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Quality initiative linked to reduction in bleeding events in patients undergoing PCI
ORLANDO, Fla. — A quality improvement initiative was associated with a 40% reduction in bleeding events in patients who had PCI, as well as a major cost reduction, researchers reported here.
Jerome E. Granato, MD, vice president and medical director, National Cardiovascular Service Line, Catholic Health Initiatives, Lexington, Kentucky, reported on the results of an enterprise-wide quality improvement project to reduce bleeding risk in patients requiring PCI. The program was implemented across 11 regional health systems including three medical schools.
Jerome E. Granato
Granato said in a presentation at the Society for Cardiovascular Angiography and Interventions Scientific Sessions that the researchers analyzed 8,713 PCI procedures from more than 200 operators at 21 hospitals in 11 states using data from the National Cardiovascular Data Registry (NCDR). They compared bleeding event rates and costs during 21 months from before and after the program was implemented.
In the program, participating centers started using the NCDR bleeding risk calculator at various points during the study period. The calculator stratified patients into high (score > 65), intermediate (score 25-65) or low (score < 25) risk for bleeding, and prompted clinicians to employ bleeding avoidance strategies, Granato said.
“For [the low-risk] group, we discouraged the use of bivalirudin and favored the use of heparin,” he said. “For [the intermediate-risk group], we left the approach and the anticoagulation choice up to the operator. For patients with scores of 66 and higher that we felt to be at high risk for bleeding, we strongly encouraged the use of bivalirudin or transradial access. In all cases, use of glycoprotein inhibitors was discouraged. [The program was] very effective at prompting operators to reduce bivalirudin use in the low-risk group, while bivalirudin continued to be used at baseline levels in the intermediate- and high-risk groups.”
The decline in bivalirudin use led to a savings of $1 million per year in pharmacy costs, according to Granato.
Bleeding incidence was 6.3% at baseline and 3.78% at 21 months, a decline of 40%, Granato said.
“It’s important to note that all sites did not immediately commence use of the bleeding risk calculator,” he said. “Had they all done so simultaneously, we would have witnessed an even greater reduction in bleeding events.”
He said each bleeding event marginally increased costs by $8,000 to $10,000, so the reduction in bleeding events saved more than $1 million per year across the hospital system.
During the study period, use of transradial access increased from 32.9% at baseline to 54% at 21 months, he said. “As a result, we were not surprised to see an overall decrease in the use of bivalirudin.”
Rates of MACE did not change over time, Granato said.
“We believe that pre-procedural knowledge of potential bleeding risk was not only a factor in the migration to transradial access, but also facilitated a recognition of which patients might be eligible for same-day discharge after PCI,” Granato said, adding that same-day discharge increased at a similar rate to transradial access. – by Erik Swain
Reference:
Granato JE, Osborne M. Late-Breaking Clinical Trials – Part 1. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; May 4-7, 2016; Orlando, Fla.
Disclosure: Granato reports no relevant financial disclosures.
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The study shows that you can implement evidence-based medicine at the bedside at a health-system level, and make real changes. This is very exciting. It was not one doctor or one practice doing this, it was implemented across a health system in a way that we always talk about: Bringing public evidence and risk scores that have been validated to the bedside and changing physician behavior. Other studies have shown that if you provide physicians with a calculated estimated risk of an event happening, it actually influences physician behavior. The system had an incentive to implement this program to reduce costs, but found that the change also improved outcomes, which ultimately is what patients care about. That kind of quality improvement research may not be as glamorous as some of the other things interventional cardiologists do, but it’s something that produces real change.
There are tons of available risk scores. One reason why validated risk scores haven’t been adopted as much as they should be is because providers think, “Oh, that’s one more thing I have to do.” I would like, in the era of smartphones and electronic medical records, to have them integrated into our normal workflow. We have the computing power to do it. We just have to be able to get to a system where, when I pull up a patient’s electronic health record, along with all their medications and lab results, there should be, based on a validated risk model, their estimated risks for bleeding, mortality, restenosis and acute kidney injury. I should be able to get those without having to calculate them. Then, based on that information, I may want to change the strategy I use in the cath lab. If we can integrate risk scores into our normal way of doing things, then they will be widely adopted.