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Competing Interests: Declaration of competing interest Dr. Doll is supported by a VA Career Development Award (1IK2HX002590). Dr. Waldo has received investigator-initiated research support to the Denver Research Institute from Abiomed, Cardiovascular Systems Incorporated, Janssen Pharmaceuticals, National Institutes of Health and VA Health Services Research and Development. Dr. Hira reports honoraria from Abbott Vascular, Boston Scientific, and Abiomed. All other authors have nothing to disclose.

Background: Recent analyses of the volume-outcome relationship for percutaneous coronary intervention (PCI) have suggested a less robust association than previously reported. It is unknown if novel factors such as lifetime operator experience influence this relationship., Objectives: To assess the relationship between annual volumes and outcomes for PCI and determine whether lifetime operator experience modulates the association., Methods: Annual PCI volumes for facilities and operators within the Veterans Affairs Healthcare System and their relationship with 30-day mortality following PCI were described. The influence of operator lifetime experience on the volume-outcome relationship was assessed. Hierarchical logistic regression was used to adjust for patient and procedural factors., Results: 57,608 PCIs performed from 2013 to 2018 by 382 operators and 63 institutions were analyzed. Operator annualized PCI volume averaged 47.6 (standard deviation [SD] 49.1) and site annualized volume averaged 189.2 (SD 105.2). Median operator experience was 9.0 years (interquartile range [IQR] 4.0-15.0). There was no independent relationship between operator annual volume, institutional volume, or operator lifetime experience with 30-day mortality (p > 0.10). However, the interaction between operator volume and lifetime experience was associated with a marginal decrease in mortality (odds ratio [OR] 0.9998, 95% CI 0.9996-0.9999)., Conclusions: There were no significant associations between facility or operator-level procedural volume and 30-day mortality following PCI in a nationally integrated healthcare system. There was a marginal association between the interaction of operator lifetime experience, operator annual volume, and 30-day mortality that is unlikely to be clinically relevant, though does suggest an opportunity to explore novel factors that may influence the volume-outcome relationship., Competing Interests: Declaration of competing interest The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. Government. Dr. Valle has received unrelated consulting fees from Philips Medical, Medtronic, and Cardiovascular Systems Incorporated. Dr. Waldo has received grants from the National Institutes of Health and VA Health Services Research and investigator-initiated research support to the Denver Research Institute from Abiomed, Cardiovascular Systems Incorporated, and Janssen Pharmaceuticals; and serves as the National Director of the VA Clinical Assessment, Reporting, and Tracking (CART) Program, the national quality and safety oversight organization for invasive cardiac procedures within the Veterans Affairs (VA) Healthcare System. The other authors have no relevant disclosures., (Published by Elsevier Inc.)

Background: Bleeding is a common complication of percutaneous coronary intervention (PCI) that is associated with worse clinical outcomes and increased costs. Improved pre-procedural bleeding risk prediction could promote strategies that have been shown to reduce post-PCI bleeding, including increased adoption of radial access., Methods: We studied patients in the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) program receiving PCI in VA hospitals. Logistic regression was performed to develop a model for major in-hospital bleeding using demographic, clinical, and procedural variables. The discriminatory ability of the model was compared to the existing National Cardiovascular Data Registry (NCDR) CathPCI bleeding risk model., Results: Among 107,451 patients treated from 2008 to 2019, 5218 (4.86%) experienced an in-hospital bleeding event. Twelve variables were associated with bleeding risk. Predictors of bleeding included emergency or salvage status, cardiogenic shock, NSTEMI, Atrial fibrillation, elevated INR, and peripheral vascular disease, while radial access, greater body surface area, and stable or unstable angina were associated with lower risk of bleeding. The developed model had superior discrimination compared with the NCDR CathPCI model (c-index 0.756, 95% CI 0.749-0.764 vs. 0.707, 95% CI 0.700-0.714, p < 0.001), especially among the highest risk patients. A web-based tool has been created to facilitate calculation of bleeding risk using this model at the point of care., Conclusion: The VA CART bleeding risk model uses baseline clinical and procedural variables to predict post-PCI in-hospital bleeding events and has improved discrimination compared to other available models in this patient population. Implementation of this model can facilitate risk stratification at the point of care and permit improved risk-adjustment for quality assessment., Competing Interests: Declaration of competing interest Dr. Waldo receives investigator-initiated research support to the Denver Research Institute from Abiomed, Cardiovascular Systems Incorporated, Janssen Pharmaceuticals, and Merck Pharmaceuticals. He serves as the national director and Dr. Doll serves as an assistant director for the Clinical Assessment, Reporting, and Tracking Program. The remaining authors have no disclosures to report., (Published by Elsevier Inc.)