title: Certificate of need regulations and the diffusion of intensity-modulated radiotherapy.
abstract: OBJECTIVE
  To better understand the associations between the certificate of need regulations and intensity-modulated radiotherapy dissemination.
  
  
  METHODS
  Using Surveillance, Epidemiology, and End Results-Medicare data, we identified men (aged ≥ 66 years) treated with radiotherapy for prostate cancer who had been diagnosed from 2001 to 2007. Using data from the American Health Planning Association, we sorted the health service areas (HSAs) according to the stringency of certificate of need regulations (low vs high) in that market. We assessed our outcomes (ie, the probability of intensity-modulated radiotherapy adoption and intensity-modulated radiotherapy use in the HSAs) using Cox proportional hazards and Poisson regression models, respectively.
  
  
  RESULTS
  The low- and high-stringency markets were similar in terms of racial composition (80% vs 85% white, P = .08), population density (1085 vs 558 people/square mile, P = .08), and income (median $38 683 vs $40 309, P = .44). However, the low-stringency markets had more patients with stage T1 disease (45% vs 36%, P < .01). The probability of intensity-modulated radiotherapy adoption across the 2 groups of HSAs was similar (P = .65). However, among the adopting HSAs, those with high stringency consistently had greater use of intensity-modulated radiotherapy (P < .01).
  
  
  CONCLUSIONS
  The certificate of need regulations fail to create significant barriers to entry for intensity-modulated radiotherapy. Among the HSAs that acquired intensity-modulated radiotherapy, high-stringency markets demonstrated a greater propensity for using intensity-modulated radiotherapy. These findings raise questions regarding the ability of the certificate of need regulations to control technology dissemination.
authors.affiliation: Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, MI 48109-2800, USA. brucejac@med.umich.edu
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Jacobs
authors.forename: Yun
authors.initials: Y
authors.lastname: Zhang
authors.forename: Ted A
authors.initials: TA
authors.lastname: Skolarus
authors.forename: John T
authors.initials: JT
authors.lastname: Wei
authors.forename: James E
authors.initials: JE
authors.lastname: Montie
authors.forename: Florian R
authors.initials: FR
authors.lastname: Schroeck
authors.forename: Brent K
authors.initials: BK
authors.lastname: Hollenbeck
mesh_terms: D000368:Aged; D002567:Certificate of Need / Q000331:legislation & jurisprudence*; D006801:Humans; D008297:Male; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D050397:Radiotherapy, Intensity-Modulated / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013219:State Government; D014481:United States