title: Pre-procedural estimate of individualized bleeding risk impacts physicians' utilization of bivalirudin during percutaneous coronary intervention.
abstract: OBJECTIVE
  This study sought to assess whether incorporation of routine bleeding risk estimates affected the utilization of bivalirudin during percutaneous coronary intervention (PCI).
  
  
  BACKGROUND
  Bivalirudin use during PCI has been shown to reduce bleeding complications. However, a risk-treatment paradox exists, in which patients at highest risk for bleeding are least likely to receive bivalirudin. Whether routine estimation of individualized bleeding risk can affect physicians' use of bivalirudin is unknown.
  
  
  METHODS
  PCI data from a single health system between 2007 and 2011 were analyzed. Beginning in July 2009, individualized bleeding risk estimates were provided immediately preceding PCI. Using a pre-post design, we compared bivalirudin use before and after this implementation, for patients across 3 strata of bleeding risk (<1%, 1% to 3%, and >3%).
  
  
  RESULTS
  Data from 6,491 PCI procedures were analyzed. Overall, bivalirudin use increased in the post-implementation period (26.9% vs. 34.2%, p < 0.001). Bivalirudin use increased in intermediate (27% to 35%, p < 0.001) and high bleeding risk patients (25% to 43%, p < 0.001), and decreased in low-risk patients (30% to 25%, p = 0.014). During the same period, bleeding complications decreased in intermediate-risk (3.4% to 1.8%, p = 0.009) and high-risk (6.9% to 3.7%, p = 0.005) patients and remained unchanged in low-risk patients (1.1% to 1.0%, p = 0.976).
  
  
  CONCLUSIONS
  There was an increase in bivalirudin use and a lower incidence of bleeding after the incorporation of individualized bleeding risk estimates into clinical practice. This implementation led to a reversal of the risk-treatment paradox, through a rational increase in bivalirudin use in patients at intermediate and high bleeding risk and decreased use in lower-risk patients.
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Missouri 64111, USA.
authors.forename: Seshu C
authors.initials: SC
authors.lastname: Rao
authors.forename: Adnan K
authors.initials: AK
authors.lastname: Chhatriwalla
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Kennedy
authors.forename: Carole J
authors.initials: CJ
authors.lastname: Decker
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Gialde
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.forename: Steven P
authors.initials: SP
authors.lastname: Marso
mesh_terms: D000368:Aged; D000991:Antithrombins / Q000008:administration & dosage; D002983:Clinical Competence; D003327:Coronary Disease / Q000601:surgery*; D005260:Female; D006470:Hemorrhage / Q000175:diagnosis* / Q000453:epidemiology; D006629:Hirudins / Q000008:administration & dosage*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008923:Missouri / Q000453:epidemiology; D010446:Peptide Fragments / Q000008:administration & dosage*; D062645:Percutaneous Coronary Intervention; D057234:Preoperative Period; D011994:Recombinant Proteins / Q000008:administration & dosage; D012189:Retrospective Studies; D018570:Risk Assessment / Q000706:statistics & numerical data*; D012307:Risk Factors
chemical_list: D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; C074619:bivalirudin