Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 911 Broxton Avenue, Los Angeles, CA 90024, USA
Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
BMJ. 2018 Sep 26;362:k3640. doi: 10.1136/bmj.k3640.
To investigate whether the (USNWR) ranking of the medical school a physician attended is associated with patient outcomes and healthcare spending.
Observational study.
Medicare, 2011-15.
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.
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.
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 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) $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.
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.
调查医生就读的医学院的（美国新闻与世界报道）排名是否与患者结局和医疗保健支出有关。
观察性研究。
2011-15 年医疗保险。
20%随机抽取的 Medicare 收费服务受益人的样本，年龄在 65 岁或以上（n=996212），因医疗状况急诊住院，并由普通内科医生治疗。
医生就读的医学院的美国新闻与世界报道排名与医生的患者结局（30 天死亡率和 30 天再入院率）和医疗保险 B 部分支出之间的关系，调整了患者和医生特征以及医院固定效应（实际上是在比较同一医院内执业的医生）。一项敏感性分析通过关注由医院医生治疗的患者进行了自然实验，因为根据他们的具体工作安排，患者可能被合理地随机分配给医院医生。还研究了基于社会使命评分或美国国立卫生研究院（NIH）资助的医学院的替代排名。
在对 30322 名医生治疗的 996212 例入院进行分析时，死亡率为 996212 例。当使用美国新闻与世界报道的初级保健排名时，毕业于排名较高学校的医生 30 天再入院率略低（排名前 10 位学校的调整后再入院率为 15.7%，排名≥50 位学校的调整后再入院率为 16.1%；调整后的风险差异为 0.4%，95%置信区间为 0.1%至 0.8%；趋势检验 P 值=0.005），支出也较低（调整后的医疗保险 B 部分支出为$1029（£790；€881），$1066；调整后的差异为$36，95%置信区间为$20 至$52；趋势检验 P 值<0.001），与排名较低学校的毕业生相比，但 30 天死亡率无差异。当使用美国新闻与世界报道的研究排名时，毕业于排名较高学校的医生的医疗保健支出略低于毕业于排名较低学校的医生，但患者死亡率或再入院率无差异。一项仅限于由医院医生治疗的患者的敏感性分析得出了类似的发现。替代排名（基于社会使命评分或 NIH 资助）与患者结局或护理费用之间几乎没有或没有关系。
总体而言，医生就读的医学院的美国新闻与世界报道排名与随后的患者死亡率或再入院率之间几乎没有或没有关系。毕业于排名较高医学院的医生的支出略低于排名较低医学院的毕业生。
