title: Identification of hospital outliers in bleeding complications after percutaneous coronary intervention.
abstract: BACKGROUND
  Post-percutaneous coronary intervention (PCI) bleeding complications are an important quality metric. We sought to characterize site-level variation in post-PCI bleeding and explore the influence of patient and procedural factors on hospital bleeding performance.
  
  
  RESULTS
  Hospital-level bleeding performance was compared pre- and postadjustment using the newly revised CathPCI Registry(®) bleeding risk model (c-index, 0.77) among 1292 National Cardiovascular Data Registry(®) hospitals performing >50 PCIs from 7/2009 to 9/2012 (n=1,984,998 procedures). Using random effects models, outlier sites were identified based on 95% confidence intervals around the hospital's random intercept. Bleeding 72 hours post-PCI was defined as: arterial access site, retroperitoneal, gastrointestinal, or genitourinary bleeding; intracranial hemorrhage; cardiac tamponade; nonbypass surgery-related blood transfusion with preprocedure hemoglobin ≥ 8 g/dL; or absolute decrease in hemoglobin value ≥ 3 g/dL with preprocedure hemoglobin ≤ 16 g/dL. Overall, the median unadjusted post-PCI bleeding rate was 5.2% and varied among hospitals from 2.6% to 10.4% (5th, 95th percentiles). Center-level bleeding variation persisted after case-mix adjustment (2.8%-9.5%; 5th, 95th percentiles). Although hospitals' observed and risk-adjusted bleeding ranks were correlated (Spearman ρ: 0.88), individual rankings shifted after risk-adjustment (median Δ rank order: ± 91.5; interquartile range: 37.0, 185.5). Outlier classification changed postadjustment for 29.3%, 16.1%, and 26.5% of low-, non-, and high-outlier sites, respectively. Hospital use of bleeding avoidance strategies (bivalirudin, radial access, or vascular closure device) was associated with risk-adjusted bleeding rates.
  
  
  CONCLUSIONS
  Despite adjustment for patient case-mix, there is wide variation in rates of hospital PCI-related bleeding in the United States. Opportunities may exist for best performers to share practices with other sites.
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.).
authors.forename: Connie N
authors.initials: CN
authors.lastname: Hess
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.).
authors.forename: Sunil V
authors.initials: SV
authors.lastname: Rao
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.).
authors.forename: Lisa A
authors.initials: LA
authors.lastname: McCoy
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.).
authors.forename: Megan L
authors.initials: ML
authors.lastname: Neely
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.).
authors.forename: Mandeep
authors.initials: M
authors.lastname: Singh
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.).
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.).
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Krone
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.).
authors.forename: W Douglas
authors.initials: WD
authors.lastname: Weaver
authors.affiliation: From the Duke Clinical Research Institute, Durham, NC (C.N.H., S.V.R., L.A.M., M.L.N., E.D.P.); Mayo Clinic, Rochester, MN (M.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.); Department of Medicine, Washington University School of Medicine, St. Louis, MO (R.J.K.); and Henry Ford Heart and Vascular Institute, Detroit, MI (W.D.W.). eric.peterson@duke.edu.
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
mesh_terms: D000368:Aged; D005260:Female; D006470:Hemorrhage / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control; D006742:Hospital Bed Capacity; D006761:Hospitals / Q000592:standards; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000592:standards; D058996:Quality Improvement; D019984:Quality Indicators, Health Care / Q000592:standards; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
keywords: percutaneous coronary intervention; quality improvement