DrPH Dissertation: Rahsaan Overton

About this event

Dissertation Title: CERTIFICATE OF NEED LAWS AND DIALYSIS CARE: A LEGAL EPIDEMIOLOGY STUDY

Dissertation Chair: Dr. Harry Heiman

Dissertation Abstract:

Background: Certificate of Need (CON) laws regulate the establishment and expansion of healthcare services and facilities in many states, including outpatient dialysis facilities. However, proponents argue that CON laws prevent duplication of services, while critics argue that they restrict market entry and limit access. CON requirements vary across states, and limited research has examined how these differences relate to dialysis access and quality of care.

Methods: This cross-sectional study applied legal epidemiology methods, combining legal mapping with descriptive analysis to examine the relationship between dialysis CON laws and measures of dialysis access and quality. Dialysis CON statutes and regulations in effect on December 31, 2022, were coded for eight states with dialysis CON laws. Each CON state was paired with a comparison state without dialysis CON laws. Dialysis access was assessed using the dialysis facility and station counts and rates relative to the total state population and end-stage kidney disease (ESKD) patient population. Quality was assessed using Centers for Medicare & Medicaid Services (CMS) Five-star quality ratings and standardized mortality ratios (SMRs). Using 2024 data from CMS and the United States Renal Data System (USRDS), selected CON legal characteristics were compared with access and quality measures among CON states. Access and quality measures were compared between CON and non-CON states using medians and interquartile ranges (IQRs).

Results: Across the 16 study states, 2,216 dialysis facilities and 38,025 dialysis stations were included in the analysis. CON laws varied considerably across the eight states, including triggering conditions, exemptions, application fees, and review periods. Among CON states, the selected legal characteristics did not correspond with clear or consistent patterns in dialysis access and quality measures. Access and quality measures were similar in CON and non-CON states, with substantial overlap in values and neither group consistently showing higher or lower measures across outcomes.

Conclusions: Differences in CON status and selected CON legal characteristics did not correspond with clear or consistent patterns in state-level dialysis access and quality measures. These findings do not establish whether CON laws are associated with dialysis outcomes but suggest that CON laws alone may not account for differences in dialysis access and quality across these states. Future research using larger samples, geospatial access measures, and data on CON implementation is needed to better understand this relationship.