End-of-Life Care Processes and Outcomes for Older Adults Treated by International Medical Graduates vs. US Medical Graduates.

IMPORTANCE

International medical graduates (IMGs-physicians who graduated from a medical school outside the US) hold a significant role in the US healthcare system. Research suggests that clinicians' attitudes towards end-of-life (EOL) care may vary across countries.

OBJECTIVE

To compare EOL care processes and outcomes for older adults treated by IMGs vs. US medical graduates (USMGs).

DESIGN

Cross-sectional study.

PARTICIPANTS

A 20% random sample of Medicare fee-for-service beneficiaries aged 66 years or older who died in 2016-2019.

MAIN MEASURES: Seven EOL care-related measures: (i) palliative care counseling or hospice enrollment in the last 180 days of life; (ii) emergency department visits, (iii) hospital admissions, (iv) intensive care unit admissions, (v) use of mechanical ventilation or cardiopulmonary resuscitation, or (vi) feeding tube placement in the last 30 days of life; and (vii) death in an acute care hospital. We adjusted for beneficiary- and physician-level confounders; P-values were adjusted using the Bonferroni-Holm method for multiple comparisons.

RESULTS

Among 391,425 beneficiaries, 117,754 (30.1%) were attributed to IMGs and 273,671 (69.9%) to USMGs. We found no evidence that six of the seven measured EOL care processes and outcomes differ between IMGs and USMGs. Beneficiaries treated by IMGs were slightly less likely to have emergency department visits in the last 30 days of life (57.1% vs. 57.6%; adjusted difference, -0.5 pp; 95% CI, -0.9 to -0.2; P = 0.04) compared with those treated by USMGs. Subgroup analyses by beneficiaries with cancer or chronic heart failure showed no evidence that EOL care processes and outcomes differ by physician's country of medical school after adjustment for multiple comparisons.

CONCLUSIONS

EOL care processes and outcomes were similar for older adults treated by IMG and USMG physicians, despite potential differences in medical training during medical school.