The provision of cross-border care is a phenomenon that has received considerable policy attention in the last few years. Nevertheless, knowledge on patient-safety and patient-centeredness issues related to patients crossing borders to obtain care remains rather scarce until now. There is remarkably little systematic information on the volume and scope of cross-border care, and in particular on the perspectives and outcomes of cross-border care at patient level. Likewise, evaluations of the needs and quality and safety outcomes of different types of cross-border patients (temporary visitors, long term residents, people living in border areas, referrals abroad for specialist services and people seeking treatment themselves) so far are rare.
The aim of this study is to seek the views of health professionals on potential quality and safety concerns for this group of patients.
Material and Methods
We carried out qualitative interviews to collect information on the views of patients, professionals and financers on the safety and patient-centeredness of cross-border care. In this paper we only present the results of the interviews with health professionals. To guide the identification of issues, we used a simplified service delivery model reflecting a functional perspective of hospital services and following the patients’ pathway. A semi-structured interview guideline was developed based on the conceptual model and existing literature on crossborder care issues. The professionals’ perspective was studied by interviewing managers and health professionals (doctors and nurses) from facilities with a high volume of cross-border patients. Interviews were held on the phone, transcribed and then reviewed for themes and emergent issues.
Overall, 30 health professionals from 14 hospitals in six European countries (Belgium, Czech Republic, Ireland, Poland, Spain and the Netherlands) participated in this study. We analysed the safety and patient-centeredness issues for cross-border care and four transversal themes emerged from this analysis (see Table 1 pg.20).
1. Communication and Information
Communication and information needs of cross-border patients are present at all stages of the care process - admission, diagnosis/ intervention and discharge- and are not limited to clinical issues but rather address the whole healthcare process and scheduling of tests and procedures for which communication is very important. The issue of informed consent both relates to communication needs and administrative and clinical procedures. In many cases, informed consent forms are only available in the local language. Moreover, what constitutes informed consent varies substantially between countries (ranging from the ‘patient being orally informed’ to ‘signing in presence of witness that he/she was provided with and understood the [long-term] implications of the procedure’). Similar issues exist for discharge information.
2. Administrative Procedures
Interviewees confirmed that administrative requirements can pose problems in individual cases, such as when patients do not carry the forms or use them fraudulently. Moreover, it was mentioned that pre-authorisation should be more strongly based on specialist and not administrative criteria, and that selective contracting between countries should be facilitated by health system level agreements.
3. Clinical Procedures
Differences in clinical procedures have been found between countries with regard to transplantation procedures (related to the use of organs from non-heart beating patients), quantity of rehabilitation services or caesarean section on demand (not uncommon in some countries). A particular problem for cross-border patients is that the discharge date (either too early, or after excessive length of stay) may be influenced by previously made travel arrangements, rather than medical criteria.
4. Hotel Services and Physical Structure
Cross-border patients have higher demands on the hotel services of hospital. The most common requests related to issues such as timing and scope of meals and privacy; other main issues were respect for families or carers’ needs, accommodation, information about the patient’s situation and purchasable items. Professionals also pointed out that cultural differences exist in the way patients from the North, South and East of Europe, respectively, collaborated in the care process.
There appear to be some potential quality and safety issues for cross-border care due to the information requirements and complexity of the care process, especially when follow-up care is required. The various comments from health professionals illustrate the different priorities and expectations people have concerning healthcare and how this can cause complications. It needs to be emphasised, however, that the legal framework under which cross-border care is provided may have an implication on administrative and quality requirements. Given the explorative nature of this research, further work is required to better understand some of the quality and safety issues that we identified in this project. But the study does serve to illustrate the actual and potential problems hospital workers are faced with concerning cross-border care and can be used as a starting block by healthcare establishments to find their own solutions.
Director of Research & Education,
Avedis Donabedian University
References available upon request
Communication and Information Issues
“There are a number of difficulties in assessing [cross-border] patients, e.g. that the patient does not carry required information/clinical records, or brings medication that can not be clearly identified so it is difficult to know what to provide. Many patients come alone and this brings along further difficulties as there is no-one to provide answers. There are obvious problems in evaluating symptoms if the patient does not speak English.” (Professional PRO 1).
“ [Cross-border patients] are usually more critical and have higher information requirements, but in the end they are even more satisfied than local patients because they compare the care they received with what they would have got in their own country.” (Professional PRO 9)
“ … a pregnant woman […] could not speak any language apart from her mother tongue, [she] did not understand what was going on , and the woman dit not understand the basic rules of hospitalisation like switching off of mobile phone in the night and visiting hours. This caused some problems to the other patients in the room.” (Professional PRO 3)
“Before the patient arrives I have had contact already, they send file, I need to agree, everything is managed before, the patients that are referred to me never come by hazard. Patients need the E-112, but sometimes the country is reluctant - there is no free movement of patients. [Movement of patients] should not only be an administrative process, there should be recommendations by [the specialist] to provide surgery” (Professional PRO-6)
“Sometimes there may be problems to discharge patients. […] Some patients need to stay in a hospital but not in this one (sic) and then sometimes it is difficult to find an ambulance to transport the patient to his country, especially on Fridays.” (Professional PRO-1)
“A serious issue is the organisation of back-transfer. We needed to transfer a patient [across the border] and when he arrived [at the hospital], there was no ICU bed available. They brought him back to our hospital, but he died on the way. There is lack of information systems to check the availability of beds.” (Professional PRO-22)
“Differences exist in type, name and dosage of drugs; this is a potential patient safety issue.” (Professional PRO-5)
“In our hospital we have more than 200 consent forms, depending on the pathology and we considered translating them, but of course, with so many forms that need to be updated, this is not feasible.” (Professional PRO-1)
“One important example [for differences in clinical procedures] would be transplantation medicine. For kidney transplants the waiting list is very long, but we have found a way to use kidneys from nonheartbeating patients. Although there are some minor differences in the quality of the organs, we have achieved some really good results. I have now experienced (sic) that it is forbidden in Germany to use organs from non-heart-beating patients and I have tried to introduce to my German colleagues our experiences. But there was a major reaction: “This will never be done in Germany!”. The response was that this is never going to happen in Germany, there seem to be major cultural differences with regard to the use of organs from nonheart- beating patients.” (Professional PRO-14)
“Many foreign patients set a time limit for the in-patient stay: “I can stay until Sunday, then I have to take my plane!”. Even if we tell them that it is not safe, they sometimes insist. There is a form for voluntary discharge to be signed.” (Professional PRO-15)
Hotel Services and Physical Structure
“Patients from Nordic countries that are used to quiet environments and everything being in order are sometimes scared when they arrive at our hospital because everything is much more busy, noisy and does not seem to be so organised to the Nordic patients. Also, the times when meals are served and our working times are strange to these patients. Patients from other Mediterranean countries are closer to our culture, for them there is no major difference.” (Professional 10)