Factors Associated with Warfarin Use in Dialysis Patients w/ Atrial Fibrillation

描述（由申请人提供）：卒中是终末期肾病（ESRD）透析人群死亡和残疾的主要原因。慢性房颤（AF）在透析人群中很常见，是一种潜在的可改变的卒中风险因素。Warcraft是一种经过充分研究的干预措施，用于降低AF普通人群的卒中风险，被国家肾脏基金会认为是AF透析患者的适当治疗。然而，即使在合适的透析患者中，华法林的使用率似乎也很低，这可能源于肾脏病学家对华法林在非透析人群中的随机对照试验结果适用于一般虚弱的透析患者持怀疑态度。 许多关于房颤透析患者卒中和华法林使用的关键问题需要紧急检查。了解华法林在卒中风险中的应用是非常必要的，因为临床医生、制定指南的思想领袖和医疗政策制定者都是在信息真空中工作的。在美国透析患者的大样本中，从未报告过华法林用于预防AF卒中的模式，主要是因为将纵向药物处方与基于个体患者水平的医疗索赔诊断联系起来所需的工具以前从未广泛使用。 本提案旨在确定人口统计学因素、合并症和医疗保健系统因素（如城市化程度和透析单位的利润状况）与透析人群中华法林处方的相关性。此外，还将检查基础医疗保健系统因素是否与该人群中卒中发生率的变化相关。这些问题将通过使用观察性数据进行调查，这提供了一个机会，有效地进行一项大型研究的决定因素华法林使用透析患者AF。为了实现这些目标，美国肾脏数据系统（USRDS）医疗保险数据和医疗补助药物索赔数据之间的一种新的联系将被使用。最终，这里提出的K23项目旨在将申请人发展成为一名成功的独立卫生服务研究人员，他们可以调查ESRD中的中风和心血管疾病预防问题，最终有助于减少这一不断增长的人口的疾病负担。 公共卫生相关性：减少透析患者的心血管原因死亡是NIH使命的核心。考虑到ESRD人群的规模以及这些患者心血管疾病的患病率，研究与华法林使用相关的因素以降低卒中风险至关重要。目前对该主题知之甚少;本申请将是确定与使用该重要疗法相关的因素的关键第一步。 中风在透析患者中非常常见。中风的一个主要原因是心房颤动，血液稀释药物华法林可以用来降低中风风险，但由于不确定的原因，在透析患者中很少使用。为了帮助确定华法林不常使用的原因，拟议项目将使用Medicare和州Medicaid数据库创建一个新的链接数据库，以确定人口统计学、合并症和医疗保健系统因素（如透析单位的利润状况和城市化程度），这些因素决定了华法林在大型和不断增长的透析人群中的使用。

DESCRIPTION (provided by applicant): Stroke is a major cause of death and disability in end stage renal disease (ESRD) population on dialysis. Chronic atrial fibrillation (AF), common in the dialysis population, is a potentially-modifiable stroke risk factor. Warfarin, a well-studied intervention used to reduce stroke risk in the general population with AF, is considered appropriate therapy for dialysis patients with AF by the National Kidney Foundation. However, use rates of warfarin appear to be low even in suitable dialysis patients, which probably originates from a deep sense of skepticism among nephrologists that the results of randomized controlled trials of warfarin in the non-dialysis population are applicable to generally frail dialysis patients. Many critical issues regarding both stroke and warfarin use in dialysis patients with AF require urgent examination. An understanding of how warfarin is used in the setting of stroke risk is imperative, since bedside practitioners, guideline-forming thought leaders, and healthcare policymakers are operating in an information vacuum. Patterns of warfarin use for stroke prevention in AF have never been reported in a large sample of U.S. dialysis patients, primarily because the tools required to link longitudinal medication prescriptions to medical claims-based diagnoses at the level of the individual patient have never before been widely available. This proposal seeks to determine how demographic factors, comorbidities, and healthcare system factors (such as degree of urbanicity and the profit status of dialysis units) are associated with warfarin prescription in the dialysis population. Additionally, whether foundational healthcare system factors are associated with variation in stroke rates in this population will be examined. These questions will be investigated through the use of observational data, which offers the opportunity to efficiently undertake a large study of determinants of warfarin use in dialysis patients with AF. To accomplish these aims, a novel linkage between the United States Renal Data System (USRDS) Medicare data and Medicaid medication claims data will be used. Ultimately, the K23 project proposed here is designed to develop the applicant into a successful independent health services researcher who can investigate issues of stroke and cardiovascular disease prevention in ESRD, ultimately contributing to the reduction of disease burden in this growing population. PUBLIC HEALTH RELEVANCE: Reducing death from cardiovascular causes in dialysis patients is central to the mission of the NIH. Given both the size of the ESRD population as well as the prevalence of cardiovascular disease in these patients, investigation into the factors associated with warfarin use to reduce stroke risk is of the utmost importance. Little is presently known about this topic; the present application will be a critical first step in determining the factors associated with use of this important therapy. Stroke is very common in dialysis patients. A major cause of stroke is atrial fibrillation, for which the blood-thinning medicine warfarin can be prescribed to lower stroke risk but which is prescribed infrequently in dialysis patients for uncertain reasons. To help determine why warfarin is used infrequently, the proposed project will create a novel linked database using Medicare and state Medicaid databases to ascertain the demographic, comorbidity, and healthcare system factors (such as profit status and degree of urbanicity of dialysis units) determining warfarin use in the large and growing dialysis population.