Transcultural lessons in the Management of Heart Failure TRANSMEDHF

项目摘要 在美国和英国，心力衰竭(HF)是一种常见的疾病 住院原因，通常延长住院时间，并与高死亡率有关。虽然 关于心力衰竭管理的国际指南是一致的，实践在以下方面存在很大差异 国家。潜在的无数因素，如医疗保健资金的可变性，民族和种族的多样性 这可能是造成实践模式差异的原因之一，但目前尚不清楚这是否会转化为 结果上的差异。因此，我们建议评估和比较患者的结果，使用 个人患者水平数据(IPLD)，在美国和美国有不同程度的心力衰竭(HF)证据 英国。比较整个人口的总体高水平数据可能会导致错误的结论。进入 个人患者级别数据(IPLD)使两国具有相似属性的患者的结果能够 被并列在一起，并以统一的方式进行分析。因为心力衰竭的定义不是强有力的和诊断性的激励因素 在美国和英国可能有很大的不同，将应用广泛的病例确定标准来捕捉 感兴趣的人群。这将包括心力衰竭的诊断和服用环状利尿剂的处方 同时或以前诊断为心力衰竭(服用环状利尿剂的患者预后较差，通常 反映漏诊心力衰竭)。 植入型心脏复律除颤器(ICD)/心脏再同步治疗的费用 (CRT)/起搏器和除颤器2009年在美国的销售额估计为58亿加元。然而，它的功效 只有在选择进行临床试验的患者中才能建立起ICD和CRT的联合试验 病态；老年人和少数族裔代表不足。因此，审判结果的外部有效性 目前还不清楚。接受ICD和CRT的“真实世界”患者的实践模式和临床结果的比较 在不同的医疗系统中采用差异很大的做法可能有助于改善患者的选择和 这两个国家的管理层。也有人怀疑CRT-D与CRT-P相比的优越性，后者 是一种成本较低的技术，需要不那么复杂的后续工作，也不太可能出现故障。这 将导致对这两个系统的更深入的了解，并可作为医疗保健的投入 政策措施。 这个雄心勃勃的现实世界项目将在三个领先的学术研究中心进行- 大学医院克利夫兰医学中心/凯斯西储大学(美国俄亥俄州克利夫兰)， 国家心肺研究所/帝国理工学院(英国伦敦)和罗伯逊生物统计中心 格拉斯哥大学(苏格兰，英国)。

PROJECT ABSTRACT In both the United States of America (USA) and the United Kingdom (UK), heart failure (HF) is a common cause of hospitalization, often prolongs length of hospitalization and is associated with high mortality. Although international guidelines on the management of HF are aligned, practice is substantially divergent across countries. There are potentially myriad factors such as variability in healthcare funding, ethnic and racial diversity among others that could be contributing to the variation in practice patterns but it is unclear if this translates into differences in outcomes. We, therefore, propose to evaluate and compare the outcome of patients, using individual patient –level data (IPLD), with varying levels of evidence for heart failure (HF) in the USA and in the UK. Comparing aggregate high level data for whole population could lead to erroneous conclusions. Access to individual patient-level data (IPLD) enables the outcome of patients with similar attributes in the two countries to be juxtaposed and be analyzed in a uniform manner. As definitions of HF are not robust and diagnostic incentives may differ substantially in the USA and UK, broad criteria for case-ascertainment will be applied to capture the population of interest. This will include both a diagnosis of HF and a prescription of a loop diuretic with a concurrent or previous diagnosis of HF (patients taking loop diuretics have a poor prognosis which may often reflect a missed diagnosis of HF). Spending on Implantable Cardioverter Defibrillator (ICD)/Cardiac Resynchronization Therapy (CRT)/Pacemakers and defibrillators estimated to be c.$5.8 billion in the USA in 2009. However, the efficacies of ICDs and CRTs have been established only in patients selected for clinical trials with relatively few co- morbidities; older people and ethnic minorities were under-represented. Thus, the external validity of trial results is unclear. Comparing practice patterns and clinical outcomes in `real world' patients receiving ICD and CRT across different health systems with widely differing practice might help improve patient selection and management in both countries. There are also doubts about the superiority of CRT-D compared to CRT-P, which is a less expensive technology requiring less sophisticated follow up and is also less likely to malfunction. This would lead to a much more in depth understanding of the two systems and could serve as an input for healthcare policy measures. This ambitious real world project will be conducted in three leading academic research centers – University Hospitals Cleveland Medical Center/Case Western Reserve University (Cleveland, Ohio, USA), National Heart and Lung Institute/Imperial College (London, England, UK) and Robertson Center for Biostatistics /University of Glasgow (Scotland, UK).