Medical travel is the practice of patients leaving their country of residence and going abroad with the purpose of getting access to medical care; this can be diagnostic, consultancy, or surgery.1 Medical travel is not uncommon, and some patients from both developed and developing countries seek medical treatment away from home, often in countries that invest in ‘medical tourism’. Reasons include lower cost for expensive procedures, better quality of care and facilities, immediate care with little or no waiting, seeking care that is not available/accessible in their home country, and more inpatient care compared to short hospitalization in their home country.2 There are, however, risks associated with medical travel. These include but are not limited to: variations in healthcare quality, safety, cultural, and ethical values, lack of continuity of care, different disease epidemiologies, lack of malpractice insurance, and building false hopes and unrealistic expectations in patients for the sake of financial benefits for the host healthcare facility.1

Reasons for medical travel by Omani patients have not been studied on a large scale but suggested reasons include long delays in public healthcare facilities, fewer competitive private facilities, the high cost of private medical services, and leisure facilities offered alongside healthcare treatments by some private facilities in some countries.1 A small survey conducted in A’Dakhiliyah governorate of Oman in 2010 showed that patients mostly traveled after being seen for the same medical condition in Oman (85%) because they were not satisfied with the current treatment (6%), wanted to confirm the treatment (9%), had an unidentified diagnosis (38%), no treatment offered following a diagnosis (9%), or ineffective treatment (38%).3 Lower cost was not identified as a reason for traveling abroad; 38% of patients spent more than OMR 2000 (USD 5000) for treatment abroad. A survey in Thailand indicated that globally, medical tourists from Oman ranked fifth with over 7000 patients visiting Thailand in 2010, after the UAE, Bangladesh, USA, and Myanmar.4 Most visits were for outpatient (93%), mostly for a medical consultation or the treatment of uncomplicated conditions. Non-medical expenses were also significant with an average of USD 5000 spent for a visitor and companion. The availability of free government funded and good quality healthcare in Oman coupled with the high financial cost and associated risks incurred outside the country forces us to question why patients in Oman seek medical care abroad?

A randomized controlled study in 587 patients compared standard of care with an intervention delivered by a pharmacist, which comprised of a medication reconciliation on admission and discharge, a medication review, bedside medication counseling, and a take-home medication list. The study was conducted at Sultan Qaboos University Hospital, Muscat, Oman.5 Studied secondary outcomes included healthcare resource utilization such as: 1) number of emergency department visits, 2) re-admission rate, 3) unplanned hospital visits, and 4) travel abroad to seek medical care or second opinion. These outcomes were assessed 30 days after discharge using patients’ electronic health records and a phone call. Among the healthcare resources utilized, the only parameter that was found to be significant was ‘travel abroad to seek healthcare’ where significantly fewer patients from the intervention group traveled abroad to seek medical care compared to patients from the standard care group (3.2% vs. 6.9%; p = 0.040). The reasons behind traveling abroad were not explored, but due to the randomized nature of the study, it can be hypothesized that both patient groups received similar medical care, were seen by the same physicians, utilized the same hospital facilities, and had similar waiting times. Moreover, this group of patients were older (57±17 years), were admitted to medical wards, and mostly suffered from chronic medical rather than surgical conditions. A possible explanation for this significant difference is the intervention itself where medication reconciliation, review, and counseling were provided to patients in the intervention group compared to standard care in the control group. Patients in the intervention group received unhurried and more detailed information about their medications, which might have provided them with some awareness of their medical problem and management than the standard care group which received basic counseling at the pharmacy window. Moreover, the intervention resulted in the reduction of preventable adverse drug events. Patients who received information about their medications from a pharmacist or other healthcare providers were less likely to suffer from adverse effects and seek other healthcare resources compared to patients who did not receive this information.6,7 Is it possible that the intervention group patients were satisfied with the information they received and did not need to seek these answers abroad? As reported in a recent survey in Oman, there is lack of clarity of current medication reconciliation and counseling practices as well as lack of agreement between pharmacists, physicians, and nurses as to who is responsible for performing medication counseling on discharge.8 Could this have contributed to patients traveling abroad to seek further medical advice and care?

Medical travel is associated with significant costs and risks. Factors motivating patients to travel need to be identified and addressed and it opens a research opportunity that may eventually promote our understanding of this phenomena. The impact of medical travel on public health is an area that needs to be studied, and measures to regulate this growing industry and reduce its risks need to be employed.

references

1. 1. Samir N, Karim S. An insight: medical tourism, local and international perspective. Oman Med J 2011 Jul;26(4):215-218.
2. 2. Al-Lamki L. Medical Tourism: Beneficence or maleficence? Sultan Qaboos Univ Med J 2011 Nov;11(4):444-447.
3. 3. Al-Hinai SS, Al-Busaidi AS, Al-Busaidi IH. Medical Tourism Abroad: A new challenge to Oman’s health system - Al Dakhilya region experience. Sultan Qaboos Univ Med J 2011 Nov;11(4):477-484.
4. 4. Noree T, Hanefeld J, Smith R. Medical tourism in Thailand: a cross-sectional study. Bull World Health Organ 2016 Jan;94(1):30-36.
5. 5. Al-Hashar A, Al-Zakwani I, Eriksson T, Sarakbi A, Al-Zadjali B, Al Mubaihsi S, et al. Impact of medication reconciliation and review and counselling, on adverse drug events and healthcare resource use. Int J Clin Pharm. 2018 May 12. [Epub ahead of print].
6. 6. Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med 2009 May;169(9):894-900.
7. 7. Koehler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, Cheng D, et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med 2009 Apr;4(4):211-218.
8. 8. Al-Hashar A, Al-Zakwani I, Eriksson T, Al Za’abi M. Whose responsibility is medication reconciliation: Physicians, pharmacists or nurses? A survey in an academic tertiary care hospital. Saudi Pharm J 2017 Jan;25(1):52-58.