Identification of hospital outliers in bleeding complications after percutaneous coronary intervention
Hess CN, Rao SV, McCoy LA, Neely ML, Singh M, Spertus JA, Krone RJ, Weaver WD, Peterson ED. Identification of hospital outliers in bleeding complications after percutaneous coronary intervention. Circ Cardiovasc Qual Outcomes. 2015;8(1):15-22.
Circ Cardiovasc Qual Outcomes
BACKGROUND: 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.
METHODS AND RESULTS: Hospital-level bleeding performance was compared pre- and postadjustment using the newly revised CathPCI Registry(®) bleeding risk model (c-index, 0.77) among 1292 National Cardiovascular Data Registry(®) 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.
CONCLUSIONS: 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.
Medical Subject Headings
Aged; Female; Hemorrhage; Hospital Bed Capacity; Hospitals; Hospitals, High-Volume; Hospitals, Low-Volume; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Quality Improvement; Quality Indicators, Health Care; Registries; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States