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Sinescu, Ruxandra Diana; Anghel, Andrea; Vulcanescu, Razvan Teohari
Article
Hand Surgery – Postoperative Recovery and Medical
Tourism
Amfiteatru Economic Journal
Provided in Cooperation with:
The Bucharest University of Economic Studies
Suggested Citation: Sinescu, Ruxandra Diana; Anghel, Andrea; Vulcanescu, Razvan Teohari
(2014) : Hand Surgery – Postoperative Recovery and Medical Tourism, Amfiteatru Economic
Journal, ISSN 2247-9104, The Bucharest University of Economic Studies, Bucharest, Vol. 16,
Iss. Special No. 8, pp. 1125-1135
This Version is available at:
http://hdl.handle.net/10419/168881
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Contemporary Approaches and Challenges of Tourism Sustainability AE

Vol. XVI • Special no. 8 • November 2014 1125
HAND SURGERY – POSTOPERATIVE RECOVERY AND MEDICAL TOURISM

Ruxandra Diana Sinescu1*, Andrea Anghel2 and Răzvan Teohari Vulc ănescu3
1) 2) Department of Plastic Surgery Carol Davila University of Medicine,
Clinical Department of Plastic Sur gery – Reconstructive Microsurgery,
Elias Emergency Hospital, Bucharest, Romania
3) The Bucharest University of Economic Studies, Bucharest, Romania

Abstract
Medical tourism is a growing industry worldwid e. Romania has spa treat ment facilities that
can ensure the development of medical tourism. Th is article presents a st atistical analysis of
hand surgery in Romania in 2012. Using adequate quantitative methods we highlight
significant differences between age groups and differences regarding procedures that have
gender particularities.
Recovery after such surgery can be achieve d through spa treatment Romania, taking
advantage of lower prices compared to other developed countries and numerous medical
tourism facilities.
Keywords: Medical tourism, spa tourism, hand surgery, gender differences, ANOVA
JEL Classification: L83, C10, C52, I11

Introduction
Traumatology and hand surgery are very common pathologies because the hand is the main
link between the human body and the environment. In this article we present a statistical
analysis of hand surgery in Romania in 2012. Rehabilitation after surgery is very important
and is a complex process that consists of electrotherapy, physiotherapy and other spa
procedures. Romania has a number of spa treat ment facilities for recovery after surgery.
Techirghiol mud massages and wraps is used for trauma recovery, treatment of tendons and
ligaments. Mangalia also uses peloid mud from the Techirghiol Lake to treat post-traumatic and postoperative after surgery.
Spa treatment facilities in Romania are the main factor for the development of medical
tourism. Thus, in 2012 the number of beds in sanatoria resorts increased to 1939 from only 910 in 2002. Another factor that determines the development of medical tourism is the
lower prices of treatments performed in resorts in Romania compared to those in other
developed countries. The development and spread of Internet communication technologies contribute significantly to the development of medical tourism (Bookman, 2007). Medical

* Corresponding author, Ruxandra Diana Sinescu – ruxandrasinescu@gmail.com

AE Hand Surgery – Postoperative Recovery and Medical Tourism

Amfiteatru Economic 1126 tourism also contributes to regional developmen t (Andrei, 2007). With the entry into force
of the European Directive on patients' rights in cross-border treatment that facilitates their
access to cross-border healthcare and reimbur sement of the expenses, medical tourism
industry in Romania can record important progresses.
There is a high potential for development of spa and medical tourism in Romania. In table 1
we present Romanian and foreign tourist arrivals in the first nine months of 2013. The data
presented here highlight the following:
• A low share of only 5.3% of foreign to urists in the total number of tourists;
• An important part of Romanian tourists choose the 2 and 3 star hotels;
• A small number of Romanian and foreign tourists choose for five-star hotels.
Table no. 1: Arrivals of tourists in tourist accommodation facilities
during the period 1.I – 30.IX.2013
Romanian
tourist
arrivals Foreign
tourist
arrivals Total The share of
Romanian
tourists in
the category
of
classificationThe share of
foreign
tourists in
the category
of
classificationThe share
of the
category in
total
Romanian
tourists The share
of the
category
in total
foreign
tourists
1 2 3 4 5 6 7 8
Unclassified 6491 38 6529 99.4 0.6 1.30 0.14
1 star 11519 184 11703 98.4 1.6 2.30 0.66
2 stars 235863 10326 246189 95.8 4.2 47.19 37.15
3 stars 170327 7261 177588 95.9 4.1 34.08 26.13
4 stars 75391 9948 85339 88.3 11.7 15.08 35.79
5 stars 208 36 244 85.2 14.8 0.04 0.13
Total 499799 27793 527592 94.7 5.3 100.0 100.0
Data source: NIS data in columns 2-4, Acco mmodation structures attendance of tourist
in the period 1.I – 30.IX.2013 November 2013, columns 5-8 authors' calculations.

1. Literature review
Recovery after hand surgery in Romania is facilitated by the existence of a number of
specialized resorts. They contribute to the de velopment of medical tourism which is a field
that records an average annu al growth rate of approximately 20% worldwide (Deloitte,
2008). Medical tourism in Romania benefits of much lower costs than in developed
countries like USA, UK, Germany (Lunt, 2012), (Andrei, 2010).
Medical tourism and the factors underlying its development are analysed in many studies.
Thus, Gan (2011) studied the differentiation of medical tourism market in the USA using
techniques such as principal component analysis and cluster analysis. Enderwick (2011) presents an analysis of how emerging economies deal with medical tourism with a
particular focus on four Asian countries: Thailand, India, Malaysia and Singapore. The
author presents a theoretical analysis of competitiveness and further development of medical tourism sector in the four Asian countries.

Contemporary Approaches and Challenges of Tourism Sustainability AE

Vol. XVI • Special no. 8 • November 2014 1127 Omay (2013) presents a number of opportunities and threats by analysing the medical
tourism in Turkey. Taiwan's medical touris m experience is presented by Liu (2012) that
emphasizes the support which the government attaches to this area by investing in health
care and promotion of the health services offered. Parsiyar (2009) presents the medical
tourism in the USA noting that many American citizens turn to health services in Latin
America that offer very competitive rates an d analyse the consequences of government
action or inaction related to this field. The author emphasize that medical tourism is growing in the Americas due to particularly low prices charged for medical services by
countries in Latin America.
Mainil (2011) analyses the impact of medical tourism through mass media pointing out that
there are still serious limitations in knowing how patients make the decision to treat in
another country, experiences in these situations and what happens to a patient when reach a
total cultural environment different from his native country.
Chee (2010) emphasizes th e involvement of the state in prom oting private sector of medical
services to patients from other countries in two Asian countries: Singapore and Malaysia.
These are two of the main count ries that provide medical tour ism services worldwide. The
article highlights medical reforms undertaken by the two countries to reduce differences in
quality of care provided by the public and private sectors.

2. Methodology
Several international studies (Alderman, et al., 2006, Tamaoki, et al., 2010) show
significant differences between men and women on the occurrence of hand surgery. There
are also highlighted specific interventions and motivations of interventions that strengthen
the differences between men and women on these procedures.
Based on these studies and using exhaustive databases (National Statistics Institute – SAN
Survey, 2012) we test the following hypotheses:
• H01 surgery in the hand differs significantly in terms of their occurrence in women
compared with men in various age groups;
• H02 emergence of types of surgery in the hand is gender specific. Some
interventions occur more frequently in women than in men;
To test these hypotheses we used ANOVA method.
To test the hypothesis H01 we considered the following procedure:
We define the following assumptions:
H
0 kμμμ …2 1==
H1 non H 0

Where iμis the average number of hand surgery corresponding to an age group.
For hypothesis testing we determine:
Total variation TS= ()2
11∑∑
==−s
jk
iijy y which is decomposed in two parts:

AE Hand Surgery – Postoperative Recovery and Medical Tourism

Amfiteatru Economic 1128 ()2
11∑∑
==− =s
jk
ii ijy y WG , which is the variation within groups determined by
random factors,
()2
11∑∑
==− =s
jk
iiyy BG , which is the variation between the groups and the
variation explained by the treatment / factor, in this case the factor or treatment being
represented by the patient's age group.
i ijyyy,, represent in this order, the individual value in age group i, the overall
average of the sample and that the average for the age group i.
We computed the Fisher statistics based on the following relationship:
)1 /() )( / () / /()1/ ( −− =− −= kkn WGBG kn WG k BG F where k is the
number of classes (age groups) and n is the sample volume.
Finally, we compared F computed based on sample data with the one given by Fished-
Snedecor distribution and for a significance level αwe took the decision as follows: if F is
not less than the critical value then reject th e null hypothesis otherwise null is accepted and
it is concluded that with the probability P=1- α the factor/treatment did not cause
significant changes in the outcome.
Testing the hypothesis H02 is similar but in this case the factor is not given by age group,
but by the type of surgical procedure.

3. Results and discussions
In Romania in 2012 there were 20086 cases of hand surgery for males and females. These
were distributed differently for males (there were 16,582 cases that represents 82.6% of total cases) and women (3,504 cases that repres ents 17.4% of total cases). The graph in
figure 1 shows the distribution of the number of surgery for men and women.

Female, 17.4
Male, 82.6

Figure no. 1: Distribution of hand surgery interventions
for men and women in 2012

Contemporary Approaches and Challenges of Tourism Sustainability AE

Vol. XVI • Special no. 8 • November 2014 1129 The graph in figure 2 shows the number of surgeries for males and females by age groups.
Data presented in this chart highlight the sign ificant differences between the two groups of
people both on total and in seven age groups considered.
177 2023306971199
794
105287629230139956038
3121
211
01000200030004000500060007000
V0_4 Years V5_14 Years V15_24 Years V25_39 Years V40_59 Years V60_79 Years V80 Years and
overFemale
Male

Figure no. 2: Distribution of the nu mber of hand surgery interventions
for men and women by age group in 2012 in Romania
To determine whether there are significant di fferences between men and women in relation
to the number of hand surgery interventions we calculated for each age the ratio of the
number of cases for men and women and we applied ANOVA. The reported values for
each age group are shown in figure 3, and the results of the ANO VA are summarized in
table 2.
1.63.17.0
5.7
5.0
3.9
2.0
0.01.02.03.04.05.06.07.08.0
V0_4 Years V5_14 Years V15_24 Years V25_39 Years V40_59 Years V60_79 Years V80 Years and over

Figure no. 3: The ratio of male a nd female hand surgery interventions

AE Hand Surgery – Postoperative Recovery and Medical Tourism

Amfiteatru Economic 1130 Table no. 2: ANOV A to establish differences between men and women
in the age distribution of the number of hand surgery
Source of Variation SS df MS F P-value F crit
Between Groups 12216720 1 12216720 4.94 0.046 4.75
Within Groups 29686755 12 2473896
Total 41903475 13
*Authors computations us ing Microsoft EXCEL.
There are important differences between the number of hand surgery in women and men.
The value of F statistics from ANOVA equals to 4.94 and confirms this difference between
the number of hand surgery for women and men. In 2012 the ratio of hand surgery
interventions for men and women was 4.7 males to a female person. This ratio is different for different age groups. The biggest differen ces between the two group s of people are in
the three age groups betw een 15-60 years. By the age of 24 years the value of the ratio of
hand surgery for men and women increased from 1.6 in the age group under four years, to 7.0 in the age group 15-24 years. From the age of 25 years the value of this ratio decreases
continuously reaching the level of 2. 0 for persons older than 80 years.
The age distribution of the number of hand surgery for men and women shown is in figure
4. In order to determine if the two data sets are significantly different we applied ANOVA
and the results are shown in table 3. The results showed no significant differences between
the two data sets.
5.15.89.419.934.2
22.7
3.0
1.73.813.924.136.4
18.8
1.3
0.05.010.015.020.025.030.035.040.0
V0_4 Years V5_14 Years V15_24 Years V25_39 Years V40_59 Years V60_79 Years V80 Years and
over(% )Female
Male

Figure no. 4: The age groups structu re of the number of hand surgery
for males and females in 2012 in Romania

Contemporary Approaches and Challenges of Tourism Sustainability AE

Vol. XVI • Special no. 8 • November 2014 1131 Table no. 3: ANOV A for computing the differences between men and women
in the age groups distribution of the number of hand surgery
ANOVA
Source of Variation SS df MS F P-value F crit
Between Groups 20004395 6 3334066 1.07 0.46 3.86
Within Groups 21899080 7 3128440
Total 41903475 13
*Authors computations us ing Microsoft EXCEL.
Although there is no significant gender differences on the frequency of appearances of hand
surgery by age groups it can be seen a parabolic trend with age. Thus, interventions appear
more frequently in the working ag e being able to associate their appearance with the type of
occupation and type of work (Sinescu, R. et. all, 2014).
In the following we analyse the frequency of surgery for men and women by the type of
intervention. In 2012 at national level there have been 20086 hand surgeries in Romanian
hospitals. Table 4 shows the distribution of ha nd surgery by the total number, male and
female. The graph in figure 5 shows for the entire population, males and females the
cumulative frequencies calculated by the types of interventions that have been previously sorted in ascending order by relative frequencies.
The results reveal the following:
• For the entire population who underwent hand surgery three types of interventions
cumulates 52.2% (they have codes 1466, 1457 and 1440) of the total number of
interventions.
• The concentration on specific types of surgical intervention is more pronounced in
females compared to the male. Thus for the females the most common five interventions
covering 65.5% of the total number of interventions in this group of people, while for males
this value is equal to 42.5%.
• The most common intervention for men is "Closed reduction of dislocation of the
hand articulation" representing 13.3%.
• The most common intervention for women is "Repair of the tendon of hand" which
represents 23.3% of total.
Table no. 4: Distribution of hand surgery by the type (%)
CODE Name Total Male Female
1445 Synovectomy of the wrist 0.18 0.01 0.49
1473 Procedures for baseball finger 0.28 0.01 0.94
1465 Ligament or interphalangeal joint capsu le at hand repair 3.09 0.02 1.83
1443 Incision procedures on wrist 0.11 0.07 0.29
1464 Other arthroplasty of the interphalange al joint of the hand 0.02 0.07 0.03
1446 Synovectomy of the tendon of hand or wrist 0.74 0.11 2.28
1452 Closed reduction of fracture of carp 0.33 0.12 0.54

AE Hand Surgery – Postoperative Recovery and Medical Tourism

Amfiteatru Economic 1132 CODE Name Total Male Female
1463 Metacarpophalangeal joint arthroplasty 0.07 0.14 0.06
1474 Procedures for hand or wrist lump 0.60 0.14 2.14
1469 Reconstruction procedures on hand 0.54 0.18 0.68
1471 Correction procedure at hand or finger 7.66 0.18 6.65
1442 Incision procedures on wrist 0.25 0.22 0.37
1462 Interphalangeal joint arthroplasty in the hand 0.14 0.28 0.17
1453 Closed reduction of fracture of metacarpus 2.21 0.29 2.00
1447 Fasciectomia for Dupuytren' s disease 3.45 0.42 2.85
1470 Reconstruction procedures on wrist 0.16 0.51 0.06
1456 Open reduction of fracture of metacarpus 4.97 0.69 3.54
1459 Open reduction of dislocation of wrist 1.32 0.70 1.54
1441 Incision procedures on a hand bone 0.86 0.88 0.74
1450 Other excision procedures on hand 1.26 0.93 1.26
1451 Other excision procedures on wrist 0.13 1.26 0.17
1460 Hand arthrodesis 1.92 1.28 1.08
1461 Bone graft at the wrist, metaca rpal or phalanx 0.29 2.10 0.34
1454 Closed reduction of hand phalanx 2.38 2.25 2.17
1455 Open reduction of fracture of carp 0.79 2.43 1.26
1466 Repair of the tendon of hand 29.82 3.35 23.32
1448 Amputation of wrist, hand or finger 8.04 3.58 9.56
1468 Other repair procedures on hand 0.36 3.78 1.23
1457 Open reduction of fracture of phalanx of hand 12.64 5.28 10.50
1449 Other excision procedures on bone of hand 1.00 7.72 1.31
1472 Correction procedures on the hand 0.02 7.87 0.09
1440 Incision procedures on a muscle, tendon or fascia of hand 9.78 8.57 15.50
1458 Closed reduction of disloca tion of hand 0.75 13.09 0.97
1467 Other repair procedures on hand 3.82 31.19 4.05
Total 100.0 100.0 100.0

Contemporary Approaches and Challenges of Tourism Sustainability AE

Vol. XVI • Special no. 8 • November 2014 1133 0.010.020.030.040.050.060.070.080.090.0100.0
1 6 11 16 21 26 31Cumulated frequencies sorted ascending (%)

Figure no. 5: Cumulative frequencies calcul ated after the types of interventions
have been previously sorted in ascending order by the relative frequencies
The linear correlation coefficient of data series that represents the number of hand surgery
by type of intervention for males and females is equal to 0.92 and indicates a strong dependence between the two data sets. The same conclusion is obtained if we apply
ANOVA for which the results are shown in Table 5.
Table no. 5: ANOVA to determine di fferences between men and women
in relation to the distribution of the types of surgic al intervention
Source of Variation SS df F P-value F crit
Between Groups 2514438 1 5.16 0.03 3.99
Within Groups 32151266 66
Total 34665704 67
*Authors computations us ing Microsoft EXCEL.

Conclusions
In 2012 there were 20086 cases of hand surgery in Romania, which are distributed
differently for the male and female persons. There were 16582 male cases which represents
82.6 % of the total number of cases for men and for women there were only 3504 cases that
are 17.4 % of total cases. The most common surgery for men in 2012 was "Closed
reduction of dislocation of the hand" representing 13.3% and for women "Repair of tendon
of hand" which represents 23.3 % of the total. By applying ANOVA we found a significant
difference between men and women in the age groups distribution of the number of hand surgery. The biggest differences between the two groups of individuals were recorded in
the three age groups be tween 15-60 years.
Current availability of data does not allow an interconnected analysis of systems to measure
the impact of hand surgery interventions on the system of spa treatment in Romania.

AE Hand Surgery – Postoperative Recovery and Medical Tourism

Amfiteatru Economic 1134 Most surgeries can be found in the working age groups, thus largely explaining the cause of
the diagnoses that result in the hand surgery. By highlighting this, new research horizons
are opened up such as: To what extent hand surgery occur for patients that have mandatory
medical insurance or faculta tive insurance? The support after surgery, treatment and
recovery is provided by CNAS, employer or pr ivate insurance companie s. Is health tourism
a burden or an economic development taking into account the possibility of a recovery
procedures spa after surgery? In these circ umstances the following question arises: is spa
tourism a burden or an economic development taking into account the possibility of a spa
recovery procedure after surgery?

Acknowledgment
This work was cofinanced from the European Social Fund through Sectoral Operational
Programme Human Resources Development 2007-2013, project number POSDRU/159/1.5/S/138907” Excellence in interdisciplinary scientific research, doctoral
and postdoctoral, in the field of Economi c, Social and Medical science-EXCELIS”.

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