How does a medical tourist make a valid comparison of a
doctor, hospital or clinic in one country with a doctor, hospital or clinic in
another? The simple answer is that he or
she can’t. And the truth is that it may never be the case (well not in my
In the hypothetical world, we talk about patients making
informed choices about treatment....about how we can provide them with the
information that they need to compare healthcare providers and make valid decisions
about which one is the “best”, the “safest”, the “highest quality”. But even if
someone is only interested in treatment within one country, this may be
impossible. In a country such as the UK where there is a national publicly
funded health system it becomes more of a possibility. In the UK, there are
quality indicators, performance measures, and outcome data that are collected
in the same way and analysed in the same way across all healthcare providers
(whether they are public or private hospitals). So, patients can make
reasonably valid comparisons of healthcare providers. However, in many
countries which are promoting themselves as medical tourism destinations, there
may be no strategy or system for collecting data on quality, performance and
outcomes on a national basis. So, making an “informed choice” even within that
country becomes a virtual impossibility.
A partially informed (or misinformed...) choice
In the real world, can a medical tourist make an informed
choice about treatment when comparing different hospitals in different
countries? The simple answer is.... no. At
best a medical tourist can make a partially informed choice. And in some
(perhaps many?) cases, a medical tourist may make a misinformed choice.
Let’s take what looks like a simple indicator.....outcome
measures for cardiac surgery. Let’s say that you need a heart bypass operation.
You cannot afford the surgery in your own country, so you start to explore what
it might cost if you went overseas. You identify a few countries that look
attractive in terms of price, but how can you compare the likely outcome of
your operation at different hospitals in different countries? It can’t be that
difficult.... Can it?
It can... Even with something as well researched as heart
bypass surgery, there is still no international consensus on how outcomes
should be measured (or there are “competing “ views), and how these data should
be adjusted to take account of risk.
Measuring quality of care
Measurement of quality of care depends on:
- the choice of outcome (is it about surviving the
operation, the number and /or complexity of complications after surgery, the
risk of post-operative infection, the length of stay in intensive care, the
readmission rate or life expectancy post-surgery?)
- the source of data used to determine outcome
(i.e. who supplied it, and how objective were any assessments undertaken)
- and the data used to account for patient risk
when measuring outcome.(i.e. older patients with co-morbidities and poor
general health will have worse outcomes)
So, you can see how difficult it is to compare outcomes and
safety in healthcare. If doctors and researchers are struggling to make valid
comparisons, what hope does a patient have?
Within the medical tourism industry, there are some who believe it’s
easy to “compare apples with apples” in healthcare. If consumers can compare cars based on
standard Euro NCAP safety ratings, then
why can’t they compare hospitals and doctors?
But people are more complex than cars, and fixing people is far more
tricky than making cars.
Fixing the problem
There is no easy fix, and it’s probably a long way off.
The work of the OECD's Health
Care Quality Indicators Project (HCQI) illustrates the problem and how far
we still have to go to solve it. This project aims to help healthcare
policy-makers and researchers to measure and report on the quality of medical
care. In this case, 'quality indicators' (QIs) means indicators of the
technical quality with which medical care is provided, i.e. measures of health
outcome or health improvement attributable to medical care.
Many OECD countries have already embarked upon national
strategies to begin collecting technical quality indicators, and establish
benchmarks for performance measurement. They have made progress in implementing
quality indicators at the level of providers (such as hospitals or doctors). BUT
these national activities do not lead, except by accident, to internationally
comparable quality indicators.
- There is a lack of international agreement on
the most promising indicators.
- There are many definitions of each indicator
that could be adopted.
So what can a medical tourist do?
With the adoption of the EU Directive on Cross Border
Healthcare, the European Commission is keen to see the OECD Health Care Quality
Indicators Project succeed but states “there is so far little possibility for
international benchmarking of the quality of health care.”
So, the EU Directive may help to move things forward, but
slowly. In the meantime, patients will have to make choices based on partial
information. What’s my advice to a medical tourist? Keep it simple. If you need
knee surgery, choose a knee specialist not a general orthopaedic surgeon who
treats hips, shoulders,hands etc. Confirm that he is truly a knee specialist.
Find out what research papers he has published. Find out what specialist associations
he belongs to related to knee surgery (e.g. the British Association for Surgery of the Knee, International Society of Arthroscopy, Knee
Surgery and Orthopaedic Sports Medicine, The Knee Society).
Find out how many procedures he carries out each year of the type that you
need. If you need a knee replacement, how many of these does he actually do? If
you need ACL reconstruction, how many of these does he actually do? Ask for
contact information for previous patients from your country.
And.... ask him for details of the quality indicators he
uses or his hospital uses to monitor his performance. But don’t expect to
compare these with indicators from elsewhere!
Date published: 11 Mar 2011
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