The Atrial Fibrillation - Factor Identification to Risk Modification Study in HD

描述(申请人提供)：超过575,000名美国人患有终末期肾病，超过350,000人接受挽救生命的透析治疗。先前的研究表明，接受血液透析的患者，特别是年龄较大的患者，患房颤的风险特别高。心房颤动与不良预后相关，包括高死亡率(每年40%)。对于老年血液透析患者心房颤动的固定和潜在可修改的RIS因素知之甚少；也只有很少的证据表明这些患者在首次诊断为心房颤动后的结果。从… 我们已经收集了一家大型透析提供商的医疗保险索赔和医疗记录，我们建议收集一个独特的数据集，提供有关这些患者的健康和他们所接受的医疗保健的前所未有的详细信息。此外，我们将拥有比这些患者开始透析的时间早至少2年的历史医疗保险索赔。使用这种独一无二的 数据库，我们将在特殊情况下能够排除那些在开始透析前有心房颤动的患者，从而能够研究发生的心房颤动。我们建议确定发生房颤的潜在可改变的危险因素，特别关注实验室测量、生命体征、透析治疗相关因素和透析设施实践。我们还将启动一项全面的结果评估，一旦患者首次被诊断为房颤，与没有发生这种心律失常的类似患者进行比较。感兴趣的结果将涵盖所有相关领域：所有原因和特定原因的死亡率；发病率，重点是血栓栓子和出血结果；患者报告的与健康相关的生活质量结果；以及卫生保健利用和费用。这些研究将填补目前现有证据中的漏洞。也许最具创新性的目标将集中在利用我们数据集中的高维和极其细粒度的数据和新的生物信息学方法来推导出新的心房颤动的近期风险的预测算法。然后，我们将在完全不同的后续时间段中，在来自相同提供商的数据中以及在来自不同透析提供商的另一数据集中验证算法。如果我们的方法被证明成功地识别出近期发生房颤风险最高的患者，那么我们就可以测试干预研究，以降低这些脆弱患者即将发生房颤的风险，从而避免这种心律失常的长期后遗症。这项拟议工作的发现有可能影响和改善终末期肾病患者所接受的护理。我们的结果可能会改善接受的护理质量，从而改善这一脆弱患者群体的结果。工作的目标和范围与国家糖尿病、消化和肾脏疾病研究所的使命完全一致，更具体地说，是与肾脏、泌尿外科和血液病学部的使命一致，后者将考虑这项资金申请。

DESCRIPTION (provided by applicant): More than 575,000 Americans have end-stage renal disease, and more than 350,000 receive life-saving dialysis treatment. Previous research has demonstrated that patients undergoing hemodialysis, especially those who are older, are at particular risk to have atrial fibrillation. Atrial fibrillation is associated with poor outcomes including high mortality (40% per year). Little is known about fixed and potentially modifiable ris factors for atrial fibrillation in older patients receiving hemodialysis; there is also only scant evidence about these patients' outcomes after their first diagnosis with atrial fibrillation. From already collected Medicare insurance claims and medical records of a large dialysis provider, we propose to assemble a unique dataset that will provide unprecedented detail about these patients health and the health care they receive. In addition, we will have historical Medicare claims predating these patients' time of dialysis initiation by at least 2 years. Using this unique database, we will be in the unusual situation to be able to exclude patients who had atrial fibrillation before they started dialysis, and therefore be able to study incident atrial fibrillaton. We are proposing to identify potentially modifiable risk factors for incident atrial fibrillation, ith particular focus on laboratory measurements, vital signs, dialysis treatment- related factors, and dialysis facility practices. We will also launch a comprehensive assessment of the outcomes of patients once they are first diagnosed with atrial fibrillation, in comparison to similar patients who have not developed this arrhythmia. Outcomes of interest will cover all relevant domains: all-cause and cause-specific mortality; morbidity with focus on thromboembolic and hemorrhagic outcomes; patient-reported health-related quality of life outcomes; and health care utilization and cost. These studies will fill gaping holes in the currently available evidence. The perhaps most innovative aim will focus on deriving a prediction algorithm for near-term risk of new atrial fibrillation using the high-dimensional and extremely granular data in our dataset and novel bioinformatic methods. We will then validate the algorithm in a completely different later time period in data from the same provider as well as in another dataset from a different dialysis provider. If our approach proves successful in identifying patients at the highest near-term risk of incident atrial fibrillation, we are then in the position to test intervention studies to reducethe risk of imminent atrial fibrillation and thus avoid longer term sequelae of this arrhythmia in thes vulnerable patients. Findings from the proposed work have the potential to impact and improve the care that patients with end-stage renal disease receive. Our results may improve the quality of care received and, thus, the outcomes of this vulnerable patient population. The aims and scope of work are in full congruence with the mission of the National Institutes of Diabetes and Digestive and Kidney Diseases, and more specifically the Division of Kidney, Urologic, and Hematologic Diseases, which will consider this application for funding.