THE BLEEDING RISK TREATMENT PARADOX AT THE PHYSICIAN 1 AND HOSPITAL LEVEL: IMPLICATIONS FOR REDUCING BLEEDING IN PATIENTS UNDERGOING PCI.

Abstract

BACKGROUND\nBleeding is a common and costly complication of percutaneous coronary intervention (PCI). Bleeding avoidance strategies (BAS) are used paradoxically less in patients at high-risk of bleeding: bleeding risk-treatment paradox (RTP). We determined whether hospitals and physicians, who do not align BAS to PCI patients bleeding risk (i.e., exhibit a RTP) have higher bleeding rates.\n\n\nMETHODS\nWe examined 28,005 PCIs from the NCDR CathPCI Registry for 7 hospitals comprising BJC HealthCare. BAS included transradial intervention (TRI), bivalirudin (BIV), and vascular closure devices (VCDs). Patients predicted bleeding risk was based on NCDR CathPCI bleeding model and categorized as low (<2.0%), moderate (2.0-6.4%), or high (≥6.5%) risk tertiles. BAS use was considered risk-concordant if: at least one BAS was used for moderate risk; two BAS were used for high risk and bivalirudin or VCDs were not used for low risk. Absence of risk-concordant BAS use was defined as RTP. We analyzed inter-hospital and inter-physician variation in RTP, and the association of RTP with post-PCI bleeding.\n\n\nRESULTS\nAmongst 28,005 patients undergoing PCI by 103 physicians at seven hospitals, RTP was observed in 12,035 (43%) patients. RTP was independently associated with a higher likelihood of bleeding even after adjusting for predicted bleeding risk, mortality risk and potential sources of variation (OR 1.66, 95%CI 1.44-1.92, P<0.001). A higher prevalence of RTP strongly and independently correlated with worse bleeding rates, both at the physician-level (Wilk s Lambda 0.9502, F-value 17.21, p<0.0001) and the hospital-level (Wilk s Lambda 0.9899, F-value 35.68, p<0.0001). All the results were similar in a subset of PCIs conducted since 2015 - a period more reflective of the contemporary practice.\n\n\nCONCLUSIONS\nBleeding RTP is a strong, independent predictor of bleeding. It exists at the level of physicians and hospitals: those with a higher rate of RTP had worse bleeding rates. These findings not only underscore the importance of recognizing bleeding risk upfront and using BAS in a risk-aligned manner, but also inform and motivate national efforts to reduce PCI-related bleeding.