Abstract 14723: Impact of Individualized Bleeding Risk Estimates on Medical Decision Making During PCI
Background: Bleeding is the most common non-cardiac complication of PCI and it is both predictable and modifiable. Nevertheless, evidence suggests that patients’ bleeding risk has little impact on the use of bleeding avoidance strategies (BAS) such as bivalirudin, radial access and vascular closure devices (VCD’s). PRISM is a tool that generates individualized risk estimates at the time of PCI to support medical decision-making. In a pre-post study design, we examined whether PRISM-generated bleeding risk estimates influenced the use of BAS during PCI at 9 U.S. hospitals.
Methods: Individualized bleeding risk was estimated for patients undergoing PCI by incorporating the previously validated National Cardiovascular Data Registry (NCDR®) bleeding risk model within the PRISM tool. Patients were stratified according to low (<1%), intermediate (1-3%), or high (>3%) bleeding risk. BAS use, before and after PRISM implementation, was compared by calculating propensity-adjusted odds ratios (OR’s) within strata of bleeding risk, after hierarchical modeling to adjust for physicians’ case volumes.
Results: There were 6,312 PCI procedures performed in the 12 months prior to PRISM implementation, and 3,027 procedures after. Patients were at low, intermediate, and high risk for bleeding in 40%, 48%, and 12% of cases, respectively. Overall BAS use increased after implementation (OR 1.61, p<0.001). There was a non-significant trend toward increased BAS use in higher-risk patients after implementation (OR’s= 1.46, 1.41, and 2.38 for patients at low, intermediate and high risk for bleeding, respectively, p=0.13 for trend). Similar trends were observed with the use bivalirudin (OR’s=1.00, 1.23, and 1.42 p=0.33) and VCD’s (OR’s = 0.99, 1.26, and 1.27; p=0.26) as individual BAS. The use of radial PCI increased in all patients after implementation (OR’s= 2.58, 1.96, and 3.15; p=0.12).
Conclusions: Individualized bleeding risk estimates were associated with increased use of bleeding avoidance strategies at 9 U.S. PCI centers. However, the trend to use BAS more frequently in patients at higher bleeding risk was not significant. Further research is necessary to identify and overcome barriers to the incorporation of clinical risk estimates in medical decision making.
- © 2012 by American Heart Association, Inc.