Waiting for surgery from the patient perspective

Measures of preoperative anxiety: Part two

The current literature indicates that routine evaluation of preoperative anxiety, its determinants, and patient-specific concerns is universally advocated. This aligns with the increasingly acknowledged importance of prehabilitation - a comprehensive process preparing patients for surgery. A crucial component of prehabilitation is assessing patients' mental health. Recommendations for psychological evaluations in prehabilitation encompass, inter alia, determining the severity of anxiety. This work builds on a 2019 article, which presented scales for preoperative anxiety assessment: the State Trait Anxiety Inventory (STAI), the Hospital Anxiety and Depression Scale (HADS), the Amsterdam Preoperative Anxiety and Information Scale (APAIS), and the Visual Analogue Scale (VAS). This article extends the possibilities of preoperative anxiety assessment by introducing four additional methods: the Surgical Fear Questionnaire (SFQ), the Anxiety Specific to Surgery Questionnaire (ASSQ), the Surgical Anxiety Questionnaire (SAQ), and Anesthesia- and Surgery-dependent Preoperative Anxiety (ASPA). The authors provide comprehensive details on these instruments, including scoring, interpretation, availability, and usefulness both in scientific research and clinical practice. The authors also provide the data on the availability of Polish versions of the presented methods and preliminary data on the reliability of SFQ in patients awaiting cardiac surgery. This review seems relevant for professionals in multiple disciplines, including anesthesiology, surgery, clinical psychology, nursing, primary care and notably prehabilitation. It emphasizes the necessity of individualizing anxiety assessment and acknowledging patient subjectivity, which the presented methods facilitate through a thorough evaluation of specific patient concerns. The literature review also identifies concerns and future research avenues in this area. The importance of qualitative studies and those evaluating prehabilitation intervention is emphasized.

A qualitative study of the impact of the COVID-19 pandemic on women seeking pelvic organ prolapse surgery in Alberta, Canada

In addition to altering public infrastructure and social patterning, the COVID-19 pandemic has delayed many pelvic organ prolapse (POP) surgeries. POP-related stigma, symptomology and the experience of waiting for POP surgery can negatively impact women's quality of life and mental health. The experience of preoperative POP patients during the pandemic thus entails a new intersection of gendered, stigmatic and medical realities. Qualitative interviews were conducted with 26 preoperative POP patients as part of a larger qualitative study, 20 of whom spontaneously volunteered information about how the pandemic coloured their experience living with and awaiting surgery for POP. Interviews occurred between January and July 2021, which coincided with the second and third waves of the pandemic in Alberta, Canada, and before full immunisation was available for all Albertans. Pandemic-related interview excerpts were thematically analysed, and four main findings emerged. (1) Though surgical delay meant living with unpleasant symptoms for longer than anticipated, some sought this out in order to protect vulnerable loved ones from possible hospital-acquired infection, (2) shifting and unclear hospital policies and logistics resulted in intense preoperative stress, at times causing women to temporarily cease treatment, (3) decreased access to public restroom infrastructure caused women to reduce their outings and (4) the imperative to minimise social gatherings made it easier for women to engage in POP-related, shame-based self-isolation without the notice of friends and family. As they can influence postoperative outcomes and treatment adherence, trends observed should be of interest to clinicians and policymakers alike.

Understanding the Needs and Priorities of People Living with Persistent Pain and Long-Term Musculoskeletal Conditions during the COVID-19 Pandemic—A Public Involvement Project

Background: Critiques of public involvement (PI) are associated with failing to be inclusive of under-represented groups, and this leads to research that fails to include a diversity of perspectives. Aim: The aim of this PI project was to understand the experiences and priorities of people from three seldom-heard groups whose musculoskeletal pain may have been exacerbated or treatment delayed due to COVID-19. Engaging representatives to report diverse experiences was important, given the goal of developing further research into personalised and integrated care and addressing population health concerns about access and self-management for people with musculoskeletal pain. Methods: The project was approved via Sheffield Hallam University Ethics but was exempt from further HRA approval. A literature review was conducted, followed by informal individual and group discussions involving professionals and people with lived experience of (a) fibromyalgia pain, (b) those waiting for elective surgery and (c) experts associated with the care home sector. Findings from the literature review were combined with the insights from the public involvement. Resulting narratives were developed to highlight the challenges associated with persistent pain and informed the creation of consensus statements on the priorities for service improvement and future research. The consensus statements were shared and refined with input from an expert steering group. Results: The narratives describe pain as a uniformly difficult experience to share with professionals; it is described as exhausting, frustrating and socially limiting. Pain leads to exclusion from routine daily activities and often resigns people to feeling and being unwell. In all cases, there are concerns about accessing and improving services and critical issues associated with optimising physical activity, functional wellbeing and managing polypharmacy. Exercise and/or mobilisation are important and commonly used self-management strategies, but opportunity and advice about safe methods are variable. Services should focus on personalised care, including self-management support and medication management, so that people’s views and needs are heard and validated by health professionals. Conclusions: More research is needed to explore the most effective pain management strategies, and public involvement is important to shape the most relevant research questions. Health and care systems evaluation is also needed to address the scale of the population health need. The pandemic appears to have highlighted pre-existing shortcomings in holistic pain management.

Identifying and Understanding the Non-Clinical Impacts of Delayed or Cancelled Surgery in Order to Inform Prioritisation Processes: A Scoping Review

The COVID-19 pandemic has resulted in significant delays to non-urgent elective surgery. Decision making regarding prioritisation for surgery is currently informed primarily by clinical urgency. The ways in which decision making should also consider potential social and economic harm arising from surgical delay are currently unclear. This scoping review aimed to identify evidence related to (i) the nature and prevalence of social and economic harm experienced by patients associated with delayed surgery, and (ii) any patient assessment tools that could measure the extent of, or predict, such social and economic harm. A rapid scoping review was undertaken following JBI methodological guidance. The following databases were searched in October 2020: AMED; BNI; CINAHL; EMBASE; EMCARE; HMIC; Medline; PsychINFO, Cochrane, and the JBI. A total of 21 publications were included. The findings were categorised into five themes: (i) employment, (ii) social function and leisure, (iii) finances, (iv) patients’ experiences of waiting, and (v) assessment tools that could inform decision making. The findings suggest that, for some patients, waiting for surgery can include significant social, economic, and emotional hardship. Few validated assessment tools exist. There is an urgent need for more research on patients’ experiences of surgical delay in order to inform a more holistic process of prioritising people on surgical waiting lists in the COVID-19 pandemic recovery stages.

Experiences of women undergoing abdominoplasty in the public sector: a qualitative study

Introduction: This study was designed to improve understanding of the experiences of women un-dergoing abdominoplasty in a public hospital setting, including their experience of processes of care, surgical treatment and outcomes of surgery. Methods: This was a prospective, qualitative study, with one-to-one interviews with women, tran-scription of interviews and development of themes. Results: Twenty interviews were carried out with 16 women, with four women being interviewed before and after surgery and the remaining 12 being interviewed one time only. Messages emerging from the interviews included gratitude for treatment in the public sector, uncertainty associated with waiting times and surgeon allocation, and varied satisfaction with outcomes. This article also explores the evidence for the association between physical symptoms and rectus diastasis (separa-tion of the rectus abdominis muscles) as well as mental health improvement. Conclusion: Women undergoing abdominoplasty in the public sector are not a homogenous group, either in their motivations for surgery or their reported outcomes. This qualitative study found evidence for improvement in physical symptoms and psychological wellbeing in women undergoing abdominoplasty, which supports existing quantitative studies, but also highlights a need for clear information for public sector patients, especially relating to scars, and for liaison psy-chiatry. Criteria-based assessment contributes an additional burden for these patients.

Cancer in the Shadow of COVID: Early-Stage Breast and Prostate Cancer Patient Perspectives on Surgical Delays Due to COVID-19

Background

During the height of the coronavirus disease 2019 (COVID-19) pandemic, elective surgeries, including oncologic surgeries, were delayed. Little prospective data existed to guide practice, and professional surgical societies issued recommendations grounded mainly in common sense and expert consensus, such as medical therapy for early-stage breast and prostate cancer patients. To understand the patient experience of delay in cancer surgery during the pandemic, we interviewed breast and prostate cancer patients whose surgeries were delayed due to the pandemic.

Patients and Methods

Patients with early-stage breast or prostate cancer who suffered surgical postponement at Brigham and Women’s Hospital (BWH) were invited to participate. Semi-structured telephone interviews were conducted with 21 breast and prostate cancer patients. Interviews were transcribed, and qualitative analysis using ground-theory approach was performed.

Results

Most patients reported significant distress due to cancer and COVID. Key themes that emerged included the lack of surprise and acceptance of the surgical delays but endorsed persistent cancer- and delay-related worries. Satisfaction with patient–physician communication and the availability of a delay strategy were key factors in patients’ acceptance of the situation; perceived lack of communication prompted a few patients to seek care elsewhere.

Discussion

The clinical effect of delay in cancer surgery will take years to fully understand, but there are immediate steps that can be taken to improve the patient experience of delays in care, including elicitation of individual patient perspectives and ongoing communication. More work is needed to understand the wider experiences of patients, especially minority, socioeconomically disadvantaged, and uninsured patients, who encounter delays in oncologic care.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10319-0.

Nephrectomy Delay of More than 10 Weeks from Diagnosis Is Associated with Decreased Overall Survival in pT3 RCC

In this study, we aimed to evaluate the impact of surgical wait time (SWT) on outcomes of patients with renal cell carcinoma (RCC), and to investigate risk factors associated with prolonged SWT. Using the National Cancer Database, we retrospectively reviewed the records of patients with pT3 RCC treated with radical or partial nephrectomy between 2004 and 2014. The cohort was divided based on SWT. The primary outcome was 5-year overall survival (OS). Logistic regression analysis was used to investigate the risk factors associated with delayed surgery. Cox proportional hazards models were fitted to assess relations between SWT and 5-year OS after adjusting for confounding factors. A total of 22,653 patients were included in the analysis. Patients with SWT > 10 weeks had higher occurrence of upstaging. Using logistic regression, we found that female patients, African-American or Spanish origin patients, treatment in academic or integrated network cancer center, lack of insurance, median household income of <$38,000, and the Charlson-Deyo score of ≥1 were more likely to have prolonged SWT. SWT > 10 weeks was associated with decreased 5-year OS (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.15-1.33). This risk was not markedly attenuated after adjusting for confounding variables, including age, gender, race, insurance status, Charlson-Deyo score, tumor size, and surgical margin status (adjusted HR, 1.13; 95% CI, 1.04-1.24). In conclusion, the vast majority of patients underwent surgery within 10 weeks. There is a statistically significant trend of increasing SWT over the study period. SWT > 10 weeks is associated with decreased 5-year OS.

Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Depression in Patients with Heart Diseases: Gender Differences and Association of Comorbidities, Optimism, and Spiritual Struggle

BACKGROUND

Depression is a well-established comorbidity of heart disease (HD) and is more prevalent in women than in men. Few studies have examined the gender effect on depression in patients with advanced heart disease prior to open heart surgery (OHS), controlling for cardiac indices. Previous studies indicated the health benefit of optimism but often lacked adjustment for medical confounders. This interdisciplinary study investigated gender differences in pre-OHS depression and the role of medical comorbidities and strength factors.

METHOD

Two waves of survey data were collected from 481 patients (mean age = 62, female 42%) along with medical indices in the Society of Thoracic Surgeon's (STS) national database used by all US cardiac surgeons.

RESULTS

A t test showed significantly higher levels of pre-OHS depressive symptoms in women than in men. In multivariate analyses, the gender effect on depression vanished after entry of other socio-demographics, medical comorbidities, objectively assessed cardiac indices in the STS database, and psychosocial strength factors. Depressive symptoms linked inversely with dispositional optimism and positively with medical comorbidities and religious/spiritual struggle, but not with any cardiac indices. A mediation analysis supported the role of comorbidities in the gender difference.

CONCLUSION

Women with heart disease were more depressed, but the gender difference may be partly explained by multiple comorbid conditions that could complicate disease burden. Reinforcing the literature, optimism, but not other strength factors, appeared to counteract depression after adjusting for health and cardiac conditions. The finding suggests that health providers should be more attentive to overall health of women with heart disease and to the positive expectations of OHS patients.

Preoperative Anxiety in Adult Patients Undergoing Day Care Surgery: Prevalence and Associated Factors

BACKGROUND

There is a paucity of data related to anxiety levels in patients undergoing day care surgery in India.

METHODS

Preoperative anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS) 1 day before surgery and on the day of surgery, and the patients were categorized as cases (APAIS score ≥13) and controls (APAIS score <13). Sociodemographic characteristics, clinical features, and fears associated with anesthesia and surgery were also noted.

RESULTS

Out of the 399 patients recruited, 58.1% experienced significant preoperative anxiety. The fear of needles (P = 0.002), fear of waking up during the surgery (P < 0.001), and the patient's need of additional information regarding anesthesia and surgery (P < 0.001) were significantly associated with preoperative anxiety.

CONCLUSION

A significant proportion of patients scheduled for day care surgery have preoperative anxiety. A preanesthetic workup of a patient with adequate clarification about their doubts and fears related to anesthesia and surgery is recommended to bring down the level of anxiety.

Heart Rehabilitation in patients awaiting Open heart surgery targeting to prevent Complications and to improve Quality of life (Heart-ROCQ): study protocol for a prospective, randomised, open, blinded endpoint (PROBE) trial

INTRODUCTION

The rising prevalence of modifiable risk factors (eg, obesity, hypertension and physical inactivity) is causing an increase in possible avoidable complications in patients undergoing cardiac surgery. This study aims to assess whether a combined preoperative and postoperative multidisciplinary cardiac rehabilitation (CR) programme (Heart-ROCQ programme) can improve functional status and reduce surgical complications, readmissions and major adverse cardiac events (MACE) as compared with standard care.

METHODS AND ANALYSIS

Patients (n=350) are randomised to the Heart-ROCQ programme or standard care. The Heart-ROCQ programme consists of a preoperative optimisation phase while waiting for surgery (three times per week, minimum of 3 weeks), a postoperative inpatient phase (3 weeks) and an outpatient CR phase (two times per week, 4 weeks). Patients receive multidisciplinary treatment (eg, physical therapy, dietary advice, psychological sessions and smoking cessation). Standard care consists of 6 weeks of postsurgery outpatient CR with education and physical therapy (two times per week). The primary outcome is a composite weighted score of functional status, surgical complications, readmissions and MACE, and is evaluated by a blinded endpoint committee. The secondary outcomes are length of stay, physical and psychological functioning, lifestyle risk factors, and work participation. Finally, an economic evaluation is performed. Data are collected at six time points: at baseline (start of the waiting period), the day before surgery, at discharge from the hospital, and at 3, 7 and 12 months postsurgery.

ETHICS AND DISSEMINATION

This study will be conducted according to the principles of the Declaration of Helsinki (V.8, October 2013). The protocol has been approved by the Medical Ethical Review Board of the UMCG (no 2016/464). Results of this study will be submitted to a peer-reviewed scientific journal and can be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02984449.

Winter cancellations of elective surgical procedures in the UK: a questionnaire survey of patients on the economic and psychological impact

OBJECTIVES

To quantify the economic and psychological impact of the cancellation of operations due to winter pressures on patients, their families and the economy.

DESIGN

This questionnaire study was designed with the help of patient groups. Data were collected on the economic and financial burden of cancellations. Emotions were also quantified on a 5-point Likert scale.

SETTING

Five NHS Hospital Trusts in the East Midlands region of England.

PARTICIPANTS

We identified 796 participants who had their elective operations cancelled between 1 November 2017 and 31 March 2018 and received responses from 339 (43%) participants.

INTERVENTIONS

Participants were posted a modified version of a validated quality of life questionnaire with a prepaid return envelope.

MAIN OUTCOME MEASURES

The primary outcome measures were the financial and psychological impact of the cancellation of elective surgery on patients and their families.

RESULTS

Of the 339 respondents, 163 (48%) were aged <65 years, with 111 (68%) being in employment. Sixty-six (19%) participants had their operations cancelled on the day. Only 69 (62%) of working adults were able to return to work during the time scheduled for their operation, with a mean loss of 5 working days (SD 10). Additional working days were lost subsequently by 60 (54%) participants (mean 7 days (SD 10)). Family members of 111 (33%) participants required additional time off work (mean 5 days (SD 7)). Over 30% of participants reported extreme levels of sadness, disappointment, anger, frustration and stress. At least moderate concern about continued symptoms was reported by 234 (70%) participants, and 193 (59%) participants reported at least moderate concern about their deteriorating condition.

CONCLUSIONS

The cancellation of elective surgery during the winter had an adverse impact on patients and the economy, including days of work lost and health-related anxiety. We recommend better planning, and provision of more notice and better support to patients.

Preoperative oral hygiene recommendation before open-heart surgery: patients' adherence and reduction of infections: a quality improvement study

Aim

To implement recommendations for oral hygiene before elective open-heart surgery in a thoracic surgery ward and to evaluate whether the number of patients who needed to be treated with antibiotics postoperatively was reduced.

Background

Healthcare systems are challenged to implement initiatives that reduce the development of nosocomial infections, to offer patients a safe and cost-efficient treatment and to reduce the use of antibiotics. Previous interventions have focused on staff behaviour in reducing postoperative infections. In this study, patients were recommended to carry out oral hygiene as recommended in a clinical guideline.

Methods

A quasiexperimental design with a control and an intervention group was used. Information on adherence to the recommendation was collected at admission. All medical information and prescriptions of antibiotics were obtained from patients’ medical records. Data were reported as intention to treat.

Results

Altogether 972 patients (506 controls and 466 interventions) were included in the study. Of the intervention patients, 405 (86.9%, 95% CI 83.3 to 89.8) reported that they had adhered to the oral hygiene recommendation. 64 (12.6%) control patients and 36 (7.7%) in the intervention group (p=0.015) were treated with antibiotics postoperatively.

Conclusions

It was feasible to involve patients in a programme for oral hygiene and thereby reduce the number of patients needing antibiotics after open-heart surgery and this might contribute to reducing costs.

Conceptualising time before surgery: the experience of patients waiting for hip replacement

Interpretations of time underlie patients' experiences of illness and the way in which the National Health Service (NHS) is organised. In the NHS, achieving short waiting times for treatment is seen as important, and this is particularly evident in relation to chronic conditions where the time waiting in care from onset of symptoms to successful management can last months and years. One example of a chronic condition with high prevalence is osteoarthritis, estimated to affect 10% of people aged over 55 years in the UK. Osteoarthritis of the hip is particularly common, and treatments include exercise and medication. If these options do not provide enough relief from pain and functional difficulties, then joint replacement may be considered. With over 70,000 such operations conducted every year in England and Wales, processes relating to waiting times impact on many patients. This article explores how 24 patients with osteoarthritis experience time during the lead up to hip replacement surgery. We draw on data collected during longitudinal in-depth interviews with patients a median of 9.5 days before surgery and at two to four weeks post-operatively. Transcripts of audio-recorded interviews were imported into Atlas.ti^® and inductive thematic analysis undertaken. Increasing pain and deterioration in function altered the experience of time during the journey towards hip replacement. Patients made essential changes to how they filled their days. They experienced lost and wasted time and faced disruption to the temporal order of their lives. A surgical date marked in the calendar became their focus. However, this date was not static, moving because of changing perceptions of duration and real-time alterations by the healthcare system. Findings highlight that patients' experience of time is complex and multi-dimensional and does not reflect the linear, monochronic conceptualisation of time embedded in the healthcare system.

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Waiting for hip replacement disrupts the temporal order of patients' lives.

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Patients' perceptions of time are multi-dimensional and complex.

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Experiences of time differ from health services' monochronic construction of time.

Patients' perceptions of waiting for bariatric surgery: a qualitative study

BACKGROUND

In Canada waiting lists for bariatric surgery are common, with wait times on average > 5 years. The meaning of waiting for bariatric surgery from the patients' perspective must be understood if health care providers are to act as facilitators in promoting satisfaction with care and quality care outcomes. The aims of this study were to explore patients' perceptions of waiting for bariatric surgery, the meaning and experience of waiting, the psychosocial and behavioral impact of waiting for treatment and identify health care provider and health system supportive measures that could potentially improve the waiting experience.

METHODS

Twenty-one women and six men engaged in in-depth interviews that were digitally recorded, transcribed verbatim and analysed using a grounded theory approach to data collection and analysis between June 2011 and April 2012. The data were subjected to re-analysis to identify perceived health care provider and health system barriers to accessing bariatric surgery.

RESULTS

Thematic analysis identified inequity as a barrier to accessing bariatric surgery. Three areas of perceived inequity were identified from participants' accounts: socioeconomic inequity, regional inequity, and inequity related to waitlist prioritization. Although excited about their acceptance as candidates for surgery, the waiting period was described as stressful, anxiety provoking, and frustrating. Anger was expressed towards the health care system for the long waiting times. Participants identified the importance of health care provider and health system supports during the waiting period. Recommendations on how to improve the waiting experience included periodic updates from the surgeon's office about their position on the wait list; a counselor who specializes in helping people going through this surgery, dietitian support and further information on what to expect after surgery, among others.

CONCLUSION

Patients' perceptions of accessing and waiting for bariatric surgery are shaped by perceived and experienced socioeconomic, regional, and waitlist prioritization inequities. A system addressing these inequities must be developed. Waiting for surgery is inherent in publicly funded health care systems; however, ensuring equitable access to treatment should be a health system priority. Supports and resources are required to ensure the waiting experience is as positive as possible.

Use of medical tourism for hip and knee surgery in osteoarthritis: a qualitative examination of distinctive attitudinal characteristics among Canadian patients

Background

Medical tourism is the term that describes patients’ international travel with the intention of seeking medical treatment. Some medical tourists go abroad for orthopaedic surgeries, including hip and knee resurfacing and replacement. In this article we examine the findings of interviews with Canadian medical tourists who went abroad for such surgeries to determine what is distinctive about their attitudes when compared to existing qualitative research findings about patients’ decision-making in and experiences of these same procedures in their home countries.

Methods

Fourteen Canadian medical tourists participated in semi-structured phone interviews, all of whom had gone abroad for hip or knee surgery to treat osteoarthritis. Transcripts were coded and thematically analysed, which involved comparing emerging findings to those in the existing qualitative literature on hip and knee surgery.

Results

Three distinctive attitudinal characteristics among participants were identified when interview themes were compared to findings in the existing qualitative research on hip and knee surgery in osteoarthritis. These attitudinal characteristics were that the medical tourists we spoke with were: (1) comfortable health-related decision-makers; (2) unwavering in their views about procedure necessity and urgency; and (3) firm in their desires to maintain active lives.

Conclusions

Compared to other patients reported on in the existing qualitative hip and knee surgery literature, medical tourists are less likely to question their need for surgery and are particularly active in their pursuit of surgical intervention. They are also comfortable with taking control of health-related decisions. Future research is needed to identify motivators behind patients’ pursuit of care abroad, determine if the attitudinal characteristics identified here hold true for other patient groups, and ascertain the impact of these attitudinal characteristics on surgical outcomes. Arthritis care providers can use the attitudinal characteristics identified here to better advise osteoarthritis patients who are considering seeking care abroad.