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The bleeding risk treatment paradox at the physician and hospital level: Implications for reducing bleeding in patients undergoing percutaneous coronary intervention - 26/11/21

Doi : 10.1016/j.ahj.2021.08.021 
Amit P. Amin, MD, MSc, MBA a, , Nathan Frogge, MD, MBA b, c, $, Hemant Kulkarni, MD d, Gene Ridolfi, RN c, Gregory Ewald, MD b, c, Rachel Miller, RN, MSN c, Bruce Hall, MD, PhD c, Susan Rogers, RN, MSN e, Ty Gluckman, MD f, Jeptha Curtis, MD g, Frederick A. Masoudi, MD, MSPH h, Sunil V. Rao, MD i
a Cardiovascular Division, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 
b Cardiovascular Division, Washington University School of Medicine, St. Louis, MO 
c Barnes-Jewish Hospital, St. Louis, MO 
d M&H Research, LLC, San Antonio, TX 
e National Cardiovascular Data Registry (NCDR), American College of Cardiology (ACC), Washington, DC 
f Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, OR 
g Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 
h Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO 
i The Duke Clinical Research Institute, Durham, NC 

Reprint requests: Amit P. Amin, MD, MSc, MBA, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, 1 Medical Center Dr, Lebanon, NH 03766.Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, 1 Medical Center Dr, Lebanon, NH 03766

Résumé

Background

Bleeding is a common and costly complication of percutaneous coronary intervention (PCI). Bleeding avoidance strategies (BAS) are used paradoxically less in patients at high-risk of bleeding: “bleeding risk-treatment paradox” (RTP). We determined whether hospitals and physicians, who do not align BAS to PCI patients’ bleeding risk (ie, exhibit a RTP) have higher bleeding rates.

Methods

We examined 28,005 PCIs from the National Cardiovascular Data Registry CathPCI Registry for 7 hospitals comprising BJC HealthCare. BAS included transradial intervention, bivalirudin, and vascular closure devices. Patients’ predicted bleeding risk was based on National Cardiovascular Data Registry CathPCI bleeding model and categorized as low (<2.0%), moderate (2.0%-6.4%), or high (≥6.5%) risk tertiles. BAS use was considered risk-concordant if: at least 1 BAS was used for moderate risk; 2 BAS were used for high risk and bivalirudin or vascular closure devices were not used for low risk. Absence of risk-concordant BAS use was defined as RTP. We analyzed inter-hospital and inter-physician variation in RTP, and the association of RTP with post-PCI bleeding.

Results

Amongst 28,005 patients undergoing PCI by 103 physicians at 7 hospitals, RTP was observed in 12,035 (43%) patients. RTP was independently associated with a higher likelihood of bleeding even after adjusting for predicted bleeding risk, mortality risk and potential sources of variation (OR 1.66, 95% CI 1.44-1.92, P < .001). A higher prevalence of RTP strongly and independently correlated with worse bleeding rates, both at the physician-level (Wilk's Lambda 0.9502, F-value 17.21, P < .0001) and the hospital-level (Wilk's Lambda 0.9899, F-value 35.68, P < .0001). All the results were similar in a subset of PCIs conducted since 2015 – a period more reflective of the contemporary practice.

Conclusions

Bleeding RTP is a strong, independent predictor of bleeding. It exists at the level of physicians and hospitals: those with a higher rate of RTP had worse bleeding rates. These findings not only underscore the importance of recognizing bleeding risk upfront and using BAS in a risk-aligned manner, but also inform and motivate national efforts to reduce PCI-related bleeding.

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Plan


 This paper was handled by Guest Editor (David R. Holmes, MD, Clin. Inv.)


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Vol 243

P. 221-231 - janvier 2022 Retour au numéro
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