Prof. Ivan perry

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HRB Centre for Health and Diet Research

Research in Irish Primary CareThe Cork & Kerry Study

Ivan J Perry,

Dept. of Epidemiology and Public Health,

University College Cork.

Inaugural National Primary Care ConferenceLivinghealth Clinic

Mitchelstown, County CorkThursday, November 17th , 2011

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HRB Centre for Health and Diet Research2

Overview• Background & context

• Cork & Kerry study sampling & methods

• Selection of key findings – CVD risk factor prevalence– Modelling of secular trends in CHD mortality in Ireland

• Data management issues

• Suggestions for further development of primary care research infrastructure

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Background & context• HRB funding for Population Health Sciences,

and Health Services Research (HSR)

• Costs and limitations of household surveys and telephone surveys for population health surveillance

• Primary care centres which serve a defined relatively large population with good links and outreach to the local community provide a potentially excellent sampling frame for population health research and HSR

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Biomedical perspective on nutrition-related diseases

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Sociological/ marketing perspective on nutrition transition

Source: Adapted from Cova and Cova, 2001, p.601; Desjeux, 19966

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0

200

400

600

800Per 100,000Per 100,000

Ireland

UK

USA

Netherlands

Finland

ItalyFrance

International mortality trends in CHD in men aged 35 to 74 years from 1968 to 2003

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Sick individuals and sick populations:Total cholesterol in three populations

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Cork & Kerry Diabetes and Heart Disease Study

• Linked cross-sectional and longitudinal studies involving representative samples of middle-aged men and women.

• Cork & Kerry Phase I and Phase II studies

» Phase I: 1998 (N=1018)

» Phase I Follow up: year 2008-2009

» Phase ll: 2010-11 (N=2000)

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Cork & Kerry Phase I Study Methods

• Cross sectional study in primary care carried out in 1998

• 17 General Practices linked to the Cork Vocational Training programme for general Practice

• 1018 participants and response rate of 69%.• Data on diet (FFQ), lifestyle, and anthropometric

measures including height, weight, waist circumference and blood pressure were obtained using standard, internationally validated questionnaires instruments and methods

• Detailed Standard Operating Procedure (SOP) and rigorous training of field survey staff

• Fasting blood samples and morning urine samples were obtained for estimation of glucose, insulin, lipids, homocysteine, microalbumin and other established biological CVD risk factors.

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Cork & Kerry Phase I-follow-up study

1018 men and women aged 50-69 years screened in 1998

156 deaths to Dec 2008

180 lost to follow-up & 43 unable to

participate

Contacted 639

362 (57%) responded

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Cork & Kerry Phase II Study Methods

• Cross sectional study in primary care carried out in 2010-2011

• Based in a single large primary care centre (LivingHealth Clinic) in Mitchelstown, Co Cork

• 2047 participants and response rate of 67%.• Dietary, lifestyle, and anthropometric

measures as in Phase I study• Addition of ACE (adverse childhood

experiences) instrument• Addition of 24 hour ambulatory BP in over

50% of participants and triaxial accelerometry data over 7-days from a sub-sample of over 400 participants

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Cork & Kerry Phase II Study Methods Contd

• Detailed SOP and rigorous training of field survey staff

• Fasting blood sample for measurement of full blood count (FBC), Glycosylated haemoglobin, glucose, estimated GFR, iron, Gamma GT, liver, renal, lipoprotein and bone profiles, serum B12, folate and ferritin.

• Blood samples are centrifuged on site and two serum bottles are stored in microlettes (1.3ml x2) in an onsite -80 degree freezer.

• Morning urine samples for estimation of electyrolytes and microalbumin

• Field work completed in April 2011

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Cork & Kerry Phase 2 StudyLivingHealth Clinic Mitchelstown

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GeneActive tri-axialAccelerometers

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Wrist worn,light, water resistant

accelerometerwith capacity to

measure physical activity over 7

days

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Cork & Kerry Phase 2 StudyLiving Health Clinic Mitchelstown

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Cork and Kerry 2010

• Study timelines =26th April 2010 to 21st April 2011 (44 weeks in total)

• Response rate =67% (2047/3043)

• Response rate for ABPM =58% (1179/2047)

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'Food Choices in Sickness and in Health

• While Irish adults may be generally aware of a link between nutrition and health, this is not reflected in everyday food choices. Food decisions may be influenced by myriad individual, social, cultural and environmental factors.

• This research explores socially- and culturally-mediated drivers of food choice decisions in sub-sets of the Cork and Kerry cohort.

• Contextualised understanding of food and eating can help to inform the design and planning of tailored public health interventions and communication strategies.

(Mary Delaney & Dr Mary McCarthy, Department of Food Business and Development UCC)

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'Food Choices in Sickness and in Health'

Study 1: Qualitative interview study on food choice influences in participants with different health and dietary profiles

Aim: To explore drivers of current eating habits in the context of everyday lives, health status, attitudes, values, beliefs, priorities and past experiences.

Method: In-depth interviews were carried out with 50 Cork and Kerry participants with varying dietary and health profiles (healthy participants with prudent and non-prudent diets and participants with diabetes and CVD). Analysis of the data will explore how the discourse on healthy eating and risk perception is situated within the wider role and meaning of food in everyday life.

Study 2: Questionnaire study on social-psychological correlates of healthy eating

Aim: To identify motivational determinants of healthy eating and behaviour change

Method: 700 Cork and Kerry participants completed a postal questionnaire on social psychological correlates of healthy eating including attitudes towards healthy eating, risk perception, normative beliefs and self-efficacy. This data will be combined with epidemiological data to identify particular group profiles and target issues for intervention.

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Prevalence of overweight and obesity by age and gender: Cork & Kerry Study 1998

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Prevalence of hypertension by age and gender Cork & Kerry Study 1998

0

10

20

30

40

50

60

%

50-54 55-59 60-64 65-69

Male Female

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Prevalence of diabetes and impaired fasting glucose (combined) by age and gender

Cork & Kerry Study 1998

0

2

4

6

8

10

12

14

%

50-54 55-59 60-64 65-69

Male Female

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Prevalence of the metabolic syndrome -US Adult Treatment Panel (ATP) III definition

23Eckel et al. Lancet 2005; 365: 1415–28 23

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Estimates of absolute risk of CVDEuropean Cardiac Society Risk Score

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The prevalence of pre-exisiting disease and the proportions identified "at risk" of a CHD event for three risk threshold, 30%,

20%, 15% over 10 years in the Cork & Kerry Study 1998

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CVD risk factors in men aged 50 to 69 years in 1998 and 2010 Cork & Kerry studies

Variables Cork & Kerry 1998 N=1018

Cork & Kerry 2010 N=2047

Weight Kg (mean (std)) 83.3 (13.4) 87.5(13.8)

BMI (kg/m2) Mean (std) 27.9 (4.1) 29.2(4.2)

Overweight % 52.1 (250) 49.2(493)

Obese I % 25.7 36.7(368)

Waist Circumference Mean cm (std) 99.3 (11.6) 102.8(11.1)

Central obesity % 68.8 (338) 78.6(789)(over 94 cms)

BP(those not on medication)

Mean SBP 136.8 (19.1) 129.3(15.1)

Mean DBP 81.6 (10.3) 79.5(9.2)

Cholesterol(those not on medication)

Mean mmol/L (std) 5.6 (0.9) 5.3(0.9)

% >5mmol/L 72.4 (297) 42.9(416)

HBA1C Mean 5.1 (0.98) 5.9(0.8)

% >6.5 2.2 (11) 8.3(81)

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24-hour ambulatory BP measurement

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24-hour ambulatory BP measurementHeadline findings

Wrist worn,light, water resistant

accelerometerwith capacity to

measure physical activity over 7

days

• 1030 individuals had measurements available for clinic, study and ambulatory blood pressure.

• Approximately 50% of individuals with hypertension based on previous GP readings and 44% of those with hypertension at the study visit had normal ABP.

• However, 21% of those with normal clinic blood pressure and 20% of those with normal study blood pressure had hypertension according to ABPM.

• Data relevant to recent NICE guidelines on use of ABPM in the diagnosis of hypertension.

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0

200

400

600

800Per 100,000Per 100,000

Ireland

UK

USA

Netherlands

Finland

ItalyFrance

International mortality trends in CHD in men aged 35 to 74 years from 1968 to 2003

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-4000

-3000

-2000

-1000

0

3763 3763 fewer deathsfewer deaths

Risk Factors worse Risk Factors worse +13.8%+13.8%

Risk Factors better Risk Factors better ––61.9%61.9%

Treatments Treatments ––43.6%43.6%

2000200019851985

Fig 2. CHD mortality fall in Ireland 1985 Fig 2. CHD mortality fall in Ireland 1985 -- 2000 explained by 2000 explained by a) treatments in CHD patients & b) population risk factora) treatments in CHD patients & b) population risk factorss

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-4000

-3000

-2000

-1000

0

37633763fewer deathsfewer deaths

Risk Factors worse +14%Risk Factors worse +14%

Risk Factors better Risk Factors better ––61%61%

Treatments Treatments -- 43.6%43.6%

2000200019851985

Fig 2. CHD mortality fall in Ireland 1985 Fig 2. CHD mortality fall in Ireland 1985 -- 2000 explained by 2000 explained by a) treatments in CHD patients & b) population risk factora) treatments in CHD patients & b) population risk factorss

Obesity (increase) + 4%Obesity (increase) + 4%Diabetes (increase) + 6%Diabetes (increase) + 6%Physical activity (less) + 4%Physical activity (less) + 4%

SmokingSmoking -- 25%25%Cholesterol Cholesterol -- 30%30%Population BP fall Population BP fall -- 6%6%

AMI treatments AMI treatments -- 4.4%4.4%Secondary prevention Secondary prevention -- 18%18%Heart failureHeart failure -- 9.1%9.1%Angina:CABG & PTCA Angina:CABG & PTCA -- 5%5%Angina: Aspirin Angina: Aspirin etcetc -- 3.4%3.4%Hypertension drugs Hypertension drugs –– 1.61.6%%StatinsStatins 11’’ prevention prevention -- 1.2%1.2%Unstable angina - 1%

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Key elements of good data management

• Data Quality

• Data Protection

• Disease Coding

• Audit

• Data Quality

• Data Protection

• Disease Coding

• Audit

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Data Quality

• Data is a key strategic resource which requires correct management

• High quality general practice health information enhances professionals efficiency and supports patient care, decision making and research.

• Requires a robust administration system with processes in place to continually update & verify patient details

• Clinical workflow practices which encompass accurate data recording

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Data Protection

• Data Protection Acts 1998 and 2003 • Freedom of Information Acts 1997 and 2003• Involves tracking compliance with core data

protection issues• Developing internal policies which reflect

and apply the eight rules of data protection• Organising staff training in measures

necessary when handling personal & sensitive information

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Disease Coding

• ICPC-2 – International Classification of Primary Care

• Coding method used in LHC to classify the episode of care between the G.P. & patient

• Multidisciplinary team established in LHC to advance & support the coding initiative

• Standardised codes discussed and agreed for clinical encounters e.g. Driving licence medical examination – Z31

• Coding adds clarity & assists rapid information retrieval, audit & research

• Information quality & consistency are important to support inputs & outcomes to facilitate performance monitoring

• Coding discharge letters expands the complete patient depository

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Disease Coding

• Supports information exchange with Public Health and Hospital Information Systems

• Supports management of chronic disease by assisting with the

formation of disease registers for coded conditions,disease management protocols and recall

• Facilitates rapid retrieval and organisation of information and linkage of signs & symptoms with outcomes

Clinical Disease Coding and Classification, An Overview for General Practitioners, Dr Brian

Meade, National GPiT Group,www.gpit.ie

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Suggestions for further development of primary care research infrastructure

• National network of primary care centres with well defined catchment populations and shared or compatible patient management systems

• Partnership with relevant academic Departments & groups and with the HRB funded Clinical Research Centres (CRC’s)

• Develop links with (or join) the UK General Practice Research Database (GPRD)

• Potential to attract HRB funding for a National Research network

• Need for transparent and common sense arrangements in relation to intellectual property and authorship issues 37

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Primary care research:not a panacea but a critical component of Irelands

research infrastructure

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Thank you

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Prof. Ivan perry

Health & Medicine