Identification of Hospital Outliers in Bleeding Complications After Percutaneous Coronary Intervention. (January 2015)

• Record Type: Journal Article
• Authors: Hess, Connie N.; Rao, Sunil V.; McCoy, Lisa A.; Neely, Megan L.; Singh, Mandeep; Spertus, John A.; Krone, Ronald J.; Weaver, W. Douglas; Peterson, Eric D.
• Is Part Of: Circulation. Volume 8:Number 1(2015)
• Publication Date: 2015-01
• Subjects: Cardiovascular system -- Diseases -- Treatment -- Periodicals; Cardiovascular system -- Diseases -- Research -- Periodicals; Outcome assessment (Medical care) -- Periodicals; Evidence-based medicine -- Periodicals; 616.1007
• DOI: 10.1161/CIRCOUTCOMES.113.000749
• Languages: English
• ISSNs: 1941-7713

Abstract

<abstract> <title> <x xml:space="preserve">Abstract</x> </title> <sec> <title>Background—</title> <p>Post-percutaneous coronary intervention (PCI) bleeding complications are an important quality metric. We sought to characterize site-level variation in post-PCI bleeding and explore the influence of patient and procedural factors on hospital bleeding performance.</p> </sec> <sec> <title>Methods and Results—</title> <p>Hospital-level bleeding performance was compared pre- and postadjustment using the newly revised CathPCI Registry<sup>®</sup> bleeding risk model (c-index, 0.77) among 1292 National Cardiovascular Data Registry<sup>®</sup> hospitals performing >50 PCIs from 7/2009 to 9/2012 (n=1 984 998 procedures). Using random effects models, outlier sites were identified based on 95% confidence intervals around the hospital's random intercept. Bleeding 72 hours post-PCI was defined as: arterial access site, retroperitoneal, gastrointestinal, or genitourinary bleeding; intracranial hemorrhage; cardiac tamponade; nonbypass surgery–related blood transfusion with preprocedure hemoglobin ≥8 g/dL; or absolute decrease in hemoglobin value ≥3 g/dL with preprocedure hemoglobin ⩽16 g/dL. Overall, the median unadjusted post-PCI bleeding rate was 5.2% and varied among hospitals from 2.6% to 10.4% (5th, 95th percentiles). Center-level bleeding variation persisted after case-mix adjustment (2.8%–9.5%; 5th, 95th percentiles). Although hospitals' observed and risk-adjusted bleeding ranks were correlated (Spearman ρ: 0.88), individual rankings shifted after risk-adjustment (median Δ rank order: ±91.5; interquartile range: 37.0, 185.5). Outlier classification changed postadjustment for 29.3%, 16.1%, and 26.5% of low-, non-, and high-outlier sites, respectively. Hospital use of bleeding avoidance strategies (bivalirudin, radial access, or vascular closure device) was associated with risk-adjusted bleeding rates.</p> </sec> <sec> <title>Conclusions—</title> <p>Despite adjustment for patient case-mix, there is wide variation in rates of hospital PCI-related bleeding in the United States. Opportunities may exist for best performers to share practices with other sites.</p> </sec> </abstract>