title: 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.
abstract: 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.
  
  
  
  Primary care practices in England (ClinicAl research using LInked Bespoke studies and Electronic health Records (CALIBER)) and New Zealand (PREDICT).
  
  
  
  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).
  
  
  
  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.
  
  
  
  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.
  
  
  
  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 (8.65-10.05×109/L) was associated with significantly increased mortality compared to the middle quintile (6.25-7.25×109/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.
  
  
  
  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.
  
  
  
  NCT02014610.
authors.affiliation: Farr Institute of Health Informatics Research, UCL Institute of Health Informatics, London, UK.|University College London Hospitals NHS Trust, London, UK.
authors.forename: Anoop Dinesh
authors.identifier: 0000-0002-8907-5724
authors.initials: AD
authors.lastname: Shah
authors.affiliation: Counties Manukau District Health Board, Auckland, New Zealand.|Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
authors.forename: Simon
authors.initials: S
authors.lastname: Thornley
authors.affiliation: Farr Institute of Health Informatics Research, UCL Institute of Health Informatics, London, UK.
authors.forename: Sheng-Chia
authors.initials: SC
authors.lastname: Chung
authors.affiliation: Farr Institute of Health Informatics Research, UCL Institute of Health Informatics, London, UK.
authors.forename: Spiros
authors.initials: S
authors.lastname: Denaxas
authors.affiliation: Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
authors.forename: Rod
authors.initials: R
authors.lastname: Jackson
authors.affiliation: Farr Institute of Health Informatics Research, UCL Institute of Health Informatics, London, UK.
authors.forename: Harry
authors.initials: H
authors.lastname: Hemingway
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D044466:Asian People / Q000706:statistics & numerical data; D015331:Cohort Studies; D057286:Electronic Health Records; D004739:England / Q000453:epidemiology; D007958:Leukocyte Count; D008498:Medical Record Linkage; D009026:Mortality / Q000208:ethnology; D009520:New Zealand / Q000453:epidemiology; D011320:Primary Health Care; D016016:Proportional Hazards Models; D012016:Reference Values; D013997:Time Factors; D044465:White People / Q000706:statistics & numerical data; D000095284:Maori People / Q000706:statistics & numerical data
keywords: Cohort studies; Electronic health records; Leukocyte count; Mortality