Prof. Ivan perry

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Research in Irish Primary Care
The Cork & Kerry Study

Ivan J Perry,
Dept. of Epidemiology and Public Health,
University College Cork.

Inaugural National Primary Care Conference
Livinghealth Clinic
Mitchelstown, County Cork
Thursday, November 17th , 2011

HRB Centre for Health and Diet Research

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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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t Biomedical perspective on nutrition-
related diseases

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t Sociological/ marketing
perspective on nutrition transition

Source: Adapted from Cova and Cova, 2001, p.601; Desjeux, 1996
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t International mortality trends in CHD in men
aged 35 to 74 years from 1968 to 2003

Per 100,000
800

Finland
600

400
Ireland
Netherlands
UK
200
USA
France Italy
0
7
0

3

6

9

2

5

8

1

4

7

0
7

7

7

7

8

8

8

9

9

9

0
9

9

9

9

9

9

9

9

9

9

0
1

1

1

1

1

1

1

1

1

1

2

t Sick individuals and sick populations:
Total cholesterol in three populations

8

t 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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t 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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t 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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t 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 12

t 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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t Cork & Kerry Phase 2 Study
LivingHealth Clinic Mitchelstown

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t GeneActive tri-axial
Accelerometers
Wrist worn,
light, water
resistant
accelerometer
with capacity to
measure physical
activity over 7
days

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t Cork & Kerry Phase 2 Study
Living Health Clinic Mitchelstown

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

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

60
50
40
% 30
20
10
0
50-54 55-59 60-64 65-69
Male Female

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t Prevalence of diabetes and impaired fasting glucose
(combined) by age and gender
Cork & Kerry Study 1998

14
12
10
8
%
6
4
2
0
50-54 55-59 60-64 65-69
Male Female

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

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

t Estimates of absolute risk of CVD
European Cardiac Society Risk Score

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t 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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t CVD risk factors in men aged 50 to 69 years
in 1998 and 2010 Cork & Kerry studies
Variables Cork & Kerry 1998 Cork & Kerry 2010
N=1018 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 Mean SBP 136.8 (19.1) 129.3(15.1)
(those not on medication)

Mean DBP 81.6 (10.3) 79.5(9.2)

Cholesterol Mean mmol/L (std) 5.6 (0.9) 5.3(0.9)
(those not on medication)

% >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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t
24-hour ambulatory BP measurement

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t 24-hour ambulatory BP measurement
Headline findings
Wrist worn,
light, water
•1030 individuals had measurements available for clinic, study
resistant
and ambulatory blood pressure.
accelerometer
with capacity to
•Approximately 50% of individuals with hypertension based on
previous GP readings and 44% ofphysical
measure those with hypertension at
activity over 7
the study visit had normal ABP.
days
•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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t International mortality trends in CHD in men
aged 35 to 74 years from 1968 to 2003

Per 100,000
800

Finland
600

400
Ireland
Netherlands
UK
200
USA
France Italy
0
29
0

3

6

9

2

5

8

1

4

7

0
7

7

7

7

8

8

8

9

9

9

0
9

9

9

9

9

9

9

9

9

9

0
1

1

1

1

1

1

1

1

1

1

2

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

Risk Factors worse +13.8%
0

-1000
Risk Factors better –61.9%

-2000

3763 Treatments –43.6%
fewer deaths
-3000

-4000

1985
1985 2000
2000 30

t Fig 2. CHD mortality fall in Ireland 1985 - 2000 explained by
a) treatments in CHD patients & b) population risk factor s
Risk Factors worse +14%
Obesity (increase) + 4%
0 Diabetes (increase) + 6%
Physical activity (less) + 4%

-1000
Risk Factors better –61%
Smoking -25%
Cholesterol -30%
Population BP fall - 6%
-2000

Treatments -43.6%
3763 AMI treatments
Secondary prevention
- 4.4%
-18%
fewer deaths
-3000
Heart failure -9.1%
Angina:CABG & PTCA - 5%
Angina: Aspirin etc - 3.4%
-4000 Hypertension drugs – 1.6%
1985 2000 Statins 1’ prevention - 31
1.2%
Unstable angina
HRB Centre for Health and Diet Research - 1%

t Key elements of good data
management
•Data Quality
•Data Quality
•Data Protection
•Data Protection
•Disease Coding
•Disease Coding
•Audit
•Audit

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t
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
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t 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

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