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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; Pv $1098; adjusted difference $47, 95% confidence interval $39 to $55, PConclusionsData 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.IntroductionInternational medical graduates make up a quarter of the physician workforce in the United States, United Kingdom, Canada, and Australia.12345 In the UK, these graduates are largely from India, Republic of Ireland, and Pakistan, and in the US, largely from India, the Philippines, and Pakistan (not including US citizens who have gone abroad for medical education and returned to the US to practice).3 The licensure process for international medical graduates varies between these countries: in the UK, students have to pass an English language and Professional and Linguistic Assessments Board tests so they can register with the UK General Medical Council to practice.6 In the US, students must pass two examinations that test medical knowledge and one examination that assesses clinical skills, and they must complete accredited residency training in the US (see supplementary appendix 1 for details).7 Although international graduates are required to pass these examinations to practice medicine in the UK and US, there have been no UK based or US based standardized accreditations of foreign medical schools, and consequently both policymakers and the public have expressed concerns about the quality of care provided by these graduates.891011 In addition, studies have suggested that there may be implicit biases that the quality of care international graduates deliver may be inferior to that of doctors trained domestically, potentially leading to discriminations against physicians who have trained abroad.121314 In response, in the US, the Educational Commission for Foreign Medical Graduates recently announced the requirement for all foreign medical schools to be accredited through a formal process by 2023.15 However, it is unclear whether current licensure processes for international medical graduates provide adequate safeguards for ensuring high quality care.Though concerns about the quality of care delivered by international medical graduates are often raised, available data comparing patterns of care and outcomes between international medical graduates and doctors trained domestically are limited. The evidence that does exist is inconsistent and has focused on measures such as test scores161718 and process measures of quality.19 The studies that have examined patient outcomes have been small and from a few US states or a single Canadian province, making it difficult to draw conclusions about the quality of care provided by international graduates more broadly.20212223 Given the substantial public interest in and ongoing concerns about the quality of care such graduates provide in the US, UK, and other high income countries891011 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.Using a national sample of elderly patients admitted to hospital in the US, we sought to answer three key questions. First, do patients treated by internists who graduated outside the US have different mortality compared with patients treated by internists who graduated from a US medical school? Second, given substantial efforts and interest in reducing rates of readmissions and costs of care, do international graduates have higher readmission rates zantac 150 how much or provide more costly care than US graduates? Finally, do differences in patient outcomes and costs of care between the two types of graduates, if any, vary by clinical condition?MethodsWe linked four data sources: the 100% Medicare Inpatient Files (2011 14), the 20% Medicare Carrier Files (2011 14), the American Hospital Association annual survey on hospital characteristics, and a comprehensive physician database collected by Doximity (see supplementary appendix 1 for details of this database, including its validation242526).

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