Seeking to characterize site-level variation in post-percutaneous coronary intervention (PCI) bleeding and understand the influence of patient and procedural factors on hospital bleeding performance, a study published Nov. 25 in Circulation: Cardiovascular Quality and Outcomes found that despite adjustments for patient case-mix, there is wide variation in rates of hospital PCI-related bleeding in the U.S., and the use of PCI-related bleeding as a site performance measure should be supported in PCI registries.

Each year over 600,000 PCI procedures are performed in the U.S. Recently, post-PCI bleeding, an important procedural complication associated with poor prognosis, has slowly been adopted as a quality of care metric, despite not being characterized among the majority of hospitals across the country. The study was spearheaded by principal investigator Connie Hess, MD, Duke Clinical Research Institute, Durham, NC, and looked at hospital-level bleeding performance pre- and post-adjustment using ACC’s CathPCI Registry.

The investigators examined almost two million PCI procedures performed at 1,292 U.S. hospitals, and results showed that hospital bleeding rates varied from 2.1 percent to 10.3 percent (fifth and 95th percentiles, respectively). Center-level bleeding variation was shown to persist after a case-mix adjustment (2.8 percent to 9.5 percent; fifth, 95th percentiles). Although hospitals’ observed and risk-adjusted bleeding ranks were correlated, individual rankings shifted after risk-adjustment and outlier classification changed post-adjustment for 29.3 percent, 16.1 percent, and 26.5 percent of low-, non-, and high-outlier sites, respectively.

“From a policy perspective, we found that adjustment for patient clinical characteristics changed hospital outlier classification for >25 percent of sites and is necessary for appropriate provider comparisons,” the authors note. “However, wide variation in hospital bleeding rates persisted after risk-adjustment. Procedural approaches, such as hospital use of bleeding avoidance strategies, were associated with reduced rates of bleeding, thereby indicating the potential for provider interventions to mitigate PCI bleeding complications.”

Associated with increased morbidity, mortality and cost, post-PCI bleedings represents an appropriate hospital performance indicator, according to Hess and her colleagues. They note that moving forward, quality improvement initiatives designed to reduce post-PCI bleeding, perhaps through wide implementation of bleeding avoidance strategies and sharing of practices from best-performing sites, might result in improved PCI outcomes.

Keywords: Diagnosis-Related Groups, Morbidity, Percutaneous Coronary Intervention, Quality Improvement, Registries, Risk Adjustment, Risk Adjustment, United States, Hemorrhage

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