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 - Funding Information:
Dr Amin is funded by a comparative effectiveness research KM1 career development award from the Clinical and Translational Science Award program of the National Center for Advancing Translational Sciences of the National Institutes of Health (grant numbers UL1TR000448, KL2TR000450, and TL1TR000449) and the National Cancer Institute of the National Institutes of Health (grant number 1KM1CA156708-01) and an AHRQ R18 grant award (grant number R18HS0224181-01A1), and is a consultant to Terumo. The remaining authors have no disclosures to report.
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 -