Effect of US State Certificate of Need regulation of operating rooms on surgical resident training

Abstract

Government regulation of health care services helps prevent costs associated with expansion and duplication of services in the United States. Certificate of Need (CON) helps restrict construction of ambulatory surgery facilities and hence controls delivery of surgical intervention, but concern exists about whether this affects resident exposure to an appropriate caseload. This study investigated how CON laws impact on surgical caseload as an index of resident surgical training. This retrospective study used State Inpatient Data compiled by the Health Care Utilization Project. Mean per capita rates of 26 diverse surgical procedures were evaluated in 21 states with CON laws and 5 states without between 2004 and 2006. The proportion of procedures performed in teaching facilities was also assessed. Student's t-tests were used to evaluate differences in these parameters between regulated and non-regulated states (a = 0.05). Multivariate analysis of variance permitted evaluation of the types of procedures that underwent shift in location performed. States with CON laws did not differ significantly in procedural rates for any of the investigated surgical procedures; however, such regulation was associated with different trends in teaching center caseload, depending on the type of procedure. Complex procedures, such as Whipple operations (p = 0.14) or resection of acoustic neuroma (p = 0.37), underwent no redistribution. Conversely, common procedures that might have previously been performed in private settings, such as total hip replacement (p = 0.003) or mastectomy (p = 0.01), did occur more commonly in teaching facilities under CON regulation. CON law did not result in relocation of surgical procedures away from teaching institutions. These results suggest that government regulations do not discriminate against teaching facilities. Surgical residents in states with such regulation gain similar or superior exposure to procedures as residents in states without such laws.