Heart Failure in the Community

描述(由申请人提供)：这项研究使用社区监测在地理上确定的人群中调查心力衰竭(HF)流行。在目前的赠款周期(2003-2006年)，我们证明了心力衰竭的发病率，包括住院和门诊病例，在延长时间内保持稳定，同时存活率有所改善，从而导致心力衰竭的患病率不断上升。这表明，出血热流行是由于越来越多的幸存者随着时间的推移住院人数增加所致。在这份修订的更新申请中，我们建议调查心力衰竭住院情况，并解决以下问题：住院人数的增加仅仅是因为心力衰竭在不断增长的人口中的患病率增加，还是与每个幸存者反复住院的次数增加有关？哪些是心力衰竭住院的危险因素，包括复发事件的决定因素？这项调查应该说明当前文献中缺乏的关键方法论要点：应该在发病队列中分析时间趋势，以避免发病率-流行率偏差。门诊病例应该包括在内，因为42%的心衰患者被诊断为门诊患者。所有原因和特定于心力衰竭的住院治疗应严格确定，并在同一人群中进行检查。事实上，与心力衰竭相关的住院治疗与心力衰竭的治疗效果有关，而各种原因的住院可能反映了老年心力衰竭患者的共病。最后，分析战略应包括对多个事件的评估。应前瞻性地记录两种基本暴露：心力衰竭的类型，由射血分数(EF)和由于心力衰竭综合征的异质性而定义的舒张期功能(社区中56%的前瞻性确诊患者的EF正常，%的患者有中度或严重的舒张期功能障碍)和心理-社会结构，特别是健康状况。我们建议应用在第一个赠款周期中实施的严格监测方法来解决以下目标：具体目标1-1979年至2008年发生心力衰竭事件后，所有原因和特定于心力衰竭的住院的临时趋势。具体目标2-心力衰竭类型(EF和舒张期功能)与住院治疗之间的关系，在一组确诊的心力衰竭患者中，预期采用一种使用电子病历的创新方法，能够快速确定活动性心力衰竭病例。具体目标3-使用通用工具(缩写为12)和疾病特定工具(堪萨斯城心肌病问卷)前瞻性测量心力衰竭患者的健康状况和住院情况之间的关系。在这种情况下，完成这些研究是唯一可能的，因为我们将建立在最初资助期经过验证的方法和结果的基础上，并利用罗切斯特流行病学项目的基础设施，该项目收集住院和门诊事件、共病情况和结果。我们的调查团队，由于增加了心力衰竭心理社会结构方面的专家莫泽博士而得到加强，将采用新颖和互补的设计和分析方法，将被动监测和在同一社区诊断为心力衰竭患者的前瞻性识别结合在一起。通过这样做，我们将获得对心力衰竭患者住院负担的重要见解，这是心力衰竭人力、社会和医疗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.