Susan L. Ettner

​Summary: There has been little research on the relationship between education and health care utilization, especially for racial/ethnic minorities. This study aimed to examine the association between education and hospitalizations, investigate the mechanisms, and disaggregate the relationship by gender, race/ethnicity, and age groups.

A retrospective cohort analyst was conducted using data from the 1992–2016 U.S. Health and Retirement Study. The analytic sample consists of 35,451 respondents with 215,724 person-year observations. The authors employed a linear probability model with standard errors clustered at the respondent level and accounted for attrition bias using an inverse probability weighting approach.

Findings: On average, compared to having an education less than high school, having a college degree or above was significantly associated with an 8.37 pp (95% CI, −9.79 pp to −7.95 pp) lower probability of being hospitalized, and having education of high school or some college was related to 3.35 pp (95% CI, −4.57 pp to −2.14 pp) lower probability. The association slightly attenuated after controlling for income but dramatically reduced once holding health conditions constant. Specifically, given the same health status and childhood environment conditions, compared to those with less than high school degree, college graduates saw a 1.79 pp (95% CI, −3.16 pp to −0.42 pp) lower chance of being hospitalized, but the association for high school graduates became indistinguishable from zero. Additionally, the association was larger for females, whites, and those younger than 78. The association was statistically significantly smaller for black college graduates than their white counterparts, even when health status is held constant.

Educational attainment is a strong predictor of hospitalizations for middle-aged and older U.S. adults. Health mediates most of the education-hospitalization gradients. The heterogeneous results across age, gender, race, and ethnicity groups should inform further research on health disparities.

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• Journal Article: The Relationship Between Educational Attainment and Hospitalizations Among Middle-Aged and Older Adults in the United States

​Summary: Reducing surgical costs is paramount to the viability of hospitals. Authors conducted a retrospective analysis of electronic health record data for 7,762 operations from two health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013, and November 30, 2017, were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.

Findings: The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.

Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

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• Journal Article: Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures

​Summary: The study examined the association between mental health staffing at health centers funded by the Health Resources and Services Administration (HRSA) and patients’ receipt of mental health treatment. Data were from the 2014 HRSA-funded Health Center Patient Survey and the 2013 Uniform Data System. Colocation of any mental health staff, including psychiatrists, psychologists, and other licensed staff, was examined. The outcomes of interest were whether a patient received any mental treatment and received any such treatment on site (at the health center). Analyses were conducted with multilevel generalized structural equation logistic regression models for 4,575 patients ages 18–64.

Findings: Patients attending health centers with at least one mental health full-time equivalent (FTE) per 2,000 patients had a higher predicted probability of receiving mental health treatment (32%) compared with those attending centers with fewer than one such FTE (24%) or no such staffing (22%). Among patients who received this treatment, those at health centers with no staffing had a significantly lower predicted probability of receiving such treatment on site (28%), compared with patients at health centers with fewer than one such FTE (49%) and with at least one such FTE (65%). The predicted probability of receiving such treatment on site was significantly higher if there was a co-located psychiatrist versus no psychiatrist (58% versus 40%). Authors conclude co-locating mental health staff at health centers increases the probability of patients’ access to such treatment on site as well as from off-site providers.

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• Journal Article: Mental Health Staffing at HRSA-Funded Health Centers May Improve Access to Care

​The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures. Authors used retrospective analysis of electronic health record data for 7,762 operations from two health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for three utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.

The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.

Authors conclude that surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

• Christopher P. Childers
• Susan L. Ettner, PhD
• Gerald F. Kominski, Ph.D.
• et al