Identification of Hospital Outliers in Bleeding Complications After Percutaneous Coronary Intervention | Journal Scan

Study Questions:

What are the site-level variations in post-percutaneous coronary intervention (PCI) bleeding, and what is the influence of patient and procedural factors on hospital bleeding performance?

Methods:

The authors compared hospital-level bleeding performance among 1,292 National Cardiovascular Data Registry hospitals performing >50 PCIs from July 2009 to September 2012 (n = 1,984,998 procedures). Outlier sites were identified using random-effects models, 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.

Results:

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). Hospital use of bleeding avoidance strategies (bivalirudin, radial access, or vascular closure device) was modestly associated with risk-adjusted bleeding rates (Spearman correlation coefficient: −0.26).

Conclusions:

Despite adjustment for patient case-mix, there is wide variation in rates of hospital PCI-related bleeding in the United States.

Perspective:

Bleeding after PCI has been associated with increased morbidity, cost, and mortality, and has been designated as a quality metric in the Centers for Medicare and Medicaid Services Acute Care Episode Demonstration program. Although it remains to be established whether the association between bleeding and mortality is causal, there is going to be greater scrutiny of bleeding as a post-PCI complication in the near-term. This study found that the widest variation in bleeding was seen with respect to decline in hemoglobin of >3 g/dl. This endpoint is most susceptible to variation in hydration status as well as ascertainment bias, and has the least clinical significance (compared with other components of the bleeding definition). While efforts to minimize bleeding are always worthwhile, the modest association of bleeding avoidance strategies with the hospital-level bleeding rate suggests that other unknown factors explain the majority of the observed differences in bleeding rates. Accordingly, it may be premature to consider bleeding as a completely preventable event or to link hospital-level bleeding incidence to reimbursement.

Clinical Topics: Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease

Keywords: Blood Transfusion, Cardiac Tamponade, Centers for Medicare and Medicaid Services (U.S.), Episode of Care, Hemoglobins, Hirudins, Intracranial Hemorrhages, Peptide Fragments, Percutaneous Coronary Intervention, Registries, Risk Adjustment


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