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Rural Hospital-Level Care at Home for Acutely Ill Adults

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT05256303
Recruitment Status : Completed
First Posted : February 25, 2022
Last Update Posted : March 6, 2024
Sponsor:
Collaborator:
The Thompson Family Foundation Inc
Information provided by (Responsible Party):
David Levine, Brigham and Women's Hospital

Brief Summary:
This study examines the implications of providing hospital-level care in rural homes.

Condition or disease Intervention/treatment Phase
Infections Heart Failure Chronic Obstructive Pulmonary Disease Asthma Gout Flare Chronic Kidney Diseases Hypertensive Urgency Atrial Fibrillation Rapid Anticoagulation Diabetes and Its Complications End of Life/Desires Only Medical Management Other: Home Hospital care Other: Traditional Hospital care Not Applicable

Detailed Description:

Home hospital is hospital-level care at home for acutely ill patients. In multiple publications mostly in urban environments, home hospital care delivered cost-effective, high-quality, excellent experience care with similar quality and safety as traditional hospital care. Most home hospital models deliver care in urban environments, not in rural environments.

To determine the effect of home hospital care in rural homes, the investigators propose to the following randomized control trial.

Layout table for study information
Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 160 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Hospital-Level Care at Home for Acutely Ill Adults in Rural Settings: A Randomized Controlled Trial
Actual Study Start Date : February 16, 2022
Actual Primary Completion Date : December 16, 2023
Actual Study Completion Date : January 17, 2024

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Experimental: Home Hospital care
Patients receive hospital-level care in their home, as a substitute to traditional hospital care.
Other: Home Hospital care
Patients receive hospital-level care in their home

Active Comparator: Traditional Hospital care
Patients receive hospital-level care in the hospital.
Other: Traditional Hospital care
Patients receive hospital-level care in the hospital.




Primary Outcome Measures :
  1. Total cost, hospitalization [ Time Frame: Date of admission to date of discharge, estimated 10 days later ]
    Published as percent change given sensitivity of these data


Secondary Outcome Measures :
  1. Total cost, discharge to 30-days post discharge [ Time Frame: Day of discharge to 30 days later ]
    Published as percent change given sensitivity of these data

  2. Unplanned readmission within 30-days of discharge [ Time Frame: Day of discharge to 30 days later ]
    Percentage

  3. Days at home [ Time Frame: Day of discharge to 30 days later ]
    The number of days spent at home from the day of discharge to 30-days later

  4. Percent of day lying down [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]

Other Outcome Measures:
  1. Length of stay, days [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  2. IV medication, days [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  3. Intravenous fluids, days [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  4. Intravenous diuretics, days [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  5. Intravenous antibiotics, days [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  6. Oxygen requirement, days [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  7. Nebulizer treatment, days [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  8. Imaging, % [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  9. Lab orders, # [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  10. MD sessions, # of notes [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  11. Consultant sessions, # of notes [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  12. PT/OT sessions, # of notes [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  13. Frequency of disposition, routine, SNF, home health, other [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  14. Follow up with patient's PCP within 14 days, y/n [ Time Frame: Up to 30 days from day of discharge, assessed up to 2 months ]
    Exploratory

  15. SNF utilization, days [ Time Frame: Up to 30 days from day of discharge, assessed up to 2 months ]
    Exploratory

  16. Home health utilization, days [ Time Frame: Up to 30 days from day of discharge, assessed up to 2 months ]
    Exploratory

  17. Unplanned readmission(s) after index, # and y/n + date [ Time Frame: Up to 30 days from day of discharge, assessed up to 2 months ]
    Exploratory

  18. ED observation stay(s), # and y/n + date [ Time Frame: Up to 30 days from day of discharge, assessed up to 2 months ]
    Exploratory

  19. ED visit(s), # and y/n + date [ Time Frame: Up to 30 days from day of discharge, assessed up to 2 months ]
    Exploratory

  20. Fall, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  21. Delirium, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  22. DVT/PE, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  23. New pressure ulcer, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  24. Thrombophlebitis at peripheral IV site, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  25. Hospital-acquired catheter-associated urinary tract infection, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  26. Hospital-acquired Clostridium difficile infection, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  27. Hospital-acquired methicillin resistant staphylococcus aureus infection, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  28. New arrhythmia, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  29. Hypokalemia, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  30. Acute kidney injury, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  31. Medication error, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  32. Unanticipated mortality, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  33. Loss of consciousness, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  34. Transfer back to hospital, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Intervention arm only; Exploratory

  35. Unplanned mortality during admission [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  36. Unplanned 30-day mortality [ Time Frame: Day of discharge to 30-days post discharge, assessed up to 2 months ]
    Exploratory

  37. Pain management, mean pain score on a scale from 0-10 where 10 is the worst pain imaginable [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  38. Hours of sleep per day [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  39. Hours of sleep per night [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  40. Hours of activity per day [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  41. Hours of activity per night [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  42. Hours of sitting upright per day [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  43. Hours of sitting upright per night [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  44. Daily steps [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  45. Use of inappropriate medications in the elderly, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  46. Use of Foley catheter, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  47. Use of restraints, y/n [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  48. EuroQol-5D-5L, visual analogue scale, 0-100, where 100 is the best imaginable health today [ Time Frame: At admission, at discharge (the day the patient leaves the hospital environment), and at 30 days after discharge, each assessed up to 2 months ]
    Exploratory

  49. SF-1 [ Time Frame: At admission, at discharge (the day the patient leaves the hospital environment), and at 30 days after discharge, each assessed up to 2 months ]
    Exploratory; 1-5 Likert scale: Excellent, very good, good, fair poor

  50. Activities of daily living, score [ Time Frame: At admission, at discharge (the day the patient leaves the hospital environment), and at 30 days after discharge, each assessed up to 2 months ]
    Exploratory

  51. Instrumental activities of daily living, score [ Time Frame: At admission, at discharge (the day the patient leaves the hospital environment), and at 30 days after discharge, each assessed up to 2 months ]
    Exploratory

  52. Patient health questionnaire-2, score [ Time Frame: At admission, at discharge (the day the patient leaves the hospital environment), and at 30 days after discharge, each assessed up to 2 months ]
    Exploratory

  53. PROMIS Emotional Support Short Form 4a, score [ Time Frame: At admission, at discharge (the day the patient leaves the hospital environment), and at 30 days after discharge, each assessed up to 2 months ]
    Exploratory; I have someone who will listen to me when I need to talk I have someone to confide in or talk to about myself or my problems I have someone who makes me feel appreciated I have someone to talk with when I have a bad day Scale for each: never, rarely, sometimes, usually, always

  54. Picker Experience Questionnaire -15, score, measured 0-15, where 15 is the best patient experience [ Time Frame: Within 30 days after discharge, assessed up to 2 months ]
    Exploratory

  55. Global satisfaction with care, score, 0-10, where 10 is the best global satisfaction [ Time Frame: Within 30 days after discharge, assessed up to 2 months ]
    Exploratory

  56. Recommend care, score, 0-10, where 10 is the best recommendation possible [ Time Frame: Within 30 days after discharge, assessed up to 2 months ]
    Exploratory

  57. Qualitative interview [ Time Frame: Day of discharge to 30 days after discharge, assessed up to 2 months ]
    Exploratory

  58. Caregiver burden (Zarit), 0-48, where 48 indicates the worst possible caregiver burden [ Time Frame: Day of admission and within 30 days after discharge, assessed up to 2 months ]
    Exploratory

  59. Number of RN visits, in-person [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  60. Number of RN visits, virtual [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  61. Number of RN visits, total [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  62. RN travel time [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  63. Failed connectivity, % [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  64. Number of "on call" MD interactions (video or phone) [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  65. Duration of 1st RN visit [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  66. Duration of subsequent RN visit, in-person [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  67. Duration of subsequent RN visit, virtual [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  68. Other metrics captured on the clinician process survey and nursing visit form [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  69. Insufficient handoff [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  70. Documentation error [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  71. Equipment malfunction [ Time Frame: Day of admission to day of discharge, assessed up to 2 months ]
    Exploratory

  72. Age [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  73. Gender [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  74. Race/ethnicity [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  75. Primary language [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  76. Health insurance states, public/private/none [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  77. BMI [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  78. Comorbidities, type and # [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  79. Partner status [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  80. Education [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  81. Zip code [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  82. Employment [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  83. Smoking status [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  84. Medications used as outpatient, # [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  85. DNR/I code status [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  86. Lives alone [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  87. Home health aide prior to admission [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  88. Elective and urgent admissions in the previous year, # [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  89. ED visits in the previous 6 months, # [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  90. Interqual disease-specific leveling [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  91. PRISMA-7 [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  92. Eight-item Interview to Differentiate Aging and Dementia [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  93. Would you be surprised if this patient died in the next year? [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  94. BRIEF health literacy screening tool [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  95. Readmission risk score on discharge (HOSPITAL) [ Time Frame: Day of discharge, assessed up to 2 months ]
    Exploratory

  96. Admitting diagnosis [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  97. Admission source [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  98. COVID case count on day of admission [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  99. Degree of rurality [ Time Frame: Day of admission, assessed up to 2 months ]
    Exploratory

  100. [intervention arm only] RHH admission, daily care, and discharge processes accomplished [ Time Frame: Twice a week, day of enrollment to day of final discharge, assessed up to 2 months ]
    Exploratory

  101. [intervention arm only] Perceived acceptability of RHH care [ Time Frame: Day of discharge to 30 days postdischarge, assessed up to 2 months ]
    Exploratory

  102. [intervention arm only] Perceived safety, quality of care, caregiver burden [ Time Frame: Day of discharge to 30 days, assessed up to 2 months ]
    Exploratory

  103. Qualitative interviews [ Time Frame: Day of enrollment to day of final discharge, assessed up to 4 months ]
    Interviews with patients, caregivers, and rural home hospital clinicians.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


Layout table for eligibility information
Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

Patient clinical inclusion criteria:

  • >=18 years old
  • Any infectious process (e.g., pneumonia, diverticulitis, cellulitis, complicated urinary tract infection)
  • Heart failure exacerbation
  • Asthma and chronic obstructive pulmonary disease exacerbation
  • Atrial fibrillation with rapid ventricular response
  • Diabetes and its complications
  • Venous thromboembolism
  • Gout exacerbation
  • Chronic kidney disease with volume overload
  • Hypertensive urgency
  • End of life / desires only medical management

Patient environmental inclusion criteria:

  • Lives in a rural area that can be served by the RHH team.
  • Has capacity to consent to study OR can assent to study and has proxy who can consent (see subject enrollment, below)
  • Can identify a potential caregiver who agrees to stay with patient for first 24 hours of admission. Caregiver must be competent to call care team if a problem is evident to her/him. After 24 hours, this caregiver should be available for as-needed spot checks on the patient.

    • This criterion may be waived for highly competent patients at the patient and clinician's discretion.

Patient caregiver inclusion criteria: (not required for patient participation):

  • Age >= 18 years old
  • Has capacity to consent to study
  • Lives within 15 minutes travel time.

Clinician inclusion criteria:

  • The rural home hospital clinical team will be identified by the site PI at each study site prior to the start of the study. The site PI will recruit local RNs and/or EMT-Ps, and attending physicians (MD) to deploy and provide rural home hospital care.
  • Any member of the rural home hospital clinical team (a clinician providing care in the home) who will be participating in research activities, including the screening and recruitment of patients for the rural home hospital intervention and/or providing care to rural patients that enroll in the intervention.

Sites without continuous monitoring will make amendments to the above inclusion criteria

Exclusion Criteria:

  • Patient exclusion clinical criteria:

    • Acute delirium, as determined by the Confusion Assessment Method
    • Cannot establish peripheral access by any means
    • Secondary condition: active non-melanoma/prostate cancer, end-stage renal disease, acute myocardial infarction, acute cerebral vascular accident, acute hemorrhage (unless part of end of life pathway)
    • Primary diagnosis requires multiple or routine administrations of intravenous narcotics for pain control
    • Cannot independently ambulate to bedside commode, unless home-based aides are available
    • As deemed by on-call MD, patient likely to require any of the following procedures that have not already occurred: computed tomography, magnetic resonance imaging, endoscopic procedure, blood transfusion, cardiac stress test, or surgery (unless these can be coordinated with appropriate facilities during the home hospitalization)
    • For pneumonia:

      • Most recent CURB65 > 3: new confusion, BUN > 19mg/dL, respiratory rate>=30/min, systolic blood pressure<90mmHg, Age>=65 (<14% 30-day mortality)15
      • Most recent SMRTCO > 2: systolic blood pressure < 90mmHg (2pts), multilobar CXR involvement (1pt), respiratory rate >= 30/min, heart rate >= 125, new confusion, oxygen saturation <= 90% (<10% chance of intensive respiratory or vasopressor support)16
      • Absence of clear infiltrate on imaging
      • Cavitary lesion on imaging
      • Pulmonary effusion of unknown etiology
      • O2 saturation < 90% despite 5L O2
    • For heart failure:

      • Has a left ventricular assist device
      • GWTG-HF17 (>10% in-hospital mortality) or ADHERE18 (high risk or intermediate risk 1)*
      • Severe pulmonary hypertension
    • For complicated urinary tract infection:

      • Absence of pyuria
      • Most recent qSOFA > 1 (SBP≤100 mmHg, RR≥22, GCS<15 [any AMS]) (if sepsis, >10% mortality)19
    • For other infection

      • Most recent qSOFA > 1 (SBP≤100 mmHg, RR≥22, GCS<15 [any AMS]) (if sepsis, >10% mortality)19
    • For COPD

      • BAP-65 score > 3 (BUN>25, altered mental status, HR>109, age>65) (<13% chance in-hospital mortality): exercise caution
    • For asthma

      o Peak expiratory flow < 50% of normal: exercise caution

    • For diabetes and its complications

      o Requires IV insulin

    • For hypertensive urgency

      • Systolic blood pressure > 190 mmHg
      • Evidence of end-organ damage; for example, acute kidney injury, focal neurologic deficits, myocardial infarction
    • For atrial fibrillation with rapid ventricular response

      • Likely to require cardioversion
      • New atrial fibrillation with rapid ventricular response
      • Unstable blood pressure, respiratory rate, or oxygenation
      • Despite IV beta and/or calcium channel blockade in the emergency department, HR remains > 125 and SBP remains different than baseline
      • Less than 1 hour of time has elapsed with HR < 125 and SBP similar or higher than baseline
    • Home hospital census is full

      • GWTG-HF: AHA Get with the Guidelines: SBP, BUN, Na, Age, HR, Black race, COPD ADHERE: Acute decompensated heart failure national registry: BUN, creatinine, SBP

Patient environmental exclusion criteria:

  • Undomiciled
  • No working heat (October-April), no working air conditioning if forecast > 80°F (June-September), or no running water
  • On methadone requiring daily pickup of medication
  • In police custody
  • Resides in facility that provides on-site medical care (e.g., skilled nursing facility)
  • Domestic violence screen positive

Sites without continuous monitoring will make amendments to the above exclusion criteria


Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT05256303


Locations
Layout table for location information
United States, Illinois
Blessing Health System
Quincy, Illinois, United States, 62301
United States, Kentucky
Appalachian Regional Healthcare, Inc.
Hazard, Kentucky, United States, 41701
Canada, Alberta
Wetaskiwin Hospital and Care Centre
Wetaskiwin, Alberta, Canada, T9A 3N3
Sponsors and Collaborators
Brigham and Women's Hospital
The Thompson Family Foundation Inc
Publications:
2014 National and State Healthcare-Associated Infections Progress Report.; 2016. http://www.cdc.gov/hai/surveillance/progress-report/index.html. Accessed April 19, 2016.
Bureau UC. What is Rural America?https://www.census.gov/library/stories/2017/08/rural-america.html. Published 2017. Accessed May 31, 2019.
Parker K, Horowitz J, Brown A, Fry R, Cohn D, Igielnik R. What Unites and Divides Urban, Suburban and Rural Communities.; 2018. https://www.pewsocialtrends.org/wpcontent/uploads/sites/3/2018/05/Pew-Research-Center-Community-Type-Full-Report-FINAL.pdf. Accessed May 31, 2019

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Responsible Party: David Levine, Dr. David Levine MD, MPH, MA, Director, Brigham and Women's Hospital
ClinicalTrials.gov Identifier: NCT05256303    
Other Study ID Numbers: 2021P000334
First Posted: February 25, 2022    Key Record Dates
Last Update Posted: March 6, 2024
Last Verified: March 2024
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

Layout table for additional information
Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by David Levine, Brigham and Women's Hospital:
home hospital
hospital at home
hospital in the home
Additional relevant MeSH terms:
Layout table for MeSH terms
Lung Diseases, Obstructive
Pulmonary Disease, Chronic Obstructive
Kidney Diseases
Renal Insufficiency, Chronic
Atrial Fibrillation
Hypertensive Crisis
Death
Heart Diseases
Cardiovascular Diseases
Arrhythmias, Cardiac
Pathologic Processes
Urologic Diseases
Female Urogenital Diseases
Female Urogenital Diseases and Pregnancy Complications
Urogenital Diseases
Male Urogenital Diseases
Lung Diseases
Respiratory Tract Diseases
Chronic Disease
Disease Attributes
Renal Insufficiency
Hypertension
Vascular Diseases