Abstract
Large-scale registries have demonstrated that in-hospital mortality after percutaneous coronary intervention (PCI) varies widely across institutions. However, whether this variation is related to major procedural complications (e.g., bleeding) is unclear. In this study, institutional variation in in-hospital mortality and its association with PCI-related bleeding complications were investigated. We analyzed 388,866 procedures at 718 hospitals performed from 2017 to 2018, using data from a nationwide PCI registry in Japan. Hospitals were stratified into quintiles according to risk-adjusted in-hospital mortality (very low, low, medium, high, and very high). Incidence of bleeding complications, defined as procedure-related bleeding events that required a blood transfusion, and in-hospital mortality in patients who developed bleeding complications were calculated for each quintile. Overall, 4,048 (1.04%) in-hospital deaths and 1,535 (0.39%) bleeding complications occurred. Among patients with bleeding complications, 270 (17.6%) died during hospitalization. In-hospital mortality ranged from 0.22% to 2.46% in very low to very high mortality hospitals. The rate of bleeding complications varied modestly from 0.27% to 0.57% (odds ratio, 1.95; 95% confidence interval, 1.58-2.39). However, mortality after bleeding complications markedly increased by quintile and was 6-fold higher in very high mortality hospitals than very low mortality hospitals (29.0% vs. 4.8%; odds ratio, 12.2; 95% confidence interval, 6.90-21.7). In conclusion, institutional variation in in-hospital mortality after PCI was associated with procedure-related bleeding complications, and this variation was largely driven by differences in mortality after bleeding complications rather than difference in their incidence. These findings underscore the importance of efforts toward reducing not only bleeding complications but also, even more importantly, subsequent mortality once they have occurred.
Highlights
Despite advances in percutaneous coronary intervention (PCI) over the last 40 years, bleeding has been regarded as one of the most serious procedure-related complications [1, 2]
This study examined 388,866 PCI procedures performed at 718 hospitals and registered within the Japanese Percutaneous Coronary Intervention (J-PCI) registry
Our main findings are as follows: (i) institutional variation in in-hospital mortality after PCI was associated with procedure-related bleeding complications; (ii) this variation was mainly caused by differences in mortality of patients who developed bleeding complications rather than crude incidence of bleeding complications; (iii) this trend was consistently observed in both bleeding complications from non-access and access site
Summary
Despite advances in percutaneous coronary intervention (PCI) over the last 40 years, bleeding has been regarded as one of the most serious procedure-related complications [1, 2]. Large-scale registries have demonstrated that in-hospital mortality in patients underwent PCI varies widely across institutions [12,13,14], though the underlying reasons are not fully understood We hypothesized that this variation may be involved in bleeding complications because their incidence or subsequent clinical outcomes can be largely dictated by hospital’s capacity (e.g., the ability to prevent, expeditiously recognize or properly manage complications). Identifying this association has the potential to improve the prognosis of PCI in the contemporary era when patients with a high risk of bleeding are commonly treated
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