Open AccessReversing the “Risk‐Treatment Paradox” of Bleeding in Patients Undergoing Percutaneous Coronary Intervention: Risk‐Concordant Use of Bleeding Avoidance Strategies Is Associated With Reduced Bleeding and Lower Costs
Author(s) -
Amin Amit P.,
Miller Samantha,
Rahn Brandon,
Caruso Mary,
Pierce Andrew,
Sorensen Katrine,
Kurz Howard,
Zajarias Alan,
Bach Richard,
Singh Jasvindar,
Lasala John M.,
Kulkarni Hemant,
CrimminsReda Patricia
Publication year - 2018
Publication title -
journal of the american heart association
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.494
H-Index - 85
ISSN - 2047-9980
DOI - 10.1161/jaha.118.008551
Subject(s) - medicine , percutaneous coronary intervention , confidence interval , absolute risk reduction , relative risk , percutaneous , surgery , myocardial infarction
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.