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

描述（由申请人提供）：本申请是GEMSSTAR R 03奖，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。作为一名接受过奖学金培训的心脏病专家，他已经完成了老年临床流行病学的培训课程，申请人坚定地致力于研究心血管疾病和衰老的交叉点。多德森博士将在哈佛医学院教授、布里格姆妇女医院老龄化科科长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医学教授兼主席玛丽蒂内蒂博士和耶鲁大学医学院成果研究和评估中心教授兼主任哈兰克鲁姆霍尔茨博士将担任共同导师。该奖项旨在联合收割机这三位导师的独特优势，以及申请人进行了重要的博士后研究的两个机构。本研究的总体目标是确定一个大型抗凝老年房颤（AF）患者队列中跌倒相关大出血的发生率和独立风险因素。超过80%的AF患者年龄>65岁，随着美国人口的老龄化，预计到2050年，大多数AF患者的年龄将达到80岁或以上。年龄本身也是AF相关血栓栓塞性卒中的一个潜在风险因素，虽然抗凝治疗可以将老年人的卒中风险降低三分之二，但有强有力的证据表明，这些人中有相当一部分没有使用抗凝剂。临床医生反复引用对跌倒风险和跌倒相关大出血后遗症的担忧，作为他们犹豫为老年房颤患者开抗凝剂的主要因素; 然而，我们目前缺乏一个准确的估计，在实践中跌倒相关的大出血的发生率，以及这种结果的风险因素。拟议的研究将通过开发一个由20，000名AF患者组成的初始队列来解决这一知识差距，这些患者在10年的时间内（2001年1月1日至2010年12月31日）被转介到退伍军人管理局抗凝诊所，并将这些数据与因跌倒相关大出血住院的医疗保险索赔数据联系起来。我们假设跌倒相关大出血的发生率将是先前报告的1/100人-年发生率的两倍以上，并且已知的跌倒损伤风险因素（例如认知障碍、镇静剂使用、关节炎、贫血和既往跌倒）以及HAS-BLED模型中全因出血的协变量将与该结局独立相关。申请人将利用本研究产生的知识申请随后的职业发展奖，该奖项将为临床医生开发和试点决策支持工具，以更好地对老年房颤患者跌倒相关大出血进行风险分层。在获奖期间，申请人还将继续学习生物统计学和流行病学课程，这些课程将应用于MPH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.