Transplantation tourism: high risk for the recipients

A Survey Study to Examine Willingness to Travel for Transplantation and Consider Commercial Transplantation Among a Multi-Ethnic Cohort of Canadians

Introduction

Travel for transplantation is the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders for transplantation purposes and is considered transplant tourism if transplant commercialism is involved. Little is known about the willingness of patients at risk for transplant tourism to engage in this practice.

Methods

A cross-sectional survey of patients with end-stage renal disease was conducted in Canada to determine interest in travel for transplantation and transplant tourism, characterize patients according to their willingness to consider transplant tourism, and identify factors to deter willingness to consider transplant tourism. Surveys were conducted face-to-face and in multiple languages.

Results

Among the 708 patients surveyed, 418 (59%) reported a willingness to travel outside of Canada for transplantation, with 24% reporting a strong willingness. One hundred sixty-one (23%) reported a willingness to travel and purchase a kidney overseas. On multivariate analysis, male sex, younger age, and Pacific Islander ethnicity were associated with higher odds of willingness to travel for transplant, whereas male sex, annual income greater than $100,000, and Asian and Middle Eastern ethnicity were associated with higher odds of willing to travel to purchase a kidney. Willingness reduced when respondents were informed of medical risks and legal implications related to travel for transplantation. Financial and ethical considerations were less effective at reducing willingness to travel for transplantation.

Conclusion

There was a high level of interest in travel for transplantation and transplant tourism. Legal consequences and education on medical risks of transplant tourism may be effective deterrent strategies.

Infectious complications related to medical tourism

BACKGROUND

Medical tourism has been increasing dramatically globally, with people travelling from developed countries to low-income or middle-income countries, often to avoid high costs or long delays associated with seeking healthcare in their countries of origin. The current review summarizes healthcare-related infections associated with medical tourism, focusing on cosmetic surgery and organ transplantation.

METHODS

A systematic MEDLINE and PubMed search from January 2010 to December 2019 yielded 80 relevant articles, including 49 articles on medical tourism-related infections focusing on cosmetic surgery and organ transplantation, which were included in this reviews.

RESULTS

The literature reveals specific types of cross-border, healthcare-related infections depending on medical intervention. Destinations include low-income countries such as countries of Asia and the Indian subcontinent, middle-income countries including Central and South America, and high-income countries such as the United States and Europe. In terms of type of infections, in 36 (68%) and 15 (28.3%) studies, wound and blood-borne infections were documented, respectively, while in 21 studies (58.3%) non-tuberculous mycobacteria were isolated, including Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium senegalense and Mycobacterium fortuitum. The choices of medical tourists could have significant consequences for them and their home countries, including infectious complications and importation of pathogens, particularly antibiotic-resistant microorganisms, with public health implications.

CONCLUSIONS

There is a need for public health strategies in order to prevent morbidity and mortality as well as future management and education of patients engaging in medical tourism.

Early Surgical Management of Medical Tourism Complications Improves Patient Outcomes

BACKGROUND

Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs.

METHODS

A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors' primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis.

RESULTS

Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003).

CONCLUSIONS

Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Management of Patients Who Receive an Organ Transplant Abroad and Return Home for Follow-up Care: Recommendations From the Declaration of Istanbul Custodian Group

Eradicating transplant tourism depends on complex solutions that include efforts to progress towards self-sufficiency in transplantation. Meanwhile, professionals and authorities are faced with medical, legal, and ethical problems raised by patients who return home after receiving an organ transplant abroad, particularly when the organ has been obtained through illegitimate means. In 2016, the Declaration of Istanbul Custodian Group convened an international, multidisciplinary workshop in Madrid, Spain, to address these challenges and provide recommendations for the management of these patients, which are presented in this paper. The core recommendations are grounded in the belief that principles of transparency, traceability, and continuity of care applied to patients who receive an organ domestically should also apply to patients who receive an organ abroad. Governments and professionals are urged to ensure that, upon return, patients are promptly referred to a transplant center for evaluation and care, not cover the costs of transplants resulting from organ or human trafficking, register standardized information at official registries on patients who travel for transplantation, promote international exchange of data for traceability, and develop a framework for the notification of identified or suspected cases of transnational transplant-related crimes by health professionals to law enforcement agencies.

Population Health Implications of Medical Tourism

BACKGROUND

Fifteen million U.S. patients each year seek medical care abroad; however, there are no data on outcomes and follow-up of these procedures. This study aims to identify, evaluate, and survey patients presenting with complications from aesthetic procedures abroad and estimate their cost to the U.S. health care system.

METHODS

A single-center retrospective review was conducted. A cohort of patients presenting with complications from aesthetic procedures performed abroad was generated. Demographic, complication, and cost data were compiled. Patients were surveyed to assess their overall experience.

RESULTS

Over a 36-month period, 42 patients met inclusion criteria (one man and 41 women), with an average age of 35 ± 11.4 years (range, 20 to 60 years). Comorbidities included four active smokers, two patients with hypertension, and one patient with diabetes. Average body mass index was 29 ± 4.4 kg/m (range, 22 to 38 kg/m). Procedures performed abroad included abdominoplasty (n = 28), liposuction (n = 20), buttock augmentation (n = 10), and breast augmentation (n = 7), with several patients undergoing combined procedures. Eleven patients presented with abscesses and eight presented with wound dehiscence. Eight of the 18 patients who were surveyed were not pleased with their results and 11 would not go abroad again for subsequent procedures. Average cost of treating the complications was $18,211, with an estimated cost to the U.S. health care system of $1.33 billion. The main payer group was Medicaid.

CONCLUSIONS

Complications from patients seeking aesthetic procedures abroad will continues to increase. Patients should be encouraged to undergo cosmetic surgery in the United States to improve patient outcomes and satisfaction and because it is economically advantageous.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Commercial Kidney Transplantation: Attitude, Knowledge, Perception, and Experience of Recipients

INTRODUCTION

Kidney transplantation is the gold standard for patients with end-stage kidney disease. In view of shortages of available organs, long wait times for possible transplantation, and strict regulation, many patients opt for commercial transplantation. This study elicits the reasons and motivations for patients with end-stage kidney disease to elect for commercial transplant.

METHODS

A questionnaire-based evaluation was conducted during the period from July 2015 until late December 2015. It consisted of 29 multiple choice questions and was distributed to all patients who underwent commercial kidney transplantation.

RESULTS

One hundred and fifty patients were approached to participate and 106 agreed. Of the participants, 60% were male with an average age of 41.5 (SD 14.8) years and ranged from 18 to 83 years. The majority (82%) of our participants were educated ranging from primary to college level. The major reason (71%) for these participants to obtain commercial transplants was stated as the unavailability of a live related donor. Thirteen percent stated that they objected to getting a kidney donated from a family member, and 9% stated that they were worried about taking a kidney from a family member. Finally, 3% of participants stated that they needed prompt transplant and could not wait for a long time for transplant investigations and the workup associated with this program.

DISCUSSION

The study showed that the most common underlying cause for seeking commercial transplantation is the unavailability of a national transplant program, particularly transplantation from deceased sources. All western ethical arguments turn out to become of vital importance in developing countries, because transplantation is the cheapest renal replacement therapy. However, it must be emphasized that commercial transplants should not be an alternative to building a national transplant initiative. The national diseased program must be a priority with full financial and administrative support. All government agencies including religious affairs must work together to support the program and to provide the citizens with a good transplantation service and ameliorate the impact of commercial transplantation.

On Patients Who Purchase Organ Transplants Abroad

The international transplant community portrays organ trade as a growing and serious crime involving large numbers of traveling patients who purchase organs. We present a systematic review about the published number of patients who purchased organs. With this information, we discuss whether the scientific literature reflects a substantial practice of organ purchase. Between 2000 and 2015, 86 studies were published. Seventy-six of these presented patients who traveled and 42 stated that the transplants were commercial. Only 11 studies reported that patients paid, and eight described to what or whom patients paid. In total, during a period of 42 years, 6002 patients have been reported to travel for transplantation. Of these, only 1238 were reported to have paid for their transplants. An additional unknown number of patients paid for their transplants in their native countries. We conclude that the scientific literature does not reflect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafficking networks is a potential strategy to collect and quantify cases.

Country-to-country transfer of patients and the risk of multi-resistant bacterial infection

Management of patients with a history of healthcare contact in multiple countries is now a reality for many clinicians. Leisure tourism, the burgeoning industry of medical tourism, military conflict, natural disasters, and changing patterns of human migration may all contribute to this emerging epidemiological trend. Such individuals may be both vectors and victims of healthcare-associated infection with multiresistant bacteria. Current literature describes intercountry transfer of multiresistant Acinetobacter spp and Klebsiella pneumoniae (including Klebsiella pneumoniae carbapenemase- and New Delhi metallo-β-lactamase-producing strains), methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and hypervirulent Clostridium difficile. Introduction of such organisms to new locations has led to their dissemination within hospitals. Healthcare institutions should have sound infection prevention strategies to mitigate the risk of dissemination of multiresistant organisms from patients who have been admitted to hospitals in other countries. Clinicians may also need to individualize empiric prescribing patterns to reflect the risk of multiresistant organisms in these patients.