Category Archives: Quality Control/ Medical Standards

The Medical Tourism Association, Quality and Accountability

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Over at the Traveling 4 Health blog, I’ve been talking to Ilene Little and reading about the Medical Tourism Association’s (MTA)newest publication promoting Las Vegas as a new medical tourism destination for both American and International patients.

The irony of this destination is highlighted by the city’s own newspaper, The Las Vegas Sun, which has an extensive series, ‘Do No Harm: Hospital Care in Las Vegas’ detailing recent health scandals in Las Vegas hospitals, as well as 2010 reports ranking several of the facilities in Las Vegas among the worst in the nation.  In fact, the opening sentences in the article series are, ” There’s a running joke about hospitals here: “Where do you go for great health care in Las Vegas?”

“The airport.”

It’s a disappointing entry by an organization I admire – but unfortunately, it highlights the lack of accountability by medical tourism companies to their clients. Someone needs to care about the quality of the product (providers and services) that they are promoting.  Too bad it isn’t the MTA since they are certainly among the movers and shakers in the international medical tourism industry.  The rest of us are just tiny fish in a great big pond of obscurity.

Medical Tourism backlash

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One of the trends I’ve seen in the last few months is a growing assortment of medical propaganda that can only be termed ‘medical tourism backlash’.  Frighteningly, these writers are often willfully misinformed and published on websites that give the appearance of legitimacy.  I’ve included an example here – published on a website called News Junky Journal.  The junky part is certainly accurate.

This article is a thinly disguised ad for a US based plastic surgeon – Dr. Delgado and persists in spreading misinformation, untruths and some blatant lies.  The author, Charles Hale makes no effort to distinguish between medical tourism destinations, much less the facilities and surgeons themselves but uses a blanket brush to depict all non-US surgeons as poorly trained uncredentialled hacks operating without consideration for patient outcomes due to a lack of fear for repercussions.  He presents his ‘facts’ as absolutes – and as all educated consumers know – there are no absolutes.  Yes, there are bad surgeons (everywhere – and quite a few unlicensed frauds in the USA as well, as we’ve documented over at Cartagena Surgery as part of a series explaining how to evaluate medical and surgical providers.)

But there are also well-educated, kind, caring EXCELLENT surgeons like the ones we’ve identified during this project.  Fear-mongering is not the way to drum up patients or protect people from adverse outcomes.  Objective, and honest research is.

There are several other blatant inaccuracies in the above mentioned article – including statements that insurance companies NEVER pay for medical tourism – as we’ve discussed here, and in the book – several American health care companies such as Blue Cross actually have medical tourism divisions to help patients find providers overseas.  This medical tourism company helps people use their Health Savings Accounts for medical travel.

He also ignores ‘complication insurance’ as offered by many of the providers interviewed in Bogotá – which explicitly covers the treatment of any surgical complications whether at the destination or after patients return home.

As I’ve mentioned numerous times, I do think that the medical tourism industry should be regulated – ‘tour operators’ shouldn’t sell the services of people they’ve never met, but to disregard medical tourism as simply a plaything of indulgent people wanting to have surgery while frolicking on the beach, as implied in his last paragraph is ignorant and insulting to the very people who rely on medical tourism as their only option outside of complete financial devastation.

Sadly, I think scare articles like this are only the beginning; as American surgeons (particularly plastic surgeons who rely on elective procedures for their income) continue to feel the effects of a poor economy.  But slandering an entire industry and hundreds of thousands of hard-working medical professionals, and terrorizing patients is not the answer.

More scrutiny for medical tourism and patient safety.

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Another article detailing the importance of investigative medical writing projects such as the Bogotá book.  Hopefully, this increased scrutiny will bring more attention to projects such as this – and the need for a comprehensive, detailed review of services by qualified individuals.

Maybe this will bode well for a possible Cali book in the future.

Putting your money where your mouth is..

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or more accurately, less money – more like putting your health in the hands of the people I’ve spend the last year writing and talking about.

Many people have asked me that question – “Gee – but would you go to Colombia and have these physicians take care of you?”  And, it’s a legitimate question, after all – it’s all well and good to send other people to far off places (foreign countries!) when it isn’t your own health and well-being at stake.  But what would the writer do in a similar position?  So I’d like to answer that question here.

Yes, Yes, I would and yes, I have.  In fact, this very question is what prompted my investigations into health, medicine, surgery and surgeons in Bogota.  I don’t usually disclose this information because I don’t think it is germaine to the majority of the discussions (it is briefly mentioned in the book) – since most of my previous posts have been more on the basis of rational inquiry then personal accounts.  It’s also difficult for me to talk about private matters – but today, for the purpose of legitimacy and credibility, I’ve decided to set my privacy aside.

I usually omit the ‘personal experience’ because I find it less than helpful for patients since our experiences are not objective, but are rather colored with previous experiences, our culture and upbringing as well as our expectations.  I don’t believe in “patient testimonials”, per se because I feel it gives a false representation.  After all, a charismatic individual may not be as skilled or talented surgically as someone who is less loveable, so to speak.

But, I do think that it’s important in this instance for me to share some of these experiences with readers, because it speaks to the validity of my research – I have interviewed and been in the operating room with these individuals, and have knowledge that many of you (the readers) are not always privy to.  And knowing all of this, I elect to return to Colombia to see my surgeon here.

This week, I am having another CT of the abdomen to follow-up on a medical ‘issue’ I experienced while living on the island of St. Thomas.  Immediately after being diagnosed with this problem – when I had the choice of seeing doctors in nearby Puerto Rico, or Miami (where Caribbean patients often seek care) or going home to Duke – I chose to come to Bogotá.  I didn’t do it for cost – though as a person with very poor health coverage, that was certainly a factor, I did it as both part of my research and because of the absolute confidence I had in one of the surgeons I had met during the writing of the first book, in Cartagena.  (Dr. Hector Pulido).

After a month of worry (okay, to be honest – terror) while I wrapped up my life in the Virgin Islands – my first peace came as our plane landed in Bogotá.  I still had worries about my health, but I felt calmer than I had in weeks – since the first, fateful CT scan showed a rare abnormality.  This sense of security and well-being only increased with my interactions with the staff at Santa Fe de Bogotá, and under the care of my surgeon, Dr. Roosevelt Fajardo.  He had already communicated with me prior to my arrival by email, viewed my medical records and conferred with several other specialists.

Now, admittedly, my experience is colored by the outcomes, and I was extraordinarily lucky, for someone in my position.  I had been tentatively diagnosed (at my home hospital) with a serious malignant illness – and was gifted with a new diagnosis of a rare, but benign condition instead, which has made no impact on my daily life.  I take no medications, there is no sequelae or complications – and it appears that it is just a variation of ‘normal’ that woud have never been discovered if I hadn’t originally become ill in St. Thomas and had a CT scan*.

But, I know, in my heart of hearts, that had the outcomes been different – I still would have been in great hands – with caring, compassionate individuals who understood my fears and concerns.  That is worth its weight in gold – but being in Colombia, the entire experience cost considerably less than that.

I can also say – that if I ever needed heart surgery, lung surgery or any number of procedures (who know?  plastic surgery may be in my future..) that I wouldn’t hesitate to place myself in the care of any number of the fine surgeons profiled in my book.

* Transitory illness, now fully recovered and unrelated to current care.

Now in today’s litigious society, I probably need to put some sort of disclaimer that my results are not typical – usually people turn out to have the maladies they were originally diagnosed with.  But as I said – it’s a rare circumstance, and I had the benefit of having multiple specialists confer in my case – so as I said, I was lucky.  I also probably need to make a statement about safety and surgery, such as surgery always carries risk – and that bad things can happen no matter how great your surgeon is, or how good the facility is.  I hate having to put this stuff because people comes to me for answers, but unfortunately, there are no guarantees when it comes to things like this.  I hope I haven’t offended my readers, and I apologize because I feel that having to make these disclaimers cheapens the message.

Update:  18 August 2011

Dr. Fajardo contacted me this afternoon a few hours after my CT scan.  Results of my follow up CT scan show everything is indeed unchanged and remains a benign, if uncommon variation of normal.   This is greatly relieving, but more than that – part of a consistent pattern of genuine care and excellence in medicine.

Sorry to my friends at the paper – whom I had promised an in-operating room exclusive, if the situation had changed.  (Sorry for them, not for me!)

I hope that by sharing this more personal experience, I have been able to give some of my readers a little different perspective than what they are used to seeing here at Bogota Surgery.

The Chicago Tribune, Medical Tourism and Patient Safety

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The Chicago Tribune recently published an article about medical tourism  by Alexia Elejalde Ruiz that quotes Joseph Woodman pretty heavily.  He writes about medical tourism and quality but from more of a statistical and policy perspective (no medical background.)

The article was written to give tips to potential medical travelers, and mentions JCI accreditation and standards etc.  I think this shows a growing awareness among the media and consumers that there is a need to regulate this industry to protect patients from harm.

Unfortunately, this article did not go into more detail, and despite mentioning Colombia in the article subtitle, there was nothing further about Colombia in the article.

Too bad – as my long time readers know – my entire purpose and mission in writing and researching this book was to provide consumers with exactly this sort of information  – from first hand observation.

“Hospitals riskier than airplanes”

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It looks like our last post,  Reputation, Rankings and Objective Measures was more timely than I ever expected.  While I always feel urgency over patient safety issues – now the news media has joined in after the release of the latest World Health Organization report.  For more about this report – see our posting at Cartagena Surgery.  Hopefully, this media attention will help the public to understand why books such as this are needed.

In other news – the first shipment of books for transportation to Bogotá has arrived!

Reputation, Ranking and Objective Measures:

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Reputation,  Rankings and Objective measures

The top-10 heart and heart surgery hospitals (according to US News 2011) were as follows:

  1. Cleveland Clinic
  2. Mayo Clinic
  3. Johns Hopkins
  4. Texas Heart Institute at St Luke’s Episcopal
  5. Massachusetts General
  6. New York Presbyterian University
  7. Duke University Medical Center
  8. Brigham and Women’s Hospital
  9. Ronald Reagan UCLA Medical Center
  10. Hospital of the University of Pennsylvania

(US News, July 19, 2011)

The First shall be First..

Well, the latest US News hospital rankings are out – and as usual, John Hopkins is at the top of the list – as they have been for the last seventeen years.  Or are they on the top of the list because they were ranked #1 for the previous sixteen years?

How much do these or any rankings actually reflect the reality of the health care provided?  What are they really measuring?  These are important questions to consider.  While US News uses these rankings to sell magazines, other people are using these results to plan their medical care.

 So, what do these rankings or studies show[1]?  The answer depends on two things:

1.  Who you ask.  2. The measure(s) used.

Reed Miller, over at Heartwire.com reported the results of a study by Dr. Ashwini Sehgal over at Case Western Reserve examining the US News Rankings back in 2010 (and re-posted below.)  Dr. Sehgal explains that much of what the US News is measuring is not scientific, nor objective data – it’s public opinion, which as we all know, may have little basis in actual facts.  Ask any fifteen-year- old girl who is the most qualified candidate for president – now imagine Justin Bieber in the White House[2].  An extreme example, to be sure – but one that fully illustrates the pitfalls of relying on this sort of subjective data.

News versus Tabloid

This isn’t the first time that the magazine has come under scrutiny for the methodology of their ‘ranking’ practices.  Teasley (1996) exposed similar flaws in their ranking schemes almost fifteen years ago.  Green, Winfield, Krasner & Wells (1997) explained in JAMA that there
were additional limitations to US News approaches due to a lack of availability of standardized data, despite the magazine using what they considered to be a strong conceptual design.  They cite the same concerns with the weight given to reputation as a majority deficiency.

However,  these significant oversights does not prevent the media and hospitals from continuing to present their results as a legitimate measure of  performance. In fact, more people know about these rankings than they do about government data collected for the same purpose.

Core Measures

Compare this well-known ranking, with governmental attempts to quantify and compare American hospitals.  Medicare and Health and Human Services quantifies and ranks hospital  performance using a ‘score card’ scenario known as “Hospital Compare.”

While this government system is far from perfect since it relies heavily on individual physician documentation, it is an evidence-based measurement tool, making it far more objective.  The government rating system uses a series of specific criteria called Core Measures.  These core measures are used to evaluate adherence to accepted treatment strategies for different conditions such as heart failure, heart attack, and pneumonia.  This data is then published on-line for consumers.

The advantages to measurement tools such as Core Measures is that it an easily applied checklist type scoring system.

For example, the core measures used to evaluate the appropriateness of treatment for an acute myocardial infarction (heart attack) are pretty clear cut:

– Amount of time in minutes for patient to receive either cardiac cath or thrombolytic drugs “clot busters”

– How long (minutes) for patient to receive first EKG after presenting with complaints consistent with AMI

– Did patient receive aspirin on arrival?

– Did patient receive ACE/ ARB for LV dysfunction?

– Did patient receive scripts for beta blockers, ACE/ ARB, aspirin at discharge?

As you can see – all of these measurements are clear, easily defined and objective in nature.  The main problem with core measures in many institution is getting doctors to clearly document whether or not they instituted these measures.  (But that too reflects on the institution, so hospitals with multiple staff members not adhering to the national guidelines will have lower scores than other facilities.)  In fact, this is the main criticism of this measurement tool – and this criticism often comes from the very doctors that omit this data.  (In recent years – hospitals have tried to address this shortcoming by making documentation an easier, more streamlined process – and allowing other members of the health care team to participate in this documentation.)

Then this data is compared to other hospitals nationwide, with subsequent percentile ratings, and status.  Ie. a hospital may rank higher or lower than national average for death rate or re-admission for heart attack, pneumonia, post-surgical infection or several other diagnoses/ conditions.  Consumers can also use this database to compare different facilities to each other (such as several hospitals in a local area).

The accessibility and publication of this data for health care consumers is a very real and meaningful public service.  This allows people to make more informed choices about their care, without relying on third-party anecdotes, or reputation alone.

How does this tie in with surgical tourism?  (or what does this have to do with Bogotá Surgery?)

As part of my efforts to provide objective, unbiased information on the institutions, physicians and surgical procedures in Bogotá, Colombia, I applied the Core Measures criteria as part of my evaluation.  I used these measures not on an institutional level, but on an individual provider level – to each and every surgeon that participated in this project.

However, core measures (NSQIP) was not the only tool I used during my assessment.  I also used several other measurements to get a fair/ well-balanced evaluation of the providers listed in my publication.  (Other criteria used  as part of this process will be discussed more fully in a future post.)

Surgical tourism information needs to be clear, objective and meaningful to be of use to potential consumers.  Reputation alone is not sufficient when considering medical treatment either in the United States or abroad – and consumers should seek out this information to help safeguard their health.

Article Re-post from Heartwire.com

Popular best-hospital list tracks subjective reputation, but not quality measures

April 20, 2010 | Reed Miller

Cleveland, OH – US News & World Report‘s list of the top 50 hospitals
in the US reflects the subjective reputations of the institutions and not
objective measures of hospital quality, according to a new analysis [1].

The magazine’s ranking methodology includes results of a survey of 250 board-certified physicians from across the country, plus various objective data such as availability of specific medical technology, whether the hospital is a teaching institution or not, nurse-to-patient ratios, risk-adjusted mortality index based on Medicare claims, and whether the American
Nurses Credentialing Center has designated the center as a nurse magnet.

In his analysis of the US News rankings system, published April 19, 2010 in the Annals of Internal Medicine, Dr Ashwini Sehgal (Case Western Reserve University, Cleveland, OH) points out that previous investigations have compared the US News rankings with external measures and found that highly ranked cardiology hospitals had lower adjusted 30-day mortality among elderly patients with acute MI, but that many of the high-ranked centers scored poorly in providing evidence-based care for patients with MI and heart failure. Also, performance on Medicare’s core measures of MI, congestive heart failure, and community-acquired pneumonia were frequently at odds with US News rankings.

Sehgal sought to examine a broader range of measures internal to the US News system and “found little relationship between rankings and objective quality measures for most
specialties.” He concludes that “users should understand that the relative standings of US News & World Report‘s top 50 hospitals largely indicate national reputation, not objective measures of hospital quality.”

Sehgal performed multiple complementary statistical analyses of the US News & World Report 2009 rankings of the top 50 hospitals in the US, as well as the distribution of reputation scores among 100 randomly selected unranked hospitals.

He examined the association between reputation score and the total score and the connection of objective measures to reputation score. According to Sehgal’s analysis, the statistical association is strong between the total US News score and the reputation score. The association between the total US News score and total objective scores is variable, and there is minimal connection between the reputation score and objective scores.

The majority of rankings based on reputation score alone agreed with US News overall rankings. The top five heart and heart-surgery hospitals based on reputation score alone were the same as those of the US News top five heart hospitals (Cleveland Clinic, Mayo Clinic—Rochester, Johns Hopkins University, Massachusetts General Hospital, and the Texas Heart Institute), and 80% of the 20 heart and heart-surgery hospitals with the best reputation scores were also on the US News top-20 heart and heart-surgery centers.

Objective measures were relatively more influential on cardiology centers’ total scores than in some other categories, but reputation still carried a lot more weight than objective measures. Sehgal used the nonparametric Spearman rank correlation p value to assess the univariate associations among reputation score, total objective-measures score, and total US News score. The p2 value indicates the proportion of variation in ranks of one score that are accounted for by the other score.

Additional Resources and References

1.  Teasley, C. E. III (1996).  Where’s the best medicine? The hospital rating game. Eval Rev. 1996 Oct;20(5):568-79.

2. Green J,  Wintfeld  N., Krasner M.  & Wells C.  (1997).  In search of America’s best
hospitals. The promise and reality of quality assessment. JAMA. 1997 Apr 9;277(14):1152-5.

3. Sehgal, A. R. (2010). The role of reputation in U.S. News & World Report’s rankings of the top 50 American hospitals. Ann  Intern Med. 2010 Apr 20;152(8):521-5.

[1] US News may be the best known, and most widely published source, but there are multiple
studies and reports attempting to rank facilities and services nationwide.

[2] This is probably not a fair analysis given the current state of American politics.