Title: Technology Adoption in the United States
Description: Objectives: Technological innovation in medicine is a significant driver of healthcare spending growth in the United States. Factors driving adoption and utilization of new technology is poorly understood, however market forces may play a significant role. Vascular surgery has experienced a surge in development of new devices and serves as an ideal case study. Specifically, the share of total abdominal aortic aneurysm (AAA) repairs performed by endovascular aneurysm repair (EVAR) increased rapidly from 32% in 2001 to 65% in 2006 with considerable variation between states. This paper hypothesizes that that hospitals in competitive markets were early EVAR adopters and had improved AAA repair outcomes.

Methods: The Nationwide Inpatient Sample (NIS) and linked Hospital Market Structure (HMS) data was queried for patients who underwent repair for non-ruptured AAA in 2003. In HMS the Herfindahl Hirschman Index (HHI, range 0-1) is a validated and widely accepted economic measure of competition. Hospital markets were defined using a variable geographic radius that encompassed 90% of discharged patients. Bivariable and multivariable linear and logistic regression analyses were performed for the dependent variable of EVAR use. A propensity score-adjusted multivariate logistic regression model was used to control for treatment bias in the assessment of competition on AAA-repair outcomes.

Results: A weighted total of 21,600 patients was included in the analyses. Patients at more competitive hospitals (lower HHI) were at increased odds of undergoing EVAR vs. open repair (Odds Ratio 1.127 per 0.1 decrease in HHI, P<0.0127) after adjusting for patient demographics, co-morbidities and hospital level factors (bed size, teaching status, AAA repair volume and ownership). Competition was not associated with differences in in-hospital mortality or vascular, neurologic or other minor post-operative complications.

Conclusion: Greater hospital competition is significantly associated with increased EVAR adoption at a time when diffusion of this technology passed its tipping point. Hospital competition does not influence post-AAA repair outcomes. These results suggest that adoption of novel technology is not solely driven by clinical indications, but may also be influenced by market forces.