Commentary on: Surgical Management of Cosmetic Surgery Tourism-Related Complications: Current Trends and Cost Analysis Study of the Financial Impact on the UK National Health Service (NHS)

Ever since our 2011 published report “Complications from International Surgery Tourism” in this journal,¹ there have been dozens of reports from various investigators highlighting the increased incidence, cost, and healthcare burden of global medical tourism complications. I applaud this study by Thacoor et al,² who analyzed a retrospective review of 24 consecutive cosmetic surgery complications that were surgically managed at a London teaching hospital in a 12-year period. The authors of this study arrived at the expected findings of increased costs (average cost per patient, $16,296) correlated with increased hospitalizations and operating room visits, which were in turn closely associated with wound infections and dehiscence. This study confirms many of the ongoing trends we see in global surgery tourism.

Price Rather Than Value Is Driving the Medical Tourism Phenomenon

As alluded to in my earlier commentaries, if we define healthcare value as outcomes divided by cost, then lower cost is perceived as better value by the consumer as long as they believe outcomes are the same.³ However, “the magic” of social media and internet marketing provide tangible proof to the prospective patient that postoperative photos from an exotic destination clinic are just as good as the plastic surgeon in their community. Therefore, if the outcomes are fixed and cost is lower, the value is “perceived” as superior. This is the reason why I implore my colleagues to continue publishing and presenting data from surgery tourism.

Most of the Tourism Surgeries Are Aggregated in Select Countries and Cities

Thacoor and colleagues² have shown that half of their study population come from 2 countries. This is expected because countries such as Turkey and Colombia have an excellent advanced plastic surgery market with easy access airports. It would have been more interesting if the authors drilled down on the actual providers in each country to see if the complications were coming from the same clinic within each country. As an investigator on clinical trials, I have been privy to the role of one provider completely skewing the results by having a higher complication rate. This trend is also true in the United States where some of the larger cities such as New York, Los Angeles, or Miami are a medical tourist destination because of their mature aesthetic market driven by marketers. However, just because an observation is true does not make it the cause of an effect.

Observational Studies Such as This Are Inherently Prone to Selection and Confounding Bias

As the authors have aptly pointed out, this study is severely limited in its sample size, retrospective nature, and exclusion of nonoperative cases. These types of studies inherently suffer from selection bias because they are only capturing complications that were referred to their hospital.⁴ We cannot possibly know the numerator or the denominator of the ultimate complication rates. Having reviewed the excellent paper from Klein et al on their complication rates from cosmetic surgery tourism, I was able to extrapolate the data to obtain a 1.3% complication rate from these types of procedures, which is acceptable.⁵ We have no way of knowing in this study whether the reported 24 complications occurred after 240 operations or 2400! We know that medical tourism has grown in size from an estimated 6 million in 2010 to over 15 million in 2017. Therefore, we should expect that the complications would also increase over time. The question is, what we do with them?

The Shift in Care for Medical Tourism Complications Parallels the Shift in Care for Complex, Underinsured Surgical Patients

Perhaps the most defining trend in healthcare today is the shift in care of underinsured complex surgical patients from elective settings to hospital-based emergency departments. This was recently studied by Patel and colleagues who showed that the availability of specialists for “emergent” complicated cases has dropped in the 52 hospitals surveyed.⁶ The patients in the current study fit that profile. They are likely under- or uninsured with a complicated presentation in a potentially liable case, which means their ability to obtain medical attention in an elective setting is very low. Therefore, they often present late to emergency departments when the wound dehiscence has now turned into a frank infection requiring multiple debridements, operative intervention, and prolonged hospitalizations.

What We Have Seen in Published Reports Represents the Tip of the Iceberg

Medical tourism is a growing and profitable trend that continues to expand. Unfortunately, it is not profitable for the mostly urban hospital centers that have to care for these complex patients, as demonstrated in this paper. Ultimately, the tax payers will carry the burden of individuals who make bad decisions about their personal care, which is no different than the public health threat from obesity, smoking, or dangerous driving. With increasing access to national data statistics from hospitals, it is time to measure national data statistics from surgical complications from core vs non-core physicians performing specialized operations. I predict that we will next see a wave of complications and disabilities from nonsurgical interventions such as lasers and vascular occlusions from injectables. These injuries are just as devastating because they require close monitored care as well as lost days from work and family.

Time to Get on the Soapbox

The only way to get ahead of these trends is to improve public awareness and educate patients about medical tourism whether in our own communities or abroad.⁷ We need to have deeper conversation about this topic at our national meetings and teach our residents about global health and surgical tourism issues. We need to drive legislation for transparency in advertising and push for clarity about board certification in core specialties. Ultimately, we want to make sure that our patients are getting the best care with adequate follow-up, which translates to greater good for the public.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.