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Published on: June 12, 2021
The Impact of Bleeding Avoidance Strategies on Hospital-Level Variation in Bleeding Rates Following Percutaneous
Amit N Vora1, Eric D Peterson1, Lisa A McCoy1
1Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
Insights
Bleeding avoidance strategies (BAS) modestly explain variations in bleeding after percutaneous coronary intervention. Hospitals using more BAS had lower bleeding rates, but other factors still drive most differences.
Area of Science:
- Cardiology
- Healthcare Quality Improvement
- Interventional Cardiology
Background:
- Bleeding rates after percutaneous coronary intervention (PCI) vary significantly across hospitals.
- The contribution of bleeding avoidance strategies (BAS) to this inter-hospital variability is not well understood.
Purpose of the Study:
- To investigate whether the adoption of BAS influences hospital-level bleeding rates following PCI.
- To quantify the impact of BAS on explaining variations in bleeding outcomes.
Main Methods:
- Analysis of 2,459,686 PCI procedures from the ACC National Cardiovascular Data Registry (CathPCI Registry).
- Utilized multivariable models to assess bleeding rates, adjusting for patient risk and BAS use (transradial access, bivalirudin, vascular closure devices).
- Examined the association between hospital-level BAS adoption rates and predicted bleeding rates.
Main Results:
- A total of 125,361 bleeding events (5.1%) were recorded.
- Significant hospital-level variation in bleeding rates persisted even after adjusting for patient risk.
- Hospitals with higher BAS use demonstrated significantly lower observed bleeding rates (aOR 0.90; 95% CI: 0.88-0.93).
Conclusions:
- Differential use of BAS accounts for a small portion of the variability in hospital-level bleeding after PCI.
- Further research is needed to identify the primary drivers of the remaining ~70% of inter-hospital variation in PCI-related bleeding.
Objectives:
The aim of this study was to explore whether the use of bleeding avoidance strategies (BAS) explains variability in hospital-level bleeding following percutaneous coronary intervention.
Background:
Prior studies have reported that bleeding rates following percutaneous coronary intervention vary markedly among hospitals, but the extent to which use of BAS explains this variation is unknown.
Methods:
Using the American College of Cardiology National Cardiovascular Data Registry's CathPCI Registry, estimated hospital-level bleeding rates from 2,459,686 procedures at 1,358 sites were determined. A series of models were fit to estimate random-effect variance, adjusting for patient risk (using the validated CathPCI bleeding risk model, C statistic = 0.77) and various combinations of BAS (transradial access, bivalirudin, vascular closure device use). The rate of any BAS use was also estimated for each hospital, and the association between percentage BAS use and predicted bleeding rates was determined.
Results:
In total, 125,361 bleeding events (5.1%) were observed; patients experiencing bleeding events had lower rates of radial access (5.0% vs. 11.2%; p < 0.001), bivalirudin therapy (43.8% vs. 59.4%), and vascular closure device use (32.9% vs. 42.4%, p < 0.001) than those without bleeding. There was significant variation in bleeding rates across hospitals (median 5.0%; interquartile range [IQR]: 2.7% to 6.6%), which persisted after incorporating patient-level risk (median 5.1%; IQR: 4.0% to 4.4%). Patient factors accounted for 20% of the overall hospital-level variation, and radial access plus bivalirudin use accounted for an additional 7.8% of the overall hospital-level variation. The median hospital rate of any BAS use was 86.6% (IQR: 72.5% to 94.1%). A significant decrease in observed hospital-level bleeding was seen in hospitals above the median in BAS use (adjusted odds ratio: 0.90; 95% confidence interval: 0.88 to 0.93).
Conclusions:
A modest proportion of the variation in hospitals' rates of bleeding following percutaneous coronary intervention is attributable to differential use of BAS. Further analyses are required to determine the remaining approximately 70% causes of variation in percutaneous coronary intervention bleeding seen among hospitals.
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