title: Precision medicine to improve use of bleeding avoidance strategies and reduce bleeding in patients undergoing percutaneous coronary intervention: prospective cohort study before and after implementation of personalized bleeding risks.
abstract: OBJECTIVE
  To examine whether prospective bleeding risk estimates for patients undergoing percutaneous coronary intervention could improve the use of bleeding avoidance strategies and reduce bleeding.
  
  
  METHODS
  Prospective cohort study comparing the use of bleeding avoidance strategies and bleeding rates before and after implementation of prospective risk stratification for peri-procedural bleeding.
  
  
  METHODS
  Nine hospitals in the United States.
  
  
  METHODS
  All patients undergoing percutaneous coronary intervention for indications other than primary reperfusion for ST elevation myocardial infarction.
  
  
  METHODS
  Use of bleeding avoidance strategies, including bivalirudin, radial approach, and vascular closure devices, and peri-procedural bleeding rates, stratified by bleeding risk. Observed changes were adjusted for changes observed in a pool of 1135 hospitals without access to pre-procedural risk stratification. Hospital level and physician level variability in use of bleeding avoidance strategies was examined.
  
  
  RESULTS
  In a comparison of 7408 pre-intervention procedures with 3529 post-intervention procedures, use of bleeding avoidance strategies within intervention sites increased with pre-procedural risk stratification (odds ratio 1.81, 95% confidence interval 1.44 to 2.27), particularly among higher risk patients (2.03, 1.58 to 2.61; 1.41, 1.09 to 1.83 in low risk patients, after adjustment for control sites; P for interaction = 0.05). Bleeding rates within intervention sites were significantly lower after implementation of risk stratification (1.0% v 1.7%; odds ratio 0.56, 0.40 to 0.78; 0.62, 0.44 to 0.87, after adjustment); the reduction in bleeding was greatest in high risk patients. Marked variability in use of bleeding avoidance strategies was observed across sites and physicians, both before and after implementation.
  
  
  CONCLUSIONS
  Prospective provision of individualized bleeding risk estimates was associated with increased use of bleeding avoidance strategies and lower bleeding rates. Marked variability between providers highlights an important opportunity to improve the consistency, safety, and quality of care. Study registration Clinicaltrials.gov NCT01383382.
authors: Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA University of Missouri-Kansas City, Kansas City, MO, USA spertusj@umkc.edu.
authors: John A
authors: JA
authors: Spertus
authors: Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA University of Missouri-Kansas City, Kansas City, MO, USA.
authors: Carole
authors: C
authors: Decker
authors: Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA.
authors: Elizabeth
authors: E
authors: Gialde
authors: Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA.
authors: Philip G
authors: PG
authors: Jones
authors: Kaiser-San Francisco, San Francisco, CA, USA.
authors: Edward J
authors: EJ
authors: McNulty
authors: Washington University, Saint Louis, MO, USA.
authors: Richard
authors: R
authors: Bach
authors: Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA University of Missouri-Kansas City, Kansas City, MO, USA.
authors: Adnan K
authors: AK
authors: Chhatriwalla
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000517:prevention & control* / Q000706:statistics & numerical data; D003661:Decision Support Techniques; D005260:Female; D006305:Health Status Indicators; D006488:Hemostasis, Surgical / Q000379:methods / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000379:methods; D019990:Perioperative Care / Q000379:methods*; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000517:prevention & control*; D011446:Prospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome; D014481:United States