Multi-morbidity in Heart Failure

描述(由申请人提供)：这份R21申请，响应RFA-AG-13-003，重点关注心力衰竭(HF)的多病。在过去的20年中，心力衰竭的发病率没有明显变化，而存活率的提高导致了老年人住院治疗的高负担流行。由于临床指南是以疾病为中心的，而心力衰竭患者存在多发病，因此护理提供者和系统对此类患者的护理装备不足。未能充分了解心力衰竭的多发病可能解释了为什么心力衰竭的疾病管理策略只有部分有效，以及为什么心力衰竭住院的流行没有得到控制。最后，心力衰竭患者越来越多地被转诊到急性护理(PAC)后，然而，多病、PAC使用和PAC治疗后预后之间的关系尚不清楚。这一知识差距可以通过对纵向数据集的二次分析来解决，这些数据集捕获了包括本文所建议的PAC在内的整个护理范围。我们申请的中心原则是，未能控制心力衰竭的流行反映了对心力衰竭多病的了解不足，社区从未对此进行检查，当前以疾病为中心的策略也不能充分管理。为了使新的方法有效，我们必须首先在临床相关的社区实践中解决，在诊断时如何出现和聚集并存的情况，以及不同类型的心衰(保留与减少EF)，多病如何影响预后(住院、PAC使用和死亡)，特别是哪些并存的情况与较差的预后相关。我们将实现以下目标：在目标1中，我们将检查心力衰竭(首次诊断)患者的社区队列中共病情况的分布和聚集性。我们将研究合并症的分布如何因心衰类型的不同而不同(保留EF与减少EF)。在目标2中，我们将通过将我们社区心力衰竭队列的数据与明尼苏达州养老院的文件联系起来，评估多发病如何影响预后(住院、PAC使用和死亡)。将丰富的临床数据与PAC使用的管理数据联系起来，将创建一个独特的综合数据集，以评估不同护理提供环境(包括医院和PAC)的心力衰竭患者的表现和轨迹。了解这些患者的全部健康护理经验对于了解心力衰竭的多发病和确定导致预后极差的各种情况的组合是必不可少的。这些二次分析将提供重要的信息，以针对特定的条件组合来评估HF的新管理战略。拟议的研究显然是可行的，因为它利用了罗切斯特流行病学项目(R01 AG034676)的基础设施，并建立在研究团队的强大经验基础上。

DESCRIPTION (provided by applicant): This R21 application, which responds to RFA-AG-13-003 focuses on multimorbidity in heart failure (HF). The incidence of HF did not change appreciably in the past 2 decades while survival improved leading to a highly burdensome epidemic of hospitalizations among older individuals. Care providers and systems are ill-equipped to care for such patients because clinical guidelines are disease-centric, whereas patients with HF present with multimorbidity. The failure to adequately understand multimorbidity in HF likely explains why disease management strategies in HF are only partially effective and why the epidemic of hospitalizations in HF is not contained. Finally, patients with HF are increasingly referred to post acute care (PAC), yet the association between multimorbidity, PAC use and outcome after PAC is poorly characterized. This gap in knowledge can be addressed by secondary analyses of longitudinal datasets that capture the entire spectrum of care including PAC as proposed herein. The central tenet of our application is that the failure to control the epidemic of HF reflects an inadequate understanding of multimorbidity in HF, which has never been examined in the community and is inadequately managed by current disease-centric strategies. For novel approaches to be effective, we must first address in clinically relevant community practices, how comorbid conditions present and cluster at the time of diagnosis and vary by the type of HF (preserved vs. reduced EF), how multimorbidity influences outcomes (hospitalizations, PAC use and death) and specifically what combination of comorbid conditions are associated with the worse outcomes. We will execute the following aims: in Aim 1, we will examine the distribution and clustering of comorbid conditions in a community cohort of persons with incident (first diagnosis) of HF. We will study how the distribution of comorbidities differs by type of HF (preserved vs. reduced EF). In Aim 2, we will assess how multimorbidity impact outcome (hospitalizations, PAC use and death), by linking the data from our community HF cohort to the State of Minnesota nursing home files. Linking rich clinical data to administrative data on PAC use will create a uniquely comprehensive dataset to assess the presentation and trajectory of persons with HF across care delivery settings, including hospital and PAC. Capturing the full health care experience of these patients is indispensable to understand multimorbidity in HF and to identify combinations of conditions that contribute to exceptionally poor outcomes. These secondary analyses will provide important information to target specific combinations of conditions to evaluate new management strategies in HF. The proposed research is distinctly feasible as it capitalizes on the infrastructure of the Rochester Epidemiology Project (R01 AG034676) and builds on the research team's robust experience.