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.
OBJECTIVE
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.
Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina. Electronic address: a.vora@duke.edu.
Amit N
AN
Vora
Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
Eric D
ED
Peterson
Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
Lisa A
LA
McCoy
Center for Heart and Vascular Health, Christiana Care Health System, Wilmington, Delaware.
Kirk N
KN
Garratt
Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Michael A
MA
Kutcher
University of Texas Southwestern Medical Center, Dallas, Texas.
Steven P
SP
Marso
Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
Matthew T
MT
Roe
Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
John C
JC
Messenger
Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
Sunil V
SV
Rao
D000368:Aged; D000991:Antithrombins / Q000627:therapeutic use; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods / Q000639:trends*; D002406:Catheterization, Peripheral / Q000639:trends; D016009:Chi-Square Distribution; D005260:Female; D054625:Healthcare Disparities / Q000639:trends*; D006470:Hemorrhage / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D006629:Hirudins; D006761:Hospitals / Q000639:trends*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010446:Peptide Fragments / Q000627:therapeutic use; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods / Q000639:trends*; D010818:Practice Patterns, Physicians' / Q000639:trends*; D017064:Process Assessment, Health Care / Q000639:trends*; D017534:Radial Artery; D011994:Recombinant Proteins / Q000627:therapeutic use; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D065506:Vascular Closure Devices
D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; C074619:bivalirudin
PCI; bleeding avoidance; performance measure; quality measure