[编辑按]：众所周知，美国医院中有很多其他国家毕业的医生。通常观点认为，其他国家医学院毕业生的能力不如美国医学院毕业生。本研究非常有趣，一方面用患者预后数据比较外国医学院毕业生与美国医学院毕业生的医疗质量，另一方面也提醒那些言必称美国的医学同道，美国的医疗体系不一定是我们学习的榜样。

Research

Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study

Yusuke Tsugawa, Anupam B Jena, E John Orav, et al.

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j273 (Published 03 February 2017)

Cite this as: BMJ 2017;356:j273

Abstract

Objective 背景

To determine whether patient outcomes differ between general internists who graduated from a medical school outside the United States and those who graduated from a US medical school.

确定美国以外医学院毕业的普通内科医生与美国医学院毕业的普通内科医生所负责诊疗的患者预后是否存在差异。

Design 设计

Observational study.

观察性研究

Setting 场景

Medicare, USA.

美国的Medicare

Participants 研究人群

20% national sample of data for Medicare fee-for-service beneficiaries aged 65 years or older admitted to hospital with a medical condition in 2011-14 and treated by international or US medical graduates who were general internists. The study sample for mortality analysis included 1 215 490 admissions to the hospital treated by 44 227 general internists.

2011年-2014年间，Medicare付费的因内科疾病住院的65岁以上患者全国数据库中20%的病例，患者由国际或美国医学院毕业的普通内科医生负责诊治。病死率分析的研究样本包括由44227名普通内科医生诊治的1215490名住院患者。

Main outcome measures 主要预后指标

Patients' 30 day mortality and readmission rates, and costs of care per hospital admission, with adjustment for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). As a sensitivity analysis, we focused on physicians who specialize in the care of patients admitted to hospital ("hospitalists"), who typically work in shifts and whose patients are plausibly quasi-randomized based on the physicians' work schedules.

30天病死率及再入院率，每次住院的医疗费用，根据患者及医生特征以及医院固定效应（比较同一所医院的不同医生）进行校正。在敏感性分析中，我们关注了那些仅负责住院患者诊治的医生(hospitalist)。这些医生通常轮班工作，根据医生的排班表，患者近似随机分配。

Results 结果

Compared with patients treated by US graduates, patients treated by international graduates had slightly more chronic conditions. After adjustment for patient and physician characteristics and hospital fixed effects, patients treated by international graduates had lower mortality (adjusted mortality 11.2% v 11.6%; adjusted odds ratio 0.95, 95% confidence interval 0.93 to 0.96; P<0.001) and slightly higher costs of care per admission (adjusted costs $1145 (£950; €1080) v $1098; adjusted difference $47, 95% confidence interval $39 to $55, P<0.001). Readmission rates did not differ between the two types of graduates. Similar differences in patient outcomes were observed among hospitalists. Differences in patient mortality were not explained by differences in length of stay, spending level, or discharge location.

与美国医学院毕业生治疗的患者相比，国外毕业生治疗的患者慢性疾病稍多。针对患者及医生特征以及医院固定效应进行校正后，国外毕业生负责治疗的患者病死率较低（校正后病死率 11.2% v 11.6%；校正后比数比 0.95, 95% 可信区间 0.93 - 0.96；P<0.001），每次住院的医疗费用稍高（校正后费用 $1145 (£950; €1080) v $1098；校正后差异$47, 95% 可信区间 $39 - $55, P<0.001).

Conclusions 结论

Data on older Medicare patients admitted to hospital in the US showed that patients treated by international graduates had lower mortality than patients cared for by US graduates.

有关美国住院的老年Medicare患者的资料显示，与美国毕业生负责的患者相比，由国外毕业生负责诊治的患者病死率较低。