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Contemporary impact of state certificate-of-need regulations for cardiac surgery : An analysis using the society of thoracic surgeons' national cardiac surgery database
Journal article   Open access   Peer reviewed

Contemporary impact of state certificate-of-need regulations for cardiac surgery : An analysis using the society of thoracic surgeons' national cardiac surgery database

Verdi J DISESA, Sean M O'BRIEN, Karl F WELKE, Sarah M BELAND, Constance K HAAN, Mary S VAUGHAN-SARRAZIN and Eric D PETERSON
Circulation (New York, N.Y.), Vol.114(20), pp.2122-2129
2006
DOI: 10.1161/CIRCULATIONAHA.105.591214
PMID: 17075012
url
https://doi.org/10.1161/CIRCULATIONAHA.105.591214View
Published (Version of record) Open Access

Abstract

Background: Prior research using administrative data associated certificate-of-need (CON) regulation for open heart surgery with higher hospital coronary artery bypass grafting (CABG) volume and lower CABG operative mortality rates in elderly patients. It is unclear whether these findings apply in a general population and after controlling for detailed clinical characteristics and region. Methods and results: Using the Society of Thoracic Surgeons' (STS) National Cardiac Surgery Database, we examined isolated CABG surgery volume, operative mortality, and the composite end point of operative mortality or major morbidity for the years 2000 to 2003. The presence of CON regulations for open heart surgery was ascertained from the National Directory of the American Health Policy Association and by contacting CON administrators. Results were analyzed nationally, by state, and by region (West, Northeast, Midwest, South) and were adjusted for clinical factors and both population density and region with mixed-effects hierarchical logistic regression models. During 2000 to 2003, there were 314,710 isolated CABG surgeries performed at 294 STS hospitals in CON states (n=27, including Washington, DC) and 280 512 procedures at 343 STS hospitals in non-CON states (n=24). Patient clinical characteristics were similar among CON and non-CON hospitals. States with CON regulations tended to have higher population densities and had significantly higher median hospital annual CABG volumes in each of the years 2000 to 2003 (P<0.005). This difference remained significant after adjustment for region and population density. Operative mortality was 2.52% for CON versus 2.62% for non-CON states (P=0.32). There was a significant association between CON law and operative mortality in the South. After adjustment for patient risk factors and region, there was a marginally significant reduction of mortality risk in states with CON regulation (adjusted OR 0.92, 95% CI 0.86 to 1.00). However, this difference was not statistically significant when a revised model accounted for random state effects. Similar volume and outcomes results were seen when the analysis was repeated with data from the national Medicare database. Conclusions: CON states have significantly higher hospital CABG surgery volumes but similar mortality compared with non-CON states. CON regulation alone is not a sufficient mechanism to ensure quality of care for CABG surgery.
 Cardiology. Vascular system Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous Atherosclerosis (general aspects, experimental research) Biological and medical sciences Medical sciences Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases Blood and lymphatic vessels

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