1396. Increased Interhospital Competition is Associated with Higher Complications, Length of Stay, and Costs for Tumor Craniotomy

Authors: Oliver Tang; Wesley Durand; Krissia Rivera Perla; David Karambizi, BS; Steven Toms, MD, MPH (Providence, RI)


Interhospital competition has been shown to influence patient outcomes, hospital resource utilization, and adoption of new surgical approaches for a wide range of procedures. However, the impact of competition on tumor craniotomies has not been characterized.


We identified all patients that underwent craniotomy for a brain tumor in the National Inpatient Sample database from 2003, 2006, and 2009. These years contained data on the Herfindahl-Hirschman Index (HHI), a validated economic measure that quantifies a hospital market’s competitive intensity from 0 (significant competition) to 1 (monopolization). We analyzed how county HHI was associated with in-hospital mortality, postoperative complications, length of stay, and hospital costs. Multivariate regression was used to adjust for eleven confounding variables: patient characteristics (age, sex, insurance, risk of mortality and severity of illness ratings), hospital characteristics (region, location/teaching status, bed size, ownership), malignant status, and year. We reported odds ratios (ORs) for binary outcomes and percent changes for continuous outcomes, with all results corresponding to a 0.1 decrease in HHI (greater competition).


51,568 admissions for tumor craniotomy were analyzed. While no significant relationship was observed between HHI and mortality, greater interhospital competition was associated with increased odds of developing a postoperative complication (OR=1.09, P=0.002) and higher length of stay (+4% or 0.31 days, P<0.001) for tumor craniotomy patients. Subtype analysis of complications indicated that patients at hospitals in more competitive markets were more likely to have a postoperative infection (OR=1.10, P=0.01). Furthermore, higher interhospital competition was associated with elevated hospital costs (+3% or $814, P<0.001).


Greater interhospital competition was associated with increased likelihood of postoperative complications, higher length of stay, and more expensive admissions. As reimbursement reform and practice consolidation continue, it is critical to evaluate the influence of competition on other procedures and characterize the mechanisms by which competition may affect neurosurgical outcomes.