all parties involved in evaluating and costing domestic medical tourism is that it is not a small sample one.

The researchers examined data from 9,440,503 Medicare patients who were readmitted within 30 days after undergoing any of 12 major surgical procedures between 2001 and 2011, the largest analysis of surgical patients of its kind. 66 to 83 % of patients who had complications were readmitted to the same hospital. Statistical analyses demonstrate that these patients were more likely to survive 90 days after readmission than those who received post-operative treatment at a different hospital.

The trend was consistent across all surgeries, and ranged from a 44% decrease in risk for death for those who had a pancreatectomy, to 13% for coronary artery bypass surgery

The study adds to mounting evidence that continuity of care leads to better outcomes for a variety of acute and chronic medical conditions. Report co-author Professor Sam Finlayson says, “Most people do not think about the implications of travelling far for an operation. As with many health care decisions, there are trade-offs to consider. Travelling may confer the best chance of a favourable outcome with surgery, but it may hinder access to optimal care in the event of a serious complication after discharge. The interesting question that our results raise is why outcomes appear to be better when a patient returns to the hospital where her or his operation was performed. Discovering the answers could help improve the way we deliver care.”

The work was published as “Readmission destination and risk of mortality after major surgery: an observational cohort study” online on June 18, 2015 in The Lancet.