Table 3 Summary of Studies on the Effect of CON on Mortality for Coronary Artery Bypass Graft (CABG) Procedures
From: Certificate of need laws: a systematic review and cost-effectiveness analysis
STUDY | DESIGN | STATES | YEARS | POP-ULATION | CONTROLS | ESTIMATED EFFECT OF CON ON MORTALITY | NOTES | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
Mortality measure | Mean change1 | Stand-ard error | Net change, deaths per 1000 patients2 | Pop-ulation weight3 | Recency weight4 | |||||||
Total Population Studies | ||||||||||||
Ho [65] | Retro-spective cohort | 18 CON vs. 8 no CON | 1988–2000 | All | State fixed effects, patient characteristics | Inpatient mortality | −2.6% | 0.8% | −1.00 | 77.1% | 50.0% | Only one state in sample dropped CON during the study period. Finds no mortality effect of CON on PTCA. SE imputed from reported t statistic. |
DiSesa et al. [52] | Retro-spective cohort | 27 CON vs. 24 no CON | 2000–2003 | All | State and hospital fixed effects, patient controls | Operative mortality | −4.9% | 5.7% | −1.25 | 100.0% | 100.0% |  |
Robinson et al. [42] | Pre-post | PA | 1994–1999 | All | Patient characteristics | Inpatient mortality | 0.0% | 0.9% | 0.00 | 0.0% | 50.0% | After CON lifted, actual mortality matched expected mortality for both old and new cardiac programs; uses same PHC4 data as Kolstad |
Kolstad [39] | Pre-post | PA | 1994–2003 | All | Compares incumbent hospitals to new entrants |  | 2.9% | 0.9% | 0.62 | 4.3% | 100.0% | Kolstad calculates that 11 deaths are averted annually by CON repeal. His Table 1.1 shows that in 2000–2003, the 40 incumbent hospitals performed an average of 349 CABGs, for a total of 13,960 (RAMR = 2.17%) while 24 new entrants performed an average of 160 (RAMR = 2.04%). Weighted average mortality = 2.14% vs. 2.20% if 11 additional deaths had occurred. |
Cutler et al. [53] | Pre-post | PA | 1994–2003 | All | Compares incumbent hospitals to new entrants |  | 2.9% | 0.9% | 0.62 | 0.0% | 100.0% | Essentially the same paper as Kolstad [39] |
Weighted average: |  |  |  |  |  |  |  |  | −1.13 |  |  |  |
Medicare Patient Studies | ||||||||||||
Vaughan-Sarrazin et al. [57] | Retro-spective cohort | 27 continuous CON vs. 18 no CON | 1994–1999 | Medicare (excludes managed care) | Patient characteristics | In-hospital mortality | −17.3% | 2.6% | − 8.70 | 77.1% | 25.0% | States without CON exhibited CABG higher mortality (OR = 1.22) than states with continuous CON; this implies CON is associated with an 17.3% decrease in mortality rates, derived algebraically. No effect in intermittent CON states |
Popescu et al. [58] | Retro-spective cohort | 27 CON vs. 23 no CON | 1998–2000 | Medicare | Patient characteristics | 30-day all-cause mortality | −5.0% | 1.0% | −8.90 | 100.0% | 50.0% |  |
DiSesa et al. [52] | Retro-spective cohort | 27 CON vs. 24 no CON | 2001 | Medicare patients age 65 and older (excludes managed care) | State and hospital fixed effects, patient controls | Operative mortality | −0.3% | 4.9% | −0.10 | 100.0% | 75.0% |  |
Popescu, Vaughan-Sarazin and Rosenthal [55] | Retro-spective cohort | 27 CON vs. 24 no CON | 2000–2003 | Medicare (age 68+) | Patient characteristics | 30-day all-cause mortality | 0.0% | 1.5% | 0.00 | 100.0% | 100.0% | Vaughan-Sarazin is co-author on this paper; her most recent work, using the most recent data she uses, finds zero effect (a true 0.00 estimate; not just statistically insignificant) |
Ho et al. [59] | Retro-spective cohort | 27 continuous CON vs. 7 dropped CON | 1989–2002 | Medicare patients age 65 and older (excludes managed care) | State fixed effects, extensive hospital and patient controls | Procedural mortality | 10.8% | 3.3% | 5.20 | 63.9% | 100.0% | Dropping CON reduces mortality at first, but the effect dissipates 5 years after CON is removed |
Weighted average: |  |  |  |  |  |  |  |  | −0.93 |  |  |  |
Popescu, Vaughan-Sarazin and Rosenthal [55] | Retro-spective cohort | 27 CON vs. 24 no CON | 2000–2003 | Medicare (age 68+) | Patient characteristics | 30-day all-cause mortality | −4.2% | 2.6% | −7.31 | 100.0% | 100.0% | States with stringent CON lower mortality but effect is of borderline statistical significance |