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

项目摘要/摘要 尽管循证药物使动态心力衰竭(HF)的治疗发生了革命性的变化 和设备疗法，在病情恶化入院的患者的护理方面没有这样的平行进展 高频(WHF)。为了激励医疗系统减少30天的再入院时间，《平价医疗法案》(ACA) 2012年启动了医院再入院减少计划(HRRP)，该计划对医院进行经济处罚 如果他们的风险调整后的30天再住院率高于预期，包括心力衰竭。虽然 HRRP略微减少了重新入院人数，这一计划产生了意想不到的后果 心力衰竭相关护理的很大一部分是在门诊环境中。因此，这一领域的兴趣越来越大 将WHF从护理地点分离出来，不再使用住院作为急性 失代偿性心衰。然而，关于流行病学、临床特征、治疗模式和/或 门诊WHF的结果。此外，虽然门诊心衰患者的总体存活率有所改善， 引人注目的是，指南指导的医疗疗法(GDMT)对健康损害的影响微乎其微- 相关生活质量(HRQOL)。尽管存在这样的现实，但几乎没有可用的真实数据源来描述 动态环境下HRQOL的运动轨迹。为了解决这些关键的知识差距，我们提出(1) 系统地描述当代流行病学、临床特点、治疗模式和 与门诊WHF相关的结局和(2)评估一次门诊WHF对 在完全整合的卫生保健提供系统的背景下，一般和特定疾病的HRQOL。第一 目标将利用来自大型、最先进且经过验证的电子健康记录的观察数据 用于自然语言处理(NLP)的(EHR)系统和机器学习算法 确定并综合描述门诊WHF的发作情况。第二个目标是 前瞻性地应用这一基于软件的解决方案来评估一般和特定疾病的HRQOL 最近一次临床相遇的患者的门诊WHF。这份职业发展的首要目标是 奖项是为我提供研究方法和项目经验方面的必要培训，以此为基础 我过去作为一名传统的临床试验人员所取得的成功，是为了也成为卫生服务的领导者， 实施科学，并在学习型卫生系统内进行务实的临床试验。我的长处 建议书包括我以前的相关培训和研究记录，我的经验和我的承诺 导师、合作者和顾问，以及大量的机构资源和支持。总而言之，这是 研究计划将采用创新的分析方法来阐明流行病学、临床特征、 以及这一先前被低估的新的临床实体的结果。鉴于目前的趋势是 主要在门诊环境下处理急性心脏疾病，这些发现立即 对制定公共卫生政策以及未来临床试验的设计和进行的影响。

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.