Regional Market Competition is Associated with Aneurysm Diameter at the Time of EVAR

Abstract

Background: Local market competition has been previously associated with more aggressive surgical decision-making. For example, more local competition for organs is associated with acceptance of lower quality kidney offers in transplant surgery. We hypothesized that market competition would be associated with the size of an abdominal aortic aneurysm (AAA) at the time of elective endovascular aneurysm repair (EVAR). Methods: We included all elective EVARs reported in the Vascular Quality Initiative database (2012e2018). Small AAAs were defined as a maximum diameter <5.5 cm in men or <5.0 cm in women. We calculated the Herfindahl-Hirschman Index (HHI), a measure of physician market concentration (higher HHI ¼ less market competition), for each US census region. Multilevel regression was used to examine the association between the size of AAA at EVAR and HHI, clustering by region. Results: Of 37,914 EVARs performed, 15,379 (40.6%) were for small AAAs. There was significant variation in proportion of EVARs performed for small AAAs across regions (P < 0.001). The South had both the highest proportion of EVARs for small AAAs (44.2%) as well as the highest market competition (HHI 50), whereas the West had the lowest proportion of EVARs for small AAAs (35.0%) and the lowest market competition (HHI 107). Adjusting for patient characteristics, each 10 unit increase in HHI was associated with a 0.1 mm larger maximum AAA diameter at the time of EVAR (95% CI 0.04e0.24 mm, P ¼ 0.005). Conclusions: Physician market concentration is independently associated with AAA diameter at time of elective EVAR. These data suggest that physician decision-making for EVAR is impacted by market competition.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

“…Physician participation in these programs should be encouraged, and educational interventions and training should be provided to disseminate knowledge and improve performance, which will help increase awareness for patients and physicians in less-populated, underserved areas. 1-3…”

Director’s Perceived Competition and Its Relationship with Hospital’s Competitive Behaviors: Evidence from County Hospitals in China

“…On the one hand, the increasing number of health-care providers in rural medical market drives hospitals to compete for limited market share in a fixed area. 45 On the other hand, the government’s financial subsidies provided to public hospitals have been greatly reduced, while the drug revenue, as the main source of hospital’s income, was cut off by the zero mark-up policy for drugs. 44 , 46 These policies motivated hospitals to compete for patients for financial interests.…”