Outpatient Worsening Heart Failure in an Integrated Health Care Delivery System: An Innovative Approach to Characterizing a Novel Clinical Entity

项目总结/摘要 尽管循证药物治疗使非卧床心力衰竭（HF）的治疗发生了革命性变化， 和器械治疗，在因病情恶化而入院的患者的护理方面没有类似的进展 HF（WHF）。为了激励卫生系统减少30天的再入院，《平价医疗法案》（ACA） 2012年启动了减少再入院计划（HRRP），对医院进行经济处罚 如果他们的风险调整后30天再入院率高于预期，包括HF。虽然 HRRP已经适度减少了再入院，这个计划已经产生了意想不到的后果， 很大一部分HF相关护理提供给门诊患者。因此，在该领域中， 将WHF与护理地点分开，不再使用住院治疗作为急性 失代偿性HF。然而，对流行病学、临床特征、治疗模式和/或 门诊WHF的结局。此外，虽然非卧床HF患者的总体生存率有所改善， 引人注目的是，指南导向的药物治疗（GDMT）对健康损害的影响微乎其微- 相关生活质量（HRQOL）。尽管存在这种现实，但几乎没有真实的数据源可用于描述 HRQOL在门诊环境中的轨迹。为了解决这些关键的知识差距，我们建议（1） 系统地描述当代流行病学，临床特征，治疗模式， 与门诊WHF相关的结局和（2）评价门诊WHF发作对 在一个完全整合的卫生保健提供系统的背景下，一般和疾病特异性HRQOL。第一 目标将利用来自大型、最先进和经过验证的电子健康记录的观察数据 (EHR)自然语言处理（NLP）的系统和机器学习算法， 确定并全面描述门诊WHF的发作。第二个目标将 前瞻性地应用这种基于软件的解决方案来评估一般和疾病特异性HRQOL， 近期门诊WHF的患者。这个职业发展的首要目标是 奖励是为我提供研究方法和项目经验的必要培训，以建立在 我过去作为一名传统临床试验者的成功，也是为了成为卫生服务的领导者， 实施科学和实用的临床试验在学习卫生系统。我的强项 我的建议包括我以前的相关培训和研究记录，我的经验和承诺， 导师、合作者和顾问，以及大量的机构资源和支持。总之，这 研究建议将采用创新的分析方法，阐明流行病学，临床特征， 以及这种以前被低估的新型临床实体的结果。鉴于目前的趋势， 管理急性心脏病主要是在门诊设置，这些发现有立即 对制定公共卫生政策以及设计和开展未来临床试验的影响。

PROJECT SUMMARY/ABSTRACT Although the management of ambulatory heart failure (HF) has been revolutionized by evidence-based drug and device therapies, there has been no such parallel progress in the care of patients admitted for worsening HF (WHF). To incentivize health systems to reduce 30-day readmissions, the Affordable Care Act (ACA) launched the Hospital Readmission Reduction Program (HRRP) in 2012, which penalizes hospitals financially if they have higher than expected risk-adjusted 30-day readmission rates for conditions including HF. Although the HRRP has modestly reduced readmissions, this program has had the unintended consequence of shifting a significant fraction of HF-related care to the outpatient setting. Thus, there is a growing interest in the field to disentangle WHF from location of care and move away from using hospitalization as a surrogate for acute decompensated HF. However, little is known about the epidemiology, clinical profile, treatment patterns, and/or outcomes of outpatient WHF. In addition, while the overall survival of ambulatory HF patients has improved dramatically, guideline-directed medical therapy (GDMT) has had minimal impact on impairments in health- related quality of life (HRQOL). Despite this reality, there are few real-world data sources available to describe the trajectory of HRQOL in the ambulatory setting. To address these critical knowledge gaps, we propose (1) to systematically describe the contemporary epidemiology, clinical characteristics, treatment patterns, and outcomes associated with outpatient WHF and (2) to evaluate the impact of an episode of outpatient WHF on generic and disease-specific HRQOL in the context of a fully integrated health care delivery system. The first objective will leverage observational data from a large, state-of-the-art, and validated electronic health record (EHR) system and machine learning algorithms for natural language processing (NLP) to systematically ascertain and comprehensively characterize episodes of outpatient WHF. The second objective will prospectively apply this software-based solution to evaluate generic and disease-specific HRQOL among patients with a recent clinical encounter for outpatient WHF. The overarching goal of this career development award is to provide me with the requisite training in research methodology and project experience to build upon my past successes as a traditional clinical trialist in order to also becoming a leader in health services, implementation science, and pragmatic clinical trials within a learning health system. Strengths of my proposal include my prior relevant training and track record in research, the experience and commitment of my mentors, collaborators, and consultants, and the vast institutional resources and support. In summary, this research proposal will employ innovative analytic approaches to elucidate the epidemiology, clinical features, and outcomes of this previously underappreciated and novel clinical entity. Given the current trend towards managing acute cardiac conditions primarily in the ambulatory setting, these findings have immediate implications for formulating public health policy as well as the design and conduct of future clinical trials.