TY - JOUR
T1 - Reversing the “risk-treatment paradox” of bleeding in patients undergoing percutaneous coronary intervention
T2 - Risk-concordant use of bleeding avoidance strategies is associated with reduced bleeding and lower costs
AU - Amin, Amit P.
AU - Miller, Samantha
AU - Rahn, Brandon
AU - Caruso, Mary
AU - Pierce, Andrew
AU - Sorensen, Katrine
AU - Kurz, Howard
AU - Zajarias, Alan
AU - Bach, Richard
AU - Singh, Jasvindar
AU - Lasala, John M.
AU - Kulkarni, Hemant
AU - Crimmins-Reda, Patricia
N1 - Publisher Copyright:
© 2018 The Authors.
PY - 2018/11/1
Y1 - 2018/11/1
N2 - Background-Bleeding is a common, morbid, and costly complication of percutaneous coronary intervention. While bleeding avoidance strategies (BAS) are effective, they are used paradoxically less in patients at high risk of bleeding. Whether a patient-centered approach to specifically increase the risk-concordant use of BAS and, thus, reverse the risk-treatment paradox is associated with reduced bleeding and costs is unknown. Methods and Results-We implemented an intervention to reverse the bleeding risk-treatment paradox at Barnes-Jewish Hospital, St. Louis, MO, and examined: (1) the temporal trends in BAS use and (2) the association of risk-concordant BAS use with bleeding and hospital costs of percutaneous coronary intervention. Among 3519 percutaneous coronary interventions, there was a significantly increasing trend (P=0.002) in risk-concordant use of BAS. The bleeding incidence was 2% in the risk-concordant group versus 9% in the risk-discordant group (absolute risk difference, 7%; number needed to treat, 14). Risk-concordant BAS use was associated with a 67% (95% confidence interval, 52-78%; P<0.001) reduction in the risk of bleeding and a $4738 (95% confidence interval, 3353-6122; P<0.001) reduction in per-patient percutaneous coronary intervention hospitalization costs (21.6% cost-savings). Conclusions-In this study, patient-centered care directly aimed to make treatment-related decisions based on predicted risk of bleeding, led to more risk-concordant use of BAS and reversal of the risk-treatment paradox. This, in turn, was associated with a reduction in bleeding and hospitalization costs. Larger multicentered studies are needed to corroborate these results. As clinical medicine moves toward personalization, both patients and hospitals can benefit from a simple practice change that encourages objectivity and mitigates variability in care.
AB - Background-Bleeding is a common, morbid, and costly complication of percutaneous coronary intervention. While bleeding avoidance strategies (BAS) are effective, they are used paradoxically less in patients at high risk of bleeding. Whether a patient-centered approach to specifically increase the risk-concordant use of BAS and, thus, reverse the risk-treatment paradox is associated with reduced bleeding and costs is unknown. Methods and Results-We implemented an intervention to reverse the bleeding risk-treatment paradox at Barnes-Jewish Hospital, St. Louis, MO, and examined: (1) the temporal trends in BAS use and (2) the association of risk-concordant BAS use with bleeding and hospital costs of percutaneous coronary intervention. Among 3519 percutaneous coronary interventions, there was a significantly increasing trend (P=0.002) in risk-concordant use of BAS. The bleeding incidence was 2% in the risk-concordant group versus 9% in the risk-discordant group (absolute risk difference, 7%; number needed to treat, 14). Risk-concordant BAS use was associated with a 67% (95% confidence interval, 52-78%; P<0.001) reduction in the risk of bleeding and a $4738 (95% confidence interval, 3353-6122; P<0.001) reduction in per-patient percutaneous coronary intervention hospitalization costs (21.6% cost-savings). Conclusions-In this study, patient-centered care directly aimed to make treatment-related decisions based on predicted risk of bleeding, led to more risk-concordant use of BAS and reversal of the risk-treatment paradox. This, in turn, was associated with a reduction in bleeding and hospitalization costs. Larger multicentered studies are needed to corroborate these results. As clinical medicine moves toward personalization, both patients and hospitals can benefit from a simple practice change that encourages objectivity and mitigates variability in care.
KW - Anticoagulant
KW - Bleeding
KW - Cost
KW - Percutaneous coronary intervention
KW - Radial artery catheter
UR - http://www.scopus.com/inward/record.url?scp=85055651773&partnerID=8YFLogxK
U2 - 10.1161/JAHA.118.008551
DO - 10.1161/JAHA.118.008551
M3 - Article
C2 - 30376760
AN - SCOPUS:85055651773
SN - 2047-9980
VL - 7
JO - Journal of the American Heart Association
JF - Journal of the American Heart Association
IS - 21
M1 - e008551
ER -