Author + information
- Received December 22, 2015
- Accepted January 14, 2016
- Published online April 25, 2016.
- Amit N. Vora, MD, MPHa,∗ (, )
- Eric D. Peterson, MD, MPHa,
- Lisa A. McCoy, MSa,
- Kirk N. Garratt, MDb,
- Michael A. Kutcher, MDc,
- Steven P. Marso, MDd,
- Matthew T. Roe, MD, MHSa,
- John C. Messenger, MDe and
- Sunil V. Rao, MDa
- aDuke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- bCenter for Heart and Vascular Health, Christiana Care Health System, Wilmington, Delaware
- cWake Forest University School of Medicine, Winston-Salem, North Carolina
- dUniversity of Texas Southwestern Medical Center, Dallas, Texas
- eDepartment of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- ↵∗Reprint requests and correspondence:
Dr. Amit N. Vora, Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, North Carolina 27705.
Objectives The aim of this study was to explore whether the use of bleeding avoidance strategies (BAS) explains variability in hospital-level bleeding following percutaneous coronary intervention.
Background Prior studies have reported that bleeding rates following percutaneous coronary intervention vary markedly among hospitals, but the extent to which use of BAS explains this variation is unknown.
Methods Using the American College of Cardiology National Cardiovascular Data Registry’s CathPCI Registry, estimated hospital-level bleeding rates from 2,459,686 procedures at 1,358 sites were determined. 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 (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.
Results In total, 125,361 bleeding events (5.1%) were observed; patients experiencing bleeding events had lower rates of radial access (5.0% vs. 11.2%; p < 0.001), bivalirudin therapy (43.8% vs. 59.4%), and vascular closure device use (32.9% vs. 42.4%, p < 0.001) than those without bleeding. There was significant variation in bleeding rates across hospitals (median 5.0%; interquartile range [IQR]: 2.7% to 6.6%), which persisted after incorporating patient-level risk (median 5.1%; IQR: 4.0% to 4.4%). 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% (IQR: 72.5% to 94.1%). A significant decrease in observed hospital-level bleeding was seen in hospitals above the median in BAS use (adjusted odds ratio: 0.90; 95% confidence interval: 0.88 to 0.93).
Conclusions A modest proportion of the variation in hospitals’ rates of bleeding following percutaneous coronary intervention is attributable to differential use of BAS. Further analyses are required to determine the remaining approximately 70% causes of variation in percutaneous coronary intervention bleeding seen among hospitals.
This research was supported by the American College of Cardiology Foundation’s National Cardiovascular Data Registry. The analytic work for this investigator-initiated study was performed by the Duke Clinical Research Institute, with financial support from the American College of Cardiology. The CathPCI Registry is an initiative of the American College of Cardiology Foundation and the Society for Cardiovascular Angiography and Interventions. The manuscript was reviewed by the National Cardiovascular Data Registry for compliance with registry description and representation, but the sponsor had no role in the design and conduct of the study, analysis and interpretation of the data, preparation of the manuscript, or decision to submit the manuscript for publication. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 22, 2015.
- Accepted January 14, 2016.
- 2016 American College of Cardiology Foundation