The Effect of Hospital Market Competition on the Adoption of Transcatheter Aortic Valve Replacement

Background: The use of transcatheter aortic valve replacement (TAVR) has grown rapidly. The purpose of this study was to assess whether hospital market competition was associated with the use of TAVR. Methods: We used 5 Healthcare Cost and Utilization Project state inpatient databases (Arizona, Florida, Iowa, Massachusetts, Washington) to identify patients undergoing TAVR (n = 5563) or surgical aortic valve replacement (n = 30,672) across 154 hospitals from 2011 to 2014. Using the Herfindahl-Hirschman Index (HHI) to calculate market competition, hospitals were categorized into commonly used categories of low (HHI >0.25), moderate (HHI 0.15-0.25), and high (HHI <0.15) competition. We associated market competition category with TAVR utilization using hierarchical logistic regression, adjusting for patient characteristics, hospital characteristics, year, and hospital random effect. We modeled associations between HHI category and in-hospital mortality, admission length of stay, and discharge to home as secondary outcomes. Results: After adjustment, patients treated at high-competition hospitals had higher odds of receiving TAVR, relative to patients at low-competition hospitals (adjusted odds ratio [OR_adj], 5.31; 95% confidence interval [CI], 2.10-13.4). TAVR use increased each year (OR_adj, 1.73; 95% CI, 1.38-2.17) but was similar across HHI categories. Competition was not associated with in-hospital mortality or length of stay. Patients at high-competition hospitals were more likely to be discharged home (OR_adj, 2.39; 95% CI, 1.23-4.66) compared with patients at low-competition hospitals. Conclusions: Market competition was positively associated with a hospital's adoption of TAVR. Future studies should further examine the impact of competition on quality and appropriateness.