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

Sara Sakowitz; Syed Shahyan Bakhtiyar; Yas Sanaiha; Sameer Hirji; Sara Pereira; Shayan Ebrahimian; Radoslav Zinoviev; Richard J Shemin; Peyman Benharash

doi:10.1016/j.jacadv.2025.102313

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

JACC Adv. 2026 Jan;5(1):102313. doi: 10.1016/j.jacadv.2025.102313. Epub 2025 Dec 15.

Authors

Sara Sakowitz¹, Syed Shahyan Bakhtiyar², Yas Sanaiha³, Sameer Hirji⁴, Sara Pereira⁵, Shayan Ebrahimian³, Radoslav Zinoviev⁶, Richard J Shemin⁷, Peyman Benharash⁸

Affiliations

¹ Cardiovascular Outcomes Research Laboratories (CORELAB), University of California-Los Angeles, Los Angeles, California, USA; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
² Cardiovascular Outcomes Research Laboratories (CORELAB), University of California-Los Angeles, Los Angeles, California, USA; Department of Surgery, University of Colorado, Aurora, Colorado, USA.
³ Cardiovascular Outcomes Research Laboratories (CORELAB), University of California-Los Angeles, Los Angeles, California, USA.
⁴ Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁵ Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA.
⁶ Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
⁷ Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
⁸ Cardiovascular Outcomes Research Laboratories (CORELAB), University of California-Los Angeles, Los Angeles, California, USA; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Center for Advanced Surgical and Interventional Technology (CASIT), David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Electronic address: Pbenharash@mednet.ucla.edu.

Abstract

Background: 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.

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

Methods: 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).

Results: 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.

Conclusions: 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.

Keywords: SAVR; TAVR; aortic stenosis; market competition; transcatheter aortic valve replacement.