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author:("kleiman, M")
1.  Evaluation of long-term clinical and health service outcomes following coronary artery revascularisation in Western Australia (WACARP): a population-based cohort study protocol 
BMJ Open  2014;4(10):e006337.
Coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) are procedures commonly performed on patients with significant obstructive coronary artery disease to relieve symptoms of ischaemia, improve survival or both. Although the efficacy of both procedures at the individual level has been established, the impact of advances in coronary artery revascularisation procedures (CARP) on long-term outcomes and cost-effectiveness at the population level are yet to be assessed. Our aim is to evaluate a minimum of 6-year outcomes and costs for the total population of patients who had CARP in Western Australia (WA) in 2000–2005.
Methods and analysis
This retrospective population cohort study will link clinical and administrative health data for a previously defined cohort including all patients in WA who had a CARP in the period 2000–2005. The cohort consists of 19 014 patients who had 21 175 procedures (15 429 PCI and 5746 CABG). We are now collecting a minimum of 6 years follow-up of morbidity and mortality data for the cohort using the WA Data Linkage System, clinical registries and hospital records, with 12 years follow-up for cases in the year 2000. Comparison of long-term outcomes for different CARP will be reported (PCI vs CABG; bare metal stents vs drug-eluting stents vs CABG). Cost-effectiveness analysis of CARP from the perspective of the healthcare sector will be performed using individual level cost data and average costs from Australian Refined Diagnosis Related Groups.
Ethics and dissemination
This study has received ethics approval from the University of Western Australia, the Western Australian Department of Health and all participating hospitals. Being a large population cohort study, approval included a waiver of informed consent. All findings will be presented at local, national and international healthcare/academic conferences and published in peer-reviewed journals.
PMCID: PMC4187452  PMID: 25280811
2.  Long term survival after evidence based treatment of acute myocardial infarction and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005 
Objective To examine trends in long term survival in patients alive 28 days after myocardial infarction and the impact of evidence based medical treatments and coronary revascularisation during or near the event.
Design Population based cohort with 12 year follow-up.
Setting Perth, Australia.
Participants 4451 consecutive patients with a definite acute myocardial infarction according to the World Health Organization MONICA (monitoring trends and determinants in cardiovascular disease) criteria admitted to hospital during 1984-7, 1988-90, and 1991-3.
Main outcome measures All cause mortality identified from official mortality records and the hospital morbidity data, with death from cardiovascular disease as a secondary end point.
Results In the 1991-3 cohort, 28 day survivors of acute myocardial infarction had a 7.6% absolute event reduction (95% confidence interval 4% to 11%) or a 28% lower relative risk reduction (16% to 38%), unadjusted for risk of death, over 12 years after the incident admission compared with the 1984-7 cohort, similar to the survival of the 1988-90 cohort. The improved survival for the 1991-3 cohort persisted after adjustment for demographic factors, coronary risk factors, severity of disease, and event complications with an adjusted relative risk reduction of 26% (14% to 37%), but this was not apparent after further adjustment for medical treatments in hospital and coronary revascularisation procedures within 12 months of the incident myocardial infarction.
Conclusion The improving trends in 12 year survival after a definite acute myocardial infarction are associated with progressive use of evidence based treatments during the initial admission to hospital and in the 12 months after the event. These changes in the management of acute myocardial infarction are probably contributing to the continuing decline in mortality from coronary heart disease in Australia.
PMCID: PMC2769031  PMID: 19171564
3.  Left-handedness and risk of breast cancer 
British Journal of Cancer  2007;97(5):686-687.
Left-handedness may be an indicator of intrauterine exposure to oestrogens, which may increase the risk of breast cancer. Women (n=1786) from a 1981 health survey in Busselton were followed up using death and cancer registries. Left-handers had higher risk of breast cancer than right-handers and the effect was greater for post-menopausal breast cancer (hazard ratio=2.59, 95% confidence interval 1.11–6.03).
PMCID: PMC2360366  PMID: 17687338
breast cancer; left-handedness; fetal origins of disease; cohort
4.  Impact of voluntary folate fortification on plasma homocysteine and serum folate in Australia from 1995 to 2001: a population based cohort study 
Study objective: To investigate the effect of the voluntary folate fortification policy in Australia on serum folate and total plasma homocysteine (tHcy) concentrations.
Design: Population based cohort study.
Setting: Perth, Western Australia.
Participants: Men and women aged 27 to 77 years (n = 468), who were originally randomly selected from the Perth electoral roll. The cohort was surveyed in 1995/96 before widespread introduction of folate fortification of a variety of foods, and followed up on two occasions, firstly in 1998/99 and again in 2001, when a moderate number of folate fortified foods were available. Subjects with abnormal serum creatinine concentrations at baseline were excluded from this analysis.
Main results: Repeated measures analysis of variance was used to determine changes in serum folate and tHcy over the three surveys and to assess whether time trends were related to age, sex, MTHFR C677T genotype, or consumption of folate fortified foods. An increase (38%) in mean serum folate (p<0.0005) and a decrease (21%) in mean tHcy (p<0.0005) were seen after introduction of the voluntary folate fortification policy in Australia. Serum folate was consistently higher (p = 0.032) and tHcy was consistently lower (p = 0.001) in subjects who consumed at least one folate fortified food compared with subjects who did not consume any folate fortified foods in the previous week. The time related changes in serum folate and tHcy were affected only by intake of folate fortified foods (p<0.0005) and not by any other measured variables including age, sex, or MTHFR genotype.
Conclusion: Voluntary fortification of foods with folate in Australia has been followed by a substantial increase in serum folate and decrease in tHcy in the general population.
PMCID: PMC1733078  PMID: 15831684
5.  Trends in coronary artery revascularisation procedures in Western Australia, 1980–2001 
Heart  2004;90(9):1036-1041.
Objectives: To describe trends in the use of coronary artery revascularisation procedures (CARPs) and to determine whether or when CARP rates will stabilise.
Setting: State of Western Australia.
Patients: All patients treated by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1980 and 2001.
Design: Descriptive study.
Main outcome measures: Age standardised rates of first and total CARPs, CABGs, and PCIs.
Results: Overall rates for both total and first CARPs among men and women rose steeply from 1980 to 1993, when they abruptly stabilised or actually started to decline. Rates in age groups under 65 years tended to rise earlier in the period and remained relatively flat, while rates for people over the age of 75 years started to rise later and were still increasing at the end of the study.
Conclusions: Despite continuing increases in capacity to perform both CABG and PCI in Western Australia and evidence of continuing increases in the use of CARPs in the elderly population, rates appear to have stabilised for the first time since they were introduced.
PMCID: PMC1768454  PMID: 15310694
age standardised rates; coronary artery bypass graft; angioplasty
6.  Trends in two year risk of repeat revascularisation or death from cardiovascular disease after coronary artery bypass grafting or percutaneous coronary intervention in Western Australia, 1980–2001 
Heart  2004;90(9):1042-1046.
Aims: To investigate whether, over the 21 year period 1980–2001, there had been a reduction in the risk of repeat revascularisation or death from cardiovascular disease in the cohort of all patients who were treated by coronary revascularisation in Western Australia.
Setting: State of Western Australia.
Patients: All patients treated by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1980 and 2001.
Design: Cohort study.
Main outcome measures: Risk of repeat coronary artery revascularisation procedures (CARP) and risk of death from cardiovascular disease after first CARP.
Results: After a CABG procedure, the two year risk of repeat revascularisation remained low (less than 2%) across the period 1980–2001. For PCI, however, this risk declined significantly from 33.6% in 1985–9 to 12.4% in 2000–1. The risk of death from cardiovascular disease after a CARP declined by about 50% between 1985 and 2001.
Conclusions: Outcomes such as the risk of repeat revascularisation and the risk of death from cardiovascular disease have improved significantly for patients who underwent CARPs across the period 1980–2001. This has occurred despite an increasing trend in first CARP rates among older people and those with a recent history of myocardial infarction.
PMCID: PMC1768428  PMID: 15310696
coronary artery bypass; angioplasty; survival analysis
7.  Health status of users of hormone replacement therapy by hysterectomy status in Western Australia 
Study objectives: To compare the demographic, behavioural, and biological correlates of use of hormone replacement therapy (HRT) in women with an intact uterus and women who have undergone hysterectomy.
Design: Cross sectional analysis of data from the Busselton Health Study and the 1994 Healthway-National Heart Foundation Risk Factor Survey.
Setting: Busselton and Perth, Western Australia, 1994.
Participants: 2540 women aged 35–79 years.
Main outcome measures: Demographic, behavioural, and biological correlates of use of HRT by hysterectomy status.
Results: In women with an intact uterus, after adjustment for age and place of residence, current use of HRT was significantly associated with having a professional level of occupation, ever use of alcohol, having a history of smoking, and a lower body mass index. Current users of HRT had significantly lower levels of total cholesterol and higher levels of triglycerides than non-users. In women who had undergone hysterectomy, the only non-biological characteristic associated with use of HRT was having a history of smoking. Current users of HRT had lower levels of systolic blood pressure, lower levels of LDL cholesterol, higher levels of HDL cholesterol, and higher levels of triglycerides. The association between use of HRT and participation in exercise, level of systolic blood pressure, level of HDL cholesterol, and total/HDL cholesterol ratio varied significantly by hysterectomy status. After adjustment for age and place of residence, the mean levels of systolic and diastolic blood pressure, body mass index, waist/hip ratio, LDL cholesterol, and total/HDL cholesterol ratio were highest in women who had undergone hysterectomy and were not using HRT.
Conclusions: Demographic/behavioural and biological correlates of use of HRT varied depending on hysterectomy status. Demographic and behavioural characteristics were more important as selection factors for use of HRT in women with an intact uterus than in women who had undergone hysterectomy. Women who had undergone hysterectomy and were not using HRT had a significantly worse profile for CHD than did women with an intact uterus. These results indicate that any bias in estimates of the protective effect of HRT on risk of CHD in observational studies is likely to depend on the prevalence of hysterectomy within the study population. Hysterectomy status needs to be taken into account in any studies that investigate the effect of HRT on risk of CHD.
PMCID: PMC1732422  PMID: 12646547
8.  Trends in road injury hospitalisation rates for Aboriginal and non-Aboriginal people in Western Australia, 1971–97 
Injury Prevention  2002;8(3):211-215.
Objective: To examine trends in road injury hospitalisation rates for Aboriginal and non-Aboriginal people in Western Australia.
Methods: Data from the Western Australian Hospital Morbidity Data System for the years between 1971 and 1997 were analysed. Poisson regression models were fitted to determine whether the trends were significant.
Results: The rate of hospitalisation due to road injury for Aboriginal people (719.1 per 100 000 population per year) over the time period examined was almost twice as high as that for non-Aboriginal people (363.4 per 100 000 population per year). Overall, the results showed that while hospitalisations from road injury involving non-Aboriginal people have been decreasing by 6.7% per three year period since 1971, the rates of hospitalisation for Aboriginal people have been increasing by 2.6% per three year period. Both of these trends were statistically significant. The alarming increasing trend observed for Aboriginal people was more pronounced in males, those aged 0–14 years and over 45 years, and for those living in rural areas.
Conclusions: As the rates of road injury for Aboriginal people are higher than for non-Aboriginal people, and are also following an increasing trend, road safety issues involving Aboriginal people need to be addressed urgently by health and transport authorities.
PMCID: PMC1730892  PMID: 12226118
9.  Decline in lung function and mortality: the Busselton Health Study 
BACKGROUND: There is a direct association between level of lung function, measured by forced expiratory volume in 1 second (FEV1) and mortality rates. A low FEV may result from an increased decline in FEV1 with age, which may be an independent predictor of mortality. OBJECTIVE: To examine the association between decline in FEV1 and mortality in a cohort from a community health study. SETTING AND METHODS: From five cross sectional studies in Busselton between 1969 and 1981 a cohort of 751 men and 940 women was identified who had three assessments of lung function over a six year period and had other health related data collected. Each subject's average FEV1 and decline in FEV1 (litre/year) were calculated from these three measurements. Mortality follow up to December 1995 was obtained. Cause of death was taken as the certified cause of death from the death certificate using ICD9 categories. RESULTS: The average decline in FEV1 was 0.04 litre per year (SD = 0.07) for men and 0.03 litre per year (SD = 0.06) for women. Average FEV1 was significantly associated with all cause and cardiovascular disease mortality in both sexes. In women there was a significant association between decline in FEV1 and death from all causes, after adjusting for average FEV1, age, smoking, coronary heart disease, and cardiovascular disease risk factors; a 0.05 litre per year increase in the rate of decline of FEV1 increased the risk of death for all causes by 1.23 (95% confidence interval 1.06, 1.44). In men the effect of decline in FEV1 on death rate was less; for all men the hazard ratio for a 0.05 litre/year greater decline in FEV1 was 1.19 (0.99, 1.21). CONCLUSION: Decline in lung function, measured by FEV1 is a predictor of death, independent of average FEV1 and risk factors for cardiovascular disease.
PMCID: PMC1756854  PMID: 10396549
10.  Prediction of coronary heart disease mortality in Busselton, Western Australia: an evaluation of the Framingham, national health epidemiologic follow up study, and WHO ERICA risk scores. 
STUDY OBJECTIVES: To evaluate the performance of the Framingham, national health epidemiologic follow up study, and the WHO ERICA risk scores in predicting death from coronary heart disease (CHD) in an Australian population. DESIGN: Cohort follow up study. SETTING AND PARTICIPANTS: The cohort consisted of 1923 men and 1968 women who participated in health surveys in the town of Busselton in Western Australia over the period 1966-81. Baseline assessment included cardiovascular risk factor measurement. Mortality follow up to 31 December 1994 was used. MAIN RESULTS: Risk scores for death from CHD within 10 years based on age, systolic blood pressure, cholesterol, smoking, and BMI were derived from the Busselton study data using logistic regression analysis. Similar risk scores developed from the Framingham, the national health epidemiologic follow up study, and the WHO ERICA cohorts were found to perform just as well in Busselton as the Busselton-derived scores, both before and after controlling the effect of age. There was considerable overlap across the different risk scores in the identification of individuals in the highest quintile of risk. Those in the top 20% of scores included about 41% of deaths from CHD among men and about 63% of deaths from CHD among women. CONCLUSION: Although there is variation in risk score coefficients across the studies, the relative risk predictive performance of the scores is similar. The use of Framingham and other similar risk scores will not be misleading in white Australian populations.
PMCID: PMC1060537  PMID: 9425461

Results 1-10 (10)