BACKGROUND Bleeding is a common and costly complication of percutaneous coronary intervention (PCI). Bleeding avoidance strategies (BAS) are used paradoxically less in patients at high-risk of bleeding: "bleeding risk-treatment paradox" (RTP). We determined whether hospitals and physicians, who do not align BAS to PCI patients' bleeding risk (ie, exhibit a RTP) have higher bleeding rates. METHODS We examined 28,005 PCIs from the National Cardiovascular Data Registry CathPCI Registry for 7 hospitals comprising BJC HealthCare. BAS included transradial intervention, bivalirudin, and vascular closure devices. Patients' predicted bleeding risk was based on National Cardiovascular Data Registry CathPCI bleeding model and categorized as low (<2.0%), moderate (2.0%-6.4%), or high (≥6.5%) risk tertiles. BAS use was considered risk-concordant if: at least 1 BAS was used for moderate risk; 2 BAS were used for high risk and bivalirudin or vascular closure devices were not used for low risk. Absence of risk-concordant BAS use was defined as RTP. We analyzed inter-hospital and inter-physician variation in RTP, and the association of RTP with post-PCI bleeding. RESULTS Amongst 28,005 patients undergoing PCI by 103 physicians at 7 hospitals, RTP was observed in 12,035 (43%) patients. RTP was independently associated with a higher likelihood of bleeding even after adjusting for predicted bleeding risk, mortality risk and potential sources of variation (OR 1.66, 95% CI 1.44-1.92, P < .001). A higher prevalence of RTP strongly and independently correlated with worse bleeding rates, both at the physician-level (Wilk's Lambda 0.9502, F-value 17.21, P < .0001) and the hospital-level (Wilk's Lambda 0.9899, F-value 35.68, P < .0001). All the results were similar in a subset of PCIs conducted since 2015 - a period more reflective of the contemporary practice. CONCLUSIONS Bleeding RTP is a strong, independent predictor of bleeding. It exists at the level of physicians and hospitals: those with a higher rate of RTP had worse bleeding rates. These findings not only underscore the importance of recognizing bleeding risk upfront and using BAS in a risk-aligned manner, but also inform and motivate national efforts to reduce PCI-related bleeding.

中文翻译：

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医生和医院层面的出血风险治疗悖论：减少经皮冠状动脉介入治疗患者出血的意义。

背景出血是经皮冠状动脉介入治疗（PCI）常见且代价高昂的并发症。出血避免策略 (BAS) 在出血风险高的患者中使用较少：“出血风险治疗悖论” (RTP)。我们确定了未将 BAS 与 PCI 患者的出血风险（即表现出 RTP）进行比较的医院和医生是否具有更高的出血率。方法 我们检查了来自国家心血管数据注册中心 CathPCI 注册中心的 28,005 例 PCI，包括 BJC HealthCare 在内的 7 家医院。BAS 包括经桡动脉介入、比伐卢定和血管闭合装置。患者的预测出血风险基于国家心血管数据登记处 CathPCI 出血模型，分为低 (<2.0%)、中 (2.0%-6.4%) 或高 (≥6.5%) 风险三分位数。在以下情况下，BAS 的使用被认为是风险一致的： 至少 1 个 BAS 用于中等风险；2 BAS 用于高风险，比伐卢定或血管闭合装置不用于低风险。没有使用风险一致的 BAS 被定义为 RTP。我们分析了 RTP 的医院间和医师间差异，以及 RTP 与 PCI 后出血的关联。结果 在 7 家医院的 103 名医生接受 PCI 的 28,005 名患者中，12,035 名 (43%) 患者观察到 RTP。即使在调整了预测的出血风险、死亡风险和潜在的变异来源后，RTP 与更高的出血可能性独立相关（OR 1.66，95% CI 1.44-1.92，P < .001）。RTP 的较高患病率与更差的出血率强烈且独立地相关，无论是在医生层面（Wilk 的 Lambda 0.9502，F 值 17.21，P < .0001）和医院级别（Wilk's Lambda 0.9899，F 值 35.68，P < .0001）。自 2015 年以来进行的部分 PCI 的所有结果都相似——这一时期更能反映当代实践。结论 出血 RTP 是一个强有力的、独立的出血预测因子。它存在于医生和医院层面：RTP 率较高的患者出血率较低。这些发现不仅强调了提前识别出血风险和以风险一致的方式使用 BAS 的重要性，而且还为国家减少 PCI 相关出血的努力提供了信息和激励。结论 出血 RTP 是一个强有力的、独立的出血预测因子。它存在于医生和医院层面：RTP 率较高的患者出血率较低。这些发现不仅强调了提前识别出血风险和以风险一致的方式使用 BAS 的重要性，而且还为国家减少 PCI 相关出血的努力提供了信息和激励。结论 出血 RTP 是一个强有力的、独立的出血预测因子。它存在于医生和医院层面：RTP 率较高的患者出血率较低。这些发现不仅强调了提前识别出血风险和以风险一致的方式使用 BAS 的重要性，而且还为国家减少 PCI 相关出血的努力提供了信息和激励。