Prep and protect medical tourists to prevent tragedies

It sounds great—get the surgery you need and a tropical vacation for less than the procedure alone would cost at home.

But medical tourism also carries risks, as some patients have learned the hard way. In 2013 and 2014, rapidly growing mycobacteria was found in 21 Americans who had undergone cosmetic surgery in the Dominican Republic. In 2018, dozens of patients were found to have carbapenem-resistant Pseudomonas aeruginosa after bariatric surgery in Baja California, Mexico. At least one patient died in each outbreak.

Medical tourism doesn't have to end so tragically, according to two CDC experts who spoke during the annual meeting of the Association for Professionals in Infection Control, held online in June.

There are “several things that those considering medical tourism can do to help mitigate risk and make the process as safe as possible, as well as important things for a physician to discuss with the potential medical tourists prior to their seeking care abroad,” said Matthew Crist, MD, a medical officer with the CDC's Division of Healthcare Quality Promotion.

He and Rhett Stoney, MPH, an epidemiologist with the CDC's Division of Global Migration and Quarantine, reviewed some of those key considerations, as well as telling some cautionary tales.

Reasons to do it

There are a number of factors that lead patients to seek surgery outside the U.S., Mr. Stoney explained. “Cost is a major reason people travel outside of the country for medical care,” he said. This is true for both uninsured and insured patients. “Insurance companies may offer incentives for outsourcing,” he said, noting that some employers may also do so to reduce their health care costs.

Foreign-born Americans may be more comfortable receiving care in a more familiar setting. Other medical tourists may believe the quality of certain procedures to be higher in other countries. “Medical tourists may also travel abroad for care if it is not approved or available in their home country,” said Mr. Stoney.

To better understand how these many factors contribute to medical tourism by Americans, the CDC included some questions in its Behavioral Risk Factor Surveillance System. Ten states and the territory of Puerto Rico collected data in 2016.

“We approached states with an established interest in medical tourism,” Mr. Stoney said. In total, the survey found 517 people who had been medical tourists, 4.6% of the 93,492 surveyed. Twenty-four people (5%) reported an unexpected or undesirable outcome as a result of the care they received abroad, 18 of them requiring health care in the U.S. after their return.

“Dental surgeries, treatments, and procedures were the most frequently reported,” Mr. Stoney said, but cosmetic and bariatric surgery also made the list. Over half of the medical tourists gave cost as the reason for their choice.

“We calculated the prevalence of medical tourism in 11 states and territories to be 1.32%, representing approximately 1,130,000 individuals,” said Mr. Stoney. People without health insurance were more likely to be medical tourists, “although it is important to note that medical tourism was still prevalent among those with health insurance,” he added.

Risks and consequences

The association between lack of insurance and medical tourism has posed challenges to identifying complications from surgery abroad, the experts explained.

“Medical tourists may lack health insurance and may be hesitant to present for care in the United States, delaying diagnosis and possibly inhibiting treatment options, resulting in a longer clinical course,” said Mr. Stoney.

As an example, he offered the outbreak among patients who went to the Dominican Republic for cosmetic surgery, described in the August 2016 Emerging Infectious Diseases. This was first identified when a physician in Maryland reported to the state department of health that two patients had Mycobacterium abscessus-complex surgical-site infections after procedures in the Dominican Republic. The patients reported knowing another woman in Massachusetts who had been treated at the same clinic and developed similar problems.

The CDC then initiated an investigation, which eventually identified 21 cases in six states. At least 14 required therapeutic surgical procedures after returning home, and one death was reported.

The carbapenem-resistant Pseudomonas aeruginosa outbreak proceeded similarly, as Dr. Crist explained. It started out with a report of a single patient, then a few more who had used the same travel agency to schedule their surgeries in Tijuana. Eventually, public health authorities found 38 cases across 18 states, more than a third requiring hospitalization.

“CDC and state and local health departments partnered with Mexican health authorities to conduct the investigation, which began in November of 2018,” said Dr. Crist. The CDC put out a travel notice warning against traveling to the implicated hospital for surgery. The Mexican authorities inspected the facility where most of the infected patients had been treated and found some serious hygiene problems.

“Most notably, there were issues with sterilization of surgical instruments, and there were no indicators, either biological or chemical indicators, being used to verify appropriate sterilization of surgical instruments,” said Dr. Crist. In response, the Mexican authorities closed the surgical suite for 10 weeks.

Safety steps

To reduce their risk for adverse outcomes, patients considering medical tourism should discuss the plan with their primary care physicians, recommended Dr. Crist.

“Just like before any surgery or medical procedure, their current medical conditions should be well controlled. And they should also make sure that they have enough medication for the duration of their trip,” he said.

Patients should also undergo the pretravel care that would be recommended for regular tourists, four to six weeks before the trip. “Medical tourists should be up to date on their routine vaccinations, and they should consider travel-related vaccines, which are based on their destination,” said Dr. Crist.

They should also have the typical conversation about the risks and benefits of the procedure with a clinician. “That needs to be done in the context of the patient's individual health status, just as if they were having the surgery or procedure done in the United States. These things include their weight, their age, as well as underlying medical conditions,” he said.

Patients also need to be told about additional risks they might face abroad, such as infectious and legal complications. “There's also a risk of acquisition of bloodborne pathogens, which include hepatitis B and C as well as HIV and CMV [cytomegalovirus],” said Dr. Crist. “It's important that patients are aware that if there is a complication resulting from a procedure or surgery abroad that they may not have a lot of legal recourse.”

Travel can complicate recovery, so physicians should review patients' planned itineraries. Whether medical tourists are headed on vacation or straight home after surgery, “They should understand the additional risks associated with air travel while recovering from recent surgery or other procedures,” he said. Those include clots and the effects of atmospheric pressure changes; for example, patients should not fly for 10 days after chest or abdominal surgery.

In addition to consulting with a physician, patients should review their health insurance policy to understand what coverage, if any, they have outside of the United States. “They should consider purchasing supplemental travel health insurance, in addition to their regular medical insurance,” said Dr. Crist.

It's also important to do research on the qualifications and accreditation of the treating surgeon and facility, as well as the reputation of any third party arranging the care. Data on patient outcomes should be available from the facility or clinician. The International Society of Aesthetic Plastic Surgery and The Joint Commission International can be useful resources for checking on accreditation of foreign facilities, but all surgeries carry risk, and accreditation should not be considered a guarantee of a positive outcome, Dr. Crist noted.

Patients should also have thought about what will happen after the procedure. “There needs to be a good plan and understanding of what follow-up care will be provided by the overseas provider versus what will be provided by the U.S. provider,” said Dr. Crist. “If some of the postoperative care will occur abroad, is it going to be done at the same facility or will it be done at a different facility by a different provider?”

The cost of follow-up care is another important consideration. “Sometimes one or two postoperative visits are included as part of the overall cost of getting the surgery abroad, but not always,” he said.

Patients should also be sure to get a complete copy of their medical record before returning home, since it will be essential if complications develop. Of course, they should also be warned to seek care immediately, wherever they are, if any signs or symptoms of a complication appear.

“Unfortunately, this isn't always the case. Medical tourists are often hesitant to seek care,” said Dr. Crist. “So clinicians should ask about travel history, especially among those patients who are presenting with evidence of recent surgery and potential complications of that surgery.”

If physicians ever suspect an infection is related to medical tourism, they should notify health officials, even if that's not required by state regulations. “In the bariatric surgery outbreak that I've discussed, a key part of recognizing that outbreak was that multiple physicians from different parts of the country reported those infections,” he said. “It takes reports coming from multiple areas to generate a signal for public health intervention.”

The sharing of information among patients, physicians, and public health officials across borders, as occurred in the outbreak originating in Mexico, can potentially reduce both the complications and the incidence of infections in medical tourists. “We were able to assist a foreign country in providing training for a local facility to not only stop an outbreak but to hopefully implement better practices moving forward,” said Dr. Crist.