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Editorial
Ghislain & Marie David de Los/Getty
A data toolkit to improve patient care
For Acute care toolkit 11: using
data to improve care see https://
www.rcplondon.ac.uk/resources/
acute-care-toolkit-11-usingdata-improve-care
Quality of care is a major concern for clinicians, but faced
with the complexity of modern health care, assessing how
an individual and their team is doing and what they can
do to improve can be challenging. To help demystify the
process, the UK Royal College of Physicians has published a
toolkit that acts as a starting point for clinicians on how to
collect and interpret data to improve patient care.
An important consideration is what types of data are
used and for what purpose. At the level of individual
clinicians and teams, quantitative data about patient
outcomes are of limited value because the small sample
sizes are too greatly affected by random variation, whereas
qualitative data provide a more meaningful source of
information. For example, although a comparison of the
rates of safety incidents between clinicians is generally
inconsequential, understanding the reasons for and
nature of the incidents can benefit the whole team.
The toolkit advises that clinicians need to draw
information from various sources to get a clear overall
picture of how they are doing. Advice is offered about
how to learn from clinical incidents and complaints,
use feedback from colleagues and staff, review and
understand mortality case notes, use data from national
audits to plan and measure improvements in quality of
health care, and structure “look back and learn” meetings
to bring all these elements together.
Rather than health-care services only organising
separate meetings that look at each measure of quality
and performance of care in isolation, the toolkit
recommends multidisciplinary “look back and learn”
meetings, which aim to integrate data at a unit or ward
level, generating insights into system issues that need
to be tackled to improve care. The meetings should be
documented and led by a senior clinician who can teach
others to understand and learn from the data, providing
a valuable resource for individuals and organisations
to improve care. This synthesis of data is a positive
step towards improving patient care and outcomes:
monitoring, transparent review, and action provide the
basis for effective individual accountability. „ The Lancet
Correcting the scientific literature: retraction and republication
Articles
RETRACTED: ST-segment elevation myocardial infarction in
China from 2001 to 2011 (the China PEACE-Retrospective
Acute Myocardial Infarction Study): a retrospective analysis
of hospital data
Jing Li, Xi Li, Qing Wang, Shuang Hu, Yongfei Wang, Frederick A Masoudi, John A Spertus, Harlan M Krumholz*, Lixin Jiang*, for the China PEACE
Collaborative Group†
Summary
Background Despite the importance of ST-segment elevation myocardial infarction (STEMI) in China, no nationally
representative studies have characterised the clinical profiles, management, and outcomes of this cardiac event
utcomes for patients with
during the past decade. We aimed to assess trends in characteristics, treatment, and outcomes
STEMI in China between 2001 and 2011.
Methods In a retrospective analysis of hospital records, we used a two-stage
ge random sampling design tto create a
nationally representative sample of patients in China admitted to hospital
(2001, 2006, and
spital
pital for STEMI in 3 years (2
economic–geographical region to
2011). In the first stage, we used a simple random-sampling procedure
dure stratified by economic–ge
economic–geo
generate a list of participating hospitals. In the second stage we obtained case data for rates
rate of STEMI, treatments,
and baseline characteristics from patients attending each sampled
systematic
sampling approach. We
d hospital with a sys
system
weighted our findings to estimate nationally representative
changes from 2001 to 2011. This study is
ntative
tive rates and assess change
registered with ClinicalTrials.gov, number NCT01624883.
01624883.
3.
Findings We sampled 175 hospitals (162
2 participated in the study) and 18 631 acute myocardial infarction admissions,
of which 13 815 were STEMI admissions.
issions. 12 264 patients we
were iincluded in analysis of treatments, procedures, and
Between 2001 and 2011, estimated national rates
tests, and 11 986 were included
d in analysis of in-hospital outcomes.
out
of hospital admission forr STEMI per 100 000 people increased
(from 3·7 in 2001, to 8·1 in 2006, to 15·8 in 2011;
in
ptrend<0·0001) and thee prevalence
evalence of risk factors—
factors—including
factors—i
smoking, hypertension, diabetes, and dyslipidaemia—
oted significant increases in u
increased. We noted
use of aspirin within 24 h (79·3% [95% CI 77·3–81·3] in 2001 vs 91·2%
[90·5–91·9] in 2011
2011, ptrend
clopidogrel (95% CI 1·5% [0·9–2·1] in 2001 vs 80·7% [79·8–81·6] in 2011,
rend<0·0001) and clo
ptrend<0·0001) in patients without documented
d
contraindications. Despite an increase in the use of primary
nary interven
intervent
percutaneous coronary
intervention (10·2% [95% CI 8·1–12·3] in 2001 vs 27·6% [26·1–29·1] in 2011, ptrend<0·0001),
ients w
the proportion of patients
who did not receive reperfusion did not significantly change (44·8% [95% CI 41·3–48·3] in
2001 vs 45·0% [43·3–46·7] in 2011, ptrend=0·82). The median length of hospital stay decreased from 13 days (IQR 7–18)
in 2001 to 11 days (7–14) in 2011 (ptrend<0·0001). Adjusted in-hospital mortality did not significantly change between
2001 and 2011 (odds ratio 0·84, 95% CI 0·62–1·12, ptrend=0·06).
T
RE
Interpretation During the past decade in China, hospital admissions for STEMI have risen; in these patients,
comorbidities and the intensity of testing and treatment have increased. Quality of care has improved for some
treatments, but important gaps persist and in-hospital mortality has not decreased. National efforts are needed to
improve the care and outcomes for patients with STEMI in China.
Funding National Health and Family Planning Commission of China.
Introduction
As China has grown economically, it has experienced an
epidemiological transition, with mortality due to
ischaemic heart disease more than doubling during the
past two decades to more than 1 million deaths per year.1,2
This trend is expected to accelerate, with the World Bank
estimating that the number of individuals with
myocardial infarction in China will increase to 23 million
by 2030.3 Concurrent with this changing epidemiology,
the Chinese medical care system has developed rapidly,
implementing policies that have improved access by
reducing financial barriers and increasing the numbers
of hospitals and physicians.4,5
Despite the importance of acute myocardial infarction
in China—particularly ST-segment elevation myocardial
infarction (STEMI), which accounts for more than 80% of
such events in the country6,7—no nationally representative
studies have defined the clinical profiles, management,
and outcomes of patients with this disorder during the
past decade. The scarcity of contemporary national
estimates and data for changes in burden of disease,
quality of care (including use of recommended treatments
www.thelancet.com Published online June 24, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60921-1
Published Online
June 24, 2014
http://dx.doi.org/10.1016/
S0140-6736(14)60921-1
See Online/Comment
http://dx.doi.org/10.1016/
S0140-6736(14)61033-3
*Joint senior authors
†Members listed in appendix
National Clinical Research
Center of Cardiovascular
Diseases, State Key Laboratory
of Cardiovascular Disease, Fuwai
Hospital, National Center for
Cardiovascular Diseases, Chinese
Academy of Medical Sciences
and Peking Union Medical
College, Beijing, China (J Li PhD,
X Li PhD, Q Wang MS, S Hu PhD,
Prof L Jiang MD); Center for
Outcomes Research and
Evaluation, Yale-New Haven
Hospital, New Haven, CT, USA
(Y Wang MS,
Prof H M Krumholz MD); Section
of Cardiovascular Medicine
(Y Wang, H M Krumholz) and
Robert Wood Johnson Clinical
Scholars Program
(H M Krumholz), Department of
Internal Medicine, Yale
University School of Medicine,
New Haven, CT, USA;
Department of Health Policy
and Management, Yale School
of Public Health, New Haven,
CT, USA (H M Krumholz);
Division of Cardiology,
University of Colorado Anschutz
Medical Campus, Aurora, CO,
USA (Prof F A Masoudi MD); and
Saint Luke’s Mid America Heart
Institute/University of MissouriKansas City, Kansas City, MO,
USA (Prof J A Spertus MD)
Correspondence to:
Prof Lixin Jiang, National Clinical
Research Center of
Cardiovascular Diseases, State
Key Laboratory of Cardiovascular
Disease, Fuwai Hospital, National
Center for Cardiovascular
Diseases, Beijing 100037, China
[email protected]
1
See Comment pages 400
and 402
See Articles page 441
394
This week we publish a comment with the unusual
heading “Retraction and republication…..” linked to the
China PEACE study. For the first time, we retract a version
of a paper that was published online in June last year
and republish a corrected version in print together with
a supplementary appendix that clearly highlights the
discrepancies. We made this decision because the paper
needed substantive corrections of its findings. The authors
had pointed out this error to us shortly after publication.
Retractions are never easy and journals and editors are
still all too often reluctant to take this step. However, it
is important to reiterate that the purpose of retractions
is the correction of the scientific literature, if the findings
as presented are invalid or unreliable. Retraction is
not a punishment or tainting of the reputation of one
or more authors. When a retraction is due to serious
misconduct rather than honest error further appropriate
actions against the researchers responsible must be
taken by their employers, such as academic institutions
or pharmaceutical companies. By contrast, a retraction
due to an honest error in the form of a miscalculation or
misclassification can be followed by republication of a
corrected paper, as in this case.
So where do we draw the line between a correction
and a retraction followed by republication? The
Committee on Publication Ethics states in its retraction
guidelines that “journal editors should consider issuing
a correction if a small portion of an otherwise reliable
publication proves to be misleading (especially because
of an honest error)”. So what should happen if a large
portion is misleading? We believe that if many of the
numerical findings in the results section change or
the interpretation of the work is altered following a
miscalculation or misclassification due to an honest
error, republication should be considered. The corrected
paper should pass peer review and editorial scrutiny
once again and when republished the changes should
be made transparent. Retraction and republication is a
further example of correcting the scientific literature. In
our opinion, it should be considered by journal editors in
the interests of readers, research users, and the scientific
community. „ The Lancet
www.thelancet.com Vol 385 January 31, 2015