Association between Regional Market Competition and Early Femoropopliteal Interventions for Claudication

Regional market competition is known to impact practice patterns in surgical care. We aimed to investigate the association of regional market competition with the utilization of early peripheral vascular interventions (PVIs) for the treatment of claudication, and the subsequent impact on clinical outcomes.

We conducted a retrospective analysis of 100% Medicare fee-for-service claims data from January 2019 to December 2021 to identify patients with a new diagnosis of claudication. We calculated the Herfindahl-Hirschman Index for all sites of service performing PVI according to Health Service Area. Multivariable logistic regression and Cox proportional hazards models were used to assess the association of regional market competition with early (<6 months) PVI for claudication, and progression to chronic limb-threatening ischemia, repeat PVI, and major amputation.

We identified 300,492 patients with a new diagnosis of claudication (mean age 73.8 years, 51.6% male, 11.1% Black), of which 6.1% underwent an early PVI for claudication. Most patients (72.4%) were treated in low-competition markets. After adjusting for patient characteristics, patients treated in moderate-competition markets had the highest odds of receiving an early PVI. Regional market competition was not associated with conversion to chronic limb-threatening ischemia or repeat PVI (P > 0.05), but patients treated in high- (adjusted hazard ratio [aHR] 0.70, 95% confidence interval [CI] 0.56-0.86) and moderate- (aHR 0.82, 95% CI 0.69-0.92) competition markets had lower hazards of major amputation compared to patients treated in low-competition markets. Early PVI was significantly associated with worse clinical outcomes after adjusting for all factors including market competition (all, P < 0.05).

There is a complex interplay between regional market competition, early PVI utilization, and subsequent clinical outcomes for patients with claudication. Early PVI continues to demonstrate a strong association with unfavorable clinical outcomes even when accounting for market competition.