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White cell count in the normal range and short-term and long-term mortality: international comparisons of electronic health record cohorts in England and New Zealand.

White cell count in the normal range and short-term and long-term mortality: international comparisons of electronic health record cohorts in England and New Zealand.
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Shah AD, Thornley S, Chung SC, Denaxas S, Jackson R, Hemingway H,


Shah AD, Thornley S, Chung SC, Denaxas S, Jackson R, Hemingway H, (click to view)

Shah AD, Thornley S, Chung SC, Denaxas S, Jackson R, Hemingway H,

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BMJ open 2017 02 177(2) e013100 doi 10.1136/bmjopen-2016-013100
Abstract
OBJECTIVES
Electronic health records offer the opportunity to discover new clinical implications for established blood tests, but international comparisons have been lacking. We tested the association of total white cell count (WBC) with all-cause mortality in England and New Zealand.

SETTING
Primary care practices in England (ClinicAl research using LInked Bespoke studies and Electronic health Records (CALIBER)) and New Zealand (PREDICT).

DESIGN
Analysis of linked electronic health record data sets: CALIBER (primary care, hospitalisation, mortality and acute coronary syndrome registry) and PREDICT (cardiovascular risk assessments in primary care, hospitalisations, mortality, dispensed medication and laboratory results).

PARTICIPANTS
People aged 30-75 years with no prior cardiovascular disease (CALIBER: N=686 475, 92.0% white; PREDICT: N=194 513, 53.5% European, 14.7% Pacific, 13.4% Maori), followed until death, transfer out of practice (in CALIBER) or study end.

PRIMARY OUTCOME MEASURE
HRs for mortality were estimated using Cox models adjusted for age, sex, smoking, diabetes, systolic blood pressure, ethnicity and total:high-density lipoprotein (HDL) cholesterol ratio.

RESULTS
We found ‘J’-shaped associations between WBC and mortality; the second quintile was associated with lowest risk in both cohorts. High WBC within the reference range (8.65-10.05×10(9)/L) was associated with significantly increased mortality compared to the middle quintile (6.25-7.25×10(9)/L); adjusted HR 1.51 (95% CI 1.43 to 1.59) in CALIBER and 1.33 (95% CI 1.06 to 1.65) in PREDICT. WBC outside the reference range was associated with even greater mortality. The association was stronger over the first 6 months of follow-up, but similar across ethnic groups.

CONCLUSIONS
Clinically recorded WBC within the range considered ‘normal’ is associated with mortality in ethnically different populations from two countries, particularly within the first 6 months. Large-scale international comparisons of electronic health record cohorts might yield new insights from widely performed clinical tests.

TRIAL REGISTRATION NUMBER
NCT02014610.

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