Background-An epidemic increase in heart failure (HF) mortality, hospitalization, and prevalence rates has been observed among older persons in recent years. It is unclear whether this reflects an increase in incidence or survival. Methods and Results-We conducted a retrospective cohort study comparing HF in 1970comparing HF in to 1974comparing HF in and 1990comparing HF in to 1994 persons Ն65 years old belonging to a large, well-defined population with complete medical records available for research. Using Framingham clinical criteria, we identified incident cases of HF in the respective periods. Age-specific and age-adjusted incidence, mortality, and survival rates were compared. Cox proportional-hazards models were used to assess association of comorbidities and medications with survival. During 38 800 and 127 419 person-years for 1970 to 1974 and 1990 to 1994, respectively, 387 and 1555 confirmed incident cases were identified. When adjusted for age, incidence increased by 14% (95% CI 2% to 28%). Increased incidence tended to be greater for older persons and for men. Based on 5-year follow-up and adjustment for age and comorbidities, the mortality hazards decreased 33% (95% CI 14% to 48%) among men and 24% (95% CI Ϫ1% to 43%) among women. Conclusions-The epidemic increase in HF among the older population between the 1970s and 1990s is associated with increased incidence and improved survival, with both of these effects being greater in men.

OBJECTIVE:To describe the etiologies of syncope in hospitalized patients and determine the factors that influence survival after discharge. lation-based studies from the 1980s underscored the importance of diagnosing the cause of syncope. 2-6 Individuals with syncope of cardiovascular origin had a higher 1-year mortality (18%-33%) than individuals with noncardiovascular or unexplained syncope (6%-12%), 2-6 and this increased risk continued for 5 years. 7 However, determining the etiology of a syncopal event was a diagnostic challenge that was unsuccessful in up to 47% of cases. [2][3][4][5][6] This discordance between a physician's ability to establish a diagnosis for a syncopal event and the prognostic importance of doing so has inspired much research on evaluating syncopal events. This literature on syncope, often involving single-center referral populations and a single diagnostic test, [8][9][10][11][12][13] was summarized by a recent consensus conference. 14,15 However, the use of these newer diagnostic testing modalities and the ability to identify etiologies of syncope, have not been described in an unselected population. Furthermore, the prognostic significance of cardiovascular syncope has been questioned in patients with heart disease and in the elderly, 9,16 but has not been reevaluated in more broadly defined populations during the current era of diagnostic testing. DESIGN:The goals of this study were to characterize the epidemiology of individuals hospitalized with syncope in a broad range of health care delivery settings. We wanted to describe the diagnostic testing and the results of diagnostic evaluations, and to determine if the etiology of syncope continued to predict mortality in an unselected communitybased population. METHODS Study Design and Source of PatientsThis study used an observational cohort design. To minimize referral and institutional bias, we selected populations served by three diverse health care systems in Oregon: a tertiary-care VA hospital, a group-model HMO, and Medicare. The Medicare population was drawn from all hospitals in Oregon. We reviewed the hospitalization databases of these organizations from January 1, 1992, through December 31, 1994, identifying patients with ICD-9-CM code 780.2 (syncope and collapse) as an admission diagnosis or as any one of the discharge diagnoses. This method of retrospectively identifying individuals with syncope on the basis of coded diagnoses is similar to methods used in several previous studies. 3,5,17,18 The first admission for a patient during the study time frame was identified for review; subsequent admissions were not included. There were 324 patients identified at the VA (0.98% of all admissions), 818 at the HMO (0.92%), and

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Although primary prevention studies are important tools in helping the healthy elderly stay healthy, recruiting from a community-based cohort of healthy elderly individuals for a primary prevention study involves numerous barriers. To better identify and understand these barriers, we conducted and evaluated a comprehensive recruitment strategy for a primary prevention study testing aspirin in an HMO population. In the recruitment phase, we identified healthy individuals (65 years of age or older) who were members of a large, group-model HMO in Oregon and Washington, and used computerized medical database screening, statistical sampling, health plan mailings, e-mail communication with primary care providers, and the experience of a well-established research clinic in an effort to enroll health elderly in this primary prevention trial. Among a random sample of 47,453 eligible patients over the age of 65, 44% responded to recruitment efforts, but only 3% were enrolled--an overall yield of slightly less than 2%. To evaluate these results, we then conducted focus groups with 225 randomly selected "eligible refusers." We determined that healthy elders were hesitant to give up their choice to use aspirin, unwilling to travel to the research center, and reluctant to risk their tenuous hold on good health to participate in a study of primary prevention. Awareness of these attitudes is an indispensable step toward designing effective recruitment strategies for primary prevention studies involving the healthy elderly.