Bleeding Avoidance Strategies Account for Modest Proportion of Hospital Variations in Bleeding Rates After PCI

April 26, 2016—Findings from a study of whether the use of bleeding avoidance strategies (BAS) explain variability in hospital-level bleeding after percutaneous coronary intervention (PCI) were published by Amit N. Vora, MD, et al in the Journal of the American College of Cardiology (JACC): Cardiovascular Interventions (2016;9:771–779). The investigators concluded that a modest proportion of the variation in hospitals’ rates of bleeding after PCI is attributable to differential use of BAS.

The investigators determined the estimated hospital-level bleeding rates from 2,459,686 procedures at 1,358 sites using the American College of Cardiology National Cardiovascular Data Registry’s CathPCI Registry. 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 (eg, 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.

As summarized in JACC: Cardiovascular Interventions, 125,361 bleeding events (5.1%) were observed; patients experiencing bleeding events had lower rates of radial access (5.0% vs 11.2%), bivalirudin therapy (43.8% vs 59.4%), and vascular closure device use (32.9% vs 42.4%) than those without bleeding. There was significant variation in bleeding rates across hospitals (median, 5%), which persisted after incorporating patient-level risk (median, 5.1%).

The investigators found that 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%. A significant decrease in observed hospital-level bleeding was seen in hospitals above the median in BAS use.

Further analyses are required to determine the remaining approximately 70% causes of variation in PCI bleeding seen among hospitals, advised the investigators in JACC: Cardiovascular Interventions.