Potential downside to domestic surgical tourism

Published in The Lancet, the findings have implications for patients who take part in domestic medical tourism programs.

Some of the nation's largest businesses encourage employees to travel to large U.S. medical centers for complex elective surgical procedures. As part of these medical travel programs, companies negotiate lower prices for patients to receive high-quality surgical care at some of the nation's premier hospitals.

But many participants must travel long distances -- sometimes hundreds of miles from home -- to reach destination hospitals, meaning it can be difficult to return should complications arise.

"This is not a small issue. Between 5 to 22 percent of patients were readmitted in our study, depending on the type of surgery," says lead author Benjamin Brooke, M.D., Ph.D., an assistant professor of surgery at the University of Utah School of Medicine. "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 site where the original operation was done was associated with improved survival regardless of whether it was a large teaching hospital or smaller community hospital. Patients fared slightly better when also treated by the same surgical team. The trends held true for patients who underwent 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 traveling to a destination hospital, planning to stay in the area during recovery. He adds that 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."

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 percent of patients who had complications were readmitted to the same hospital. Statistical analyses demonstrated 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 percent decrease in risk for death for those who underwent pancreatectomy, to 13 percent for coronary artery bypass surgery, according to risk-adjusted, inverse probability weighted models. A second statistical method, instrumental variable analysis, showed attenuated results but supported the findings from these models. Because the results are observational in nature, a randomized trial is needed to prove a causal link.

The current results add to mounting evidence that continuity of care leads to better outcomes for a variety of acute and chronic medical conditions. The reports support the notion that returning to the same hospital may be more important than other measures of health care quality such as being treated at large medical centers that perform high volumes of specific procedures.

Senior author Sam Finlayson, M.D., MPH, says even though the current study examined patients of retirement age, it warrants consideration by anyone, no matter how old they are.

"Most people do not think about the implications of traveling far for an operation," says Finlayson, also professor and chair of surgery. "As with many health care decisions, there are trade-offs to consider. Traveling may confer the best chance of a favorable outcome with surgery, but it may hinder access to optimal care in the event of a serious complication after discharge."

"The interesting questions that our results raise are why outcomes appear to be better when a patient returns to the hospital where her or his operation was performed," he says. "Discovering the answers could help improve the way we deliver care."