Market Competition and Use of Transcatheter Aortic Valve Replacement in the United States

Transcatheter aortic valve replacement (TAVR) has transformed the gold standard management of aortic stenosis (AS). Following device approval, surrounding market competition was noted to spur institutional adoption. With the exponential growth of TAVR, it remains unclear how market competition may influence utilization.

The authors sought to evaluate the association of hospital market competition with TAVR utilization in the contemporary period.

All adults undergoing TAVR or surgical aortic valve replacement for AS from 2018 to 2021 were tabulated from 7 Healthcare Cost and Utilization Project State Inpatient Databases. Market competition was calculated using the Herfindahl-Hirschman Index, based on a variable radius comprising 75% of total discharges for each institution. Patients treated at hospitals in high market competition areas were grouped as competitive (others: noncompetitive).

Among 137,734 patients undergoing surgical aortic valve replacement or TAVR, 83,650 (61%) were competitive. The 2 groups were of clinically similar age, sex, and preoperative comorbidity burden. Following risk-adjustment, treatment at a high market competition hospital was associated with significantly greater likelihood of receiving TAVR (adjusted OR [AOR]: 1.68; CI: 1.26-2.23). On age stratification, this effect remained true across age strata, with the greatest effects noted among patients <50 years (AOR: 1.54; CI: 1.12-2.11) and 50 to 60 years (AOR: 1.30; CI: 1.14-1.48). Moreover, care at a high market competition center was linked with similar odds of mortality and composite complications but significantly greater per-patient costs.

Increasing hospital market competition was linked with increased likelihood of TAVR, particularly among younger populations. Our findings suggest regional competition may be 1 variable that influences clinical practice in the treatment of AS.