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February 5, 2003

Certificate of Need Regulations and Hospital Mortality

JAMA. 2003;289(5):551. doi:10.1001/jama.289.5.551-a

To the Editor: Dr Vaughan-Sarrazin and colleagues1 found that states with continuous certificate of need (CON) regulations had higher hospital volume and lower mortality rates for coronary artery bypass graft (CABG) surgery.

However, the Medicare Provider Analysis and Review (MedPAR) files that the authors used do not include data for patients enrolled in Medicare Part C, which covers almost all Medicare managed care patients. Population-weighted Medicare managed care penetration rates2 differ considerably by CON status: in December 1999 the penetration rates were 26.4% for states with no CON regulations, 17.6% for those with continuous CON regulations, and 16.9% for those with intermittent CON regulations. Thus, the data may be missing information for as many as 25% of patients undergoing CABG surgery in states without CON. Therefore, the results of Vaughan-Sarrazin et al probably overstate the difference in average volume between states with and without CON regulations. Moreover, the reported mortality differentials between regulated and unregulated states do not include managed care patients.

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