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Bleeding avoidance strategies account for modest proportion of variation in post-PCI bleeding
Differences between U.S. hospitals in the implementation of bleeding avoidance strategies appear to account for only a modest percentage of differences in the rates of post-PCI bleeding events, according to a recent report.
Researchers reviewed the American College of Cardiology National Cardiovascular Data Registry’s CathPCI Registry to determine approximate hospital-level rates of bleeding events from 2,459,686 patients undergoing PCI at 1,358 sites. Patients were classified as treated with a bleeding avoidance strategy if they underwent radial artery access PCI, if they were treated with periprocedural bivalirudin for anticoagulation regardless of access site or, in the case of femoral access, if they received a vascular closure device at the end of the procedure. The researchers constructed a series of eight models to estimate random-effect variance, adjusting for patient risk and various combinations of bleeding avoidance strategies. Hospital bleeding rates adjusted by patient risk were estimated using logistic regression with random intercepts for hospital. The validated CathPCI bleeding risk model was used to determine bleeding risk. The rate of bleeding avoidance strategy use was estimated for each hospital, and correlations between percentage bleeding avoidance strategy use and projected bleeding risk was established.
Overall, there were 125,361 bleeding events (5.1%). The following strategies were less frequently used in patients who experienced bleeding events vs. those who did not have bleeding events: radial access (5% vs. 11.2%; P < .001); periprocedural bivalirudin treatment (43.8% vs. 59.4%) and use of a vascular closure device (32.9% vs. 42.4%; P < .001). Significant disparities in bleeding rates were seen across hospitals (median, 5%; interquartile range, 2.7%-6.6%); this finding remained consistent after adjusting for patient-level risk. Although 20% of this disparity in these rates could be attributed to patient factors and an additional 7.8% to the use of radial access and bivalirudin treatment after adjusting for patient factors, use of vascular closure devices accounted for only 0.88% of the overall variation. The median use rate of any bleeding avoidance strategy in hospitals was 86.6% (interquartile range, 72.5%-94.1%). Hospitals with bleeding avoidance strategy use above the median demonstrated a significant decrease in observed hospital level bleeding (adjusted OR = 0.9; 95% CI, 0.88-0.93).
The researchers noted that despite the role played by bleeding avoidance strategy in hospital-level differences in post-PCI bleeding events, the cause of 70% of this disparity has not yet been identified.
“This study urges caution in the use of post-PCI bleeding as a performance measure, as a significant proportion of the hospital-level variation in bleeding remains unexplained,” the researchers wrote. “More granular data collection and further analyses are necessary to explain this variation in bleeding rates to develop best practices to mitigate bleeding following PCI.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.