Variation in in-hospital mortality and its association with percutaneous coronary intervention-related bleeding complications: A report from nationwide registry in Japan.

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.
Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. Yamaji has received investigator-initiated grant funding from Abbott. Dr. Kohsaka has received investigator-initiated grant funding from Bayer and Daiichi Sankyo and lecture fees from Bristol-Myers Squibb. Dr. Ishii has received lecture fees from Astellas Pharma, AstraZeneca, Bayer, Chugai Pharma Inc., Daiichi Sankyo, and MSD. Dr. Amano has received lecture fees from Astellas Pharma, AstraZeneca, Bayer, Daiichi Sankyo, and Bristol-Myers Squibb. Dr. Ikari has received research grants from Boston Scientific and Bayer. Dr. Nakagawa has received investigator-initiated grant funding from Terumo, Abbott, and Boston Scientific and lecture fees from Daiichi Sankyo, Bayer, and Bristol-Myers Squibb. The other authors declare no conflicts of interest associated with this manuscript. This does not alter our adherence to PLOS ONE policies on sharing data and materials.