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

BMJ 2017; 356 doi: (Published 03 February 2017) Cite this as: BMJ 2017;356:j273
  1. Yusuke Tsugawa, research associate1 2 3,
  2. Anupam B Jena, Ruth L Newhouse associate professor, and faculty research fellow4 5 6,
  3. E John Orav, associate professor2 7,
  4. Ashish K Jha, K T Ki professor of international health, and director12 3 8
  1. 1Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
  2. 2Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
  3. 3Harvard Global Health Institute, Cambridge, MA, USA
  4. 4Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
  5. 5Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
  6. 6National Bureau of Economic Research, Cambridge, MA, USA
  7. 7Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
  8. 8VA Boston Healthcare System, Boston, MA, USA
  1. Correspondence to: Y Tsugawa ytsugawa{at}
  • Accepted 3 January 2017


Objective 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.

Design Observational study.

Setting Medicare, USA.

Participants 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.

Main outcome measures 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.

Results 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.

Conclusions 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.


  • Contributors: All authors conceived and designed the study, analyzed and interpreted the data, and critically revised the manuscript for important intellectual content. ABJ and AKJ acquired the data. YT and EJO carried out the statistical analysis. YT drafted the manuscript and is the guarantor.

  • Funding: This study received no support from any organization.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at YT was supported in part by the Abe Fellowship Program (administered by Social Science Research Council with funds from the Japan Foundation Center for Global Partnership) and St Luke’s International University. ABJ was supported by the Office of the Director, National Institutes of Health (NIH early independence award, grant 1DP5OD017897-01). ABJ reports receiving consulting fees unrelated to this work from Pfizer, Hill Rom Services, Bristol Myers Squibb, Novartis Pharmaceuticals, Vertex Pharmaceuticals, and Precision Health Economics (a company providing consulting services to the life sciences industry).

  • Ethical approval: This study was reviewed and granted exemption by the institutional review board of Harvard Medical School.

  • Data sharing: No additional data available.

  • Transparency: The lead author (YT) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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