Data element mapping to analyze fit for use of three XML standards for health workforce tracking.

BACKGROUND: Ensuring a sufficient supply and distribution of health care professionals is essential to meeting public health needs. Regulatory agencies protect their communities by ensuring that new health professionals have the required qualifications to practice safely and by tracking the volume and distribution of those professionals on an ongoing basis. The speed and accuracy of sharing these data could be greatly improved through the adoption of a data standard for information about health professionals. To date, however, no internationally accepted standard has emerged for this purpose. PURPOSE: This study examines three existing XML standards designed for the representation of individual worker data to determine if, and to what degree, each could be used for the tracking of health professionals. METHODS: The data elements of the Europass schema, the HR Open Standard Recruiting specification, and the MedBiquitous Healthcare Professional Profile standard were fully examined and matching elements were mapped to the 200+ elements identified from a prior content analysis as required by a sample of 20 international regulatory agencies. RESULTS: None of the schemas examined addressed more than half of the information elements required by regulators. All three schemas are found lacking in some key areas of interest, especially vital information that could disqualify ineligible applicant practitioners. CONCLUSIONS: The three standards could all be improved by including new elements essential to regulatory agencies. Regulatory agencies should be consulted in the development of new standards for representing potentially disqualifying information about candidates for professional practice.

Patients of doctors further from medical school graduation have poorer outcomes.

CONTEXT: There is an apparent contradiction between the findings of studies indicating that patient outcomes are better when physicians have a greater volume of practice and those that find outcomes to be worse with increased time since training, which implies greater volume. OBJECTIVES: This study was designed to estimate the adjusted relationships between physicians' characteristics, including recent practice volume and time since medical school graduation, and patient outcomes. METHODS: This is a retrospective observational study based on all Pennsylvania hospitalisations over 7 years for acute myocardial infarction, congestive heart failure, gastrointestinal haemorrhage, hip fracture and pneumonia. It refers to 694 020 hospitalisations in 184 hospitals attended by 5280 internists and family physicians. Patient severity of illness at admission and in-hospital mortality, hospital location and volume, and the physician's recent practice volume, time since medical school graduation, board certification, and citizenship or medical school location were analysed. RESULTS: After adjustment, recent practice volume did not have a statistically significant association with in-hospital mortality for all of the conditions combined. By contrast, each decade since graduation from medical school was associated with a 4.5% increase in relative risk for patient mortality. CONCLUSIONS: Recent practice volume does not mitigate the increase in patient mortality associated with physicians' time since medical school graduation. These findings underscore the need to finds ways to support and encourage learning.

Overview of the world's medical schools: an update.

CONTEXT: That few data are available on the characteristics of medical schools or on trends within medical education internationally constitutes a major challenge when developing strategies to address physician workforce shortages. Quality and up-to-date information is needed to improve health and education policy planning. METHODS: We used publicly available data from the International Medical Education Directory and Avicenna Directories, and an internal education programme database to gather data on medical education provision worldwide. We sent a semi-structured questionnaire to a selection of 346 medical schools, of which 218 (63%) in 81 different countries or territories replied. We contacted ministries of health, national agencies for accreditation or similar bodies to clarify inconsistencies among sources. We identified key informants to obtain country-level specific information. Descriptive statistics were used to analyse current medical school data by country. RESULTS: There are about 2600 medical schools worldwide. The countries with the largest numbers of schools are India (n = 304), Brazil (n = 182), the USA (n = 173), China (n = 147) and Pakistan (n = 86). One-third of all medical schools are located in five countries and nearly half are located in 10 countries. Of 207 independent states, 24 have no medical school and 50 have only one. Regionally, numbers of citizens per school differ: the Caribbean region has one school per 0.6 million population; the Americas and Oceania each have one school per 1.2 million population; Europe has one school per 1.8 million population; Asia has one school per 3.5 million population, and Africa has one school per 5.0 million population. In 2012, on average, there were 181 graduates per medical school. CONCLUSIONS: The total number and distribution of medical schools around the world are not well matched with existing physician numbers and distribution. The collection and aggregation of medical school data are complex and would benefit from better information on local recognition processes. Longitudinal comparisons are difficult and subject to several sources of error. The consistency and quality of medical school data need to be improved to accurately document potential supply; one example of such an advancement is the World Directory of Medical Schools.

Outcomes of cardiac surgery: associations with physician characteristics, institutional characteristics, and transfers of care.

BACKGROUND: Although there are several studies of the human and system factors that influence the outcomes of cardiac surgery, it remains difficult to draw conclusions because many do not simultaneously adjust for the characteristics of patients, physicians, and institutions. The current study explores the associations between these factors and inhospital mortality, with a particular focus on whether patients had the same operating and attending physician. METHOD AND RESULTS: This is a retrospective observational study of 114,751 hospitalizations from 2003 to 2009 in Pennsylvania that included a coronary artery bypass graft, valve surgery, or both. The study included 70 teaching and nonteaching hospitals, 289 operating physicians who were also the attending physicians for 75% of the hospitalizations, and 2654 attending physicians for the remaining hospitalizations. After adjustment, there was a 38.4% decrease (95% CI, 20.3%-56.5%) in mortality when the operating and attending physician were the same. For the operator, each procedure performed was associated with a 0.05% (95% CI, 0.04%-0.06%) decrease in mortality and each year since medical school was associated with a 0.9% (95% CI, 0.02%-1.8%) increase in mortality. For the attending, each year since medical school was associated with a 0.67% (95% CI, 0.01%-1.4%) decrease in patient mortality. CONCLUSIONS: The findings indicated that an increase in the log odds of mortality was associated with the transfer of care between an attending and operating physician. Better patient outcomes were associated with an operator with higher volume who was closer to medical school graduation and an attending physician with more clinical experience.

The role of international medical graduate psychiatrists in the United States healthcare system.

OBJECTIVE: International medical graduates (IMGs) make up a substantial proportion of the United States physician workforce, including psychiatrists in practice. The purpose of this study was to describe, based on current data, the characteristics and qualities of IMG psychiatrists who provide patient care in the US. METHOD: Physician data from the Educational Commission for Foreign Medical Graduates, American Medical Association, and American Board of Medical Specialties were combined. Descriptive statistics provided an overview of the characteristics and qualities of IMG psychiatrists. The authors contrasted demographic and practice profiles of IMG and U.S. medical graduate (USMG) psychiatrists. RESULTS: International medical graduates make up almost one-third of the practicing psychiatrist workforce. Nearly one-quarter of these individuals attended medical school in India. Compared with USMG psychiatrists, IMG psychiatrists were more likely to be employed in a hospital and less likely to be Board-certified by the American Board of Psychiatry and Neurology. CONCLUSIONS: International medical graduate psychiatrists play an important role in the U.S. healthcare system. Given their numbers and their propensity to practice in settings and areas where USMGs do not, efforts to monitor their practice patterns and qualities, both cross-sectionally and longitudinally, are warranted.

Specialty Board Certification Rate as an Outcome Metric for GME Training Institutions: A Relationship With Quality of Care.

Educational outcome measures, known to be associated with the quality of care, are needed to support improvements in graduate medical education (GME). This retrospective observational study sought to determine whether there was a relationship between the specialty board certification rates of GME training institutions and the quality of care delivered by their graduates. It is based on 7 years of hospitalizations in Pennsylvania (N = 354,767) with diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal hemorrhage, or pneumonia. The 2,265 attending physicians were self-identified internists, and they completed their training in 59 institutions. The percentage of board-certified physicians from each training institution, excluding the physician herself or himself, was calculated and an indicator of whether it exceeded 80% was created. This was analyzed against inhospital mortality and length of stay, adjusted for patient/physician/hospital characteristics. There were significantly lower odds of mortality (adjusted Odd's ratio [OR] = .92, 95% CI [0.86, 0.98]) and log length of stay (adjusted OR = .98, 95% CI [.94, .99]) when the attending physician trained in a residency program with an 80% or greater certification rate. The results suggest that specialty certification rates may be a useful educational outcome for residency training programs.

U.S. citizens who graduated from medical schools outside the United States and Canada and received certification from the Educational Commission for Foreign Medical Graduates, 1983-2002.

PURPOSE: To provide a descriptive overview of international medical school graduates (IMGs), U.S. and non-U.S. citizens, who obtained their medical degrees outside of the United States and Canada, with a focus on where U.S. citizens received their medical education and how this choice has changed over time. METHOD: The study group included all IMGs (n = 143,926) certified by the Educational Commission for Foreign Medical Graduates (ECFMG) from 1983-2002. Descriptive statistics were calculated, including historical certification rates for non-U.S. citizen and U.S. citizen IMGs. For IMGs who were U.S. citizens (n = 18,762), the data were summarized by medical school and country of medical school. RESULTS: U.S. citizens who attended medical schools abroad were more likely to attend schools in Central America and the Caribbean than in any other geographic region. There was a steady decrease in the number of U.S. citizens graduating from European medical schools. Conversely, the number graduating from medical schools in India and Israel rose. Over the period studied, the regions of Africa, Oceania, and South America graduated relatively few U.S. citizens. CONCLUSIONS: From 1983-2002, U.S. citizens graduated from medical schools in Central America and the Caribbean more than any other geographic region. Studying the characteristics of medical schools in this region and their similarities to U.S. medical schools, such as a four-year curriculum, may explain why U.S. citizens are attracted to this region in large numbers. Additional studies focusing on the characteristics of medical schools that train IMGs, the performance of the graduates, and their posttraining practice patterns are warranted.

The relationship between licensing examination performance and the outcomes of care by international medical school graduates.

PURPOSE: The Step 2 Clinical Knowledge (CK) examination of the United States Medical Licensing Examination sequence is a requirement for the certification of international medical graduates (IMGs) by the Educational Commission for Foreign Medical Graduates. An association between scores on the test and the quality of care later provided by those who take it is central to its use in certification and licensure. The purpose of this study was to determine whether there is a relationship between scores on Step 2 CK and patient outcomes for IMGs. METHOD: This is a retrospective observational study of the 60,958 hospitalizations from 2003 to 2009 in Pennsylvania where the principal diagnosis was acute myocardial infarction or congestive heart failure and the attending physician (N = 2,525) was an IMG who had taken the Step 2 CK. The main measures were the three-digit scores on Step 2 CK and in-hospital mortality. RESULTS: After adjustment for severity of illness, physician characteristics, and hospital characteristics, performance on Step 2 CK had a statistically significant inverse relationship with mortality. Each additional point on the examination was associated with a 0.2% (95% CI: 0.1%-0.4%) decrease in mortality. The size of the effect is noteworthy, with each standard deviation (roughly 20 points) equivalent to a 4% change in mortality risk. CONCLUSIONS: These findings provide evidence for the validity of Step 2 CK scores. Given the magnitude of its relationship with patient outcomes, the results support the use of the examination as an effective screening strategy for licensure.

Evaluating the quality of care provided by graduates of international medical schools.

One-quarter of practicing physicians in the United States are graduates of international medical schools. The quality of care provided by doctors educated abroad has been the subject of ongoing concern. Our analysis of 244,153 hospitalizations in Pennsylvania found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly lower mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad. The patient population consisted of those with congestive heart failure or acute myocardial infarction. We found no significant mortality difference when comparing all international medical graduates with all U.S. medical school graduates.