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Market Competition and Density in Liver Transplantation: Relationship to Volume and Outcome
*Joel T Adler1, *Heidi Yeh1, James F Markmann1, *Louis L Nguyen2
1Massachusetts General Hospital, Boston, MA;2Brigham and Women's Hopsital, Boston, MA

OBJECTIVE: Liver transplantation centers (LTC) are grouped within Donor Service Areas (DSA) with varying density and competition. We sought to analyze how market competition and LTC density affect access to transplantation as measured by the number of liver transplants (LT) per population (LTP).
DESIGN: Retrospective cohort study of adult LT from the Scientific Registry of Transplant Recipients. Market competition was measured using the Herfindahl-Hirschman Index (HHI). LTC were geocoded to measure spatial organization by average nearest neighbor (ANN). LT quality was assessed by the liver donor risk index (LDRI).
SETTING: Liver transplant centers
PATIENTS: Adult liver transplant recipients
INTERVENTION: Liver transplantation
MAIN OUTCOME MEASURE: Liver transplants per population (LTP) per DSA in a hierarchical mixed effects linear model over time
RESULTS: 53,156 LT were performed at 120 adult LTC in 46 DSAs (1-7 LTC per DSA). 21 LTC closed and 9 opened, usually in competitive markets. One year LT graft survival improved over the study (82.1% to 88.2%, P<0.0001). LTC clustering was associated with more competitive DSAs (P<0.0001, Figure). In multivariable analysis, increased LTC (P=0.006), more new candidate listings (P<0.0001), additional deceased donors (P<0.0001), clustered ANN (P=0.009), higher MELD at transplant (P<0.0001), and higher LDRI (P<0.0001) were associated with increased LTP.
CONCLUSIONS: After controlling for market factors, more LTC were associated with more LTP without compromising graft survival. These market models suggest that increasing LTC density could use scarce resources more efficiently and provide better access to care despite the high barrier of market entry.


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