US Patient Mortality Lower With Non-US-Trained Physicians

Ricki Lewis, PhD

February 02, 2017

Medicare patients admitted to the hospital and treated by internists who graduated from medical schools outside the United States had lower 30-day mortality than matched patients cared for by graduates of US schools, according to results of a study published online today in the British Medical Journal (BMJ).

To practice in the US, international medical school graduates must pass two exams on medical knowledge and one assessment of clinical skills, and complete accredited residency training here. However, medical schools outside the US are not accredited by any domestic agency. In response to concerns about quality of care from internationally trained physicians, the Educational Commission for Foreign Medical Graduates will require accreditation of medical schools outside the US by 2023.

Studies comparing the quality of care provided by internationally trained physicians with that by domestically trained physicians are few and small in scope. Yet, physicians trained outside the US may be perceived by some as not as competent as physicians who attended medical school in the US.

To compare the two, Yusuke Tsugawa, MD, MPH, PhD, from the TH Chan School of Public Health at Harvard, and colleagues conducted a large observational study of hospitalized Medicare beneficiaries to assess whether outcomes differ depending upon whether or not their general internists were trained domestically or abroad. The study excluded graduates from Central America and the Caribbean to minimize inclusion of US citizens trained outside the country. The countries that contributed the most internists to US hospitals were China, Egypt, India, Mexico, Nigeria, Pakistan, the Philippines, and Syria.

The researchers assessed 30-day mortality rate (the primary outcome), readmission rate, and costs of care (total part B spending), and whether clinical condition influences differences in patient outcomes and care costs between the two groups of patients. In addition, they adjusted their models for patient characteristics (age, sex, race or ethnic group, diagnosis, and income), physician characteristics (age, sex, and patient volume,) and hospital fixed effects (characteristics of hospitals).

Results indicated that 44.3% (19,589 of 44,227) of general internists in the US graduated from medical schools outside the country. They were slightly younger than US graduates (46.1 v 47.9 years; P < .001), and were more likely to work in medium-sized, nonteaching, for-profit hospitals without intensive care units.

In addition, their patients were more likely to be nonwhite, have Medicaid, have lower median household income, and have more chronic comorbidities (congestive heart failure [CHF], chronic obstructive pulmonary disease [COPD], and diabetes).

The mortality analysis included 1,215,490 patients admitted to the hospital under the care of 44,227 general internists between 2011 and 2014. Patients treated by international graduates had lower mortality (adjusted mortality, 11.2% v 11.6%; adjusted odds ratio, 0.95; 95% confidence interval [CI], 0.93 - 0.96; P < .001).

"Based on the risk difference of 0.4 percentage points, for every 250 patients treated by US medical graduates, one patient's life would be saved if the quality of care were equivalent between the international graduates and US graduates," the authors write.

The cost analysis included 1,276,559 patients treated by 44,680 physicians during the same study period.

Overall, patients of internationally trained internists had slightly higher adjusted costs of care per admission ($1145 v $1098; adjusted difference, $47; 95% CI, $39 - $55; P < .001).

Meanwhile, adjusted readmission rates among 1,182,268 patients who were treated by 44,201 physicians did not differ between the two patient groups.

When the researchers examined 30-day mortality in patients with one of six conditions (sepsis, pneumonia, CHF, COPD, urinary tract infection, and arrhythmia), they found that patients of international graduates had lower mortality than patients of US graduates for pneumonia and CHF.

"Taken together, our findings should reassure policymakers and the public that our current approach to licensing international medical graduates in the US is sufficiently rigorous to ensure high quality care," the researchers conclude.

They suggest that the testing process may select for the top international medical school graduates. The fact that some internationally trained internists may have completed two residencies (one in the home country and one here) might also contribute to the slightly better mortality outcomes of their patients.

A limitation of the study was the inability to assign patient outcomes to physicians from individual countries.

The researchers have disclosed no relevant financial relationships.

BMJ. Published online February 2, 2017. Abstract

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