title: Market competition influences renal transplantation risk and outcomes.
abstract: OBJECTIVE
  To evaluate the impact of market competition on patient mortality and graft failure after kidney transplantation.
  
  
  BACKGROUND
  Kidneys are initially allocated within 58 donation service areas (DSAs), which have varying numbers of transplant centers. Market competition is generally considered beneficial.
  
  
  METHODS
  The Scientific Registry of Transplant Recipients database was queried and the Herfindahl-Hirschman index (HHI), a measure of market competition, was calculated for each DSA from 2003 to 2012. Receipt of low-quality 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
  A total of 127,355 adult renal transplants were performed. DSAs were categorized as 7 no (HHI = 1), 17 low (HHI = 0.52-0.97), 17 medium (HHI = 0.33-0.51), or 17 high (HHI = 0.09-0.32) competition. For deceased donor kidney transplantation, increasing market competition was significantly associated with mortality [hazard ratio (HR): 1.11, P = 0.01], graft failure (HR: 1.18, P = 0.0001), and greater use of low-quality kidneys (odds ratio = 1.39, P < 0.0001). This was not true for living donor kidney transplantation (mortality HR: 0.94, P = 0.48; graft failure HR: 0.99, P = 0.89). Competition was associated with longer waitlists (P = 0.04) but not with the number of transplants per capita in a DSA (P = 0.21).
  
  
  CONCLUSIONS
  Increasing market competition is associated with increased patient mortality and graft failure and the use of riskier kidneys. These results may represent more aggressive transplantation and tolerance of greater risk for patients who otherwise have poor alternatives. Market competition should be better studied to ensure optimal outcomes.
authors.affiliation: *Center for Surgery and Public Health at Brigham and Women's Hospital †Department of Surgery, Massachusetts General Hospital ‡Division of Transplant Surgery, Massachusetts General Hospital §Harvard Medical School ¶Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA.
authors.forename: Joel T
authors.initials: JT
authors.lastname: Adler
authors.forename: Rosh K V
authors.initials: RK
authors.lastname: Sethi
authors.forename: Heidi
authors.initials: H
authors.lastname: Yeh
authors.forename: James F
authors.initials: JF
authors.lastname: Markmann
authors.forename: Louis L
authors.initials: LL
authors.lastname: Nguyen
mesh_terms: D000328:Adult; D004465:Economic Competition; D005260:Female; D006085:Graft Survival; D006801:Humans; D016030:Kidney Transplantation / Q000191:economics / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D016016:Proportional Hazards Models; D018570:Risk Assessment; D014019:Tissue Donors; D009927:Tissue and Organ Procurement / Q000191:economics / Q000458:organization & administration*; D014481:United States