Variation in Bleeding Avoidance Strategies After Percutaneous Coronary Intervention

Following percutaneous coronary intervention (PCI), a “modest proportion” of variations in hospitals’ bleeding rates is attributable to discrepancies in bleeding avoidance strategies (BAS), according to research published in JACC: Cardiovascular Interventions.

While multiple BAS have been developed to reduce periprocedural bleeding, previous studies have revealed significant variation in BAS use across patient populations.

Therefore, researchers set out to identify hospital-level variation in observed bleeding rates following PCI, determine the extent of which specific BAS might explain the variances, and evaluate the relationship between hospital-level BAS and bleeding rates.

Using the CathPCI Registry—the largest quality improvement program for PCI in the world—they selected more than 2.5 million patients undergoing PCI at 1453 hospitals.

Patients with missing variables to define bleeding or who had contraindications to, were blinded to, or had missing information regarding bivalirudin administration were excluded, as well as those who had undergone coronary bypass grafting or who went to hospitals that performed fewer than 50 PCIs annually. The total patient population was 2 459 686 at 1358 sites.

Patients treated in the lowest tertile of BAS use were more likely to be women and more likely to have had a myocardial infarction, heart failure, stroke, peripheral vascular disease, diabetes, and renal failure, compared with patients at the highest tertile of BAS.

Those patients who experienced bleeding events had lower rates of radial access (5.0% vs 11.2%; P<.001), bivalirudin therapy (43.8% vs 59.4%; P<.001), and vascular closure device use (32.9% vs 42.4%; P<.001).

Bleeding rates across hospitals demonstrated a significant variation (median: 5.0%; interquartile range: 2.7% to 6.6%). This variation persisted after incorporation of patient-level risk (median: 5.1%; interquartile range: 4.0% to 4.4%).

For the overall hospital-level variation, patient factors accounted for 20% and radial access plus bivalirudin use accounted for an additional 7.8% of the overall hospital-level variation. Any BAS use was reported at a median rate of 86.6% (interquartile range: 72.5% to 94.1%). Hospitals that used BAS above the median rate saw a significant decrease in bleeding (adjusted odds ratio: 0.90; 95% confidence interval: 0.88-0.93).

“After risk adjustment that incorporated individual bleeding risk using the CathPCI bleeding risk model and accounting for in-hospital clustering, the median hospital bleeding rate was similar (5.14%; IQR: 4.00% to 6.60%), with a similar range (5th percentile 2.65%; 95th percentile 9.36%),” the researchers pointed out.

“As PCI-related bleeding becomes more prominent as a potential hospital quality indicator, it will be important to ensure that hospital bleeding rates are standardized according to patient risk,” they added.

“However, our analysis demonstrates that even after taking patient risk and BAS use into account, more than two-thirds of the overall variation in bleeding rates continues to remain unexplained, highlighting a significant limitation in the use of bleeding rates as a performance measure under the current data collection structure.”

The authors encouraged more specific data collection, which will hopefully explain the variation in bleeding rates and eventually, help develop best practices following PCIs.

Reference

Vora AN, Peterson ED, McCoy LA, et al. The impact of bleeding avoidance strategies on hospital-level variation in bleeding rates following percutaneous coronary intervention. Insights from the National Cardiovascular Data Registry CathPCI Registry. JACC Cardiovasc Interv. 2016;9(8):771-779. doi: 10.1016/j.jcin.2016.01.033.