Reevaluating Certificate-of-Need: Outcomes after Gastrointestinal Cancer surgery.

Authors

Areesh Mevawalla, Meher Angez, Zayed Rashid, Aayan Kibria, Charalampos M Charalampous, Abdulaziz Elemosho, Odysseas P Chatzipanagiotou, Qaidar Alizai, Rabia Bega, Rida Ejaz, Timothy M Pawlik

Published in

Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. Pages 102616. Sep 29, 2026. Epub Sep 29, 2026.

Abstract

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.
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.
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).
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.

PMID:
42810506
Bibliographic data and abstract were imported from PubMed on 30 Sep 2026.

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