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

Figures

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  Figure 1. Study Consolidated Standards of Reporting Trials Diagram Among the 137,734 records included for analysis, 83,650 entailed care at centers located in high market competition areas and were considered competitive. CABG = coronary artery bypass grafting; SAVR = surgical aortic valve replacement; TAVR = transcatheter aortic valve replacement.

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  Figure 2. Trends in Transcatheter Aortic Valve Replacement Utilization, Stratified by Market Competition Among both competitive and noncompetitive centers, transcatheter aortic valve replacement (TAVR) utilization dramatically increased over the study period, from 57% in 2016% to 86% in 2021 (P for trend<0.001).

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  Figure 3. Risk-Adjusted Likelihood of Transcatheter Aortic Valve Replacement, Stratified by Age and Market Competition After comprehensive risk adjustment, care at a competitive hospital was associated with higher likelihood of receiving transcatheter aortic valve replacement (TAVR) over surgical aortic valve replacement. (A) However, there was a significant interaction between market competition and patient age. (B) Stratifying by age group, treatment at a competitive center was linked with greater odds of TAVR among patients across age strata, with the greatest magnitude of effect among patients <60 years.

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  Figure 4. Independent Association of Market Competition with Outcomes following Aortic Valve Replacement Following risk adjustment, care at hospitals located in high market competition areas was associated with similar likelihood of in-hospital mortality, major morbidity as defined by the Society of Thoracic Surgeons, and nonhome discharge. However, undergoing aortic valve replacement at competitive hospitals was also linked with greater adjusted odds of any complication. Error bars represent 95% CIs. ∗Statistical significance, P < 0.001. STS = society of thoracic surgeons.

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  Figure 5. Association of Care at Competitive Hospitals With Expenditures Stratified by Age Following multivariable risk adjustment, care at competitive hospitals was associated with a $7,670 incremental increase in per-patient costs, relative to treatment at noncompetitive centers. Stratifying by patient age group, undergoing aortic valve replacement at institutions located in high market competition area was linked with significantly greater costs among those ages <50 years, 50 to 60 years, 60 to 70 years, and 70 to 80 years. ∗Statistical significance, P < 0.001.

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  Central Illustration. Association of Care at Market Competition with Odds of Receiving Transcatheter Aortic Valve Replacement Increasing hospital market competition was linked with greater likelihood of transcatheter aortic valve replacement (TAVR), with the largest effect noted among younger populations. Our findings suggest regional competition may influence clinical practice in the treatment of aortic stenosis.