TY - JOUR
T1 - Pre-procedural estimate of individualized bleeding risk impacts physicians' utilization of bivalirudin during percutaneous coronary intervention
AU - Rao, Seshu C.
AU - Chhatriwalla, Adnan K.
AU - Kennedy, Kevin F.
AU - Decker, Carole J.
AU - Gialde, Elizabeth
AU - Spertus, John A.
AU - Marso, Steven P.
N1 - Funding Information:
Ms. Gialde has received consulting honoraria from Health Outcomes Sciences, LLC. Dr. Spertus has an equity interest in Health Outcomes Sciences, LLC. Dr. Marso has received research grants and consulting fees from The Medicines Company , Novo Nordisk , Abbott Vascular , Amylin Pharmaceuticals , Boston Scientific , Volcano Corporation , and Terumo Medical , which are paid directly to the Saint Luke's Hospital Foundation of Kansas City. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
PY - 2013/5/7
Y1 - 2013/5/7
N2 - Objectives: This study sought to assess whether incorporation of routine bleeding risk estimates affected the utilization of bivalirudin during percutaneous coronary intervention (PCI). Background: Bivalirudin use during PCI has been shown to reduce bleeding complications. However, a risk-treatment paradox exists, in which patients at highest risk for bleeding are least likely to receive bivalirudin. Whether routine estimation of individualized bleeding risk can affect physicians' use of bivalirudin is unknown. Methods: PCI data from a single health system between 2007 and 2011 were analyzed. Beginning in July 2009, individualized bleeding risk estimates were provided immediately preceding PCI. Using a pre-post design, we compared bivalirudin use before and after this implementation, for patients across 3 strata of bleeding risk (<1%, 1% to 3%, and >3%). Results: Data from 6,491 PCI procedures were analyzed. Overall, bivalirudin use increased in the post-implementation period (26.9% vs. 34.2%, p < 0.001). Bivalirudin use increased in intermediate (27% to 35%, p < 0.001) and high bleeding risk patients (25% to 43%, p < 0.001), and decreased in low-risk patients (30% to 25%, p = 0.014). During the same period, bleeding complications decreased in intermediate-risk (3.4% to 1.8%, p = 0.009) and high-risk (6.9% to 3.7%, p = 0.005) patients and remained unchanged in low-risk patients (1.1% to 1.0%, p = 0.976). Conclusions: There was an increase in bivalirudin use and a lower incidence of bleeding after the incorporation of individualized bleeding risk estimates into clinical practice. This implementation led to a reversal of the risk-treatment paradox, through a rational increase in bivalirudin use in patients at intermediate and high bleeding risk and decreased use in lower-risk patients.
AB - Objectives: This study sought to assess whether incorporation of routine bleeding risk estimates affected the utilization of bivalirudin during percutaneous coronary intervention (PCI). Background: Bivalirudin use during PCI has been shown to reduce bleeding complications. However, a risk-treatment paradox exists, in which patients at highest risk for bleeding are least likely to receive bivalirudin. Whether routine estimation of individualized bleeding risk can affect physicians' use of bivalirudin is unknown. Methods: PCI data from a single health system between 2007 and 2011 were analyzed. Beginning in July 2009, individualized bleeding risk estimates were provided immediately preceding PCI. Using a pre-post design, we compared bivalirudin use before and after this implementation, for patients across 3 strata of bleeding risk (<1%, 1% to 3%, and >3%). Results: Data from 6,491 PCI procedures were analyzed. Overall, bivalirudin use increased in the post-implementation period (26.9% vs. 34.2%, p < 0.001). Bivalirudin use increased in intermediate (27% to 35%, p < 0.001) and high bleeding risk patients (25% to 43%, p < 0.001), and decreased in low-risk patients (30% to 25%, p = 0.014). During the same period, bleeding complications decreased in intermediate-risk (3.4% to 1.8%, p = 0.009) and high-risk (6.9% to 3.7%, p = 0.005) patients and remained unchanged in low-risk patients (1.1% to 1.0%, p = 0.976). Conclusions: There was an increase in bivalirudin use and a lower incidence of bleeding after the incorporation of individualized bleeding risk estimates into clinical practice. This implementation led to a reversal of the risk-treatment paradox, through a rational increase in bivalirudin use in patients at intermediate and high bleeding risk and decreased use in lower-risk patients.
KW - PCI
KW - bivalirudin
KW - bleeding
KW - bleeding risk
KW - catheterization
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U2 - 10.1016/j.jacc.2013.02.017
DO - 10.1016/j.jacc.2013.02.017
M3 - Article
C2 - 23500304
AN - SCOPUS:84876968876
SN - 0735-1097
VL - 61
SP - 1847
EP - 1852
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 18
ER -