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As such, in the remainder of the article we are referring to patients traveling from developed nations to developing ones unless otherwise stated, though certainly some of the findings are applicable to south-south patient flows. Three issues were most discussed with regard to decision-making: 1 push factors i. The push factor noted most frequently was that of cost [ 25 — 30 ]. It was commonly reported that the high cost of out-of-pocket payments for procedures in patients' home countries likely pushes them to consider medical tourism [ 5 , 17 , 31 — 34 ].

Related to cost, a lack of insurance, or being underinsured, may also push people into medical tourism, in that if procedures cannot be covered by their insurance plans then they may be pushed abroad in search of more affordable care [ 5 , 17 , 35 — 38 ]. The other most frequently noted push factor was that of wait-times, with the promise of more timely care in other countries potentially drawing them abroad [ 17 , 39 — 43 ]. The pull factors identified in the reviewed sources were more numerous than the push factors.

The most frequently discussed pull factor was quality. Patients can be pulled towards medical tourism hospitals that are renowned for the quality of service, care, and facilities they offer [ 1 , 20 , 26 , 32 , 40 , 44 ]. Language is also factored into decision-making, wherein patients are thought to be drawn to receiving care in places where hospital employees speak their language [ 1 , 45 — 48 ]. Related to this, the religious accessibility of medical tourism facilities and destination nations is another consideration that can pull patients to one location over another.

More specifically, patients may seek out facilities that observe the same religious protocols they do [ 48 , 49 ].


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The political climate of countries or regions may also pull people to receive care in particular locations, in that patients are unlikely to want to travel to places that are politically or even culturally unstable or inaccessible [ 20 , 50 — 52 ]. The vacation aspect of medical tourism serves as another pull factor, in that patients may be drawn to receive care in places they are interested in holidaying in [ 2 , 3 , 46 , 53 — 55 ].

Having access to information while decision-making about medical tourism is vital given the range of factors that patients needed to consider before committing to going abroad, such as the credentials of doctors [ 56 — 58 ]. The presence of such marketing informs potential patients about treatment options, tourism opportunities, and other key pieces of information that assist with decision-making. The internet also offers patients other types of information about medical tourism.

For example, websites created by former medical tourists to share their experiences can act as an information source for those at the decision-making stage [ 56 ]. Word-of-mouth is also an important information source, with some medical tourists having first learned about the potential for accessing procedures abroad from friends and family [ 6 , 20 , 34 , 63 — 65 ].

In addition to wanting to address a personal health need through surgery, the review captured three types of factors motivating patients' engagement in medical tourism: 1 procedure-based; 2 travel-based; and 3 cost-based. A procedure-based motivator noted in several sources is that patients may wish to pursue procedures abroad that are illegal or not available in their home countries [ 1 , 66 — 70 ].

For example, some patients can gain access to experimental procedures abroad that have yet to be approved for use by doctors in their local hospitals, such as stem cell therapies [ 71 ]. Related to this, medical tourism can enable access to specific expertise and specialization [ 44 ] as well as advanced technologies [ 22 , 66 , 72 , 73 ]. These factors may also be particularly motivating for middle- and upper-class residents of developing countries who can afford to pay for more sophisticated care abroad [ 25 ].

Furthermore, hearing success stories about positive outcomes from others, whether by word-of-mouth or online, can serve as a motivator for potential medical tourists [ 20 ]. As noted in the previous section, the potential for travel and tourism is something that patients may consider when decision-making about medical tourism.

It is thus not surprising that certain travel-based factors may actually serve as motivations for ultimately deciding on medical tourism, including on the destination location. Such motivators are thought to be the increasing ease and affordability of international travel, the frequency of flights to major destinations, and the streamlining of visa procedures and expediting of applications for international patients [ 47 , 74 — 77 ]. Another travel-based motivator may be the presence of package deals, in that their affordability and ease of booking again may appeal to those looking for guidance in planning [ 45 , 72 , 78 ].

Not surprisingly, cost and affordability were often discussed as potential motivations for patients' engagement in medical tourism. In countries that have public health care coverage, such as Canada, the often inaccurate perception among patients that they may receive a partial or full reimbursement for the travel and procedure costs incurred abroad is thought to motivate some to engage in medical tourism [ 40 , 73 , 79 , 80 ]. However, it was noted that restrictions were typically placed on the availability of reimbursements for planned procedures undertaken abroad via medical tourism and that out-of-pocket cost coverage is extremely rare [ 6 , 40 , 80 — 82 ].

A significant amount of the discussion coming out of the US, a country without a public health insurance plan, reveals that others' desires to keep patients' health care costs low may ultimately influence patients' choices regarding going abroad. More specifically, some employers and insurance companies are encouraging people to access surgeries abroad because costs, even when travel is factored in, are substantially lower than what would be incurred at home [ 1 , 64 , 83 — 85 ].

Given the challenges that people may face when undergoing surgery or traveling abroad, it is not surprising that the risks of medical tourism, which combines both of these aspects, were discussed throughout the reviewed literature. Three categories of risk were covered: 1 risks to patients' health; 2 risks of travel; and 3 risks pre- and post-operatively in the home country.

Risks that patients may be exposed to that can have clearly negative impacts on their health include: contracting an infection post-operatively while in the hospital, travelling during the recuperative period, and an inadequate blood supply being available on-site at the hospital to meet the patients' needs [ 35 , 86 , 87 ].

It is also thought that undertaking procedures that are illegal in patients' home countries or experimental may expose medical tourists to unknown health risks, which may be the very reason that these same surgical procedures are not being performed in their home countries [ 46 ].

Related to cost motivations and decision-making factors, there is also a broad concern that making clinical decisions based on procedure costs is risky and may have negative outcomes for medical tourists and their health [ 39 ]. While there are always risks associated with travel, two travel-related risks that are particularly relevant to medical tourists were highlighted in the literature. The first pertains to airline travel. More specifically, flying with a serious health condition either in advance of the surgery i.

This occurs when blood clots form in deep veins and cause affected areas to swell. Patients not well enough to move around during the flight may have restricted blood flow to areas of the body, thus resulting in deep vein thrombosis [ 86 ]. In some instances the clots may dislodge and travel to the lungs, thereby causing a pulmonary embolism.

The risks of medical tourism are not restricted to occurring while patients are abroad, nor do they end upon check-out from the hospital. Patients may not seek advice from their regular doctors, or may go against their doctors' advice, regarding whether or not surgery is needed [ 19 , 71 , 90 , 91 ]. Related to this, patients' medical records may become discontinuous, in that there are not presently adequate systems in place for transferring health information between medical tourism hospitals and patients' home doctors [ 39 , 92 , 93 ].

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This problem may be overcome by patients carrying their records with them overseas and bringing back new files from abroad for inclusion in their permanent records [ 65 ]. Some reviewed sources further suggested that there may also be health risks upon return due to a lack of after-care planning [ 42 , 89 , 94 ], or that after-care may be challenging due to informational discontinuity [ 85 ].

Another risk post-operatively that may be experienced upon returning home is that there is commonly little legal recourse for procedures for which complications have arisen [ 86 , 95 , 96 ]. This is primarily due to weak malpractice laws that exist in many destination countries [ 73 , 92 , 97 ]. A related risk is that some doctors in home countries may be reluctant to treat medical tourists upon returning home for fear that they will be sued for complications arising from procedures undertaken abroad in countries with limited options for legal redress [ 90 ].

First-hand accounts of medical tourists' experiences were found mostly in reports and media sources. These accounts typically focused on one of three things: 1 positive and negative aspects of medical tourism; 2 sensationalized issues; and 3 reports of post-recovery life.

Announcements

Topics often covered in these accounts ranged from reports of being satisfied with the care received [ 11 ] and the benefits and drawbacks of recovering in a relaxing tourist locale away from home [ 42 , 98 ] to the experience of deciding on a particular hospital [ 61 ]. The perspectives offered on these issues were quite broad, and covered both positive and negative experiences. On the more negative side, accounts covered details such as patients having to borrow heavily from family in order to afford to access care abroad [ 18 ] and concerns about being treated by foreign doctors who may speak a different language and have different care standards [ 2 ].

One of the more sensationalized topics shared in patients' published accounts of medical tourism were stories of their own and others' expectations of cleanliness and care quality in hospitals abroad. A patient reporting on care having been received in Thailand said: " It is not surprising that patients emphasized such issues in their accounts given that there were reports of having to counter others' perceptions of care abroad.

As a woman from the US who had received surgery in Thailand explained: "They [friends, family, and others] roll their eyes up in their heads and say, 'I can imagine' and I say, 'no, you can't I went down and had lunch at the Starbucks in the lobby of the hospital, came back up and the doctor had on his desk the most beautiful file, all bound with tabs and everything, with all the results of the tests that they had done' Something like that, as you know, is impossible in America I mean, it's inconceivable" p.

A6 [ ]. Others shared this experience, including another US patient who said that: "when I told people I was having surgery in Southeast Asia, some looked at me like I was crazy. They were clearly imagining me in a straw hut with someone holding fishing line and tweezers" p.

The Patient Travel Subsidy Scheme (PTSS)

P01 [ ]. Others' accounts focused on how care at hospitals abroad was not as sterile as they had expected [ ]. Retrospective, post-recovery reports were abundant in the media sources reviewed. In these accounts former medical tourists reflect, overwhelmingly positively, on their experience overall and the positive impact that receiving a procedure abroad has had for their health. A former Canadian medical tourist had this to say: "Life is too precious. I'm in my early 50s and I have lots of things to do in my life and one of them isn't lying at home in pain I'm a Victoria firefighter.

I have been for 29 years and I don't want to retire that way, you know, with a disability" n. Accessing surgery abroad enabled him to maintain his employment. Another Canadian retrospectively proclaimed "I think it's the best money I've ever spent" n.

What is known about the patient's experience of medical tourism? A scoping review

Table 3 summarizes the themes and issues generated from the sources included in this scoping review. The informational points extracted in the review, generated primarily from sources reliant on speculation, reveal how complex the patient experience is, in that it involves many components ranging from early decision-making about multiple factors to ensuring appropriate arrangements for post-operative care in one's home system.

In the remainder of this section we explore the implications of the key issues identified about the patient's experience of medical tourism, knowledge gaps that exist on this topic, and also the overall limitations of the scoping review process employed. From the sources reviewed for this scoping review it can be understood that patients are likely to hold significant responsibilities in the practice of medical tourism. For example, informational continuity of care is a quality indicator and is established through patient information being available over time and to multiple practitioners in different locations [ , ].

While patients often have roles to play in its establishment [ ], medical tourists may hold particular responsibilities in this regard as they may literally be expected to transport hard copy records vast distances and ensure that they arrive safely to the correct people.


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    8. Certainly, concerns are that these records may become damaged during transit or that the patient may choose not to share details of their procedure abroad with their regular doctor, thereby threatening informational continuity of care and the benefits it bestows.

    Another responsibility is that it may be advisable for patients to take active measures to avoid encountering risks when traveling and also while abroad. While all patients run the risk of being exposed to any number of health threats when receiving surgery, such as surgical site infections and clotting complications [ , ], there can be additional risks that pertain to the 'travel' and 'receiving care abroad' dimensions of medical tourism that patients must take responsibility for minimizing or eliminating.

    Related to this, patients interested in medical tourism are also likely to hold responsibility for evaluating the trustworthiness and reliability of information sources e. It has been said that international regulation of the medical tourism industry is lacking [ ], and so patients are left to their own - possibly with the assistance of others - to rate and rank things such as the quality of facilities and procedure outcomes using available information. Clearly, it can be understood that how patients address these potential responsibilities is likely to directly shape their experiences of intentionally accessing medical care abroad via medical tourism.

    This scoping review has revealed that the patient's experience of medical tourism might not end upon returning home, nor begin at the point of departure.

    An Official Journal of the International Academy of Health Preference Research

    In fact, it can extend far in advance of and beyond when care is received. The law reviews examined have focused extensively on the fact that there is typically little legal recourse for patients accessing surgeries and other procedures abroad in countries with weak malpractice laws. For patients who experience negative outcomes, their pursuit of compensation, whether financial or otherwise, may draw on over an extended period of time, quite possibly with little result, extending well beyond the post-operative recovery period.

    It was noted in the findings section that word-of-mouth is likely to be important within the medical tourism industry: satisfied patients can spread information about facilities and destination countries to interested others.