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Home > Blog > 2011 > Comparing quality in medical tourism

Comparing quality in medical tourism

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 lifetime).

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.

Why? Because:

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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Comments provided below do not represent the views of IMTJ. Comments will be published 'as is' and will not be edited by IMTJ staff. IMTJ is hosting these comments, and is not undertaking an editorial role. However, it is editorial policy to publish comments that have been submitted anonymously.

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About me

Keith Pollard

I am Managing Director of Intuition Communication Ltd, a web publishing business in the healthcare sector. Our sites include International Medical Travel Journal, Treatment Abroad, the medical tourism portal, DoctorInternet, the Arabic medical tourism portal and Private Healthcare UK, the UK's leading site for private healthcare services. I am a regular speaker and commentator on medical tourism and the independent healthcare sector.

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Thanks Todd

I can only comment for QHA Trent. We recommend a policy of openess, transparency, honesty and integrity by hospitals and clinics, as we ourselves believe we adhere to when we openly publish our own charging structure (see http://www.qha-international.co.uk/what-charges-do-qha-trent-make-for-accreditation-services).

QHA Trent would recommend that any hospital or clinic we work with publishes the accreditation documents that are generated by the pre-survey, survey and the accreditation process, and the consumer can, and should, then judge for themselves should a hospital or clinic be unwilling to do this.

Our good professional reputation is vital to us, and QHA Trent is perfectly prepared to get its hand bitten if that is the price we must pay for maintaining it!

Steve Green (06/04/2011 08:54:28)

The fact that a hospital is accredited is good but by itself is NOT ENOUGH to drive patients to choose a hospital. In fact I would contend that in the next couple of years you will hospitals start dropping their JCI accreditation. It provides no value to them.

The JCI and and I would think Trent have outcome data (e.g. noscomial infections, readmissions, hemorrhage complications, mortality, etc.) that could be easily disseminated to the public. However, the JCI is afraid of "Biting the hand that feeds". They make a lot of money on those surveys and would not want to put anything negative about a hospital in a public domain.

Thus, the need for someone else to step up and provide data to consumers. Who might that be? Again, just keep it simple.

Todd Madden (16/03/2011 18:36:28)

A thought when it comes to the independence of data and analysis being put "out there" for public consumption - when it comes to which way to lean when assessing the financial health of a country, a corporation or an investment product, the world very often dances to the tunes played by the likes of Moody's, Fitch and Standard and Poor (the leading NRSROs) – but interestingly although mega-wealthy and massively influential the NSROs themselves claim that their ratings are only protected “opinions” and no more (http://www.bankingandfinancelawreport.com/tags/nrsros/). .

Holistic accreditation schemes are similar to this and, while based on opinion, they can offer extremely useful guidance to stakeholders – but the more independent they are of external influences, and hence of conflicts of interest (e.g. governments, insurance companies, healthcare provider companies etc.), the better.

And they can ask questions and demand standards. For example, QHA Trent Accreditation, which is based on UK NHS clinical governance principles, insists on an informed consent form and process being in place which must be gone through with the patient by the surgeon or other operator who is going to be performing the procedure - and they must be scrupulously honest when advising that patient about their own personal experience and outcomes when doing that procedure, clearly a much more pertinent and important indicator than the overall outcomes for the establishment for any particular procedure.

If anyone is interested, QHA Trent Accreditation UK is to be found at www.qha-international.co.uk.

Steve Green (14/03/2011 15:41:38)

(cont)
Accordingly, as for the measuring of outcomes from hospitals and clinics I wouldn't bother going too far with this until all the basics are demonstrably and transparently in place and all management and all staff are signed up to the process. Of course, outcomes are what healthcare is all about, but the healthcare provider must first be definitely fit for purpose (and remain so) before any meaningful work can be done on this. If I read another hospital's blurb on the web saying “We are the best at XX in the known galaxy” I may contemplate cutting my wrists.

The point is that if you slap a gamma knife, a PET scanner or an IVF unit into the middle of a hospital or clinic that is not at first functioning well and in which all medical staff (whether on the staff or visiting specialists) are signed up to "playing ball", then don't expect the best of results to emerge. A lousy surgeon will carry out lousy surgery whether or not he has a gamma knife to mess around with, a poorly-interpreted PET scan result made by an inadequately trained doctor is dangerous, and - as happened in Singapore recently - IVF carried out in a sloppy fashion can lead the wrong spermatozoa and ovum coming together with serious consequences. Probity is everything, and should always be fostered and nurtured.

Hands-on holistic independent accreditation, whether by QHA Trent or JCI or anyone else in our line is, at the end of the day, the end result of a serious of judgements and opinions by the accreditation scheme. But accreditation at least represents something solid and independent (QHA Trent and JCI (to the best of my knowledge) are independent of all governments as well as of all healthcare providers and insurance companies) on which a judgement can be based as to whether or not a healthcare provider establishment is in the correct ball park when it comes to risk, safety and quality.

Steve Green (14/03/2011 15:39:57)

By way of personal background, I am with the QHA Trent Accreditation Scheme from England UK. I also happen to be a fully CCT'd Consultant Physician in Infectious Diseases, Tropical Medicine and Internal Medicine, and a Fellow of the Faculty of Travel Medicine of the Royal College of Physicians of Glasgow. I earn my corn in the UK's NHS as a doctor. I therefore have something of a professional interest in the subject being discussed here.

I would suggest that people, and hospitals and clinics, anywhere in the world don't run before they can walk. The governance of a hospital or clinic has to be fit for purpose, or else nothing else matters and patients and staff will remain at risk. Good governance (eg. http://www.rcn.org.uk/development/practice/clinical_governance) includes ensuring that a myriad of factors are in place and activities are happening, including high-quality nursing handovers on wards, staff quality (e.g. credentials & continuing educational development), clinical protocols and standard operating procedures, policies and policy development, active clinical audit programmes, expert clinical ethics committee, a risk register established, infection control, complaints handling, medico-legal indemnity, handling of estates issues such as fire safety, sharps injury prevention, laundry and sterile services, night nursing staff still engaging in update training etc etc etc .. obviously it is a very long list and I could go on for ever.

Steve Green (14/03/2011 15:34:07)

Even if there were consensus on how outcomes are to be recorded and statistics made available in an easily comprehensible format, who is raising the awareness level of the patient to collect information that is pertinent? How many patients even understand the terminology, let alone providers agree on the lingo for comparison? Do patients know what JCI accreditation means? Do they also know that JCI accreditation does nothing for the healthcare traveller?
So, quite right, keep it simple. And, it's not a poor man's choice either; patients today are far better informed and doctors brought down to earth from their erstwhile status as demigods, above and beyond reproach.
If one is looking to help the not-so-hapless patient, let's empower patients as we deal with them in our roles in the equation; impartially, ethically and professionally, and as part of processes that account for well-informed decisions. Keep it simple and honest!

Zahid Hamid (11/03/2011 20:48:06)

Very good point. This article hit home as when we began mapping out our dental travel company, the first order of business, was quality of care and safety. If sterilization wasn't adequate, nothing else matters. To our amazement, no one else seems to offer a real solution or professional inspections process for dental facilities AND quality of care.

In order to meet that goal, Dental Destinations has created a Quality Assurance Program under the direction of a former US periodontist, US regulator, President of the Regional Examining Board, and adviser to the American Dental Association on credentialing criteria for 10 US states.

The goal of the process is to thoroughly screen the dentists, as an unbiased 3rd party in foreign nations. This program allows Dental Destinations to assist our clients in selecting the dentist best suited to their needs. .

The Quality Assurance program consists of an evaluation and credentials review of the

-practitioners
-facilities
-staff
-protocols
-treatment procedures
-outcomes

We only partner with offices located in safe, tourist friendly locations. We make sure the office is:

-modern
-easy to navigate
-All the doctors are fluent in English and good communicators
-The dental materials used are up-to-date and of the highest quality.

We review the office sterilization and infection control procedures to maximize your safety. We evaluate treatment they have completed for quality.

More details on our Quality Assurance Program can be found at http://dentaldestinationsdds.com/consumer-guide-to-dentistry/how-to-choose-a-dentist/inspections-criteria.html

Michael Hardenbrook (11/03/2011 19:55:03)

Work is much further along than many may realize in offering objective 3rd party verification of quality indicators between different hospitals. While an initial roll out of comparison data may be somewhat overly simplistic and not ideal, it is BETTER THAN NOTHING.

If we continue to spin our wheels worry about risk adjustment after risk adjustment, we go nowhere slow. Lets get some basic indicators (mortality, hemorrhage complication, noscomial infection, etc.) and have a 3rd party put them out there.

Going along as we always have thinking the US has the best healthcare with no data support just perpetuates the very misconceptions we want to overcome.

Todd Madden (11/03/2011 17:40:14)

Attributes of Hospital Quality
These attributes are important because they signal what the hospital's culture is like. A culture of excellence makes a big difference in your patient experience and also in your chances for a great outcome. Great hospitals:
• Cultivate top reputations and prestige through exclusive affiliations and accreditations.
• Work from internationally vetted medical guidelines (protocols), which govern the medical care they administer.
• Have support from national, regional and local governments.
• Are acknowledged by the media.
• Are close enough to large population centers and transportation hubs to draw both local and health travel patients.
• Have powerful ownership groups that engender government, academic, media, business and social support. (Don't confuse a publicly traded company as necessarily having community support.)
• Are keenly aware of what is necessary to build sustainable competitive advantage in medical excellence and healthcare delivery.
• Focus on product offerings needed to draw patients.
• Have a research / clinical trials component.
• Create superior value-for-money.
• Have been building their offerings longer than new entrants have.
• Leverage Information Technologies to control costs, improve safety and improve care throughout.
• Are preparing to measure and improve value (patient outcomes per healthcare dollar spent).
• Have a value orientation rather than an accounting orientation.
• Have a culture of patient orientation and excellence.

Scott Frankum (11/03/2011 17:11:13)

Building Features for Hospital Quality
The Best New Hospital Buildings:
• Have building-wide air locks to keep air borne contagions in or out.
• Have physical plants (electricity, security, water filtration, computer systems and HVAC) with multiple redundancies.
• Are planned for human survivability in natural or man-made disasters.
• Incorporate environmental, sustainable and healthy-hospital initiatives.
• Isolate potentially harmful (X-ray or imaging) equipment away from hospital employees and patients for greater safety.
• Have redundant patient security.
• Have a variety of rooms from patient suites to budget multi-bed rooms.
• Integrate Health Information Technology (HIT) to medical touch points.
• Are designed to American Institute of Architects (AIA) or other international design standards.
• Are designed to qualify for Leadership in Energy & Environmental Design, (LEED) certification.
• Incorporate business process design to rationalize / lower costs while maximizing patient experience.
• Take simple, practical steps like putting in more sinks for hand washing.
• Meet or exceed requirements for international accreditations.
• Have recent, tricked-out medical capital equipment.

Scott Frankum (11/03/2011 17:10:43)

I agree with Keith and Arlen but think introducing the idea of patient checklists could really help, in patient terms if not in audited terms. Here is one I'm working on for a hip surgery project.

• What is the success rate of the surgery I'm having?
• What are the main reasons for lack of success?
• If the surgery is not successful what would happen next?
• What would my financial responsibility be in a second, revision surgery?
• Is this an open surgery or less invasive?
• What incision length should I expect?
• Will the incisions go in through the front or back of the hip?
• What bone length will you cut away?
• What is the brand name of the implant?
• What is the height and weight range recommended for this implant?
• What are the materials in the implant?
• Are there any problems with this type of hip or the company that makes it?
• Given my general age and health, are there special risks in my case and what medical result should I expect?
• Given my general age and health, how long will I be in the hospital? Recovery facility? On a walker? On crutches? With a cane?
• Given my general age and health, how long before I'll be able to, without assistance, Bathe? Use the toilet? Make a meal? Go to work? Drive? Swim? Ride a bike? Bend? Cross my legs? Stop physical therapy?
• How long before I'll be able to walk for thirty minutes to an hour?
• What range of motion will my hip have when I am fully healed?
• Will I ever be able to resume medium impact sports like tennis or high impact sports like running?
• When this implant wears out, what surgery will likely happen next and how will this surgery affect what happens in that one?
• What lifelong precautions will I need to observe, (like taking antibiotics)?

Scott Frankum (11/03/2011 17:10:01)

Todd Madden (11/03/2011 17:08:23)

I agree that we have a long way to go in standardizing global outcomes measurements. However, medical travelers should be aware of:
1. Attempts to integrate price data with quality of care data. The goal is define value, not quality alone.
2. Attempts to measure the patient experience and report them using social networks and the Internet
3. Market forces pushing medical travel destinations to improve their quality of care and quality of service
4. The commercial opportunity driving quality of care and pricing transparency

Arlen Meyers, MD, MBA (11/03/2011 14:22:07)