Cardiac Certificate of Need regulations and the availability and use of revascularization services

Abstract

Background: Many states enforce Certificate of Need (CON) regulations for cardiac procedures, but little is known about how CON affects utilization. We assessed the association between cardiac CON regulations, availability of revascularization facilities, and revascularization rates.

Methods: We determined when state cardiac CON regulations were active and obtained data for Medicare beneficiaries > or = 65 years old who received coronary artery bypass graft surgery (CABG) or a percutaneous coronary intervention (PCI) between 1989 and 2002. We compared the number of hospitals performing revascularization and patient utilization in states with and without CON regulations, and in states which discontinued CON regulations during 1989 to 2002.

Results: Each year, the per capita number of hospitals performing CABG and PCI was higher in states without CON (3.7 per 100,000 elderly for CABG, 4.5 for PCI in 2002), compared with CON states (2.5 for CABG, 3.0 for PCI in 2002). Multivariate regressions that adjusted for market and population characteristics found no difference in CABG utilization rates between states with and without CON (P = .7). However, CON was associated with 19.2% fewer PCIs per 1000 elderly (P = .01), equivalent to 322,526 fewer PCIs for 1989 to 2002. Among most states that discontinued CON, the number of hospitals performing PCI rose in the mid 1990s, but there were no consistent trends in the number of hospitals performing CABG or in PCIs or CABGs per capita.

Conclusions: Certificate of Need restricts the number of cardiac facilities, but its effect on utilization rates may vary by procedure.

Figure I. Status of Cardiovascular CON Regulation during Sample Period 1989-2002

* Year cardiac CON was removed ^† Delaware had cardiac CON for percutaneous coronary intervention only.

Figure II. Number of Hospitals per Capita* Performing 3 or more CABGs per year, by CON Status^†

* per Capita = per 100,000 residents age 65+. ^† Mean values for states with continuous CON versus states without CON from 1989 to 2002. Vertical lines indicate when states dropped CON.

Figure III. Number of Hospitals per Capita* Performing 3 or more PCIs per year, by CON Status^†

* per Capita = per 100,000 residents age 65+. ^† Mean values for states with continuous CON versus states without CON from 1989 to 2002. Vertical lines indicate when states dropped CON.

Figure IV. Number of CABG procedures per Capita*, by CON Status^†

* per Capita = per 100,000 residents age 65+. ^† Mean values for states with continuous CON versus states without CON from 1989 to 2002. Vertical lines indicate when states dropped CON.

Figure V. Number of PCI procedures per Capita*, by CON Status^†

* per Capita = per 100,000 residents age 65+. ^† Mean values for states with continuous CON versus states without CON from 1989 to 2002. Vertical lines indicate when states dropped CON.