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Market Competition Influences Renal Transplantation Risk and Outcomes
Joel T Adler*1, Rosh KV Sethi*2, Heidi Yeh*1, James F Markmann1, Louis L Nguyen*3
1Massachusetts General Hospital, Boston, MA;2Harvard Medical School, Boston, MA;3Brigham and Women's Hospital, Boston, MA
OBJECTIVE:Market competition is generally considered beneficial. Kidney transplantation (KT) occurs within 58 donation service areas (DSA) with varying number of centers and levels of competition. We sought to evaluate the impact of market competition on mortality and graft failure after KT.
METHODS:The Scientific Registry of Transplant Recipients was queried. The Herfindahl-Hirschman index (HHI), a widely used market competition measure, was calculated for each DSA from 2003-2012. Transplantation of lower quality/higher risk kidneys (Kidney Donor Profile Index >=85) was modeled with multivariable logistic regression, and Cox proportional hazards models were created for graft failure and patient mortality.
RESULTS:127,355 adult renal transplants were performed. There were 7 no (HHI 1), 17 low (HHI 0.52-0.97), 17 medium (HHI 0.33-0.51), and 17 high (HHI 0.09-0.32) competition DSAs (Figure). For deceased donor KT, increasing market competition was significantly associated with higher mortality (HR 1.11, P=0.01), higher graft failure (HR 1.18, P=0.0001), and greater use of riskier kidneys (OR 1.39, P<0.0001). This was not true for living donor KT (mortality HR 0.94, P=0.48; graft failure HR 0.99, P=0.89). In a DSA, competition was associated with longer waitlists (P=0.04) but not per capita kidney transplants (P=0.21).
CONCLUSIONS:Increasing market competition is associated with increased patient mortality and graft failure concurrent with the use of riskier donor kidneys. Competition can be valuable in healthcare, but its effects must be better studied to ensure optimal outcomes.
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