Reevaluating Certificate-of-Need: Outcomes after Gastrointestinal Cancer surgery.
Abstract
Background
Certificate-of-Need (CON) programs regulate hospital expansion to align capacity with community needs and may centralize complex surgery. We sought to characterize the association between state CON status with postoperative outcomes among Medicare beneficiaries undergoing gastrointestinal cancer (GI) surgery.
Methods
Medicare beneficiaries undergoing GI cancer resection (2014-2021) were identified and stratified by state CON status. Hospital density was defined as hospitals per state per 100,000 people and compared with the national means. Multivariable logistic regression assessed outcomes, and difference-in-differences analysis evaluated Florida's CON repeal.
Results
Among 216,866 patients, median age was 76 years (IQR, 71-82), 86.8% (n=188,248) were White, and 67.9% (n=147,354) underwent surgery in CON states. Compared with patients in non-CON states, those in CON states were more frequently treated at high-volume hospitals (33.4% vs 29.3%) and hospitals with high state-level market share (36.9% vs 25.7%) (both P<0.001), whereas teaching-hospital use was similar (57.5% vs 56.7%). After adjustment, CON status was not associated with 90-day readmission (aOR, 1.00; 95% CI, 0.96-1.04), complications (aOR, 0.99; 95% CI, 0.95-1.02), discharge home (aOR, 0.97; 95% CI, 0.79-1.18), 90-day mortality (aOR, 1.09; 95% CI, 0.99-1.21), extended length of stay (aOR, 1.04; 95% CI, 0.97-1.11), or textbook outcome (aOR, 1.00; 95% CI, 0.88-1.14) (all P>0.05). Following Florida's CON repeal, complications (-0.97 percentage points [pp]), 90-day mortality (-0.76 pp), and extended length of stay (-1.38 pp) decreased relative to other states, while discharge home (-1.07 pp) and textbook outcome (-0.81 pp) also decreased; 90-day readmission was unchanged (+0.26 pp; P=0.261).
Conclusion
CON regulation was associated with greater concentration of GI cancer surgery at higher-volume, higher-market-share hospitals, but not with differences in adjusted perioperative outcomes. Findings from Florida's repeal were mixed, suggesting that structural centralization alone may be insufficient to consistently improve surgical outcomes.