Quality of Care of International and Canadian Medical Graduates in Acute Myocardial Infarction

ORIGINAL INVESTIGATION Quality of Care of International and Canadian Medical Graduates in Acute Myocardial Infarction

Dennis T. Ko, MD; Peter C. Austin, PhD; Benjamin T. B. Chan, MD, MPA; Jack V. Tu, MD, PhD

Background: International medical graduates (IMGs) Results: Of the 127275 admitted AMI patients, 28061 make up a substantial proportion of the physician work- (22.0%) were treated by IMGs and 99214 (78.0%) by Ca- force and play an important role in the care of patients nadian medical graduates. The risk-adjusted mortality rates with acute myocardial infarction (AMI). There are con- of IMG- and Canadian medical graduate–treated patients cerns that IMGs may provide inferior medical care com- were not significantly different at 30 days (13.3% vs 13.4%, pared with locally trained medical graduates, but that has P=.57) and at 1 year (21.8% vs 21.9%, P=.63). Further- not been established. more, AMI patients treated by both groups had similar adjusted likelihood of receiving secondary prevention medi- Methods: We performed a retrospective cohort study cations at 90 days and cardiac invasive procedures at 1 year. of linked administrative databases containing health care claims of physicians’ service payments, hospital dis- Conclusions: The use of secondary prevention medications charge abstracts, and patients’ vital status. We included and cardiac procedures and the mortality of AMI patients 127275 AMI patients admitted between April 1, 1992, were similar, regardless of the origin of medical education and March 31, 2000, to acute care hospitals in Ontario. of the admitting physician. This information places the care We then compared the risk-adjusted mortality rates and provided by IMGs into perspective and supports the abil- adjusted use of secondary prevention medications and ity of well-selected IMGs in caring for AMI patients. cardiac invasive procedures in patients treated by IMGs vs Canadian medical graduates. Arch Intern Med. 2005;165:458-463

NTERNATIONAL MEDICAL GRADU- evidence-based therapy for secondary ates (IMGs) in the United States prevention in patients with acute myocar- and Canada are usually referred dial infarction (AMI),9,10 and the appli- to as physicians who have com- cation of these therapies has been used pleted their undergraduate medi- as quality indicators of care.11 This well- calI education outside of these countries. established performance framework al- They may have entered practice directly lowed a unique opportunity to compare or after completing a period of postgradu- the quality of medical care provided by Author Affiliations: Division of ate training in North America. Both coun- IMGs with the care provided by Cana- Cardiology and Schulich Heart tries use licensing requirements to screen dian medical graduates (CMGs). In addi- Centre (Dr Ko), Institute for the competency of IMGs,1,2 but whether tion, we compared the risk-adjusted mor- Clinical Evaluative Sciences these efforts translate into selecting those tality rates of AMI patients treated by IMGs (Drs Ko, Austin, Chan, and Tu), who can provide high-quality medical care and CMGs. and Division of General Internal Medicine and Clinical is uncertain. Many suspect that the qual- Epidemiology and Health Care ity of medical care provided by IMGs may METHODS 3-6 Research Program (Dr Tu), be inferior, but this hypothesis has not Sunnybrook and Women’s been fully evaluated.3 International medi- College Health Sciences Centre; cal graduates play a substantial role in the DATA SOURCES and Departments of Public delivery of health care, as they make up Health Sciences (Drs Austin, approximately one quarter of the physi- The Ontario Myocardial Infarction Database has 12 Chan, and Tu), Family and cian workforce in both countries.7,8 Un- previously been described. Briefly, the infor- Community Medicine derstanding the potential discrepancies of mation in this database is obtained by linking (Dr Chan), Health Policy, care provided by IMGs is important in the several health care administrative databases in Management and Evaluation Ontario. All 190354 patients admitted to On- (Drs Chan and Tu), and interests of many health care consumers tario hospitals with an AMI between April 1, Medicine (Dr Tu), Faculty and policy makers. 1992, and March 31, 2000, were identified of Medicine, University The American College of Cardiology based on a “most responsible diagnosis” of AMI of Toronto; Toronto, Ontario. and American Heart Association practice (International Classification of Diseases, Ninth Financial Disclosure: None. guidelines have highlighted the use of Revision code 410) in the Canadian Institute

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Downloaded From: https://jamanetwork.com/ on 09/27/2021 for Health Information hospital discharge database. We ex- STATISTICAL ANALYSIS cluded patients younger than 20 years or older than 105 years, as well as those who were not Ontario residents, had an in- We first compared the physician characteristics of IMGs and valid Ontario health card number, were admitted as transfers CMGs. Then, we compared the demographic and clinical char- from another acute care institution or to a noncardiac surgical acteristics of patients treated by IMGs with those of patients service, had an AMI coded as an in-hospital complication, were treated by CMGs. Categorical variables were compared be- discharged alive with a length of stay of less than 3 days, or tween the 2 groups using ␹2 tests, while continuous variables were admitted with an AMI in the year before the index ad- were compared using t tests or nonparametric tests. ␹2 Tests mission. The rationale for these inclusion and exclusion crite- compared the use of medical therapy, cardiac procedure use, ria is detailed elsewhere.12 A total of 146382 patients met these and mortality between IMG- and CMG-treated patients. This criteria, and the coding accuracy of AMI in this cohort is greater was repeated comparing IMGs from English-speaking devel- than 94%.12 The Canadian Institute for Health Information da- oped countries (England, Ireland, Australia, New Zealand, and tabase was then linked to the Ontario Registered Persons Da- South Africa) with IMGs originating from all other countries tabase, which contains information on the vital status of all On- where English was not the predominant language. We ex- tario residents. cluded US medical graduates in all our analyses because of their similarities with CMGs, which was consistent with previous studies.14,15 CLASSIFICATION OF ADMITTING PHYSICIANS We used the Ontario AMI mortality prediction rules to cal- culate risk-adjusted mortality rates.16 These rules are based on The admitting physician for each AMI patient was determined logistic regression models that predict 30-day and 1-year mor- by linking the Ontario Myocardial Infarction Database cohort tality after an AMI. International Classification of Diseases, Ninth to the Ontario Health Insurance Plan database, which con- Revision codes were used to identify the prevalence of 9 clinical tains information on physician claims for all fee-for-service bill- risk factors in the 15 secondary diagnostic fields of the Cana- ings in Ontario. The billing codes for each patient were ana- dian Institute for Health Information database and the age and lyzed, and the admitting physician was identified as the first sex of the patients. These variables included severity of cardiac physician who submitted a claim rendered on or after the ad- disease (shock, congestive heart failure, pulmonary edema, and mission date. Billing codes for emergency department physi- arrhythmia) and comorbid conditions (cerebrovascular dis- cians were not included in determining the admitting physi- ease, cancer, diabetes mellitus, and acute and chronic renal fail- cian. In the event that 2 or more physicians submitted claims ure). This model has good predictive power, with areas under on the admission date, the admitting physician was defined as the receiver operating characteristic curve of 0.78 for 30-day mor- the physician who submitted the most claims for follow-up care tality and 0.79 for 1-year mortality. These rules were validated during that hospitalization. A unique admitting physician was in 2 separate independent data sets in California and Manitoba, identified for 127275 patients, representing the final study co- with receiver operating characteristic curves of 0.77 and 0.78 for hort. Additional characteristics of the admitting physician were 30-day and 1-year mortality, respectively. The model develop- identified by linkage to the Corporate Provider Database of the ment and validation are described in detail elsewhere.16 Ontario Ministry of Health and verified against information in Multivariate analyses of the use of secondary prevention the Ontario Physician Human Resource Data Centre Data- medications and cardiac procedures provided by IMGs were base. These data sources provided information on the age, sex, also conducted using random-effects hierarchical logistic re- self-reported medical specialty, and medical school education gression models. A multilevel analysis allows one to correctly of the physicians. All patient identifiers and physician billing incorporate variables measured at different levels of the hier- numbers were encrypted to maintain patient and physician con- archy and to take into account the fact that the outcomes of fidentiality. patients under the care of a single physician or within the same hospital may be correlated.17 For use of medical therapy, we adjusted for patient characteristics, including all the clinical vari- USE OF SECONDARY PREVENTION ables that were used to construct the Ontario AMI prediction MEDICATIONS AND CARDIAC rules, and other physician characteristics (age, sex, specialty, INVASIVE PROCEDURES and physician volume of AMI patients treated). In a similar man- ner, for use of cardiac invasive procedures, we adjusted for pa- Data on the use of secondary prevention medications in 63301 tient and physician characteristics and other hospital factors older survivors of AMI were obtained by linkage to the On- (hospital volume, teaching status, and availability of revascu- tario Drug Benefit database.13 This database is a government- larization facilities) that may influence procedure use. funded drug benefit program that covers outpatient drug costs Multilevel models were fitted using the software package for all Ontario residents 65 years or older. Our aspirin use rates HLM (Scientific Software International, Lincolnwood, Ill). All are likely underestimates, as patients may have elected to pur- traditional statistical analyses were conducted using SAS ver- chase aspirin over the counter. sion 8 software (SAS Institute, Cary, NC). As part of the Ontario Myocardial Infarction Database ini- tiative, information on medical therapy provided during the AMI hospitalizations was abstracted for a random sample of 4383 RESULTS patients of all ages, drawn from 44 hospitals in Ontario between 1994 and 1996. These supplemental data allowed us to CHARACTERISTICS OF AMI PATIENTS measure the use of secondary prevention medications offered during the inpatient stay. Information on the use of cardiac in- The median age was 69 years and 36% were female among vasive procedures (cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass surgery) within 127275 patients admitted to the hospital with an AMI 1 year of the index AMI was obtained by linkage to the On- between April 1, 1992, and March 31, 2000, in Ontario tario Health Insurance Plan physician services and the Cana- (Table 1). The IMG- and CMG-treated patients had simi- dian Institute for Health Information hospital discharge lar clinical characteristics, comorbidities, and expected database.12 mortality rates. The IMG-treated patients were less likely

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Downloaded From: https://jamanetwork.com/ on 09/27/2021 Table 1. Characteristics of the Patients* Table 2. Characteristics of the Admitting Physicians*

P P Characteristic IMGs CMGs Value Characteristic IMGs CMGs Value No. (%) of patients 28 061 (22.0) 99 214 (78.0) . . . No. (%) of physicians 1036 (18.6) 4538 (81.4) . . . Age, mean (median), y 67.1 (69) 67.3 (69) .002 Age, median (interquartile 51 (44-59) 40 (33-47) Ͻ.001 Female 36.0 36.1 .77 range), y Admission characteristics Age group, y and comorbidities 20-34 3.1 30.4 Ͻ.001 Congestive heart failure 20.4 21.0 .046 35-44 23.1 37.3 Shock 2.4 2.3 .28 45-54 35.1 20.6 Cardiac arrhythmia 15.0 14.4 .007 55-64 26.1 7.5 Diabetes mellitus with 2.5 2.4 .47 Ն65 12.6 4.2 complications Female 10.4 19.5 Ͻ.001 Acute renal failure 1.6 1.6 .72 Rural 8.6 9.5 .36 Chronic renal failure 2.7 2.6 .47 Medical specialty Cerebrovascular disease 3.9 3.9 .81 Family physician 59.1 68.6 Ͻ.001 History of cancer 2.2 2.2 .74 General internist 18.1 9.0 Medical specialty of Cardiologist 4.7 5.7 admitting physicians Other 18.1 16.7 Family physician 20.9 29.8 Ͻ.001 Mean (median) annual volume 4.7 (1.8) 4.0 (2.0) Ͻ.001 General internist 48.2 25.6 of acute myocardial Cardiologist 21.1 30.0 infarction patients treated Characteristics of admitting hospitals Abbreviations: CMGs, Canadian medical graduates; IMGs, international Teaching hospital 12.9 17.4 Ͻ.001 medical graduates. Cardiac invasive facilities *Data are given as percentages unless otherwise indicated. None 87.2 85.6 Ͻ.001 Catheterization only 3.5 3.9 Percutaneous coronary 9.3 10.5 intervention or coronary Table 3. Location of Medical Education artery bypass grafting of International Medical Graduates (IMGs) Expected 1-y mortality rate† 21.7 21.9 .16

Abbreviations: CMGs, Canadian medical graduates; IMGs, international Location No. (%) of IMGs medical graduates. Africa, excluding South Africa 16 (1.5) *Data are given as percentages unless otherwise indicated. Asia 67 (6.5) †Expected mortality was calculated using the Ontario acute myocardial Australia or New Zealand 22 (2.1) infarction mortality prediction rules that were based on patient age, sex, severity Former Soviet Union 84 (8.1) of cardiac disease, and comorbid conditions. Ireland 149 (14.4) Indian subcontinent 139 (13.4) Middle East 32 (3.1) South Africa 51 (4.9) to be admitted to teaching hospitals (12.9% vs 17.4%, South or Central America 36 (3.5) PϽ.001) and hospitals with revascularization facilities England 377 (36.4) (9.3% vs 10.5%, PϽ.001). Western Europe 63 (6.1) Total 1036 (100.0) CHARACTERISTICS OF IMGS

Of the 5574 physicians who treated at least 1 AMI patient between April 1, 1992, and March 31, 2000, in On- tients had lower crude use rates of statins at discharge tario, 1036 (18.6%) were IMGs and 4538 (81.4%) were and of ␤-blockers at discharge and by 90 days. These dif- CMGs (Table 2). The IMGs were significantly older, less ferences, however, were not observed after multivariate likely to be female, and less likely to be a family physi- adjustment. The adjusted use of secondary prevention cian, and they had a slightly higher volume of AMI pa- medications was not significantly different between the tients treated per year compared with the CMGs. 2 groups, except for angiotensin-converting enzyme in- More than half of all IMGs in Ontario obtained their hibitors and statins at 90 days, whereas IMG-treated pa- medical degrees from England and Ireland. Other re- tients were slightly more likely to receive therapy after gions of origin, in order of frequency, included the In- adjusting for patient and other physician characteris- dian subcontinent, former Soviet Union, Asia, Western tics. Similarly, patients treated by IMGs had slightly lower Europe, and South Africa (Table 3). crude use rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass sur- SECONDARY PREVENTION MEDICATIONS, gery within 1 year of their AMIs, but these trends were CARDIAC PROCEDURES, AND MORTALITY not observed after adjustment for other patient, physician, and hospital characteristics. Table 4 details the use rates of secondary prevention The AMI mortality rates were similar between pa- medications and cardiac procedures. The IMG-treated patients treated by IMGs and CMGs. For IMG- and CMG-

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Downloaded From: https://jamanetwork.com/ on 09/27/2021 treated patients, the 30-day risk-adjusted mortality rates were 13.3% and 13.4%, respectively (P=.57) (Table 5). Table 4. Use of Secondary Prevention Medications The 1-year risk-adjusted mortality rates were 21.8% and and Cardiac Invasive Procedures After Acute Myocardial Infarction (AMI)* 21.9%, respectively (P=.63). Adjusted Odds Ratio IMGS FROM ENGLISH-SPEAKING AND (IMGs/CMGs) (95% NON–ENGLISH-SPEAKING COUNTRIES Variable IMGs CMGs Confidence Interval)† Medications at hospital Among the 1036 IMGs, 437 (42.2%) originated from non– discharge‡ English-speaking countries. Compared with IMGs from Aspirin 77.1 79.2 0.94 (0.71-1.25) ␤ English-speaking countries, their median age was younger -Blockers 54.8 59.5 0.89 (0.70-1.13) ACE inhibitors 30.7 33.7 0.88 (0.72-1.08) (49 vs 53 years) and they were more likely to be female HMG-CoA reductase 6.3 8.9 0.85 (0.62-1.15) (15.6% vs 6.7%) (data not shown). Their countries of ori- inhibitors (statins) gin (in order of frequency) were India (25.4%), Poland Medications within 90 d (6.9%), China (including Hong Kong) (4.6%), Taiwan of hospital discharge§ (3.2%), former Czechoslovakia (3.7%), Pakistan (3.2%), Aspirin 61.4 60.4 1.00 (0.94-1.06) ␤-Blockers 53.8 56.4 1.01 (0.94-1.08) and the Philippines (2.8%). The adjusted use of aspirin ACE inhibitors 51.3 52.0 1.07 (1.01-1.14) in the hospital was higher in patients treated by IMGs HMG-CoA reductase 19.1 19.8 1.10 (1.01-1.20) from English-speaking countries (odds ratio, 1.85; 95% inhibitors (statins) confidence interval, 1.12-3.06). However, the adjusted Calcium channel blockers 36.3 35.6 0.97 (0.91-1.04) use of other medical therapies and cardiac procedures was Cardiac procedures within 1 y not significantly different between the 2 groups. The risk- Cardiac catheterization 31.0 32.6 1.06 (1.01-1.11) Percutaneous coronary 9.1 9.9 1.08 (1.02-1.14) adjusted mortality rates of AMI patients were not sig- intervention nificantly different at 30 days (13.1% vs 13.6%, P=.11) Coronary artery 9.6 10.3 1.00 (0.95-1.06) but were slightly lower in patients treated by IMGs from bypass grafting non–English-speaking countries at 1 year (21.3% vs 22.3%, P=.02). Abbreviations: ACE, angiotensin-converting enzyme; CMGs, Canadian medical graduates; HMG-CoA, 3-hydroxy-3-methylglutaryl coenzyme A; IMGs, international medical graduates. COMMENT *Data are given as percentages unless otherwise indicated. †Odds ratios adjusted for the differences between IMGs and CMGs in patient and physician characteristics for medication use. In addition to Despite concerns that IMGs may provide inferior care, patient and physician characteristics, we adjusted for hospital characteristics for cardiac procedure use. An odds ratio greater than 1 indicates higher this study suggests that little difference existed between adjusted use by IMGs. patients managed by IMGs and CMGs. The IMGs in our ‡The sample included 4383 patients of all ages with detailed medical chart study came from all over the world, with more than 60 abstraction of their AMIs. §The sample was restricted to older (Ն65 years) survivors of AMI eligible countries of origin. We found similar use of secondary for Ontario drug benefits and included 63 301 patients. prevention medications and cardiac invasive procedures. Furthermore, the mortality rates of AMI patients after discharge were essentially identical. This information places the care provided by IMGs into perspective Table 5. Mortality of the Patients* and should reassure patients and policy makers about their ability to deliver AMI care. Outcome IMGs CMGs P Value There is considerable suspicion that IMGs in North Mortality at 30 d America are not as well trained or as qualified as gradu- Crude 13.3 13.5 .46 ates of domestic medical schools.3-6 This perception is Risk adjusted† 13.3 13.4 .57 Mortality at 1 y based on the fact that IMGs face cultural and language Crude 21.6 21.9 .24 barriers, may have had exposure to different disease epi- Risk adjusted† 21.8 21.9 .63 demics, or did not receive adequate medical education 3-6 to practice medicine at a technologically advanced level. Abbreviations: CMGs, Canadian medical graduates; IMGs, international To date, however, there has been little evidence to sup- medical graduates. 3 *Data are given as percentages unless otherwise indicated. port or refute this hypothesis. Previous evaluations of †Risk-adjusted mortality was calculated using the Ontario acute medical knowledge of IMGs using test scores have yielded myocardial infarction mortality prediction rules that were based on patient conflicting results. Although IMGs consistently scored age, sex, severity of cardiac disease, and comorbid conditions. lower on the US Medical Licensing Examination,18 IMGs enrolled in training programs scored higher on the In- Training Examination in Internal Medicine compared with ity of care. On outcome measures, patients treated by IMGs their US counterparts.15 Other attempts to evaluate the and CMGs had identical risk-adjusted mortality rates at quality of IMGs have been limited by the lack of recom- 30 days and 1 year after AMI. On process measures, both mended practice guidelines and the lack of correlation groups prescribed aspirin, ␤-blockers, angiotensin- between medical practices and outcomes.3 converting enzyme inhibitors, and statins at the same fre- Our study demonstrates that, in the setting of AMI, quency, after adjusting for other physician characteris- IMGs performed as well as CMGs in all aspects of qual- tics. Furthermore, there was no substantial difference

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Downloaded From: https://jamanetwork.com/ on 09/27/2021 between the care provided by IMGs from English- with the use of evidence-based therapy and the outcome speaking countries and non–English-speaking coun- of AMI patients.25 Second, the generalizability of our find- tries. Interestingly, only half of the patients were pre- ings to other jurisdictions such as the United States re- scribed ␤-blockers after AMI, despite practice guidelines mains to be established. The IMGs in the United States tend strongly advocating their use.9,10 This finding repre- to proportionately come from non–English-speaking coun- sents an opportunity to improve care and outcome of AMI tries that represent approximately 40% of all the physi- patients, regardless of the background origin and medi- cians in our cohort. The large sample of IMGs from En- cal training of the physician. gland and Ireland in our cohort represents an older Recent studies have demonstrated the benefits of car- generation of physicians who immigrated between the 1960s diac invasive procedures in AMI patients over conven- and the early 1980s, while newer generations of IMGs are tional medical therapy,19-21 and new indications have been drawn predominantly from non–English-speaking coun- incorporated into practice guidelines.10 Although the op- tries,26 as they are in the United States. Finally, our find- timal use rates and methods to evaluate quality in the use ings may not be generalizable to other areas of medicine, of cardiac invasive procedures are not known,22 we exam- as we only evaluated the quality of care of AMI patients. ined their application in our study not to measure quality In summary, we found no difference in the pre- of care but to evaluate potential differences in treatment scribed therapies and the mortality rates of AMI pa- patterns. In IMG-treated patients, we found lower crude tients admitted to Ontario hospitals treated by IMGs and use rates of cardiac catheterization, percutaneous coro- CMGs. This evidence supports the notion that carefully nary intervention, and coronary artery bypass grafting. How- selected IMGs can provide quality health care to AMI pa- ever, these differences disappeared after adjusting for hos- tients, after passing national certification examinations pital characteristics, such as cardiac procedural capacities. and having time to assimilate into practice in Canada. This is not surprising, as the use of cardiac procedures is Further studies are needed to confirm our findings in dif- influenced by the availability of resources.23,24 Therefore, ferent areas of medicine and to evaluate the ability of IMGs the lower unadjusted rates likely do not represent inferior working in other jurisdictions. care but suggest that IMGs have less access to invasive procedures, as they more frequently practice in hospitals with- Accepted for Publication: July 21, 2004. out revascularization facilities. Correspondence: Jack V. Tu, MD, PhD, Institute for Clini- One of the reasons to explain a lack of difference in cal Evaluative Sciences, Sunnybrook and Women’s Col- care between IMGs and CMGs may relate to the careful lege Health Sciences Centre, Building G-106, 2075 Bay- screening and training process before licensure is granted view Ave, Toronto, Ontario, Canada M4N 3M5 (tu@ices to all physicians in Ontario. Ontario has a high propor- .on.ca). tion of IMGs (40% of all IMGs in Canada), while only Funding/Support: This project was supported by an op- accounting for one third of the Canadian population. The erating grant from the Canadian Institutes of Health Re- requirements for obtaining licensure have varied over search, Ottawa. Dr Tu is supported by a Canada Re- time, with the number of IMGs licensed highest in the search Chair in Health Services Research, Ottawa. Dr 1960s to the early 1980s, followed by more restrictive Austin is supported by a Canadian Institutes of Health licensing policies beginning in the mid 1980s, when policy Research New Investigator Award. makers believed that there was an impending surplus of Disclaimer: The results and conclusions of this study are physicians in Canada. Consequently, the mean age of the those of the authors and should not be attributed to any IMGs was 10 years older than that of the CMGs in our of the sponsoring agencies. study. Most of the IMGs in our study had already been in practice for several years (and may have taken some REFERENCES additional residency training in Canada) and thus had time to become familiar with Canadian standards regard- 1. Barer ML, Stoddart GL. Toward integrated medical resource policies for Canada, ing the treatment and management of AMI patients. Fur- 4: graduates of foreign medical schools. 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