Multi-morbidity in Heart Failure

描述（由申请人提供）：本R21申请响应RFA-AG-13-003，重点关注心力衰竭（HF）中的多药耐药。在过去的20年中，HF的发病率没有明显变化，而生存率的提高导致老年人住院的高度负担流行。护理提供者和系统不具备护理此类患者的能力，因为临床指南是以疾病为中心的，而HF患者则表现为多发病。未能充分了解HF中的多发病可能解释了为什么HF中的疾病管理策略仅部分有效以及为什么HF中的住院流行病未得到控制。最后，越来越多的HF患者被转诊至急性期后护理（PAC），但多药耐药、PAC使用和PAC后结局之间的相关性尚不清楚。这种知识差距可以通过纵向数据集的二次分析来解决，纵向数据集捕获了包括本文提出的PAC在内的整个护理范围。我们申请的中心原则是，未能控制HF的流行反映了对HF中的多发病的认识不足，这在社区中从未进行过检查，并且目前以疾病为中心的策略管理不足。为了使新方法有效，我们必须首先在临床相关的社区实践中解决，诊断时合并症如何存在和聚集，并因HF类型而异（EF保留vs.减少），多发病如何影响结局（住院，PAC使用和死亡），特别是合并症的组合与更差的结局相关。我们将执行以下目标：在目标1中，我们将检查HF事件（首次诊断）人群社区队列中共病状况的分布和聚类。我们将研究合并症的分布如何根据HF类型（EF保留vs. EF降低）而有所不同。在目标2中，我们将通过将我们社区HF队列的数据与明尼苏达州养老院文件相关联，评估多死亡率如何影响结局（住院、PAC使用和死亡）。将丰富的临床数据与PAC使用的管理数据联系起来，将创建一个独特的综合数据集，以评估HF患者在护理提供环境（包括医院和PAC）中的表现和轨迹。获取这些患者的完整医疗保健经验对于了解HF中的多发病和识别导致异常不良结局的条件组合是必不可少的。这些二次分析将提供重要的信息，以针对特定的条件组合，以评估新的管理策略，在HF。拟议的研究是明显可行的，因为它利用了罗切斯特流行病学项目（R 01 AG 034676）的基础设施，并建立在研究团队的强大经验。

DESCRIPTION (provided by applicant): This R21 application, which responds to RFA-AG-13-003 focuses on multimorbidity in heart failure (HF). The incidence of HF did not change appreciably in the past 2 decades while survival improved leading to a highly burdensome epidemic of hospitalizations among older individuals. Care providers and systems are ill-equipped to care for such patients because clinical guidelines are disease-centric, whereas patients with HF present with multimorbidity. The failure to adequately understand multimorbidity in HF likely explains why disease management strategies in HF are only partially effective and why the epidemic of hospitalizations in HF is not contained. Finally, patients with HF are increasingly referred to post acute care (PAC), yet the association between multimorbidity, PAC use and outcome after PAC is poorly characterized. This gap in knowledge can be addressed by secondary analyses of longitudinal datasets that capture the entire spectrum of care including PAC as proposed herein. The central tenet of our application is that the failure to control the epidemic of HF reflects an inadequate understanding of multimorbidity in HF, which has never been examined in the community and is inadequately managed by current disease-centric strategies. For novel approaches to be effective, we must first address in clinically relevant community practices, how comorbid conditions present and cluster at the time of diagnosis and vary by the type of HF (preserved vs. reduced EF), how multimorbidity influences outcomes (hospitalizations, PAC use and death) and specifically what combination of comorbid conditions are associated with the worse outcomes. We will execute the following aims: in Aim 1, we will examine the distribution and clustering of comorbid conditions in a community cohort of persons with incident (first diagnosis) of HF. We will study how the distribution of comorbidities differs by type of HF (preserved vs. reduced EF). In Aim 2, we will assess how multimorbidity impact outcome (hospitalizations, PAC use and death), by linking the data from our community HF cohort to the State of Minnesota nursing home files. Linking rich clinical data to administrative data on PAC use will create a uniquely comprehensive dataset to assess the presentation and trajectory of persons with HF across care delivery settings, including hospital and PAC. Capturing the full health care experience of these patients is indispensable to understand multimorbidity in HF and to identify combinations of conditions that contribute to exceptionally poor outcomes. These secondary analyses will provide important information to target specific combinations of conditions to evaluate new management strategies in HF. The proposed research is distinctly feasible as it capitalizes on the infrastructure of the Rochester Epidemiology Project (R01 AG034676) and builds on the research team's robust experience.