Clinical InvestigationsThe bleeding risk treatment paradox at the physician and hospital level: Implications for reducing bleeding in patients undergoing percutaneous coronary intervention
Section snippets
Methods
No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, and the drafting and edition of the paper and its final contents.
Study sample
Data for this study of 28,005 PCIs came from 26,784 patients, of whom 25,589 (95.5%) underwent 1 PCI, 1,169 (4.4%) 2 PCIs and 26 (0.1%) 3 PCIs during the study period. The average age of the patients was 65.6 years. Obesity (body mass index >30 kg/m2, 46.6%), diabetes mellitus (40.4%), dyslipidemia (84.5%), and hypertension (83.8%) were the common comorbidities. There was also a high proportion of chronic renal (26.4%) and lung (17.6%) disease. The average left ventricular ejection fraction was
Discussion
This is the first study to examine the variation of RTP among physicians and hospitals, as well as its correlation with bleeding outcomes. Hospitals and physicians with higher rates of RTP were strongly and independently associated with worse bleeding (Figure 2A and B; P-value <.0001). Consistent with prior studies of individual risk,2, 3 patients with RTP were more likely to have a bleeding complication (OR 1.66), independent of their bleeding and mortality risks. There was significant
Conclusion
Bleeding RTP is a strong and independent predictor of bleeding at both the hospital- and physician-level. It exists at the level of physicians and hospitals: hospitals and physicians with a higher rate of RTP were strongly and independently associated with worse bleeding rates. As the United States’ healthcare system increasingly focuses on quality improvement and consistency in care delivery, distribution and widespread implementation of best practices will be key. These findings underscore
Author Disclosures
Dr Amit P. Amin – has received a comparative effectiveness research KM1 career development award from the Clinical and Translational Science Award (CTSA) program of the National Center for Advancing Translational Sciences of the National Institutes of Health, Grant Numbers UL1TR000448, KL2TR000450, TL1TR000449 and the National Cancer Institute of the National Institutes of Health, Grant Number 1KM1CA156708-01; an AHRQ R18 grant award (Grant Number R18HS0224181-01A1), has received an
Funding Sources
Unrestricted grant from Terumo Corporation Inc.
Role of any Sponsor
No sponsor participated in the design and conduct of the study, collection, analysis, or interpretation of the data, nor in the preparation, review, nor approval of the manuscript.
Data Access and Responsibility
Drs Amin and Kulkarni had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
References (29)
- et al.
an updated bleeding model to predict the risk of post-procedure bleeding among patients undergoing Percutaneous Coronary Intervention: a report using an expanded bleeding definition from the National Cardiovascular Data Registry CathPCI Registry
JACC: Cardiovasc Interv
(2013) - et al.
Enhanced mortality risk prediction with a focus on high-risk percutaneous coronary intervention: results from 1,208,137 procedures in the NCDR (National Cardiovascular Data Registry)
JACC Cardiovasc Interv
(2013) - et al.
Bleeding avoidance strategies. Consensus and controversy
J Am Coll Cardiol
(2011) Bleeding avoidance strategies during percutaneous coronary interventions
J Am Coll Cardiol
(2015)- et al.
Pre-procedural estimate of individualized bleeding risk impacts physicians' utilization of bivalirudin during percutaneous coronary intervention
J Am Coll Cardiol
(2013) - et al.
Primary and secondary vascular access site complications associated with Percutaneous Coronary Intervention: insights from the BMC2 Registry
JACC Cardiovasc Interv
(2019) - et al.
Outcomes of PCI in relation to procedural characteristics and operator volumes in the United States
J Am Coll Cardiol
(2017) - et al.
Meta-analysis of randomized trials on the efficacy of vascular closure devices after diagnostic angiography and angioplasty
Am Heart J
(2010) - et al.
An updated comprehensive meta-analysis of bivalirudin vs heparin use in primary percutaneous coronary intervention
Am Heart J
(2016) - et al.
Unfractionated Heparin versus Bivalirudin in Primary Percutaneous Coronary Intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial
The Lancet
(2014)
Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial
Lancet
Understanding physician-level barriers to the use of individualized risk estimates in percutaneous coronary intervention
Am Heart J
Association between use of bleeding avoidance strategies and risk of periprocedural bleeding among patients undergoing Percutaneous Coronary Intervention
JAMA
Reversing the “Risk-Treatment Paradox” of bleeding in patients undergoing Percutaneous Coronary Intervention: risk-concordant use of bleeding avoidance strategies is associated with reduced bleeding and lower costs
J Am Heart Assoc
Cited by (0)
This paper was handled by Guest Editor (David R. Holmes, MD, Clin. Inv.)
- $
Equal contribution as first author.