Determinants of fall-related bleeding among older adults with atrial fibrillation

描述(申请人提供)：此申请是为了获得GEMSSTAR R03奖项，为Dodson博士提供两年的支持，以建立临床衰老研究的跟踪记录。作为一名完成了老年临床流行病学培训计划的研究员培训的心脏病专家，申请者坚定地致力于研究心血管疾病和老龄化的交集。多德森医生将在哈佛医学院教授、布里格姆妇女医院老年科主任J·迈克尔·加齐亚诺博士的指导下工作。耶鲁大学医学院老年病学教授兼主席玛丽·蒂内蒂博士和耶鲁大学医学院结果研究与评估中心主任哈兰·克鲁姆霍尔茨博士将担任共同导师。该奖项旨在结合这三位导师的独特优势，以及申请者进行了重大博士后研究的两个机构。这项拟议研究的总体目标是确定在大量抗凝的老年房颤患者中与跌倒相关的大出血的发生率和独立危险因素。超过80%的房颤患者年龄在65岁以上，随着美国人口老龄化，预计到2050年，大多数房颤患者的年龄将达到80岁或以上。年龄本身也是房颤相关血栓栓塞性中风的一个潜在危险因素，虽然抗凝治疗可以将老年人的中风风险降低三分之二，但有强有力的证据表明，这些人中有相当一部分人没有开出抗凝剂的处方。临床医生一再指出，对跌倒风险和跌倒相关大出血后遗症的担忧是他们犹豫是否给患有房颤的老年人开抗凝剂的主要因素； 然而，我们目前缺乏对实践中与跌倒相关的大出血发生率的准确估计，以及导致这一结果的危险因素。这项拟议的研究将解决这一知识缺口，方法是在10年期间(1/1/01-12/31/10)建立一个转诊至退伍军人管理局抗凝诊所的20,000名房颤患者的初始队列，并将这些数据与因跌倒相关的大出血住院的医疗保险索赔数据联系起来。我们假设，与跌倒相关的大出血的发生率将是之前报道的每100人年1例的两倍以上，并且跌倒损伤的已知危险因素(例如，认知障碍、镇静剂的使用、关节炎、贫血和既往的FALS)以及已有的全原因出血模型中的协变量将独立地与这一结果相关。申请者将利用这项研究产生的知识来申请后续的职业发展奖，该奖项将为临床医生开发和试验一种决策支持工具，以更好地对患有房颤的老年人进行跌倒相关大出血的风险分层。在授予期间，申请者还将继续攻读生物统计学和流行病学方面的课程，这些课程将适用于公共卫生硕士学位。

DESCRIPTION (provided by applicant): This application is for a GEMSSTAR R03 award to provide two years of support for Dr. Dodson to establish a track record in clinical aging research. As a fellowship-trained cardiologist who has completed a training program in geriatric clinical epidemiology, the applicant is firmly committed to studying the intersection of cardiovascular disease and aging. Dr. Dodson will work under the mentorship of Dr. J. Michael Gaziano, professor at Harvard Medical School and Chief of the Division of Aging at Brigham and Women's Hospital. Dr. Mary Tinetti, professor and chair of Geriatrics at Yale University School of Medicine, and Dr. Harlan Krumholz, professor and director of the Center for Outcomes Research and Evaluation at Yale University School of Medicine, will serve as co-mentors. The award aims to combine the unique strengths of these three mentors, as well as the two institutions where the applicant has performed significant postdoctoral research. The overall goal of the proposed study is to determine the incidence rate and independent risk factors for fall-related major bleeding in a large cohort of anticoagulated older adults with atria fibrillation (AF). Over 80% of patients with AF are >65 years of age, and with the aging of the U.S. population the majority of patients with AF are expected to be aged 80 or older by 2050. Age itself is also a potent risk factor for AF-related thromboembolic stroke, and while anticoagulant therapy can reduce stroke risk by two-thirds in older adults, there is strong evidence that a considerable portion of these individuals are not prescribed anticoagulants. Clinicians repeatedly have cited concerns over fall risk and the sequelae of fall-related major bleeding as a major factor in their hesitation to prescribe anticoagulants to older adults with AF; however, we are currently lacking a precise estimate of the incidence rate of fall-related major bleeding in practice, as well as the risk factors for this outcome. The proposed study will address this gap in knowledge by developing an inception cohort of 20,000 patients with AF referred to Veterans Administration anticoagulation clinics over a 10-year time period (1/1/01- 12/31/10), and linking these data with Medicare claims data for hospitalizations for fall-related major bleeding. We hypothesize that the incidence rate of fall-related major bleeding will be more than twice the previously reported rate of 1 per 100 person-years, and that known risk factors for fall injuries (e.g. cognitive impairment, sedative use, arthritis, anemia, and prior fals) as well as covariates in the HAS-BLED model for all-cause bleeding will be independently associated with this outcome. The applicant will use knowledge generated from this study to apply for a subsequent career development award that will develop and pilot a decision-support tool for clinicians to better risk-stratify older adults with AF for fall-related major bleeding. Dring the award period, the applicant will also pursue coursework in biostatistics and epidemiology that will be applied towards an MPH degree.