Published November 2011

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Reviewed October 2015; no update needed.

Preamble

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to numerous inquires made to the Society by patients, physicians, society members, hospitals, and others regarding global travel and medical tourism for bariatric surgery procedures. In this statement, available data are summarized regarding this issue based on current knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The intent of issuing such a statement is to provide objective information about the risk and benefits of travelling long distances for bariatric procedures, either out of necessity or as part of a medical tourism package, and to provide recommendations based on the current evidence. The statement is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care. The statement may be revised in the future as additional evidence becomes available.

The term medical tourism is most often used to describe travel across international borders to obtain medical care as part of a pre-arranged package. This term does not fully or accurately describe all of the issues or concerns related to bariatric surgery and the Society has adopted the term global bariatric healthcare to encompass all of the scenarios in which patients travel long distances for bariatric surgery (including medical tourism packages). For the purposes of this statement, global bariatric healthcare is defined as travel to undergo bariatric surgery across any distance that precludes routine follow-up and continuity of care with the surgeon or program. No specific type of border or distance of travel can universally apply as regional differences in surgeon availability and expertise vary greatly throughout the world. While this practice commonly involves travel across international borders, travel across long distances within a country, region, or state involves the same risks and challenges for continuity of care as does long distance travel to another country and therefore applies to this statement.

This statement is not intended to single out a specific region, country, or facility that accepts patients from long distances. Rather, it is intended to provide guidance to bariatric surgeons and patients who participate in this practice or provide follow-up care for these patients.

The Issue

In recent years, there has been a sharp increase in the number of patients who travel large distances across state or international borders for medical care.(1) This practice, often referred to as medical tourism, has spurred an industry that facilitates travel for a wide spectrum of medical and surgical procedures. This new industry has been created to advise patients on the appropriate facility in the right region or country for their condition, handle all travel arrangements, teleconference with physicians, and send medical records. The medical tourism industry is projected to become a $21 billion a year industry by 2011.(2)

The primary motivation for pursuing medical tourism is financial. These packages can offer medical care and surgical procedures at prices 40% to 80% less than the cost in the patient’s home region. (2) This practice has also been driven by long wait times or unavailability of specific therapies or surgeon expertise in the patient’s own region, rising costs of healthcare in developed countries, rising costs for adequate insurance coverage, an increasing number of uninsured or underinsured people, and regulatory issues that may preclude specific therapies (devices) from being used in certain countries. Additionally, some insurance companies and employers promote this practice and offer incentives to patients who are willing to travel internationally for less expensive medical care. (2, 3) Medical tourism internet websites are numerous and largely promote the benefits of procedures while downplaying the risks.(4) Despite some ominous predictions regarding the financial impacts of medical outsourcing, developed health care systems have not yet dealt with the legislative and health care policy issues surrounding medical tourism or the impact that medical tourism will have on individualhealth care systems and providers.(5)

Quality of the care and patient safety are the primary concerns regarding medical tourism. Several organizations including The Joint Commission International (JCI), Trent International Accreditation Scheme (U.K.), the International Society for Quality in Healthcare, the International Organization for Standardization (ISO) and the International Bariatric Surgical Review Committee (IBSRC) have responded to the growth in medical travel by establishing accreditation procedures for international medical facilities. Although outcome statistics from hospitals utilizing these procedures are rare, first-person and anecdotal reports on quality are numerous. (6) In the last five years, the number of JCI accredited public and private hospitals around the world has increased by nearly 1,000 percent. Currently, over 250 facilities in 36 countries are accredited by the JCI, up from 27 hospitals in 2004. Establishing this high standard of accreditation instills a higher level of confidence in citizens seeking affordable health care alternatives abroad. There are often regional or local variations in accreditation standards, though, based on cultural, societal, or religious differences.

The American Medical Association (AMA) and the American College of Surgeons (ACS) have developed and published guidelines regarding medical tourism and these statements provide an important set of principles for consideration by patients, employers, insurers, and other third-party groups responsible for coordinating such travel outside of the country.(7,8) These guidelines and other published recommendations(9) recognize patients’ rights to voluntarily seek medical care abroad but emphasize accreditation of the facilities, board certification of the treating physicians, appropriate documentation for the physician who will be providing follow-up care, proper informed consent policies, relevant legal standards governing privacy and confidentiality, insurance coverage for follow-up care including complications, and identification of the risks of traveling after surgical procedures.

There are currently no specific guidelines or recommendations in place regarding global bariatric healthcare. There are, however, unique risks associated with bariatric surgery that must be considered. Bariatric surgery patients are at high risk for venous thromboembolic events, and may develop infectious complications or gastrointestinal leaks after being discharged from the surgeon’s care. Additionally, the long-term need for revisional procedures in some patients must be considered. In the setting of medical travel, the preoperative evaluation and patient education component that is critical to success for bariatric surgery may be abbreviated or lacking. Also, patients may not be provided an appropriate level of continuity of care to monitor for early complications, nutritional deficiencies or late complications. Additionally, laparoscopic adjustable gastric banding is commonly performed as a medical tourism procedure without provisions for  postoperative band adjustments in the patient’s local area. Finally, unlike other kinds of surgical procedures requiring minimal postoperative followup, the successful long-term treatment of the disease of morbid obesity and its associated comorbidities requires a life-long process of care that includes a comprehensive program of surgical, medical, psychological and dietary care. This unique type of support and continuity of care is difficult to provide in the context of medical tourism or global travel.

The Data

Currently, there is little published data specifically addressing global travel for bariatric surgery. The number of patients receiving bariatric surgery abroad or across international boundaries is unknown and there is a need for more empirical research on the role, process and outcomes of medical tourism.(10) The issues raised by the AMA and ACS position statements do address the general issues that should be considered with regards to medical tourism. However, important unique factors associated with the treatment of a chronic disease such as obesity are not adequately addressed by these statements. Preoperative education, continuity of care and long-term follow-up are proven essential components for successful outcomes in bariatric surgery(11,12) and these are not necessarily provided in the setting of medical travel. In addition, the cost of treating complications for patients returning from a procedure performed abroad has been reported and may be substantial, particularly if the patient self-referred outside a singlepayer system or is uninsured when he or she develops the complication.(13)

Summary and Recommendations

Based on the limited available data, guidelines published by other medical societies, expert opinion, and a primary concern for patient safety, the American Society for Metabolic and Bariatric Surgery supports the following statements and guidelines regarding bariatric surgical procedures and global bariatric healthcare:

  1. Based on the unique characteristics of the bariatric patient, the potential for major early and late complications after bariatric procedures, the specific follow-up requirements for different bariatric procedures, and the nature of treating the chronic disease of obesity, extensive travel to undergo bariatric surgery should be discouraged unless appropriate follow-up and continuity of care are arranged and transfer of medical information is adequate

  2. The ASMBS opposes mandatory referral across international borders or long distances by insurance companies for patients requesting bariatric surgery if a high quality bariatric program is available locally.

  3. The ASMBS opposes the creation of financial incentives or disincentives by insurance companies or employers that limit patients’ choices of bariatric surgery location or surgical options and, in effect, make medical tourism the only financially viable option for patients.

  4. The ASMBS recognizes the right of individuals to pursue medical care at the facility of their choice. Should they choose to undergo bariatric surgery as part of a medical tourism package or pursue bariatric surgery at a facility a long distance from their home, the following guidelines are recommended:

    • Patients should undergo procedures at an accredited JCI institution or preferably a bariatric center of excellence.- Patients should investigate the surgeon’s credentials to ensure that the surgeon is board eligible or board certified by a national board or credentialing body. Individual surgeon outcomes for the desired procedure should be made available as part of the informed consent process whenever possible.

    • Patients and their providers should ensure that follow-up care, including the management of short and long-term complications, are covered by the insurance payer or purchased as a supplemental program prior to traveling abroad.

    • Surgical providers should ensure that all medical records and documentation are provided and returned with the patient to their local area. This includes the type of band placed and any adjustments performed in the case of laparoscopic adjustable gastric banding, as well as any postoperative imaging performed.

    • Prior to undergoing surgery, the patient should establish a plan for postoperative followup with a qualified local bariatric surgery program to monitor for nutritional deficiencies and long-term complications, and to provide ongoing medical, psychological and dietary supervision.

    • Patients should recognize that prolonged traveling after bariatric surgery may increase the risk of deep venous thrombosis, pulmonary embolism, and other perioperative complications.

    • Patients should recognize that there are risks of contracting infectious diseases while traveling abroad that are unique to different endemic regions.

    • Patients should recognize that travel over long distances in a short period of time for bariatric surgery may limit appropriate preoperative education and counseling regarding the risks, benefits, and alternatives for bariatric operations. This also significantly limits the bariatric surgery program’s ability to medically optimize the patient prior to surgery.

    • Patients should understand that compensation for complications may be difficult or impossible to obtain.

    • Patients should understand that legal redress for medical errors for procedures performed across international boundaries is difficult.
  1. When a patient who has had a bariatric procedure at a distant facility presents with an emergent life-threatening postoperative complication, the local bariatric surgeon on call should provide appropriate care to the patient consistent with the established standard of care and in keeping with previous published statements by the ASMBS (14) This care should be provided without risk of litigation for complications or long-term sequelae resulting from the initial procedure performed abroad. Routine or non-emergent care for patients who have had bariatric surgery elsewhere should be provided at the discretion of the local bariatric surgeon.

References

  1. Reed CM. Medical tourism. Med Clin North Am 2008;92:1433-46, xi.
  2. Pafford B. The third wave–medical tourism in the 21st century. South Med J 2009;102:810-3.
  3. Burkett L. Medical tourism. Concerns, benefits, and the American legal perspective. J Leg Med 2007;28:223-45.
  4. Mason A, Wright KB. Framing medical tourism: An examination of appeal, risk, convalescence, accreditation, and interactivity in medical tourism web sites. J Health Commun 2010;15:1-15.
  5. Forgione DA, Smith PC. Medical tourism and its impact on the US health care system. J Health Care Finance 2007;34:27-35.
  6. York D. Medical tourism: the trend toward outsourcing medical procedures to foreign countries. J Contin Educ Health Prof 2008;28:99-102.
  7. Unti JA. Medical and surgical tourism: the new world of health care globalization and what it means for the practicing surgeon. Bull Am Coll Surg 2009;94:18-25.
  8. American Medical Association web site. http://www.amaassn. org/ama1/pub/upload/mm/31/medicaltourism.pdf. Accessed February 10, 2010.
  9. Turner LG. Quality in health care and globalization of health services: accreditation and regulatory oversight of medical tourism companies. Int J Qual Health Care 2011;23:1-7.
  10. Lunt N, Carrera P. Medical tourism: assessing the evidence on treatment abroad. Maturitas;66:27-32.
  11. Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg 2004;14:514-9.
  12. Champion JK, Pories WJ. Centers of Excellence for Bariatric Surgery. Surg Obes Relat Dis 2005;1:148-51.
  13. Birch DW, Vu L, Karmali S, Stoklossa CJ, Sharma AM. Medical tourism in bariatric surgery. Am J Surg;199:604-8.
  14. American Society for Metabolic and Bariatric Surgery position statement on emergency care of patients with complications related to bariatric surgery. Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. Surg Obes Relat Dis. 2010 Mar 4;6(2):115-7. Epub 2009 Dec 11.