麻豆传媒

Hospitalized patients who received care from international medical graduates (IMGs) or U.S.-trained doctors had similar 30-day mortality and similar cost of care, according to a study of more than a million hospital admissions.

After adjustment for disease type, severity, and other factors, patients treated by internationally schooled doctors had a slightly -- but significantly -- lower 30-day mortality, 11.2% compared with 11.6% for patients who received care from physicians trained in the U.S. The average medical cost per admission was about $50 higher with international medical graduates.

Readmission rates and other key parameters of outcome or quality did not differ significantly between the groups of patients. Collectively, the findings suggest that the current rigorous approach for selecting international medical graduates to practice in the U.S. is working, , of Harvard T.H. Chan School of Public Health, and colleagues reported in .

"The bottom line is that physicians who are training elsewhere and providing care in the U.S. are providing high-quality care," Tsugawa told 麻豆传媒. "They are adding value to the healthcare system."

President Trump's executive order limiting immigration from certain countries could have implications for the quantity and quality of IMGs who come to the U.S., he added. Noting that IMGs make up a fourth of the physician workforce in the U.S. -- even more in certain specialties -- broader or long-term immigration restrictions could limit the number of IMGs who can come to the U.S.

From a quality perspective, "if we were to lower the bar to allow more IMGs to come to the U.S., we could lower the quality of care in the process," said Tsugawa, who attended medical school in Japan.

The findings did not come as a great surprise to an administrator at the major organization representing U.S. medical schools.

“When you look at people who go to medical school, you’ve got top-of-the-class people,” said Janis Orlowski, MD, chief health care officer at Association of American Medical Colleges. “[IMGs] are individuals who have already gone to medical school and are the best in their class. So you’ve got smart people going to medical school and then you’ve got smart people at the top of their class.

“The United States has this incredible value of being able to attract the top individuals from medical school classes from around the world, who come here to be physicians and scientists. They are the smartest and brightest of the countries we work with. You bring all of these people to the United States to collaborate, and it creates an environment of innovation and good care. It’s not surprising that they do well.”

The author of a reiterated the conclusions of his study: that IMGs face prejudice-based bias in the selection process for postgraduate training.

"The same factors ... led to discrimination against women, Jews, the Irish, African Americans, and other minorities in the history of U.S. medicine," , an internist practicing in Chattanooga, Tenn., said by email. "The only rational basis for preferring U.S. medical graduates over IMGs would be protectionism for U.S. graduates, but this policy would not lead to the best doctors for U.S. citizens. These issues have never been openly discussed."

Although his article, co-authored with , of Marshfield Clinic in Wisconsin, did not address quality of care, "our bias would have been similar to the (Tsugawa) article's findings," Desbiens said.

IMG Impact on Care

IMGs make up about a fourth of the physician workforce in the United States, United Kingdom, Canada, and Australia. The licensure process varies among the nations. In the U.S., IMGs must pass two exams, one evaluating medical knowledge and the other clinical skill. Additionally, IMGs must complete residencies at accredited training centers in the U.S., Tsugawa and colleagues noted.

Though some concerns have been raised about the quality of care provided by IMGs, evidence on the issue is lacking, the authors continued. What's more, the few studies that have addressed quality of care provided by IMGs yielded conflicting data, based primarily on test scores and process measures. Even fewer studies examined patient outcomes, making it difficult to draw broad conclusions about the quality of care.

"Given the substantial public interest in and ongoing concerns about the quality of care [IMGs] provide in the U.S., U.K., and other high-income countries, and policymakers' efforts to assure more consistency in foreign medical education, it would be helpful to have empirical data on how international medical graduates perform," the authors said.

The study involved records from two Medicare databases, the American Hospital Association annual survey, and the physician database. They identified Medicare fee-for-service beneficiaries who had non-elective admissions to acute-care hospitals from Jan. 1, 2011, to Dec. 31, 2014. Focusing on general internists, the authors used multiple sources to determine when and where physicians attended medical school and completed graduate training.

The primary outcome was 30-day mortality. Secondary outcomes included 30-day readmission rates and cost of care. The authors defined cost of care at total Medicare Part B spending associated with each hospital admission.

Key Findings

Data analysis comprised 1,215,490 hospital admissions. Of 44,227 general internists identified through the investigation, 19,589 were IMGs. The foreign graduates were slightly younger (46.1 versus 47.9, P<0.001); more likely to work in medium-sized, non-teaching, for-profit hospitals; and more likely to work at hospitals that did not have intensive care units.

Patients treated with IMGs tended to be nonwhite, have lower median household income, have Medicare coverage, and have more comorbid conditions.

The overall 30-day mortality was 11.4%. Unadjusted 30-day mortality was 11.0% among patients treated by IMGs and 11.9% for patients who received care from U.S.-trained physicians. Adjustment for patient differences brought the rates to 11.1% and 11.7%, and further adjustment for differences in physician characteristics resulted in the final adjusted mortality, which represented a mortality odds ratio of 0.95, favoring the IMG-treated group (95% CI 0.93-0.96, P<0.001).

"The difference in patient mortality between the international and U.S. graduates ... is at most a modest clinical significance," the authors noted.

Fully adjusted 30-day readmission rates did not differ between IMGs (15.4%) and U.S.-trained physicians (15.5%). Unadjusted rates were higher for the IMG group, suggesting differences that were driven by hospital-specific factors, the authors said. The adjusted median cost per hospital admission was $1,145 for IMG-treated patients and $1,098 for patients who received their care from U.S.-trained physicians, a small but significant difference (P<0.001).

Tsugawa and colleagues acknowledged limitations of the study: inability to distinguish between foreign-born physicians and those who were born in the U.S. and traveled to other countries to attend medical school; possibly incomplete coding of IMG patients' comorbidities, which could affect mortality; 30-day mortality and readmission rates, though widely accepted, are not comprehensive measures of quality of care.

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