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Comparative Study
. 2021 Jan:70:190-196.
doi: 10.1016/j.avsg.2020.07.011. Epub 2020 Jul 29.

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

Courtenay M Holscher  1 , M Libby Weaver  1 , James H Black 3rd  1 , Christopher J Abularrage  1 , Ying Wei Lum  1 , Thomas Reifsnyder  2 , Devin S Zarkowsky  3 , Caitlin W Hicks  4
Affiliations
Comparative Study

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

Courtenay M Holscher et al. Ann Vasc Surg. 2021 Jan.

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 (2012-2018). 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 = 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 0.04-0.24 mm, P = 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.

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Figures

Fig. 1.
Fig. 1.
VQI regional percentage of EVAR performed for small AAAs and market competition described by Herfindahl-Hirschman Indices. There was wide variation in percentage of EVAR performed for small AAAs (bars) and HHI (diamonds) across VQI regions.
Fig. 2.
Fig. 2.
US regional percentage of EVAR performed for small AAAs and market competition described by Herfindahl-Hirschman Index. Adjusting for patient characteristics, there was a higher odds of EVAR performed for small AAA among US regions with higher regional market competition (P = 0.03).
See this image and copyright information in PMC

References

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