Total Joint Tourism: A Literature Review of an Emerging Trend

Weis, Jamie L. PA-C

JBJS Journal of Orthopaedics for Physician Assistants: January - March 2017 - Volume 5 - Issue 1 - p e1
doi: 10.2106/JBJS.JOPA.16.00023
Review Article
Disclosures

Background: As medical costs rise, more patients are paying cash for joint replacement surgery in developing countries. The objective of this study was to assess the relative risk for medical tourism arthroplasty patients.

Methods: A comprehensive literature review was conducted to identify general and orthopaedic medical tourism articles.

Results: A systematic review of the literature identified 515 medical tourism articles; 6 were specific to orthopaedics. Themes included economic effect, patient experience, motivations, and informed consent.

Conclusions: Although medical tourists can undergo cost-effective arthroplasties in developing countries, the current literature does not quantify the infection and complication risk compared with that of arthroplasties performed in the U.S.

1Coordinated Health, Allentown, Pennsylvania

Article Outline

The emerging trend of medical tourism has American and Canadian patients traveling to low and middle-income countries (LMICs) to undergo deeply discounted hip or knee arthroplasty procedures. Total knee arthroplasty and total hip arthroplasty are excellent surgical solutions to relieve the pain of end-stage arthritis. It is projected that by 2030, 11 million U.S. citizens will have had a total knee arthroplasty or a total hip arthroplasty, thus making these procedures the most common elective surgeries in the U.S.1. The phenomenon of medical tourism for these procedures is driven by the high cost of health care in the U.S. and by long wait times in Canada2,3. Medical tourism has rapidly become a $40 billion industry, with an estimated 50 million patients participating annually4,5. In addition to total joint arthroplasties, patients travel for multiple types of procedures; cosmetic surgeries, cardiac surgeries, and bariatric surgeries are the most common. A total knee arthroplasty, which averages $61,266 in New York6, can be done in India for only $8,500, far less than the U.S. price, even with the additional cost of flights and hotel stay7 (Fig. 1). While this can be a cost-effective option, it is not without risk. Unregulated and unaccredited hospitals, endemic tropical diseases, different patterns of antibiotic resistance, and communication difficulties because of language barriers add risk that is difficult to quantify. This paper provides a review of the literature pertaining to medical tourism, specifically articles about the commonly sought procedures of hip and knee arthroplasty.

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Materials and Methods

A systematic review of the literature was conducted for medical tourism (specifically, arthroplasty tourism). Databases included PubMed, ERIC, Cochrane Library, and DynaMed. The search term medical tourism, limited to articles published in the past 5 years and written in the English language, yielded 515 results. Of these, articles that specifically focused on a nonorthopaedic topic, such as reproductive tourism or organ transplant tourism, were excluded. There were 132 articles on general or orthopaedic-specific medical tourism. Of these, 34 focused on the economics and economic effects of medical tourism, 29 focused on policy and ethics, 29 focused on the patient experience and patient motivations, 17 focused on risk and informed consent, 13 focused on medical tourism web sites and marketing, 6 focused on clinical medical specifics such as complications, and 4 were basic overviews. Approximately half (n = 62) of these articles focused on medical tourism globally, while half specifically studied medical tourism in a single country. The most frequently studied nationality of medical tourists was Canadian, and there were 15 articles focused on Canada.

A query of the term joint replacement tourism, also limited to English-language articles published in the last 5 years, yielded 7 articles; 6 were related to orthopaedic medical tourism. A query of the term arthroplasty tourism yielded 3 related articles, all of which were contained within the previous query.

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Results

The articles, which were primarily qualitative and covered a wide spectrum of related factors, did not lend themselves to a meta-analytic statistical evaluation. The majority of the articles had an economic or financial focus. One article, which specifically assessed total knee arthroplasty, total hip arthroplasty, and coronary artery bypass, estimated that the U.S. loses $1.3 to $2 billion dollars annually on procedures done on U.S. citizens in Thailand and India8. Additionally, by 2019 it is estimated that U.S. citizens will spend $300 billion abroad on health care8. Other authors focused on policy and ethics, particularly on the logistics of attracting medical tourists to certain countries3,5,7,9. Another article proposed a prescreening process, complete with video diagnosis, for Taiwanese physicians to screen potential American medical tourists prior to travel9.

Regarding patient experience and patient motivations, many studies took a qualitative approach evaluating patient perspectives2,4,5,8,10. Patients are most likely to travel for orthopaedic surgeries10, and the top orthopaedic destinations are Costa Rica, Singapore, India, and Thailand3,8. American patients tend to be middle-income individuals who are underinsured or uninsured, or those seeking an elective procedure3. Currently, there are 29 million uninsured Americans, representing 9.1% of the population11. These patients may not be able to afford a procedure in their local market, but they do have the resources to afford it in an LMIC3. Conversely, Canadian patients typically cite long wait times as their reason for pursuing surgery abroad, as the average wait for a total hip arthroplasty is 26 weeks2. Patients report using their own Internet research and word of mouth to make destination decisions2. These patients share a confidence in their medical decision-making, a perceived necessity and urgency for surgery, and a desire to stay active2.

An increased infection risk was reported in intensive care units outside of the U.S. and Europe, with a 3-fold increase in postoperative infections12. Additional risks include deep vein thrombosis (DVT) from long flights, potentially unsafe or counterfeit pharmaceuticals, and unscreened blood products2. In the U.S., only a small percentage of postoperative patients require blood transfusions following total hip arthroplasty and total knee arthroplasty13, but according to 1 leading medical tourism company, its packages include transfusion costs because “almost all knee replacement patients need blood transfusions.”14 Lastly, another difficulty patients have is the reluctance of surgeons in their home country to care for postoperative complications in a patient who had a procedure done in another country2.

Because patients report using medical tourism web sites as a main source of information, several studies have evaluated these web sites and their representative medical tourism companies. One article stated that only 4.9% of sites discussed postoperative care, 1.1% discussed legal recourse, and only 2.2% discussed medical risk8. Among medical tourism companies, 50% of the companies collected outcome data on patients, and 79% required hospitals to be accredited for referrals10.

Chen and Wilson identified a lack of research on outcomes following total joint arthroplasty performed on medical tourists in LMICs12. Identified clinical risks include infections, such as from methicillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum beta-lactamase (ESBL) organisms, with different patterns of antibiotic resistance than in North America12,15. Travel also has been recognized as affecting the dissemination of antibiotic-resistant “superbug” infections, including Klebsiella pneumoniae carbapenemase12.

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Discussion

Medical tourism for total joint replacement is a phenomenon that is attracting middle-income, uninsured, or underinsured patients in the U.S. who cannot afford the surgery at home. Therefore, the risk that these patients are weighing is not the risk of having an arthroplasty in an LMIC compared with having it in the U.S., but the risk of having it abroad compared with the lifestyle impact of not having it at all.

There are certain steps that a provider can take to mitigate risk for patients. Recommendations for patients include arranging a consultation with a travel medicine specialist for any recommended vaccines or malaria prophylaxis 6 weeks prior to departure, ensuring complete record transfer (carried by hand in order to avoid lost faxes and e-mails), and waiting at least 2 weeks postoperatively before flying16. Patients should also get documentation ahead of time on what exactly is covered by their quoted cost, know what activities (e.g., swimming) are safe in the immediate postoperative period, and make follow-up arrangements with a home-country surgeon prior to leaving for the procedure16.

Another way for home providers to aid in the planning is to validate that the destination hospital is accredited16. Joint Commission International (JCI), the international peer of The Joint Commission based in the U.S., is 1 of several organizations that accredits international hospitals to a standard similar to that in the U.S.17. The organization maintains an up-to-date list of JCI-certified hospitals searchable by country on its web site17. Additionally, several U.S. medical schools have begun international partnerships with hospitals overseas, including the Johns Hopkins Singapore International Medical Centre, Duke National University Singapore, and the Harvard Medical School Center for Global Health Delivery-Dubai. Furthermore, many U.S.-based facilities offer joint replacement surgery as a same-day procedure at ambulatory surgical centers, thus substantially lowering cost18. Considering same-day procedures or negotiating a lower cash price with a facility in the U.S. would be alternatives that may be less expensive.

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Conclusions

Additional research is needed in the area of surgical outcomes of medical tourism. The reviewed literature recognizes an increased risk of infection or complications in general in LMIC hospitals, but none of the articles were focused on the most commonly sought procedures of total joint arthroplasty, and none separated accredited from nonaccredited hospitals. For some patients who are not able to have a total hip arthroplasty or total knee arthroplasty in the U.S., having it at an accredited hospital abroad may be a realistic, cost-effective option16.

The recommendations discussed herein can aid a provider in mitigating risk, being aware of the trend, and participating in an appropriate informed consent process with the patient. However, the current literature is not able to quantify the actual risk of infection and complications in patients who travel to LMICs for total hip arthroplasty and total knee arthroplasty in comparison with the risks of having the procedure performed in the U.S.

Investigation performed at Coordinated Health, Allentown, Pennsylvania

Disclosure: The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article.

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