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Suneela Mehta,
Sue Wells,
Corina Grey,
Tania Riddell,
Andrew Kerr, Roger Marshall,
Shanthi Ameratunga,
Jeff Harrison,
Tim Kenealy,
Dale Bramley,
Wing Cheuk Chan,
Simon Thornley,
Gerhard Sundborn,
Rod Jackson
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ABSTRACT: Aim: To examine whether use of a standardized cardiovascular disease (CVD) risk assessment recommended by national guidelines is associated with appropriate initiation and maintenance of medication in a large primary care cohort.Methods and design: A total of 90,631 people aged 30-80 years were followed for up to 3 years after a formal CVD risk assessment was undertaken between January 2006 and October 2009, during routine primary care visits in New Zealand. Patients either had prior CVD or had their CVD risk estimated using a modified Framingham prediction equation for fatal or non-fatal CVD events. The individual risk profiles were anonymously linked to national dispensing data for blood-pressure-lowering and lipid-lowering medications in the 6-month period before and in consecutive 6-month blocks after the baseline CVD risk assessment.Results: At baseline, a combination of blood-pressure-lowering and lipid-lowering therapy was already being used by about two-thirds of patients with prior CVD, one-quarter with a 5-year CVD risk greater than 10% (approximately 20% 10-year risk), and one-tenth with CVD risk below this level. Among these previously treated patients, dispensing rates for blood-pressure-lowering, lipid-lowering, or both medications together declined by only 4-16% up to 3 years after baseline assessment, irrespective of risk category. Among patients untreated at baseline, combination therapy was initiated within 6 months for 21% with prior CVD, 16% with 5-year CVD risk greater than 15% (approximately 30% 10-year risk and the national drug-treatment threshold), 10% with 5-year CVD risk between 10 and 14% (approximately 20-29% 10-year risk), and 3% in the lowest risk category. Across the study population, patients with prior CVD had the highest dispensing rates for each category of medication, and incrementally higher dispensing rates were noted as CVD risk group increased.Conclusions: In this primary care cohort, most patients already using CVD medications at the time of the baseline CVD risk assessment maintained treatment over a maximum of 3 years follow up, irrespective of their estimated baseline risk. Among patients untreated at baseline, subsequent dispensing rates were strongly related to estimated CVD risk group. Around 15-20% of untreated patients meeting national drug-treatment criteria commenced combination pharmacotherapy within 6 months of CVD risk assessment.
European journal of preventive cardiology. 10/2012;
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ABSTRACT: INTRODUCTION: Few studies have measured the effect of tobacco bans on secondhand smoke (SHS) exposure in prisons. From June 1, 2011, the sale of tobacco was prohibited in New Zealand prisons. One month later, the possession of tobacco was banned. We studied the indoor air quality before and after this policy was enforced. METHODS: We measured indoor-fine-particulate (PM(2.5)) concentrations using a TSI SidePak photometer. The instrument was placed in a staff base of a New Zealand maximum-security prison, adjacent to four 12-cell wings. Measurements were made before the sales restriction, during this period, and after the ban. Data were summarized using daily geometric means and generalized least squares regression. RESULTS: A total of 7,107 observations were recorded at 5-min intervals, on 14 days before and 15 days after implementation, between 24 May and 5 August. Before the policy was implemented, the geometric mean was 6.58 μg/m(3) (95% CI = 6.29-6.58), which declined to 5.17 μg/m(3) (95% CI = 4.93-5.41) during the sales ban, and fell to 2.44 μg/m(3) (95% CI = 2.37-2.52) after the smoking ban. Regression analyses revealed an average 57% (95% CI = 42-68) decline in PM(2.5) concentrations, comparing the before and after periods.Conclusions:Our study showed a rapid and substantial improvement in indoor air quality after tobacco was banned at a prison. We conclude that prisoners have reduced their smoking in line with the ban, and that a significant health hazard has been reduced for staff and prisoners alike.
Nicotine & Tobacco Research 05/2012; · 2.58 Impact Factor
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ABSTRACT: To assess whether statin use is associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD).
Hospitalisation, drug dispensing, and mortality records were linked for New Zealanders aged 50-80 years discharged from hospital with a first admission with COPD in 2006. Patients were classified according to whether or not they were prescribed statins prior to admission. Baseline characteristics were compared and hazard ratios calculated for statin users versus statin non-users for all-cause mortality over follow-up of up to 4 years.
A total of 1,687 patients (mean age 70.6 years) were followed, including 596 statin users and 1,091 non-users. There were more men in the statin user group (58.4% vs. 48.5%), and statin users were more likely to have a history of cardiovascular disease (58.6% vs. 25.1%), prescription for frusemide as a proxy for heart failure (47.7% vs. 24.5%) or diabetes (35.4% vs.11.6%) than statin non-users (p<0.001). A total of 671 deaths occurred during the follow-up period. After adjustment for age, sex, ethnic group, history of cardiovascular disease, diabetes, and prescription for frusemide, the hazard ratio for statin users vs. statin non-users for all-cause mortality was 0.69 (95% CI 0.58 to 0.84).
Statin use is associated with a 30% reduction in all-cause mortality at 3-4 years after first admission for COPD, irrespective of a past history of cardiovascular disease and diabetes.
Primary care respiratory journal: journal of the General Practice Airways Group 01/2012; 21(1):35-40.
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ABSTRACT: Cutting and piercing injuries are among the leading causes of unintentional injury morbidity in developed countries. In New Zealand, cutting and piercing are second only to falls as the most frequent cause of unintentional home injuries resulting in admissions to hospital among people aged 20 to 64 years. Alcohol intake is known to be associated with many other types of injury. We used a case-crossover study to investigate the role of acute alcohol use (i.e., drinking during the previous 6 h) in unintentional cutting or piercing injuries at home.
A population-based case-crossover study was conducted. We identified all people aged 20 to 64 years, resident in one of three regions of the country (Greater Auckland, Waikato and Otago), who were admitted to public hospital within 48 h of an unintentional non-occupational cutting or piercing injury sustained at home (theirs or another's) from August 2008 to December 2009. The main exposure of interest was use of alcohol in the 6-hour period before the injury occurred and the corresponding time intervals 24 h before, and 1 week before, the injury. Other information was collected on known and potential confounders. Information was obtained during face-to-face interviews with cases, and through review of their medical charts.
Of the 356 participants, 71% were male, and a third sustained injuries from contact with glass. After adjustment for other paired exposures, the odds ratio for injury after consuming 1 to 3 standard drinks of alcohol during the 6-hour period before the injury (compared to the day before), compared to none, was 1.77 (95% confidence interval 0.84 to 3.74), and for four or more drinks was 8.68 (95% confidence interval 3.11 to 24.3). Smokers had higher alcohol-related risks than non-smokers.
Alcohol consumption increases the odds of unintentional cutting or piercing injury occurring at home and this risk increases with higher levels of drinking.
BMC Public Health 11/2011; 11:852. · 2.00 Impact Factor
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ABSTRACT: In New Zealand, a setting in which national guidelines recommend statins for all patients with coronary heart disease (CHD) and cost barriers are low, patterns of use of these drugs are unknown. We investigated dispensing rates after hospital discharge for acute CHD event.
Retrospective cohort study.
Drug dispensing, hospital diagnosis, and mortality records were linked by unique identifier for all New Zealanders aged 35-84 years after discharge following acute CHD event in 2007. We defined the statin dispensing ratio (SDR) as the proportion of days that 15,506 patients aged 35-84 years were dispensed such agents during the 12 months post discharge. An SDR ≥0.8 (80% or more days covered) was considered optimal.
Overall, 59% of the cohort had an SDR ≥0.8. Of patients dispensed statins in the 3 months before admission (n = 5506), almost all (99%; 5466) continued treatment during follow up and 82% had an SDR ≥0.8. In contrast, for patients not dispensed statins before admission (n = 8014), only two-thirds started statins during follow up and only 44% had an SDR ≥0.8. Of all patients with low statin dispensing (SDR <0.8), about one-quarter were not dispensed any lipid-lowering drugs, one-quarter received alternative lipid-lowering drugs, one-quarter stopped statins, and the remaining quarter were intermittent statin users.
In a setting with few barriers to statin treatment, about 40% of patients had suboptimal statin dispensing during the year after hospital treatment for CHD. This study has identified four significant categories of suboptimal adherence that could inform quality improvement programmes.
European journal of preventive cardiology. 03/2011; 19(3):349-57.
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ABSTRACT: To estimate sociodemographic differences in the prevalence of coronary heart disease (CHD) in New Zealand from linked health records.
We combined records of hospital treatment for CHD, dispensing of selected anti-anginal drugs and mortality to estimate the national point prevalence of coronary heart disease in New Zealand in December 2008. Stratified estimates are presented by gender; age; Māori, Pacific, Indian and 'Other' (mainly New Zealand European) ethnic groups; and socioeconomic status.
Among a "health contact" population of adults (greater than and equal to 15 years), about one in twenty (6.5% of men and 4.1% of women) had indicators of a past diagnosis or treatment for CHD or both. Substantial differences in prevalence occurred by gender, ethnic group and socioeconomic status. For example, among New Zealanders aged 35 to 74 years, Indian men had the highest age-adjusted prevalence (7.78%; 95%CI 7.43 to 8.15), almost double the prevalence of 'Other' males. Among women, Māori had the highest adjusted prevalence (4.03%; 95% CI 3.89 to 4.17), just over twice that of 'Others.'
Major sociodemographic disparities in the national burden of CHD persist. Our results are similar to previous studies of ethnic disparities in CHD incidence, but also confirm concerns about the emerging CHD burden among South Asians. Indian males have the highest CHD prevalence of any gender-specific ethnic group. Of equal concern, Māori women have a similar prevalence to European males.
The New Zealand medical journal 01/2011; 124(1334):21-34.
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Suneela Mehta,
Sue Wells,
Tania Riddell,
Andrew Kerr,
Romana Pylypchuk, Roger Marshall,
Shanthi Ameratunga,
Wing Cheuk Chan,
Simon Thornley,
Sue Crengle,
Jeff Harrison,
Paul Drury,
C Raina Elley,
Fionna Bell,
Rod Jackson
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ABSTRACT: Blood pressure-lowering (BPL) and lipid-lowering (LL) medications together reduce estimated absolute five-year cardiovascular disease (CVD) risk by >40%. International studies indicate that the proportion of people with CVD receiving pharmacotherapy increases with advancing age.
To compare BPL and LL medications, by sociodemographic characteristics, for patients with known CVD in primary care settings.
The study population included patients aged 35-74 with known CVD assessed in primary care from July 2006 to October 2009 using a web-based computerised decision support system (PREDICT) for risk assessment and management. Clinical data linked anonymously to national sociodemographic and pharmaceutical dispensing databases. Differences in dispensing BPL and LL medications in six months before first PREDICT assessment was analysed according to age, sex, ethnicity and deprivation.
Of 7622 people with CVD, 1625 <55 years old, 2862 were women and 4609 lived in deprived areas (NZDep quintiles 4/5). The study population included 4249 European, 1556 Maori, 1151 Pacific and 329 Indian peoples. BPL medications were dispensed to 81%, LL medications to 73%, both BPL and LL medications to 67%, and 87% received either class of medication. Compared with people aged 65-75, people aged 35-44 were 30-40% less likely and those aged 45-54 were 10-15% less likely to be dispensed BPL, LL medications or both. There were minimal differences in likelihood of dispensing according to sex, ethnicity or deprivation.
BPL and LL medications are under-utilised in patients with known CVD in New Zealand. Only two-thirds of patients in this cohort are on both. Younger patients are considerably less likely to be on recommended medications.
Journal of primary health care 01/2011; 3(2):93-101.
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ABSTRACT: With projected global increases in the prevalence of Type 2 diabetes, the health sector requires timely assessments of the prevalence of this disease to monitor trends, plan services, and measure the efficacy of prevention programmes.
To assess the validity of a method to estimate the prevalence of diagnosed diabetes from linked national health records.
We measured the agreement between a diabetes diagnosis (using combined national lists of drug dispensing, outpatient attendance, laboratory tests (HbA1c) and hospital diagnoses) and a primary care diabetes diagnosis in a (PREDICT™) cohort of 53,911 adult New Zealanders. The completeness of the diagnosis of diabetes in the cohort was estimated using capture-recapture methods.
The primary care cohort had a high prevalence of recorded diabetes (20.9%, 11,266/53,911), similar to our derived prevalence of 20.1%. Of the participants with a diagnosis of diabetes, 89% (10,182/11,266) had a similar derived diagnosis, indicating that only about one in 10 people with a primary care diagnosis had not been either admitted to hospital, seen at outpatient clinics, prescribed diabetes drugs or undertaken regular HbA1c tests. The capture-recapture prevalence of diagnosed diabetes in this cohort was 23.7% indicating that primary care diagnoses in the cohort were about 90% complete.
A method for estimating the prevalence of diagnosed diabetes from national health data shows high-level agreement with primary care records. Linked health data can provide an efficient method for estimating the prevalence of diagnosed diabetes in regions where such records are individually linked.
Journal of primary health care 01/2011; 3(4):262-8.
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ABSTRACT: To examine the ecological association between population asthma symptom prevalence in six to seven year-old children and per capita sugar consumption seven years earlier (during the perinatal period).
The asthma data (from the International Study of Asthma and Allergies in Childhood [ISAAC] study) were collected between 1999 and 2004 from 53 countries, and per capita sugar consumption data (seven years before the asthma prevalence) were extracted from United Nations Food and Agriculture (UNFAO) food balance sheets. Linear regression and Spearman's rank coefficient were used to evaluate the relationship between exposure and disease outcome.
Per capita sugar consumption varied more than six fold-between countries. A log-linear relationship was found between severe asthma symptoms (%) and per capita added sugar consumption in kg/capita/year (exponentiated beta coefficient 1.020; 95% CI 1.005 to 1.034; P = 0.012). Spearman's rank correlation coefficient was 0.34 (P= 0.015), which indicates moderate correlation.
We have demonstrated an ecological association between sugar consumption during the perinatal period and subsequent risk of severe asthma symptoms in six and seven year-olds.
Primary care respiratory journal: journal of the General Practice Airways Group 12/2010; 20(1):75-8.
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Corina Grey,
Sue Wells,
Tania Riddell,
Romana Pylypchuk, Roger Marshall,
Paul Drury,
Raina Elley,
Shanthi Ameratunga,
Dudley Gentles,
Stephanie Erick-Peletiy,
Fionna Bell,
Andrew Kerr,
Rod Jackson
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ABSTRACT: Data on the cardiovascular disease risk profiles of Pacific peoples in New Zealand is usually aggregated and treated as a single entity. Little is known about the comparability or otherwise of cardiovascular disease (CVD) risk between different Pacific groups.
To compare CVD risk profiles for the main Pacific ethnic groups assessed in New Zealand primary care practice to determine if it is reasonable to aggregate these data, or if significant differences exist.
A web-based clinical decision support system for CVD risk assessment and management (PREDICT) has been implemented in primary care practices in nine PHOs throughout Auckland and Northland since 2002, covering approximately 65% of the population of these regions. Between 2002 and January 2009, baseline CVD risk assessments were carried out on 11,642 patients aged 35-74 years identifying with one or more Pacific ethnic groups (4933 Samoans, 1724 Tongans, 1366 Cook Island Maori, 880 Niueans, 1341 Fijians and 1398 people identified as Other Pacific or Pacific Not Further Defined). Fijians were subsequently excluded from the analyses because of a probable misclassification error that appears to combine Fijian Indians with ethnic Fijians. Prevalences of smoking, diabetes and prior history of CVD, as well as mean total cholesterol/HDL ratio, systolic and diastolic blood pressures, and Framingham 5-year CVD risk were calculated for each Pacific group. Age-adjusted risk ratios and mean differences stratified by gender were calculated using Samoans as the reference group.
Cook Island women were almost 60% more likely to smoke than Samoan women. While Tongan men had the highest proportion of smoking (29%) among Pacific men, Tongan women had the lowest smoking proportion (10%) among Pacific women. Tongan women and Niuean men and women had a higher burden of diabetes than other Pacific ethnic groups, which were 20-30% higher than their Samoan counterparts. Niuean men and women had lower blood pressure levels than all other Pacific groups while Tongan men and women had the highest total cholesterol to HDL ratios. Tongan men and women had higher absolute 5-year CVD risk scores, as estimated by the Framingham equation, than their Samoan counterparts (Age-adjusted mean differences 0.71% [95% CI 0.36% to 1.06%] for Tongan men and 0.52% [95% CI 0.17% to 0.86%] for Tongan women) although these risk differences were only about 10% higher in relative terms.
The validity of the analyses depend on the assumption that the selection of participants for CVD risk assessment in primary care is similar between Pacific groups. The ethnic-specific CVD risk profiles presented do not represent estimates of population prevalence. Almost all previous Pacific data has been aggregated with Pacific peoples treated as a single entity because of small sample sizes. We have analysed data from the largest study to date measuring CVD risk factors in Pacific peoples living in New Zealand. Our findings suggest that aggregating Pacific population data appears to be reasonable in terms of assessing absolute CVD risk, however there are differences for specific CVD risk factors between Pacific ethnic groups that may be important for targeting community level interventions.
The New Zealand medical journal 01/2010; 123(1325):41-52.
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Tania Riddell,
Sue Wells,
Rod Jackson,
Ai-Wei Lee,
Sue Crengle,
Dale Bramley,
Shanthi Ameratunga,
Romana Pylypchuk,
Joanna Broad, Roger Marshall,
Andrew Kerr
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ABSTRACT: To compare the calibration performance of the original Framingham Heart Study risk prediction score for cardiovascular disease and an adjusted version of the Framingham score used in current New Zealand cardiovascular risk management guidelines for high and low risk ethnic groups.
Since 2002 cardiovascular risk assessments have been undertaken as part of routine clinical care in many New Zealand primary care practices using PREDICT, a web-based decision support programme for assessing and managing cardiovascular risk. Individual risk profiles from PREDICT were electronically and anonymously linked to national hospital admissions and death registrations in January 2008. Calibration performance was investigated by comparing the observed 5-year cardiovascular event rates (deaths and hospitalisations) with predicted rates from the Framingham and New Zealand adjusted Framingham scores. Calibration was examined in a combined 'high risk' ethnic group (Maori, Pacific and Indian) and a European 'low risk' ethnic group. There was insufficient person-time follow-up for separate analyses in each ethnic group. The analyses were restricted to PREDICT participants aged 30-74 years with no history of previous cardiovascular disease.
Of the 59,344 participants followed for a mean of 2.11 years (125,064 person years of follow-up), 1,374 first cardiovascular events occurred. Among the 35,240 European participants, 759 cardiovascular events occurred during follow-up, giving a mean observed 5-year cumulative incidence of 4.5%. There were 582 events among the 21,026 Maori, Pacific and Indian participants, corresponding to a mean 5-year cumulative incidence rate of 7.4%. For Europeans, the original Framingham score overestimated 5-year risk by 0.7-3.2% at risk levels below 15% and by about 5% at higher risk levels. In contrast, for Maori, Pacific, and Indian patients combined, the Framingham score underestimated 5-year cardiovascular risk by 1.1-2.2% in participants who scored below 15% 5-year predicted risk (the recommended threshold for drug treatment in New Zealand), and overestimated by 2.4-4.1% the risk in those who scored above the 15% threshold. For both high risk and low risk ethnic groups, the New Zealand adjusted score systematically overestimated the observed 5-year event rate ranging from 0.6-5.3% at predicted risk levels below 15% to 5.4-9.3% at higher risk levels.
The original Framingham Heart Study risk prediction score overestimates risk for the New Zealand European population but underestimates risk for the combined high risk ethnic populations. However the adjusted Framingham score used in New Zealand clinical guidelines overcompensates for this underestimate, resulting in a score that overestimates risk among the European, Maori, Pacific and Indian ethnic populations at all predicted risk levels. When sufficient person years of follow-up are available in the PREDICT cohort, new cardiovascular risk prediction scores should be developed for each of the ethnic groups to allow for more accurate risk prediction and targeting of treatment.
The New Zealand medical journal 01/2010; 123(1309):50-61.
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Corina Grey,
Sue Wells,
Tania Riddell,
Andrew Kerr,
Dudley Gentles,
Romana Pylypchuk, Roger Marshall,
Shanthi Ameratunga,
Paul Drury,
C Raina Elley,
Cambell Kyle,
Daniel Exeter,
Rod Jackson
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ABSTRACT: To investigate the differences in the baseline cardiovascular disease (CVD) risk profiles of Pacific peoples and Europeans assessed in routine primary care practice by PREDICT, a web-based clinical decision support programme for assessing and managing CVD risk.
PREDICT has been implemented in primary care practices from nine consenting PHOs in Auckland and Northland. Between 2002 and January 2009, over 70,000 CVD risk assessments were conducted. These analyses compare CVD risk factors for Pacific and European patients.
Baseline risk assessments were completed for 39,835 Europeans and 10,301 Pacific peoples aged 35-74 years. Over 85% of the Pacific cohort was comprised of the four main Pacific ethnic groups in New Zealand (Samoan, Tongan, Cook Island Maori and Niuean). Fijians (n=1341) were excluded from the analyses because of a likely misclassification error with Indian Fijians. On average, Pacific peoples in the PREDICT cohort were 4 years younger at the time of risk assessment than Europeans, and were overrepresented in areas of high socioeconomic deprivation. At risk assessment, Pacific men were 1.5 times as likely to be current smokers as European men, whereas similar or lower proportions of Pacific women smoked compared with European women. Pacific peoples were approximately three times more likely to have diabetes as Europeans. Pacific peoples had higher diastolic blood pressures and Pacific women had higher total cholesterol/HDL ratios. Both Pacific men and women had a significantly higher predicted risk of CVD in the next 5 years than Europeans, based on the Framingham risk score.
The PREDICT programme has already generated the largest cohort of Pacific peoples ever to be studied in New Zealand. This comparative analysis of patients who have been screened highlights significant disparities in CVD risk factors for Pacific peoples particularly for diabetes in both sexes and for smoking in men. Targeting these modifiable risk factors will be important in addressing the widening inequalities in CVD outcomes between Pacific peoples and Europeans.
The New Zealand medical journal 01/2010; 123(1309):62-75.
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ABSTRACT: To assess the accuracy of a method for estimating adult diabetes prevalence that combines linked, routine health datasets in South Auckland, New Zealand.
We used a simple algorithm that combined records of laboratory testing, drug dispensing and hospital diagnoses applied to National Health Index-linked health data in South Auckland to estimate the prevalence of diabetes in 2007. We investigated the sensitivity of this 'combined list' algorithm against a gold standard of individuals with diagnosed diabetes enrolled in a Chronic Care Management programme (CCMP). We also assessed the sensitivity of this algorithm against an estimated diabetes population generated using capture-recapture methods.
From the combined-list algorithm, 25,797 (7.2%) South Aucklanders aged 15 years and over had diabetes. During this period, 10,725 patients were enrolled in the CCMP. The combined list algorithm correctly identified (sensitivity) 10,351/10,725 (96.5%) of those enrolled. When we used the capture-recapture estimated diabetes population as an alternative gold standard, 34,418 [9.5%] of South Aucklanders 15 years and over had diabetes, with the sensitivity of the combined list method falling to about 75% (25,797/34,418).
Linked health data provide reasonably accurate estimates of diabetes prevalence in a New Zealand population; particularly for cases with longstanding or complicated disease.
The New Zealand medical journal 01/2010; 123(1327):76-86.
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ABSTRACT: The aim of this study is to assess whether ethnic inequalities in cervical cancer mortality are due to differences in survival independent of stage and age at diagnosis, and to assess the contribution of screening to stage at diagnosis.
Demographic data and cervical screening history were collected for 402 women with histologically proven primary invasive cervical cancer, diagnosed in New Zealand between 1 January 2000 and 30 September 2002. Date of death was available for women who died up to 30 September 2004.
A Cox proportional hazard model showed that, after adjusting for age, the Māori mortality rate was 1.80 times (95% CI 1.07-3.04) that of non-Māori. This reduced to 1.25 (95% CI 0.74-2.11) when stage at diagnosis was also adjusted for. Among determinants of late stage at diagnosis, older age and being Māori significantly increased the risk, while screening was protective.
These results indicate that later stage at diagnosis is the main determinant of Māori women's higher mortality from cervical cancer. Improving cervical screening among Māori women would reduce stage at diagnosis and therefore ethnic inequalities in mortality.
Cancer Causes and Control 10/2009; 21(2):209-14. · 2.88 Impact Factor
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ABSTRACT: We conducted an up-to-date meta-analysis of 20 eligible randomised controlled trials (RCTs) containing 3,109 patients to compare arthroplasty with internal fixation of displaced femoral neck fractures regarding the effect on clinical outcomes. Computerised databases were searched for RCTs published from January 1979 to May 2008. The results showed that compared to internal fixation arthroplasty led to significantly fewer surgical complications at two and five years postoperatively and reduced the incidence of reoperation at one, two and five years postoperatively (P < 0.001). However, arthroplasty was associated with greater risk of deep wound infection, longer operating time and greater operative blood loss. Arthroplasty substantially increased the risk of reoperation following deep wound infection (P < 0.05). For mortality, there was increased postoperative risk for arthroplasty compared with internal fixation, but there was no statistically significant difference between the two groups at the different follow-up times. For pain at one year postoperatively, the result showed no statistically significant difference.
International Orthopaedics 04/2009; 33(5):1179-87. · 2.03 Impact Factor
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ABSTRACT: To estimate the impact of population-wide and high-risk blood pressure-lowering strategies on cardiovascular disease (CVD) incidence in China.
A modelling study based on a community cohort of 30 362 men and women aged 35-74 years in urban Shanghai, China, 3.3% of whom have existing CVD.
We modelled three blood pressure-lowering strategies: population-wide salt reduction, or antihypertensive drug treatment (following Chinese guidelines) for two subpopulations with either high blood pressure (>/=150/95 mmHg), or high baseline-predicted CVD risk (>/=10% in 10 years based on a multivariate risk model). Avoidable CVD events were estimated by applying a range of relative risk reductions in CVD, 5-7.5% for population-wide salt reduction and 20-25% for drug treatment derived from meta-analyses. Drug compliance was assumed to be 50%.
Population-wide salt reduction would avoid 240-362 events per 100 000 population over 10 years. Drug treatment for the 14.1% of people with raised blood pressure could avoid 217-273 events, whereas treating the 14.2% of people with predicted 10-year CVD risk over 10% would avoid 310-385 events. Of the prevented events, 70-80% would occur in over 60 years and almost a third of the events were predicted to occur among the 3.3% of people with prevalent CVD.
Population-wide and high-risk blood pressure-lowering strategies would have a similar impact on CVD incidence in urban China. The expected epidemic of CVD could be reduced by highly targeted drug treatment while more sustainable population-wide strategies are put in place.
European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology 03/2009; 16(1):96-101. · 2.51 Impact Factor
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BMJ (Clinical research ed.). 02/2009; 339:b2673.
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ABSTRACT: Accurate ethnicity data are a prerequisite for evidence-based cardiovascular risk assessment and management according to national guidelines.
(i) To investigate the accuracy of ethnicity data in primary care medical records by comparing them with self-identified ethnicity. (ii) To determine the clinical impact of ethnicity misclassification on cardiovascular risk assessment and management.
A random sample of 870 patients from 18 general practices (who had ethnicity collected from their medical record as part of cardiovascular risk assessment using PREDICT, a web-based decision support tool) were sent a postal questionnaire asking their self-identified ethnicity using the 2001 Census ethnicity question.
Data were available for 665 people (77% response rate) who completed the postal questionnaire. Ethnicity in the primary care record and self-identified ethnicity from the questionnaire were identical for 68% of respondents at Statistics New Zealand Level 2 coding. Data concordance varied from 9.8% for the non-New Zealand European ethnic group to 90.9% for New Zealand European. The primary care record agreed with self-identified ethnicity for 64.9% of Maori respondents. Fortunately, when the same ethnicity data were categorised using the Statistics New Zealand ethnic group prioritisation rules and applied within PREDICT, which adds a risk weighting for Maori, Pacific, and Indian subcontinent peoples, the impact of misclassification was small. The main reason was that about half of misclassifications occurred between ethnic groups classified in the same high cardiovascular risk category. For about 6% of Maori, Pacific, and Indian subcontinent people in our study this misclassification could potentially have delayed risk assessment and resulted in under-treatment. In contrast, about 1.5% of those with other ethnicities may have undergone a premature risk assessment and been over-treated.
The clinical impact of ethnicity misclassification on cardiovascular risk assessment and management in primary care is modest because much of the misclassification does not alter cardiovascular risk classification. Nevertheless, efforts to improve the accuracy of ethnicity classification in primary care need to continue in order to support the sector's ability to monitor health service utilisation, outcomes, and performance related indicators.
The New Zealand medical journal 10/2008; 121(1281):40-8.
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ABSTRACT: Fecal incontinence can have a profound effect on quality of life. Its prevalence remains uncertain because of stigma, lack of consistent definition, and dearth of validated measures. This study was designed to develop a valid clinical and epidemiologic questionnaire, building on current literature and expertise.
Patients and experts undertook face validity testing. Construct validity, criterion validity, and test-retest reliability was undertaken. Construct validity comprised factor analysis and internal consistency of the quality of life scale. The validity of known groups was tested against 77 control subjects by using regression models. Questionnaire results were compared with a stool diary for criterion validity. Test-retest reliability was calculated from repeated questionnaire completion.
The questionnaire achieved good face validity. It was completed by 104 patients. The quality of life scale had four underlying traits (factor analysis) and high internal consistency (overall Cronbach alpha = 0.97). Patients and control subjects answered the questionnaire significantly differently (P < 0.01) in known-groups validity testing. Criterion validity assessment found mean differences close to zero. Median reliability for the whole questionnaire was 0.79 (range, 0.35-1).
This questionnaire compares favorably with other available instruments, although the interpretation of stool consistency requires further research. Its sensitivity to treatment still needs to be investigated.
Diseases of the Colon & Rectum 07/2008; 51(10):1502-22. · 3.13 Impact Factor
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ABSTRACT: Most blood pressure recordings end with a zero end-digit despite guidelines recommending measurement to the nearest 2 mmHg. The impact of rounding on management of cardiovascular disease (CVD) risk is unknown.
To document the use of rounding to zero end-digit and assess its potential impact on eligibility for pharmacologic management of CVD risk.
Cross-sectional study.
A total of 23,676 patients having opportunistic CVD risk assessment in primary care practices in New Zealand.
To simulate rounding in practice, for patients with systolic blood pressures recorded without a zero end-digit, a second blood pressure measure was generated by arithmetically rounding to the nearest zero end-digit. A 10-year Framingham CVD risk score was estimated using actual and rounded blood pressures. Eligibility for pharmacologic treatment was then determined using the Joint British Societies' JBS2 and the British Hypertension Society BHS-IV guidelines based on actual and rounded blood pressure values.
Zero end-digits were recorded in 64% of systolic and 62% of diastolic blood pressures. When eligibility for drug treatment was based only on a Framingham 10year CVD risk threshold of 20% or more, rounding misclassified one in 41 of all those patients subject to this error. Under the two guidelines which use different combinations of CVD risk and blood pressure thresholds, one in 19 would be misclassified under JBS2 and one in 12 under the BHS-IV guidelines mostly towards increased treatment.
Zero end-digit preference significantly increases a patient's likelihood of being classified as eligible for drug treatment. Guidelines that base treatment decisions primarily on absolute CVD risk are less susceptible to these errors.
British Journal of General Practice 12/2007; 57(544):897-903. · 1.83 Impact Factor
