Heart Failure in the Community

描述（由申请方提供）：本研究采用社区监测在地理定义的人群中调查心力衰竭（HF）流行。在当前的资助周期（2003-06）中，我们证明了HF的发病率（包括住院和门诊病例）随时间推移保持稳定，而生存率提高，从而导致HF的患病率增加。这表明HF流行是由于越来越多的幸存者随着时间的推移而住院治疗的增加。在修订后的更新申请中，我们建议调查HF住院情况并解决以下问题：住院率的增加是否仅由于不断增长的人群中HF患病率的增加，或者是否与每位幸存者复发住院次数的增加有关？HF住院的危险因素是什么，包括复发事件的决定因素？本研究应说明当前文献中缺乏的关键方法学要点：应在发病率队列中分析时间趋势，以避免发生率-患病率偏倚。应纳入门诊病例，因为42%的HF诊断为门诊病例。全因和HF特异性住院应在同一人群中严格确定和检查。事实上，HF相关住院与HF治疗的有效性有关，而全因住院可能反映老年HF患者的合并症。最后，分析战略应包括对多个事件的评估。应前瞻性采集两种基本暴露：HF类型，定义为射血分数（EF）和舒张功能，考虑到HF综合征的异质性（社区中56%的前瞻性确定患者EF正常，其中64%患有中度或重度舒张功能障碍）和心理社会结构，特别是健康状况。我们建议应用在第一个资助周期实施的严格监测方法，以解决以下目标：具体目标1- 1979年至2008年期间发生HF后全因和HF特异性住院的时间趋势。具体目标2-在一组经验证的HF患者中，HF类型（EF和舒张功能）与住院之间的相关性，前瞻性招募采用创新方法，使用电子病历快速确定活动性HF病例。具体目标3-使用通用工具（简表12）和疾病特异性工具（堪萨斯城心肌病问卷）前瞻性测量HF患者健康状况与住院治疗之间的相关性。在这种情况下，完成这些研究是唯一可能的，因为我们将建立在经过验证的方法和初步资助期间的发现基础上，并利用罗切斯特流行病学项目的基础设施，该项目捕获了住院和门诊事件、共病状况和结局。我们的研究人员团队，通过增加HF心理社会结构专家Moser博士来加强，将采用新颖和互补的设计和分析方法，将被动监测和对同一社区诊断的HF患者的前瞻性识别相结合。通过这样做，我们将获得对HF患者住院负担的重要见解，这是HF中人类，社会和医疗保健成本的主要驱动因素。这将有助于确定预防战略。

DESCRIPTION (provided by applicant): This study investigates the heart failure (HF) epidemic using community surveillance in a geographically defined population. In the current grant cycle (2003-06), we demonstrated that the incidence of HF, including in and out-patient cases, remained stable overtime while survival improved, thereby leading to an increasing prevalence of HF. This indicates that the HF epidemic is due to an increase in hospitalizations over time among a growing number of survivors. In this revised renewal application, we propose to investigate hospitalizations in HF and address the following questions: Is the increase in hospitalizations solely due to the increasing prevalence of HF in a growing population or is it related to an increasing number of recurrent hospitalizations per survivor? What are the risk factors for hospitalizations in HF, including determinants of recurrent events? This investigation should account for key methodological points, lacking from current literature: Temporal trends should be analyzed in an incidence cohort to avoid incidence-prevalence bias. Outpatient cases should be included as 42% of HF is diagnosed as outpatient. All-cause and HF-specific hospitalizations should be rigorously ascertained and examined in the same population. Indeed, HF-related hospitalizations relate to the effectiveness of the treatment of HF while all-cause hospitalization may reflect comorbidity among elderly patients with HF. Finally, analytical strategies should include the evaluation of multiple events. Two essential exposures should be prospectively captured: the type of HF, defined by ejection fraction (EF) and diastolic function given the heterogeneity of the HF syndrome (56% of prospectively ascertained patients in the community had normal EF and 64% of these have moderate or severe diastolic dysfunction) and psycho-social constructs, in particular health status. We propose to apply the rigorous surveillance methods implemented during the 1st grant cycle to address the following aims: Specific aim 1- temporal trends in all-cause and HF-specific hospitalizations after incident HF between 1979 and 2008. Specific aim 2- Association between type of HF (EF and diastolic function) and hospitalizations in a cohort of persons with validated HF, prospectively enrolled with an innovative approach using the electronic medical record that enables rapid ascertainment of cases of active HF. Specific aim 3- Association between health status and hospitalizations in HF prospectively measured using a generic instrument, the Short Form 12 and a disease specific instrument, the Kansas City Cardiomyopathy Questionnaire. The completion of these studies is uniquely possible in this setting because we will build on the proven methodology and findings of the initial funding period and capitalize on the infrastructure of the Rochester Epidemiology Project that captures in- and outpatient events, comorbid conditions and outcomes. Our team of investigators, strengthened by the addition of an expert in psychosocial constructs in HF, Dr. Moser, will employ novel and complementary design and analytical approaches that integrate passive surveillance and prospective identification of persons with HF at diagnosis in the same community. In doing so, we will gain important insights into the burden of hospitalizations among persons living with HF, which are a major driver of human, societal and heath care costs in HF. This will help define preventive strategies.