Association between physician US News & World Report medical school ranking and patient outcomes and costs of care: observational studyBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3640 (Published 26 September 2018) Cite this as: BMJ 2018;362:k3640
- Yusuke Tsugawa, assistant professor1,
- Daniel M Blumenthal, instructor234,
- Ashish K Jha, KT Li professor56,
- E John Orav, associate professor78,
- Anupam B Jena, Ruth L Newhouse associate professor91011
- 1Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 911 Broxton Avenue, Los Angeles, CA 90024, USA
- 2Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- 3Department of Medicine, Harvard Medical School, Boston, MA, USA
- 4Devoted Health, Waltham, MA, USA
- 5Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA
- 6The VA Healthcare System, Boston, MA, USA
- 7Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- 8Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
- 9Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- 10General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- 11National Bureau of Economic Research, Cambridge, MA, USA
- Correspondence to: Y Tsugawa
- Accepted 16 August 2018
Objective To investigate whether the US News & World Report (USNWR) ranking of the medical school a physician attended is associated with patient outcomes and healthcare spending.
Design Observational study.
Setting Medicare, 2011-15.
Participants 20% random sample of Medicare fee-for-service beneficiaries aged 65 years or older (n=996 212), who were admitted as an emergency to hospital with a medical condition and treated by general internists.
Main outcome measures Association between the USNWR ranking of the medical school a physician attended and the physician’s patient outcomes (30 day mortality and 30 day readmission rates) and Medicare Part B spending, adjusted for patient and physician characteristics and hospital fixed effects (which effectively compared physicians practicing within the same hospital). A sensitivity analysis employed a natural experiment by focusing on patients treated by hospitalists, because patients are plausibly randomly assigned to hospitalists based on their specific work schedules. Alternative rankings of medical schools based on social mission score or National Institute of Health (NIH) funding were also investigated.
Results 996 212 admissions treated by 30 322 physicians were examined for the analysis of mortality. When using USNWR primary care rankings, physicians who graduated from higher ranked schools had slightly lower 30 day readmission rates (adjusted rate 15.7% for top 10 schools v 16.1% for schools ranked ≥50; adjusted risk difference 0.4%, 95% confidence interval 0.1% to 0.8%; P for trend=0.005) and lower spending (adjusted Part B spending $1029 (£790; €881) v $1066; adjusted difference $36, 95% confidence interval $20 to $52; P for trend <0.001) compared with graduates of lower ranked schools, but no difference in 30 day mortality. When using USNWR research rankings, physicians graduating from higher ranked schools had slightly lower healthcare spending than graduates from lower ranked schools, but no differences in patient mortality or readmissions. A sensitivity analysis restricted to patients treated by hospitalists yielded similar findings. Little or no relation was found between alternative rankings (based on social mission score or NIH funding) and patient outcomes or costs of care.
Conclusions Overall, little or no relation was found between the USNWR ranking of the medical school from which a physician graduated and subsequent patient mortality or readmission rates. Physicians who graduated from highly ranked medical schools had slightly lower spending than graduates of lower ranked schools.
Contributors: All authors contributed to the design and conduct of the study, data collection and management, analysis, and interpretation; and preparation, review, or approval of the manuscript. YT is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding: ABJ was supported by the Office of the Director, National Institutes of Health (NIH Early Independence Award, grant 1DP5OD017897). ABJ reports receiving consulting fees unrelated to this work from Pfizer, Hill Rom Services, Bristol Myers Squibb, Novartis Pharmaceuticals, Amgen, Eli Lilly, Vertex Pharmaceuticals, Precision Health Economics, and Analysis Group. DMB has received consulting fees unrelated to this work from Precision Health Economics, Amgen, Novartis, and HLM Venture Partners, and is the associate chief medical officer of Devoted Health, which is a health insurance company. Study sponsors were not involved in study design, data interpretation, writing, or the decision to submit the article for publication.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: ABJ has received consulting fees unrelated to this work from Pfizer, Hill Rom Services, Bristol Myers Squibb, Novartis Pharmaceuticals, Amgen, Eli Lilly, Vertex Pharmaceuticals, Precision Health Economics, and Analysis Group. DMB has received consulting fees unrelated to this work from Precision Health Economics, Amgen, Novartis, and HLM Venture Partners, and is the associate chief medical officer of Devoted Health, which is a health insurance company.
Ethical approval: This study was approved by the institutional review board at 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 are disclosed.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.