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[MEDSCAPE医学新闻]:非美国培训的医生负责诊治的美国患者病死率较低
2017年02月10日 时讯速递, 进展交流 暂无评论

[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。

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).

British Medical Journal今天在线发表的一项研究结果显示,与美国医学院毕业的内科医生诊治的患者相比,由国外医学院毕业的内科医生负责治疗的Medicare住院患者30天病死率更低。

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.

国外医学院毕业生若在美国行医,必须通过有关医学知识的两项考试以及临床技能的一次评估,并在美国完成经过认证的住院医生培训。然而,其他国家的医学院并未得到美国国内任何机构的认证。为了回应有关国外培训医生医疗质量的疑虑,外国医学毕业生教育委员会要求到2023年对国外的医学院进行认证。

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.

比较国外培训医生与美国培训医生医疗质量的研究很少,样本量也很小。然而,人们可能认为国外培训的医生在能力方案不如美国医学院毕业的医生。

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.

为了对上述两类医生进行比较,哈佛医学院TH Chan公共卫生学院的Yusuke Tsugawa博士及其同事对住院的Medicare患者进行了一项大规模观察性研究,以评估美国或国外培训的普通内科医生负责诊治患者的临床预后。研究排除了中美洲及加勒比海地区的毕业生,以减少纳入在国外接受培训的美国公民的可能。美国医院中国外培训的内科医生最主要的来源包括中国,埃及,印度,墨西哥,尼日利亚,巴基斯坦,菲律宾和叙利亚。

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).

研究者对两组患者30天病死率(主要预后指标)、再入院率、医疗费用进行了评估,并评估了临床情况是否影响患者预后及医疗费用的差异。另外,他们还根据患者特征(年龄,性别,种族,诊断及收入)、医生特征(年龄,性别及诊疗量)以及医院固定效应(医生特征)对模型进行了校正。

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; < .001), and were more likely to work in medium-sized, nonteaching, for-profit hospitals without intensive care units.

研究结果提示,美国44.3% (19589/44227)的普通内科医生为国外医学院毕业生。与美国医学院毕业生相比,国外医学院毕业生年龄稍大(46.1 v 47.9 岁;< .001),更多人在中等规模的非教学性盈利医院工作,没有设置ICU的医院比例更高。

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).

另外,由国外医学院毕业的普通内科医生负责诊治的患者更多为非白人,有Medicaid保险,家庭收入中位数较低,且有很多慢性疾病(充血性心力衰竭[CHF],慢性阻塞性肺疾患[COPD]及糖尿病)。

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; < .001).

病死率分析纳入了2011年至2014年间由44227名普通内科医生负责诊治的1215490名入院患者。国外毕业生负责诊治的患者病死率较低(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)。

"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.

“根据风险差异0.4%推算,如果国外毕业生与美国毕业生的医疗质量相同,由美国医学院毕业生负责诊治的每250名患者中,将有1名患者生命得以挽救,”作者写到。

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

费用分析包括了研究期间由44680名医生负责诊治的1276559名患者。

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; < .001).

总之,经过校正后,由国外培训的内科医生负责诊疗的患者每次住院的医疗费用稍高($1145 v $1098;校正后差异$47, 95% 可信区间 $39 - $55, P<0.001).

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

同时,对44201名医生负责诊疗的1182268名患者再入院率两组间并无差异。

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.

研究者还分别比较了6种疾病(全身性感染,肺炎,CHF,COPD,泌尿系感染及心律失常)患者30天的病死率。他们发现,对于肺炎及CHF患者而言,与美国毕业生相比,由国外毕业生负责诊治的患者病死率较低。

"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.

“综合上述结果,我们的发现向政策制定者及公众表明,美国目前认证国外医学院毕业生的方式非常严格,能够保证医疗质量,”研究者总结到。

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.

研究者认为,考试方式可能选择了国外医学院顶尖的毕业生。部分国外培训的内科医生完成了两次住院医生培训(一次在祖国,一次在美国)可能也是造成患者病死率较低的原因。

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

研究的局限性之一是无法将患者预后与每个国家的医生相对应。

The researchers have disclosed no relevant financial relationships. 

BMJ. Published online February 2, 2017. Abstract

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