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Wu Y, Yu X, Zhu Y, Shi C, Li X, Jiang R, Niu S, Gao P, Li S, Yan L, Maulik PK, Guo G, Patel A, Gao R, Blumenthal JA. Integrating depression and acute coronary syndrome care in low resource hospitals in China: the I-CARE randomised clinical trial. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 48:101126. [PMID: 39040037 PMCID: PMC11261764 DOI: 10.1016/j.lanwpc.2024.101126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 05/13/2024] [Accepted: 06/11/2024] [Indexed: 07/24/2024]
Abstract
Background Acute coronary syndrome (ACS) often co-occurs with depression, which adversely affects prognosis and increases medical costs, but effective treatment models are lacking, particularly in low-resource settings. This study aims to determine the effectiveness of an ACS and depression integrative care (IC) model compared to usual care (UC) in improving depression symptoms and other health outcomes among patients discharged for ACS in Chinese rural hospitals. Methods A multicentre, randomised controlled trial was conducted in sixteen rural county hospitals in China, from October 2014 to March 2017, to recruit consecutively all ACS patients aged 21 years and older after the disease stablised and before discharge. Patients were randomly assigned in a 1:1 ratio to receive either the IC or UC, stratified by hospital and depression severity. Patients allocated to IC received an ACS secondary prevention program and depression care including case screening, group counselling, and individual problem-solving therapy. Patients allocated to UC received usual care. The primary outcome was change in Patient Health Questionnaire-9 (PHQ-9) from baseline to 6 and 12 months. Main secondary outcomes included major adverse events (MAEs) composed of all-cause death, non-fatal myocardial infarction and stroke, and all-cause re-hospitalisation. Participants were followed up till March 2018. All data were collected in person by trained assessors blinded to treatment group and MAEs were adjudicated centrally. This trial is registered with ClinicalTrials.gov, NCT02195193. Findings Among 4041 eligible patients (IC: 2051; UC: 1990), the mean age was 61 ± 10 years and 63% were men. The mean PHQ-9 score lowered at both 6 and 12 months in both groups but was not lower in IC compared to UC at 6 months (mean difference (MD): -0.04, 95% confidence interval (CI): -0.20, 0.11) or 12 months (MD: -0.06, 95% CI: -0.21, 0.09). There were no treatment group differences for MAEs or other secondary outcomes except for secondary prevention medications at 12 months (45.2% in IC vs 40.8% in UC; relative risk: 1.21, 95% CI: 1.05-1.40). Pre-specified subgroup analyses showed that IC, compared to UC, may be more effective in lowering PHQ-9 scores in women, older patients, and patients with low social support, but less effective in moderately and severely depressed patients (all p for interaction <0.05). Interpretation The study found that the cardiology nurse-led ACS- and depression-integrated care, compared to usual care, did not improve depression symptoms in all patients discharged with ACS. Greater benefits in certain subgroups warrants further studies. Funding R01MH100332 National Institute of Mental Health.
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Affiliation(s)
- Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Centre (PUHSC), Beijing, China
- Clinical Research Institute, Institute of Advanced Clinical Medicine, Peking University, Beijing, China
| | - Xin Yu
- Peking University Institute of Mental Health, National Clinical Research Centre for Mental Disorders (Peking University Sixth Hospital), Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Yidan Zhu
- The George Institute for Global Health at Peking University Health Science Centre (PUHSC), Beijing, China
- Clinical Research Institute, Institute of Advanced Clinical Medicine, Peking University, Beijing, China
| | - Chuan Shi
- Peking University Institute of Mental Health, National Clinical Research Centre for Mental Disorders (Peking University Sixth Hospital), Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Centre (PUHSC), Beijing, China
| | - Ronghuan Jiang
- Department of Psychiatry, Chinese PLA (People's Liberation Army) Medical School, Beijing, China
| | - Sheng Niu
- Department of Psychiatry, Chinese PLA (People's Liberation Army) Medical School, Beijing, China
| | - Pei Gao
- Clinical Research Institute, Institute of Advanced Clinical Medicine, Peking University, Beijing, China
| | - Shenshen Li
- The George Institute for Global Health at Peking University Health Science Centre (PUHSC), Beijing, China
| | - Lijing Yan
- The Global Health Research Centre, Duke Kunshan University, Kunshan, Jiangsu, China
| | - Pallab K. Maulik
- The George Institute for Global Health, New Delhi, India
- University of New South Wales, Sydney, Australia
| | - Guifang Guo
- Peking University School of Nursing, Beijing, China
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Runlin Gao
- The Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Centre, Durham, NC, USA
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Xie C, Zheng N, Li M, Zhang Z, Huang D, Xiao M, Chen D, He C, Zuo Z, Chen X. Comparative Analysis of Therapeutic Efficacy and Adverse Reactions among Various Thrombolytic Agents. TOXICS 2024; 12:458. [PMID: 39058110 PMCID: PMC11280831 DOI: 10.3390/toxics12070458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 05/28/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024]
Abstract
Thrombosis is a major health concern that contributes to the development of several cardiovascular diseases and a significant number of fatalities worldwide. While stent surgery is the current recommended treatment according to the guidelines, percutaneous coronary intervention (PCI) is the optimal approach for acute myocardial infarction (AMI). However, in remote areas with limited resources, PCI procedures may not be feasible, leading to a delay in treatment and irreversible outcomes. In such cases, preoperative thrombolysis becomes the primary choice for managing AMI in remote settings. The market for thrombolytic drugs is continuously evolving, and identifying a safe and effective thrombolytic agent for treating AMI is crucial. This study evaluated Urokinase, Alteplase, and Recombinant Human TNK Tissue-type Plasminogen Activator for Injection (rhTNK) as representatives of first-, second-, and third-generation thrombolytic drugs, respectively. The research included in vitro thrombolysis experiments, exposure of human cardiomyocytes, zebrafish tail vein injections, and vascular endothelial transgenic zebrafish models. The findings revealed that rhTNK is the most effective thrombolytic drug with the least adverse effects and lowest bleeding rate, highlighting its potential as the preferred treatment option for AMI. The order of thrombolytic effectiveness was Urokinase < Alteplase < rhTNK, with adverse effects on cardiomyocytes post-thrombolytic therapy ranking similarly as Urokinase < Alteplase < rhTNK, while the bleeding rate after thrombolysis followed the order of Urokinase > Alteplase > rhTNK.
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Affiliation(s)
- Chenxi Xie
- Chest Pain Center, Anxi County Hospital, Quanzhou 362300, China; (C.X.); (M.L.); (Z.Z.); (D.H.); (M.X.); (D.C.)
| | - Naying Zheng
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, Xiamen University, Xiamen 361005, China; (N.Z.); (C.H.)
| | - Mingmei Li
- Chest Pain Center, Anxi County Hospital, Quanzhou 362300, China; (C.X.); (M.L.); (Z.Z.); (D.H.); (M.X.); (D.C.)
| | - Zhiyang Zhang
- Chest Pain Center, Anxi County Hospital, Quanzhou 362300, China; (C.X.); (M.L.); (Z.Z.); (D.H.); (M.X.); (D.C.)
| | - Dongqin Huang
- Chest Pain Center, Anxi County Hospital, Quanzhou 362300, China; (C.X.); (M.L.); (Z.Z.); (D.H.); (M.X.); (D.C.)
| | - Meizhu Xiao
- Chest Pain Center, Anxi County Hospital, Quanzhou 362300, China; (C.X.); (M.L.); (Z.Z.); (D.H.); (M.X.); (D.C.)
| | - Dongdong Chen
- Chest Pain Center, Anxi County Hospital, Quanzhou 362300, China; (C.X.); (M.L.); (Z.Z.); (D.H.); (M.X.); (D.C.)
| | - Chengyong He
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, Xiamen University, Xiamen 361005, China; (N.Z.); (C.H.)
| | - Zhenghong Zuo
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, Xiamen University, Xiamen 361005, China; (N.Z.); (C.H.)
| | - Xintan Chen
- Chest Pain Center, Anxi County Hospital, Quanzhou 362300, China; (C.X.); (M.L.); (Z.Z.); (D.H.); (M.X.); (D.C.)
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Sykes M, Rosenberg-Yunger ZRS, Quigley M, Gupta L, Thomas O, Robinson L, Caulfield K, Ivers N, Alderson S. Exploring the content and delivery of feedback facilitation co-interventions: a systematic review. Implement Sci 2024; 19:37. [PMID: 38807219 PMCID: PMC11134935 DOI: 10.1186/s13012-024-01365-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 05/13/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Policymakers and researchers recommend supporting the capabilities of feedback recipients to increase the quality of care. There are different ways to support capabilities. We aimed to describe the content and delivery of feedback facilitation interventions delivered alongside audit and feedback within randomised controlled trials. METHODS We included papers describing feedback facilitation identified by the latest Cochrane review of audit and feedback. The piloted extraction proforma was based upon a framework to describe intervention content, with additional prompts relating to the identification of influences, selection of improvement actions and consideration of priorities and implications. We describe the content and delivery graphically, statistically and narratively. RESULTS We reviewed 146 papers describing 104 feedback facilitation interventions. Across included studies, feedback facilitation contained 26 different implementation strategies. There was a median of three implementation strategies per intervention and evidence that the number of strategies per intervention is increasing. Theory was used in 35 trials, although the precise role of theory was poorly described. Ten studies provided a logic model and six of these described their mechanisms of action. Both the exploration of influences and the selection of improvement actions were described in 46 of the feedback facilitation interventions; we describe who undertook this tailoring work. Exploring dose, there was large variation in duration (15-1800 min), frequency (1 to 42 times) and number of recipients per site (1 to 135). There were important gaps in reporting, but some evidence that reporting is improving over time. CONCLUSIONS Heterogeneity in the design of feedback facilitation needs to be considered when assessing the intervention's effectiveness. We describe explicit feedback facilitation choices for future intervention developers based upon choices made to date. We found the Expert Recommendations for Implementing Change to be valuable when describing intervention components, with the potential for some minor clarifications in terms and for greater specificity by intervention providers. Reporting demonstrated extensive gaps which hinder both replication and learning. Feedback facilitation providers are recommended to close reporting gaps that hinder replication. Future work should seek to address the 'opportunity' for improvement activity, defined as factors that lie outside the individual that make care or improvement behaviour possible. REVIEW REGISTRATION The study protocol was published at: https://www.protocols.io/private/4DA5DE33B68E11ED9EF70A58A9FEAC02 .
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Affiliation(s)
| | | | | | | | | | - Lisa Robinson
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Karen Caulfield
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
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Hertz JT, Stark K, Sakita FM, Mlangi JJ, Kweka GL, Prattipati S, Shayo F, Kaboigora V, Mtui J, Isack MN, Kindishe EM, Ngelengi DJ, Limkakeng AT, Thielman NM, Bloomfield GS, Bettger JP, Tarimo TG. Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention. Ann Glob Health 2024; 90:21. [PMID: 38495415 PMCID: PMC10941691 DOI: 10.5334/aogh.4361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/23/2024] [Indexed: 03/19/2024] Open
Abstract
Background Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa. Objectives Co-design a quality improvement intervention for AMI care tailored to local contextual factors. Methods An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context. Findings The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education. Conclusion MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.
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Affiliation(s)
- Julian T. Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kristen Stark
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Francis M. Sakita
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University, Moshi, Tanzania
| | | | | | | | - Frida Shayo
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Julius Mtui
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | | | | | - Alexander T. Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Gerald S. Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Janet P. Bettger
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Zhao X, Zhu Y, Zhang Z, Tao G, Xu H, Cheng G, Gao W, Ma L, Qi L, Yan X, Wang H, Xia Q, Yang Y, Li W, Rong J, Wang L, Ding Y, Guo Q, Dang W, Yao C, Yang Q, Gao R, Wu Y, Qiao S. Tenecteplase versus alteplase in treatment of acute ST-segment elevation myocardial infarction: A randomized non-inferiority trial. Chin Med J (Engl) 2024; 137:312-319. [PMID: 37265385 PMCID: PMC10836890 DOI: 10.1097/cm9.0000000000002731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND A phase II trial on recombinant human tenecteplase tissue-type plasminogen activator (rhTNK-tPA) has previously shown its preliminary efficacy in ST elevation myocardial infarction (STEMI) patients. This study was designed as a pivotal postmarketing trial to compare its efficacy and safety with rrecombinant human tissue-type plasminogen activator alteplase (rt-PA) in Chinese patients with STEMI. METHODS In this multicenter, randomized, open-label, non-inferiority trial, patients with acute STEMI were randomly assigned (1:1) to receive an intravenous bolus of 16 mg rhTNK-tPA or an intravenous bolus of 8 mg rt-PA followed by an infusion of 42 mg in 90 min. The primary endpoint was recanalization defined by thrombolysis in myocardial infarction (TIMI) flow grade 2 or 3. The secondary endpoint was clinically justified recanalization. Other endpoints included 30-day major adverse cardiovascular and cerebrovascular events (MACCEs) and safety endpoints. RESULTS From July 2016 to September 2019, 767 eligible patients were randomly assigned to receive rhTNK-tPA ( n = 384) or rt-PA ( n = 383). Among them, 369 patients had coronary angiography data on TIMI flow, and 711 patients had data on clinically justified recanalization. Both used a -15% difference as the non-inferiority efficacy margin. In comparison to rt-PA, both the proportion of patients with TIMI grade 2 or 3 flow (78.3% [148/189] vs. 81.7% [147/180]; differences: -3.4%; 95% confidence interval [CI]: -11.5%, 4.8%) and clinically justified recanalization (85.4% [305/357] vs. 85.9% [304/354]; difference: -0.5%; 95% CI: -5.6%, 4.7%) in the rhTNK-tPA group were non-inferior. The occurrence of 30-day MACCEs (10.2% [39/384] vs. 11.0% [42/383]; hazard ratio: 0.96; 95% CI: 0.61, 1.50) did not differ significantly between groups. No safety outcomes significantly differed between groups. CONCLUSION rhTNK-tPA was non-inferior to rt-PA in the effect of improving recanalization of the infarct-related artery, a validated surrogate of clinical outcomes, among Chinese patients with acute STEMI. TRIAL REGISTRATION www.ClinicalTrials.gov (No. NCT02835534).
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Affiliation(s)
- Xingshan Zhao
- Department of Cardiology, Beijing Jishuitan Hospital, Capital Medical University, The Fourth Clinical Medical College of Peking University, Beijing 100035, China
| | - Yidan Zhu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing 100191, China
| | - Zheng Zhang
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, Gansu 730013, China
| | - Guizhou Tao
- Department of Cardiology, The First Affiliated Hospital of Liaoning Medical University, Jinzhou, Liaoning 110002, China
| | - Haiyan Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Guanchang Cheng
- Department of Cardiology, Huaihe Hospital of Henan University, Kaifeng, Henan 450001, China
| | - Wen Gao
- Department of Cardiology, Bayannur Hospital, Bayannur, Inner Mongolia 015208, China
| | - Liping Ma
- Department of Cardiology, Puyang People's Hospital, Puyang, Henan 457099, China
| | - Liping Qi
- Department of Cardiology, Xingtai Third Hospital, Xingtai, Hebei 054099, China
| | - Xiaoyan Yan
- Department of Cardiology, Beijing Jishuitan Hospital, Capital Medical University, The Fourth Clinical Medical College of Peking University, Beijing 100035, China
| | - Haibo Wang
- Department of Cardiology, Beijing Jishuitan Hospital, Capital Medical University, The Fourth Clinical Medical College of Peking University, Beijing 100035, China
| | - Qingde Xia
- Department of Cardiology, Lintao County People's Hospital, Dingxi, Gansu 730599, China
| | - Yuwang Yang
- Department of Cardiology, Dancheng County People's Hospital, Zhoukou, Henan 477150, China
| | - Wanke Li
- Department of Cardiology, The First People's Hospital of Lingbao, Sanmenxia, Henan 472500, China
| | - Juwen Rong
- Department of Cardiology, Shanyin County People's Hospital, Shuozhou, Shanxi 036999, China
| | - Limei Wang
- Department of Cardiology, Uxin Banner People's Hospital, Ordos, Inner Mongolia 017399, China
| | - Yutian Ding
- Department of Cardiology, Lingqiu County People's Hospital, Datong, Shanxi 034499, China
| | - Qiang Guo
- Department of Cardiology, Huaibin County People's Hospital, Xinyang, Henan 464411, China
| | - Wanjun Dang
- Department of Cardiology, Tianzhu County People's Hospital, Wuwei, Gansu 733200, China
| | - Chen Yao
- Department of Cardiology, Beijing Jishuitan Hospital, Capital Medical University, The Fourth Clinical Medical College of Peking University, Beijing 100035, China
| | - Qin Yang
- Guangzhou Recomgen Biotech Co., Ltd, Guangzhou, Guangdong 510530, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing 100191, China
| | - Shubin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
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Qiu M, Na K, Qi Z, Zhou H, Li P, Xu K, Wang B, Liu H, Li J, Li Y, Han Y. Contemporary Use of Ticagrelor vs Clopidogrel in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A GRACE Risk Score Stratification-Based Analysis in a Large-Scale, Real-World Study From China. Mayo Clin Proc 2023; 98:1021-1032. [PMID: 37419570 DOI: 10.1016/j.mayocp.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/06/2023] [Accepted: 02/01/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To evaluate potential gains in outcomes from ticagrelor-based strategy according to risk stratification by Global Registry of Acute Coronary Events (GRACE) score. METHODS A total of 19,704 patients discharged alive post-acute coronary syndrome who underwent percutaneous coronary intervention and received ticagrelor or clopidogrel between March 2016 and March 2019 were included in the study. The primary endpoint was ischemic events at 12 months, composed of cardiac death, myocardial infarction, and/or stroke. Secondary outcomes included all-cause mortality and Bleeding Academic Research Consortium type 2 to 5 and 3 to 5 bleeding. RESULTS The ticagrelor group comprised 6432 (32.6%) patients and the clopidogrel group comprised 13,272 (67.4%) patients. During the follow-up period, there was a significant reduction in the incidence of ischemic events in patients treated using ticagrelor who had excessive risk of bleeding. According to the GRACE score, among low-risk patients, ticagrelor use compared with clopidogrel was not associated with decreased ischemic events (HR, 0.82; 95% CI, 0.57 to 1.17; P=.27) with excessive risk of Bleeding Academic Research Consortium type 3 to 5 bleeding (HR, 1.59; 95% CI, 1.16 to 2.17; P=.004). The risk of ischemic events (HR, 0.60; 95% CI, 0.41 to 0.89; P=.01) were lower in the intermediate- to high-risk patients treated with ticagrelor without significant difference in BARC type 3 to 5 bleeding risk (HR, 1.11; 95% CI, 0.75 to 1.65; P=.61). CONCLUSION There was still a gap between guideline-indicated therapy and the clinical practice in a sizable subset of patients with acute coronary syndrome who underwent percutaneous coronary intervention. The GRACE risk score could identify patients who would derive benefit from the ticagrelor-based antiplatelet strategy.
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Affiliation(s)
- Miaohan Qiu
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kun Na
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China; Shenyang Pharmaceutical University, Shenyang, China
| | - Zizhao Qi
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China; Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - He Zhou
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China; Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Pengxiao Li
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China; Air Force Medical University of PLA, Xi'an, China
| | - Kai Xu
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Bin Wang
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Haiwei Liu
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China; Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yi Li
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.
| | - Yaling Han
- Cardiovascular Research Institute & Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.
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Liao B, Han Z. Roflumilast reduces myocardial ischemia reperfusion injury in vivo and in vitro by activating the AMPK signaling pathway. Exp Ther Med 2023; 25:302. [PMID: 37229319 PMCID: PMC10203911 DOI: 10.3892/etm.2023.12001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 03/24/2023] [Indexed: 05/27/2023] Open
Abstract
Myocardial tissue cell damage induced by myocardial ischemia/reperfusion (MI/R) notably elevates the mortality rate, increases the complications of patients with myocardial infarction and decreases reperfusion benefit in patients suffering from acute myocardial infarction. Roflumilast protect against cardiotoxicity. Therefore, the present study aimed to investigate the effect of roflumilast on MI/R injury and the underlying mechanisms. To simulate MI/R in vivo and in vitro, the rat model of MI/R was established and H9C2 cells were subjected to hypoxia/reoxygenation (H/R) induction, respectively. The myocardial infarction areas were observed by 2,3,5-triphenyltetrazolium chloride staining. The myocardial enzyme levels in serum and levels of inflammatory cytokines and oxidative stress markers in cardiac tissue were assessed by corresponding assay kits. The cardiac damage was observed by hematoxylin and eosin staining. The mitochondrial membrane potential in cardiac tissue and H9C2 cells was detected using the JC-1 staining kit. The viability and apoptosis of H9C2 cells were detected by Cell Counting Kit-8 and TUNEL assay, respectively. The levels of inflammatory cytokines, oxidative stress markers and ATP in H/R-induced H9C2 cells were analyzed by corresponding assay kits. Western blotting was used for the estimation of AMP-activated protein kinase (AMPK) signaling pathway-, apoptosis- and mitochondrial regulation-associated protein levels. The mPTP opening was detected using a calcein-loading/cobalt chloride-quenching system. The results indicated that roflumilast decreased MI/R-induced myocardial infarction by alleviating myocardial injury and mitochondrial damage through the activation of the AMPK signaling pathway. In addition, roflumilast mitigated viability damage, alleviated oxidative stress, attenuated the inflammatory response and decreased mitochondrial damage in H/R-induced H9C2 cells by activating the AMPK signaling pathway. However, compound C, an inhibitor of the AMPK signaling pathway, reversed the effect of roflumilast on H/R-induced H9C2 cells. In conclusion, roflumilast alleviated myocardial infarction in MI/R rats and attenuated H/R-induced oxidative stress, inflammatory response and mitochondrial damage in H9C2 cells by activating the AMPK signaling pathway.
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Affiliation(s)
- Bo Liao
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Zhongyuan Han
- Department of Cardiovascular Medicine, The Second People's Hospital of Nantong, Nantong, Jiangsu 226002, P.R. China
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Meng L, Yu X, Han H, Jia X, Hu B, Zhang L, Wang Z, Zhang W, Zhong M, Zhu H. Circulating miR-143 and miR-145 as promising biomarkers for evaluating severity of coronary artery stenosis in patients with acute coronary syndrome. Clin Biochem 2023; 111:32-40. [PMID: 36241060 DOI: 10.1016/j.clinbiochem.2022.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/17/2022] [Accepted: 10/07/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Multiple studies have provided evidence that miR-143 and miR-145 play a crucial role in the pathogenesis and progression of atherosclerosis. In the present study, we aim to investigate the expression of plasma miR-143 and miR-145 in patients with acute coronary syndrome (ACS) and their association with the severity of coronary artery stenosis. METHODS The study enrolled 279 patients with ACS, including 201 patients with unstable angina (UA) and 78 patients with acute myocardial infarction (AMI), and 65 matched subjects as the control group. The plasma levels of miR-143 and miR-145 were detected by quantitative real-time PCR (qRT-PCR). Gensini score was applied to evaluate the severity of coronary artery stenosis. RESULTS Plasma levels of miR-143 and miR-145 in patients with ACS were both decreased compared with the control group (p < 0.001). Plasma levels of miR-143 and miR-145 were negatively correlated with Gensini score (miR-143: r = -0.246, p < 0.001; miR-145: r = -0.222, p < 0.001). Logistic regression analysis showed that miR-143 and miR-145 were protective factors for the onset of ACS, UA, or AMI separately. MiR-143 (AUC: 0.786, p < 0.001) and miR-145 (AUC: 0.793, p < 0.001) were able to predict the degree of coronary artery stenosis greater than 50 %. CONCLUSION The plasma levels of miR-143 and miR-145 were significantly decreased in ACS patients and were negatively correlated with coronary stenosis. In conclusion, plasma miR-143 and miR-145 levels can be used as noninvasive biomarkers for evaluating coronary artery stenosis.
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Affiliation(s)
- Linlin Meng
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Xin Yu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China; Department of Cardiology, The People's Hospital of Pingyi County, Shandong, China
| | - Haitao Han
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Xu Jia
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Boang Hu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Lei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Zhihao Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China; Department of Geriatric Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University; Shandong key Laboratory of Cardiovascular Proteomics, Jinan, Shandong, 250012, China
| | - Wei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Ming Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Hui Zhu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China.
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9
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Sun Y, Feng L, Li X, Wang Z, Gao R, Wu Y. In-hospital major bleeding in patients with acute coronary syndrome medically treated with dual anti-platelet therapy: Associated factors and impact on mortality. Front Cardiovasc Med 2022; 9:878270. [DOI: 10.3389/fcvm.2022.878270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveMajor bleeding is associated with poor hospital prognosis in patients with acute coronary syndrome (ACS). Despite its clinical importance, there are limited studies on the incidence and risk factors for major bleeding in ACS patients with dual anti-platelet therapy (DAPT) without access to revascularization.MethodsWe analyzed data from 19,186 patients on DAPT after ACS with no access to revascularization from Clinical Pathway for Acute Coronary Syndrome in China Phase 3 (CPACS-3) cohort, which was conducted from 2011 to 2014. Major bleeding included intracranial hemorrhage, clinically significant bleeding, or bleeding requiring blood transfusion. Factors associated with in-hospital major bleeding were assessed using Poisson regressions with generalized estimating equations to account for the clustering effect.ResultsA total of 75 (0.39%) patients experienced major bleeding during hospitalization. Among subtypes of ACS, 0.65% of patients with STEMI, 0.33% with NSTEMI, and 0.13% with unstable angina had in-hospital major bleeding (p < 0.001). The patients who experienced major bleeding had a longer length of stay (median 12 vs. 9 days, p = 0.011) and a higher all-cause in-hospital death rate (22.7 vs. 3.7%, p < 0.001). Multivariable analysis showed advancing age (RR = 1.52 for every 10 years increase, 95% CI: 1.13, 2.05), impaired renal function (RR = 1.79, 95% CI: 1.10, 2.92), use of fibrinolytic drugs (RR = 2.93, 95% CI: 1.55, 5.56), and severe diseases other than cardiovascular and renal diseases (RR = 5.56, 95% CI: 1.10, 28.07) were associated with increased risk of major bleeding, whereas using renin–angiotensin system inhibitors (RR = 0.54, 95% CI: 0.36, 0.81) was associated with decreased risk of major bleeding. These independent factors together showed good predictive accuracy with an AUC of 0.788 (95% CI: 0.734, 0.841).ConclusionAmong ACS patients on DAPT, advancing age, impaired renal function, thrombolytic treatment, and severe comorbidities were independently associated with a higher risk of in-hospital major bleeding.
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10
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Analysis of the Exploration of Security and Privacy for Healthcare Management Using Artificial Intelligence: Saudi Hospitals. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:4048197. [PMID: 36156966 PMCID: PMC9492376 DOI: 10.1155/2022/4048197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022]
Abstract
A large component of the Health Information Systems now comprises numerous independent apps created in the past that need to be merged to provide a more uniform service. In addition to affecting the Intelligent Health Board Functionality and dependability, the quality of these additional apps may also have an impact. A critical characteristic of the SHS's management and upkeep is the SHS's reliance on the real benefits provided to it. In speaking, an HMIS (Healthcare Management Information System) is a computer-based device that benefits medical practitioners to perform their duties more efficiently by coordinating all of their data. Even though these systems are widely used by most of the world, there is a significant need to comprehend these technologies and indeed the potential they provide. Healthcare data warehouses in Saudi Arabia have evolved through time, and this research examines how key service improvements in Saudi present varied viewpoints on how premium initiative help may be attained in health as well as how this could be done. When it comes to understanding how different types of medical professionals interact with healthcare systems throughout history, researchers developed stages of the maturity model.
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11
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Hategeka C, Adu P, Desloge A, Marten R, Shao R, Tian M, Wei T, Kruk ME. Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review. PLoS Med 2022; 19:e1004055. [PMID: 35877677 PMCID: PMC9359585 DOI: 10.1371/journal.pmed.1004055] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/08/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs). METHODS AND FINDINGS On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework. CONCLUSIONS Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Prince Adu
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allissa Desloge
- School of Public Health, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Robert Marten
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
| | | | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ting Wei
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
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12
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Zhou S, Ma J, Dong X, Li N, Duan Y, Wang Z, Gao L, Han L, Tu S, Liang Z, Liu F, LaBresh KA, Smith SC, Jin Y, Zheng ZJ. Barriers and enablers in the implementation of a quality improvement program for acute coronary syndromes in hospitals: a qualitative analysis using the consolidated framework for implementation research. Implement Sci 2022; 17:36. [PMID: 35650618 PMCID: PMC9158188 DOI: 10.1186/s13012-022-01207-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/27/2022] [Indexed: 11/11/2022] Open
Abstract
Background Ischemic heart disease causes a high disease burden globally and numerous challenges in treatment, particularly in developing countries such as China. The National Chest Pain Centers Program (NCPCP) was launched in China as the first nationwide, hospital-based, comprehensive, continuous quality improvement (QI) program to improve early diagnosis and standardized treatment of acute coronary syndromes (ACS) and improve patients’ clinical outcomes. With implementation and scaling up of the NCPCP, we investigated barriers and enablers in the NCPCP implementation process and provided examples and ideas for overcoming such barriers. Methods We conducted a nationally representative survey in six cities in China. A total of 165 key informant interviewees, including directors and coordinators of chest pain centers (CPCs) in 90 hospitals, participated in semi-structured interviews. The interviews were transcribed verbatim, translated into English, and analyzed in NVivo 12.0. We used the Consolidated Framework for Implementation Research (CFIR) to guide the codes and themes. Results Barriers to NCPCP implementation mainly arose from nine CFIR constructs. Barriers included the complexity of the intervention (complexity), low flexibility of requirements (adaptability), a lack of recognition of chest pain in patients with ACS (patient needs and resources), relatively low government support (external policies and incentives), staff mobility in the emergency department and other related departments (structural characteristics), resistance from related departments (networks and communications), overwhelming tasks for CPC coordinators (compatibility), lack of available resources for regular CPC operations (available resources), and fidelity to and sustainability of intervention implementation (executing). Enablers of intervention implementation were inner motivation for change (intervention sources), evidence strength and quality of intervention, relatively low cost (cost), individual knowledge and beliefs regarding the intervention, pressure from other hospitals (peer pressure), incentives and rewards of the intervention, and involvement of hospital leaders (leadership engagement, engaging). Conclusion Simplifying the intervention to adapt routine tasks for medical staff and optimizing operational mechanisms between the prehospital emergency system and in-hospital treatment system with government support, as well as enhancing emergency awareness among patients with chest pain are critically important to NCPCP implementation. Clarifying and addressing these barriers is key to designing a sustainable QI program for acute cardiovascular diseases in China and similar contexts across developing countries worldwide. Trial registration This study was registered in the Chinese Clinical Trial Registry (ChiCTR 2100043319), registered 10 February 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01207-6.
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Affiliation(s)
- Shuduo Zhou
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Junxiong Ma
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Xuejie Dong
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Na Li
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Yuqi Duan
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Zongbin Wang
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Liqun Gao
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Lu Han
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Shu Tu
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Zhisheng Liang
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | - Fangjing Liu
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
| | | | - Sidney C Smith
- Division of Cardiovascular Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China. .,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.
| | - Zhi-Jie Zheng
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China. .,Institute for Global Health and Development, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.
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13
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Kara P, Valentin JB, Mainz J, Johnsen SP. Composite measures of quality of health care: Evidence mapping of methodology and reporting. PLoS One 2022; 17:e0268320. [PMID: 35552561 PMCID: PMC9098058 DOI: 10.1371/journal.pone.0268320] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background Quality indicators are used to quantify the quality of care. A large number of quality indicators makes assessment of overall quality difficult, time consuming and impractical. There is consequently an increasing interest for composite measures based on a combination of multiple indicators. Objective To examine the use of different approaches to construct composite measures of quality of care and to assess the use of methodological considerations and justifications. Methods We conducted a literature search on PubMed and EMBASE databases (latest update 1 December 2020). For each publication, we extracted information on the weighting and aggregation methodology that had been used to construct composite indicator(s). Results A total of 2711 publications were identified of which 145 were included after a screening process. Opportunity scoring with equal weights was the most used approach (86/145, 59%) followed by all-or-none scoring (48/145, 33%). Other approaches regarding aggregation or weighting of individual indicators were used in 32 publications (22%). The rationale for selecting a specific type of composite measure was reported in 36 publications (25%), whereas 22 papers (15%) addressed limitations regarding the composite measure. Conclusion Opportunity scoring and all-or-none scoring are the most frequently used approaches when constructing composite measures of quality of care. The attention towards the rationale and limitations of the composite measures appears low. Discussion Considering the widespread use and the potential implications for decision-making of composite measures, a high level of transparency regarding the construction process of the composite and the functionality of the measures is crucial.
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Affiliation(s)
- Pinar Kara
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- * E-mail:
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jan Mainz
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- Department for Community Mental Health, University of Haifa, Haifa, Israel
- Department of Health Economics, University of Southern Denmark, Odense, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Liu R, Yu X, Zeng X, Wang Z, Zhou D, Liu Z, Liu F, Zhuang C, Zhuang Y, Zhang J, Niu P, Yan B, Zhi R, Li J, Huang J, Qin H. Preliminary evaluation of a new initiative to centralize colorectal cancer care during the COVID-19 epidemic in Shanghai, China: a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:94. [PMID: 35282090 PMCID: PMC8848422 DOI: 10.21037/atm-21-7030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/18/2022] [Indexed: 12/01/2022]
Abstract
Background A novel colorectal cancer center (CCC) was developed in the Shanghai Tenth People’s hospital of Tongji University during the COVID-19 epidemic. In this study, we aimed to evaluate the CCC model in terms of three aspects. Methods This retrospective study used data from the Shanghai Tenth People’s hospital patient databases. The research hypothesis was that the CCC reduces preoperative waiting time (PWT), length of hospital stay (LOS), and costs of hospitalization, without reducing the quality of surgery. Thus, we compared the time, cost, and quality between March 1 to December 31, 2019, and March 1 to December 31, 2020. Descriptive and inferential analyses of patient demographic characteristics, time, postoperative outcomes, and inpatient costs were conducted. Results A total of 965 hospitalizations for colorectal cancer (CRC) were identified—415 in 2019 and 550 in 2020. In the CCC, PWT declined by 26.2 hours (P<0.01). Patients in the CCC express group only needed to wait for 24.5 hours before undergoing surgery, with a shorter LOS than the normal group (P<0.01). None of the patients had any symptoms of COVID-19 or were high-risk COVID-19 contacts, and the incidence of immediate postoperative complications was low. The mean total inpatient cost (TIC) for all patients with CRC was 78,309.824 Chinese Yuan in 2020, which was slightly lower than that in 2019. Conclusions This study found that the centralized management model for CRC care could help patients save the PWT, LOS and costs of hospitalization during the COVID-19 epidemic.
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Affiliation(s)
- Rui Liu
- Tongji University Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Xuejing Yu
- Tongji University Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Xueyun Zeng
- Tongji University Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Medical Affairs, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zheng Wang
- Colorectal Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Danqing Zhou
- Tongji University Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Zhongchen Liu
- Colorectal Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Feng Liu
- Colorectal Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Chengle Zhuang
- Colorectal Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Ying Zhuang
- Colorectal Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Ji Zhang
- Medical Service Section, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Peiqin Niu
- Medical Service Section, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Gastroenterology, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Ben Yan
- Department of Infrastructure, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Rui Zhi
- Department of Infrastructure, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
| | - Jiyu Li
- Tongji University Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Geriatric Oncology Center, Huadong Hospital, Fudan University, Shanghai, China
| | - Jiaoling Huang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huanlong Qin
- Tongji University Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Colorectal Cancer Center, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital of Tongji University, Shanghai, China
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15
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Harrison LJ, Wang R. Power calculation for analyses of cross-sectional stepped-wedge cluster randomized trials with binary outcomes via generalized estimating equations. Stat Med 2021; 40:6674-6688. [PMID: 34558112 DOI: 10.1002/sim.9205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 11/08/2022]
Abstract
Power calculation for stepped-wedge cluster randomized trials (SW-CRTs) presents unique challenges, beyond those of standard parallel cluster randomized trials, due to the need to consider temporal within cluster correlations and background period effects. To date, power calculation methods specific to SW-CRTs have primarily been developed under a linear model. When the outcome is binary, the use of a linear model corresponds to assessing a prevalence difference; yet trial analysis often employs a nonlinear link function. We propose power calculation methods for cross-sectional SW-CRTs under a logistic model fitted by generalized estimating equations. Firstly, under an exchangeable correlation structure, we show the power based on a logistic model is lower than that from assuming a linear model in the absence of period effects. We then evaluate the impact of background prevalence changes over time on power. To allow the correlation among outcomes in the same cluster to change over time and with treatment status, we generalize the methods to more complex correlation structures. Our simulation studies demonstrate that the proposed power calculation methods perform well with the model-based variance under the true correlation structure and reveal that a working independence structure can result in substantial efficiency loss, while a working exchangeable structure performs well even when the underlying correlation structure deviates from exchangeable. An extension to our methods accounts for variable cluster sizes and reveals that unequal cluster sizes have a modest impact on power. We illustrate the approaches by application to a quality of care improvement trial for acute coronary syndrome.
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Affiliation(s)
- Linda J Harrison
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Rui Wang
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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16
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Wang W, van Wijngaarden J, Wang H, Buljac-Samardzic M, Yuan S, van de Klundert J. Factors Influencing the Implementation of Foreign Innovations in Organization and Management of Health Service Delivery in China: A Systematic Review. FRONTIERS IN HEALTH SERVICES 2021; 1:766677. [PMID: 36926484 PMCID: PMC10012679 DOI: 10.3389/frhs.2021.766677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022]
Abstract
Background: China has been encouraged to learn from international innovations in the organization and management of health service delivery to achieve the national health reform objectives. However, the success and effectiveness of implementing innovations is affected by the interactions of innovations with the Chinese context. Our aim is to synthesize evidence on factors influencing the implementation of non-Chinese innovations in organization and management of health service delivery in mainland China. Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched seven databases for peer-reviewed articles published between 2009 and 2020. Data were analyzed and combined to generate a list of factors influencing the implementation of foreign innovations in China. The factors were classified in the categories context, system, organization, innovation, users, resources, and implementation process. Results: The 110 studies meeting the inclusion criteria revealed 33 factors. Most supported by evidence is the factor integration in organizational policies, followed by the factors motivation & incentives and human resources. Some factors (e.g., governmental policies & regulations) were mentioned in multiple studies with little or no evidence. Conclusion: Evidence on factors influencing the implementation of foreign innovations in organization and management of health service delivery is scarce and of limited quality. Although many factors identified in this review have also been reported in reviews primarily considering Western literature, this review suggests that extrinsic motivation, financial incentives, governmental and organizational policies & regulations are more important while decentralization was found to be less important in China compare to Western countries. In addition, introducing innovations in rural China seems more challenging than in urban China, because of a lack of human resources and the more traditional rural culture.
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Affiliation(s)
- Wenxing Wang
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Jeroen van Wijngaarden
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Hujie Wang
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Martina Buljac-Samardzic
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Shasha Yuan
- Institute of Medical Information and Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Joris van de Klundert
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Mohammad Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia
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Bo X, Liu Y, Yang M, Lu Z, Zhao Y, Chen L. Development and Validation of a Nomogram of In-hospital Major Adverse Cardiovascular and Cerebrovascular Events in Patients With Acute Coronary Syndrome. Front Cardiovasc Med 2021; 8:699023. [PMID: 34434977 PMCID: PMC8380764 DOI: 10.3389/fcvm.2021.699023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/29/2021] [Indexed: 12/23/2022] Open
Abstract
Background and Objective: This study aims to develop and validate a nomogram for the occurrence of in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) in acute coronary syndrome (ACS) patients. Methods: A total of 1,360 ACS patients admitted between November 2014 and October 2019 from Zhongda Hospital and Yancheng Third People's Hospital were included. Patients admitted in Zhongda Hospital before 2018 were split into the training cohort (n = 793). Those admitted after 2018 in Zhongda Hospital and patients from Yancheng Third People's Hospital were split into the validation cohort (n = 567). Twenty eight clinical features routinely assessed including baseline characteristics, past medical history and auxiliary examinations were used to inform the models to predict in-hospital MACCE (all-cause mortality, reinfarction, stroke, and heart failure) in ACS patients. The best-performing model was tested in the validation cohort. The accuracy and clinical applicability were tested by the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analyses (DCA). Results: The in-hospital MACCE occurred in 93 (6.83%) patients. The final prediction model consists of four variables: age, Killip grading, fasting blood-glucose (FBG) and whether percutaneous coronary intervention (PCI) was performed at early stage. A nomogram was used to present the final result. Individualized nomogram exhibited comparable discrimination to the Global Registry of Acute Coronary Events (GRACE) score [AUC: 0.807 (95% CI 0.736–0.878) vs. 0.761 (95% CI 0.69–0.878)], P = 0.10) and a better discrimination than the Evaluation of the Methods and Management of Acute Coronary Events (EMMACE) score [AUC: 0.807 (95% CI 0.736–0.878) vs. 0.723(95% CI 0.648–0.798), P = 0.01] in predicting the risk of in-hospital MACCE in ACS patients. A good prediction performance was maintained in the validation cohort (AUC =0.813, 95% CI 0.738–0.889). The prediction model also exhibited decent calibration (P = 0.972) and clinical usefulness. Conclusion: The nomogram may be a simple and effective tool in predicting the occurrence of in-hospital MACCE in ACS patients. Further longitudinal studies are warranted to validate its value in guiding clinical decision-making and optimizing the treatment of high-risk patients.
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Affiliation(s)
- Xiangwei Bo
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Liu
- School of Medicine, Southeast University, Nanjing, China
| | - Mingming Yang
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhengri Lu
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yuanyuan Zhao
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Lijuan Chen
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiology, Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, Nanjing, China
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18
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Zhu Y, Chen S, Zhao X, Qiao S, Yang Q, Gao R, Wu Y. The recanalization after thrombolysis as surrogate for clinical outcomes in patients with ST-segment elevation acute myocardial infarction: A systematic review and meta-regression analysis of data from randomized controlled trials. Br J Clin Pharmacol 2021; 88:490-499. [PMID: 34309042 DOI: 10.1111/bcp.15004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/23/2021] [Accepted: 07/15/2021] [Indexed: 12/01/2022] Open
Abstract
AIMS Thrombolytic therapy has been known to be effective in reducing clinical outcomes and increasing recanalization rate among patients with ST-segment elevation acute myocardial infarction (STEMI). However, whether post-thrombolysis recanalization could be used as a surrogate for clinical outcomes is unknown. METHODS We systematically searched PubMed, EMBASE and the Cochrane Library database to identify randomized controlled trials (RCT) that examined effects of thrombolytic agents in STEMI. Recanalization was defined as TIMI grade 2 or 3 flow. The primary outcome was in-hospital all-cause mortality. Secondary outcomes included in-hospital and 30-day recurrent myocardial infarction (re-MI), composite of death and re-MI, major bleeding and all bleeding. Random-effects meta-regression was used for analysis. RESULTS We identified 111 eligible study arms and 52 eligible comparisons from 58 RCTs involving 16 536 patients. Our analyses showed that among study arms recanalization rate was significantly inversely associated with the incidence of in-hospital all-cause mortality (β: -0.07, 95% confidence interval [CI]: -0.13 to -0.02), re-MI (β: -0.09, 95%CI: -0.18 to -0.01) and the composite of death and re-MI (β: -0.17, 95%CI: -0.28 to -0.05), and positively associated with in-hospital all bleeding but not with major bleeding. Among paired comparisons, the difference in recanalization rate was associated with the corresponding difference in incidence of in-hospital all-cause mortality (β: -0.15, 95%CI: -0.28 to -0.01) but the relationship was not significant for any other outcome. CONCLUSION Pooled evidence from RCTs suggest the potential use of recanalization as a surrogate for clinical outcomes in evaluating the efficacy of thrombolysis among patients with STEMI.
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Affiliation(s)
- Yidan Zhu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Siyu Chen
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Xingshan Zhao
- Department of Cardiology, Beijing Jishuitan Hospital, The Fourth Clinical Medical College of Peking University, Beijing, China
| | - Shubin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qin Yang
- Guangzhou Recomgen Biotech Co., Ltd, Guangzhou, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
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Nguyen DD, Doll JA. Quality Improvement and Public Reporting in STEMI Care. Interv Cardiol Clin 2021; 10:391-400. [PMID: 34053625 DOI: 10.1016/j.iccl.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mortality rates for patients with ST-segment elevation myocardial infarction (STEMI) remain high despite development of novel drugs and interventions over the past several decades. There is significant variability between hospitals in use of evidence-based treatments, and substantial opportunities exist to optimize care pathways and reduce disparities in care delivery. Quality improvement interventions implemented at local, regional, and national levels have improved care processes and patient outcomes. This article reviews evidence for quality improvement interventions along the spectrum of STEMI care, describes existing systems for quality measurement, and examines local and national policy interventions, with special attention to public reporting programs.
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Affiliation(s)
- Dan D Nguyen
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA.
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Ma J, Dong X, Jin Y, Zheng ZJ. Health Care Quality Improvement for ST-Segment Elevation Myocardial Infarction: A Retrospective Study Based on Propensity-Score Matching Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18116045. [PMID: 34199816 PMCID: PMC8200089 DOI: 10.3390/ijerph18116045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/29/2021] [Accepted: 05/30/2021] [Indexed: 11/25/2022]
Abstract
Reducing the treatment delay by organizing delivery of care on a regional basis is a priority for improving the quality of ST-segment elevated myocardial infarction (STEMI) care. This study aimed to evaluate the impact of the combined measures on quality metrics of healthcare delivery in Suzhou. The data were collected from the National Chest Pain Center (CPC) Data Reporting Database. 4775 patients were recruited, and after propensity-score matching, 1078 pairs were finally included for analysis. We examined the changes in quality metrics of care including prehospital and in-hospital processes, and clinic outcomes. Quality improvement (QI) implementation improved most process indicators. However, these improvements did not yield decreased in-hospital mortality. The door-to-balloon and the FMC-to-device time decreased from 85.0 and 98.0 min to 78 and 88 min, respectively (p < 0.001). Cases transferred directly via EMS had a greater improvement in most of process indicators. The proportion of patients transferred directly via EMS was 10.3%, much lower than that of self-transported patients at 58.3%. Tertiary hospitals showed greater performance improvement in process indicators than secondary hospitals. The percentage of cases using EMS remained low for suburban areas. The establishment of coordinated STEMI care needs to be accompanied with solving the fragmented situation of the prehospital and hospital care, and patient delay should be addressed, especially in suburban areas and on transferred-in inpatients.
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Affiliation(s)
- Junxiong Ma
- Department of Global Health, School of Public Health, Peking University, Beijing 100191, China; (J.M.); (X.D.); (Z.-J.Z.)
- Institute for Global Health, Peking University, Beijing 100191, China
| | - Xuejie Dong
- Department of Global Health, School of Public Health, Peking University, Beijing 100191, China; (J.M.); (X.D.); (Z.-J.Z.)
- Institute for Global Health, Peking University, Beijing 100191, China
| | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing 100191, China; (J.M.); (X.D.); (Z.-J.Z.)
- Institute for Global Health, Peking University, Beijing 100191, China
- Correspondence: ; Tel.: +86-150-0108-1989; Fax: +86-108-280-2144
| | - Zhi-Jie Zheng
- Department of Global Health, School of Public Health, Peking University, Beijing 100191, China; (J.M.); (X.D.); (Z.-J.Z.)
- Institute for Global Health, Peking University, Beijing 100191, China
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21
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The hospital management practices in Chinese county hospitals and its association with quality of care, efficiency and finance. BMC Health Serv Res 2021; 21:449. [PMID: 33975605 PMCID: PMC8111980 DOI: 10.1186/s12913-021-06472-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/30/2021] [Indexed: 11/21/2022] Open
Abstract
Background County hospitals as the backbone of the China’s healthcare system are providing services for over 70% of the total population. However, the hospital management practice (HMP) and its links with quality of care, efficiency and finance in these hospitals are unknown. Methods We did two cross-sectional surveys of HMP in 2013 and 2015 among 101 county hospitals across rural China. Three managing roles (hospital director, director of medical affairs office and director of cardiology) and a cardiologist were invited to the surveys. A novel HMP rating scale, with 100 as full score, was used to measure the HMP in 17 indicators under four dimensions (target, operation, performance, and talent management) for each hospital. We analyzed the association of HMP score with variables on quality of care, efficiency and finance using linear mixed models with and without adjustment for potential confounders. Findings A total of 95 hospitals participated in at least one survey and were included in the analysis. The overall mean HMP score varied dramatically across the hospitals and 84% of them scored less than 60. The dimension mean HMP score was 38.6 (target), 56.4 (operation), 53.2 (performance) and 55.7 (talent), respectively. The pattern of indicator mean HMP score, however, was almost identical between hospitals with high and low overall HMP score, showing the same ‘strength’ (staff satisfaction, staff performance appraisal, ‘hard wares’, patient-centered services, etc.) and ‘weakness’ (target balance, target setting, continuous quality improvement, penalties on staff with dissatisfied performance, etc.). The associations of overall mean HMP score with quality of care and efficiency variables and cost per hospitalization was not statistically significant. The statistical significance in the association with hospital annual total income disappeared after adjusting for region, teaching status, number of competitors, number of staff and number of beds in use. Conclusion The HMP in Chinese county hospitals scores low in general and was not significantly associated with hospital care quality, efficiency and finance. The current healthcare reform in China should address the micro level issues in hospital management practices. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06472-7.
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22
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Xie W, Patel A, Boersma E, Feng L, Li M, Gao R, Wu Y. Chronic kidney disease and the outcomes of fibrinolysis for ST-segment elevation myocardial infarction: A real-world study. PLoS One 2021; 16:e0245576. [PMID: 33465135 PMCID: PMC7815111 DOI: 10.1371/journal.pone.0245576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 01/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In low-resource regions, fibrinolytic therapy is often the only option for ST-elevation myocardial infarction (STEMI) patients as primary percutaneous coronary intervention (PCI) is often not available and patients are hardly transferred to a medical center with PCI capacity within the first 120 minutes. Chronic kidney disease (CKD) is one of the most frequently encountered complications of STEMI. However, the evidence for the efficacy of fibrinolytic therapy in STEMI patients with CKD is still limited. The aim of this study is to test whether CKD modifies the association between fibrinolytic therapy and short-term major adverse cardiovascular events (MACEs) among patients with STEMI. METHODS AND FINDINGS This is a real-world study analyzing the data from 9508 STEMI patients (mean age: 64.0±12.4 years; male: 70.1%) in the third phase of Clinical Pathways in Acute Coronary Syndromes program (CPACS-3), which is a large study of the management of acute coronary syndromes (ACS) in 101 county hospitals without PCI capacity in China. CKD was defined as an estimated glomerular filtration rate of less than 60 mL/min per 1·73 m2 at the admission. The primary outcome is short-term MACEs, including all-cause death, recurrent myocardial infarction, or nonfatal stroke. Patients were recruited consecutively between October 2011 and November 2014. Out of them, 1282 patients (13.5%) were classified as having CKD. Compared with non-CKD patients, CKD patients were less likely to receive fibrinolytic therapy than non-CKD patients (26.4% vs. 38.9%, P<0.001), more likely to experience a failed fibrinolytic therapy (32.8% vs. 16.9%), and had a higher risk of short-term MACEs (19.7% vs. 5.6%). After full adjustment, use of fibrinolytic therapy was associated with a significantly lower risk of short-term MACEs in non-CKD patients (relative risk [RR] = 0.87, 95% confidence interval [CI]: 0.76-0.99), but not in CKD patients (P for interaction = 0.026). Further analysis stratified by the success of fibrinolysis showed that compared with patients who did not receive fibrinolytic therapy, patients with successful fibrinolysis had a lower risk of short-term MACEs that was similar between patients with (RR = 0.71, 95% CI: 0.55-0.82) and without CKD (RR = 0.67, 95% CI: 0.55-0.92), while patients with unsuccessful fibrinolysis had a similarly higher risk in CKD patients (RR = 1.25, 95% CI: 1.09-1.43) and non-CKD patients (RR = 1.30, 95% CI: 1.13-1.50). CONCLUSIONS CKD reduced the likelihood of successful fibrinolysis and increased the risk of short-term MACEs in patients with STEMI. Attention should be paid to how to improve the success rate of fibrinolytic therapy for STEMI patients with CKD. TRIAL REGISTRATION The CPACS-3 study was registered on www.clinicaltrials.gov (NCT01398228).
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Affiliation(s)
- Wuxiang Xie
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Eric Boersma
- Department of Cardiology, Erasmus Medical College, Rotterdam, The Netherlands
| | - Lin Feng
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Min Li
- Clinical Epidemiology and EBM Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
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Diaz-Quijano FA. Estimating and testing an index of bias attributable to composite outcomes in comparative studies. J Clin Epidemiol 2020; 132:1-9. [PMID: 33309888 DOI: 10.1016/j.jclinepi.2020.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/28/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study aimed to develop an index to evaluate the bias attributable to composite outcomes (BACOs) in comparative clinical studies. STUDY DESIGN AND SETTING The author defined the BACO index as the ratio of the logarithm of the association measure (e.g., relative risk) of the composite outcome to that of its most relevant component endpoint (e.g., mortality). Methods to calculate the confidence intervals and test the null hypotheses (BACO index = 1) were described and applied in systematically selected clinical trials. Two other preselected trials were included as "positive controls" for being examples of primary composite outcomes disregarded because of inconsistency with the treatment effect on mortality. RESULTS The BACO index values different from 1 were classified according to whether the use of composite outcomes overestimated (BACO index >1), underestimated (BACO index between 0 and <1), or inverted (BACO index <0) the association between exposure and prognosis. In 3 of 23 systematically selected trials and the two positive controls, the BACO indices were significantly lower than 1 (P < 0.005). CONCLUSION BACO index can warn that the composite outcome association is stronger, weaker, or even opposite than that of its most critical component.
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Affiliation(s)
- Fredi Alexander Diaz-Quijano
- Department of Epidemiology, Laboratório de Inferência Causal em Epidemiologia (LINCE-USP), School of Public Health, University of São Paulo, São Paulo, São Paulo, Brazil.
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Xu H, Yang Y, Wang C, Yang J, Li W, Zhang X, Ye Y, Dong Q, Fu R, Sun H, Yan X, Gao X, Wang Y, Jia X, Sun Y, Wu Y, Zhang J, Zhao W, Sabatine MS, Wiviott SD. Association of Hospital-Level Differences in Care With Outcomes Among Patients With Acute ST-Segment Elevation Myocardial Infarction in China. JAMA Netw Open 2020; 3:e2021677. [PMID: 33095249 PMCID: PMC7584928 DOI: 10.1001/jamanetworkopen.2020.21677] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE The incidence of acute myocardial infarction has increased over the past decades in China, and management challenges include an unbalanced economy, disparate resources, and variable access to medical care across the nation. OBJECTIVE To examine the variations in care and outcomes of patients with ST-segment elevation myocardial infarction among 3 levels of hospitals in the typical Chinese public hospital model. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the China Acute Myocardial Infarction Registry to compare the differences in care and outcomes among patients at 108 hospitals from 31 provinces and municipalities throughout mainland China. Participants included patients with ST-segment elevation myocardial infarction directly admitted to hospitals between January 2013 and September 2014. Data analyses were performed from June 2015 to June 2019. EXPOSURES Care in province-level, prefecture-level, or county-level hospitals in China. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included presentation, treatments, and major complications. RESULTS A total of 12 695 patients (9593 men [75.6%]; median [interquartile range] age, 63 [54-72] years) were included; 3985 were at province-level hospitals, 6731 were at prefecture-level hospitals, and 1979 were at county-level hospitals. Compared with patients admitted to province-level hospitals, those admitted to prefecture-level and county-level hospitals were older (median [interquartile range] age, 61 [52-70] years vs 63 [54-72] years and 65 [57-75] years) and more likely to be women (815 women [20.5%] vs 1620 women [24.1%] and 667 women [33.7%]). Patients in prefecture-level and county-level hospitals were less likely to use ambulances compared with patients at province-level hospitals (11.6% [95% CI, 10.8%-12.4%] and 12.0% [95% CI, 10.6%-13.5%] vs 19.4% [95% CI, 18.1%-20.7%]; P < .001) and were less likely to experience early presentation, with onset-to-arrival times less than 12 hours for 75.3% (95% CI, 73.9%-76.6%) of patients at province-level hospitals, 70.8% (95% CI, 69.7%-71.9%) of patients at prefecture-level hospitals, and 69.8% (95% CI, 67.7%-71.8%) of patients at county-level hospitals (P < .001). The rates of reperfusion therapy were significantly lower in low-level hospitals (54.3% [95% CI, 53.1%-55.5%] for prefecture-level hospitals and 45.8% [95% CI, 43.6%-48.1%] for county-level hospitals) compared with province-level hospitals (69.4% [95% CI, 67.9%-70.8%]; P < .001). There was a progressively higher rate of in-hospital mortality at the 3 levels of hospitals: 3.1% (95% CI, 2.6%-3.7%) for province-level hospitals, 5.3% (95% CI, 4.8%-5.9%) for prefecture-level hospitals, and 10.2% (95% CI, 8.9%-11.7%) for county-level hospitals (P for trend < .001). After adjustment for patient characteristics, presentation, hospital facility, and treatments, the odds of death remained higher in prefecture-level (odds ratio, 1.39 [95% CI, 1.06-1.84]) and county-level (odds ratio, 1.43 [95% CI, 0.97-2.11]) hospitals compared with province-level hospitals (P for trend = .04). CONCLUSIONS AND RELEVANCE These findings suggest that there are significant variations in care and outcomes of patients among the 3 levels of hospitals in China. More efforts should be made to address the identified gaps, particularly in the prefecture-level and county-level hospitals. This work can inform national quality improvements efforts in China and in other developing countries.
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Affiliation(s)
- Haiyan Xu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chuangshi Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jingang Yang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Li
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xuan Zhang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yunqing Ye
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qiuting Dong
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Rui Fu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hui Sun
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xinxin Yan
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaojin Gao
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xuan Jia
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yi Sun
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuan Wu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jun Zhang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Zhao
- Information Technology Center, Fuwai Hospital, Beijing, China
| | - Marc S. Sabatine
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen D. Wiviott
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Miao Y, Ding Z, Zou Z, Yang Y, Yang M, Zhang X, Li Z, Zhou L, Zhang L, Zhang X, Du D, Jiang F, Zhou P. Inhibition of MyD88 by a novel inhibitor reverses two-thirds of the infarct area in myocardial ischemia and reperfusion injury. Am J Transl Res 2020; 12:5151-5169. [PMID: 33042411 PMCID: PMC7540094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
Cardiomyocytes, macrophages, and fibroblasts play important roles in inflammation and repair during myocardial ischemia/reperfusion injury (MIRI). Myeloid differentiation primary response 88 (MyD88) is upregulated in immunocytes, cardiomyocytes, and fibroblasts during MIRI. MyD88 induces the secretion of proinflammatory cytokines, including interleukin (IL)-1β, IL-6, and tumor necrosis factor alpha (TNF-α), while fibroblasts are recruited and activated to mediate cardiac remodeling. The aim of this study was to assess the anti-MIRI effect and mode of action of the novel MyD88 inhibitor TJ-M2010-5. We synthesized TJ-M2010-5 and identified its target by co-immunoprecipitation, after which we established a murine MIRI model and tested the protective effect of TJ-M2010-5 by immunohistochemistry, flow cytometry, real-time PCR, and western blotting. Neonatal rat cardiomyocytes subjected to anoxia/reoxygenation were also isolated and their supernatants used to stimulate cardiac macrophagocytes and fibroblasts in vitro. MyD88 was found upregulated during the early and late phases after MIRI. The MyD88 inhibitor considerably improved cardiac function, reduced cardiomyocyte apoptosis, reduced IL-1β, IL-6, and TNF-α secretion, and inhibited CD80+CD86+MHCII+ macrophage and fibroblast migration. Moreover, TJ-M2010-5 markedly inhibited Toll-like receptor/MyD88 signaling in vivo and in vitro. Thus, our findings highlight TJ-M2010-5 as a potential therapeutic agent for MIRI treatment.
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Affiliation(s)
- Yan Miao
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical SciencesWuhan, China
| | - Zuochuan Ding
- Department of General Surgery, The First Affiliated Hospital of Nanchang UniversityNanchang, China
| | - Zhimiao Zou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical SciencesWuhan, China
| | - Yang Yang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical SciencesWuhan, China
| | - Min Yang
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Xiaoqian Zhang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Zeyang Li
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical SciencesWuhan, China
| | - Liang Zhou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical SciencesWuhan, China
| | - Limin Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical SciencesWuhan, China
| | - Xue Zhang
- Department of Breast Surgery, Renmin Hospital of Wuhan University, Wuhan UniversityWuhan, China
| | - Dunfeng Du
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical SciencesWuhan, China
| | - Fengchao Jiang
- Academy of Pharmacy, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Ping Zhou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical SciencesWuhan, China
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Fu R, Feng S, Wu Y, He F, Lin Z, Jiang Y, Hu Z. Association between compliance with quality indicators and hospitalisation expenses in patients with heart failure: a retrospective study using quantile regression model in China. BMJ Open 2020; 10:e033926. [PMID: 32709638 PMCID: PMC7380880 DOI: 10.1136/bmjopen-2019-033926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To explore the association between compliance with quality indicators and hospitalisation expenses in patients with heart failure. DESIGN Generalised linear model and quantile regression model were used to examine the association between compliance with five quality indicators and hospitalisation expenses. SETTING Grade A hospital in Fujian Province, China. PARTICIPANTS Data on 2568 heart failure admissions between 2010 and 2015 were analysed. RESULTS The median (IQR) of hospitalisation expenses of 2568 patients was ¥10.9 (¥6.9-¥31.6) thousand. The rates of compliance with five quality indicators were 90.3% for evaluation of left ventricular function, 43.8% for diuretics, 62.0% for ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB), 67.4% for beta-blockers, and 58.9% for aldosterone receptor antagonists. After adjustment for gender, age, residence, method of payment, number of diseases before admission, number of diseases at admission, number of emergency treatments during hospital stay and length of stay, patients who received evaluation for left ventricular function, diuretics, or ACEI or ARB had lower hospitalisation expenses, and patients who received beta-blockers had higher hospitalisation expenses, compared with their counterparts in generalised linear models. Differences in hospitalisation expenses between compliance and non-compliance with quality indicators became larger across quantile levels of hospitalisation expenses, and were found to be statistically significant when quantile level exceeded 0.80 (¥39.7 thousand) in quantile regression models. CONCLUSIONS The quality of care for patients with heart failure was below the target level. There was a negative relationship between compliance with quality indicators and hospitalisation expenses at the extreme quantile of expenses. More attention should be given to patients who may experience extreme expenses, and effective measures should be taken to improve the quality of care they receive.
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Affiliation(s)
- Rong Fu
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Shaodan Feng
- Emergency Department, Fujian Medical University Affiliated Fuzhou First Hospital, Fuzhou, Fujian, China
| | - Yilong Wu
- Emergency Department, Fujian Medical University Affiliated Fuzhou First Hospital, Fuzhou, Fujian, China
| | - Fei He
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Zheng Lin
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Yixian Jiang
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Zhijian Hu
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
- Fujian Digital Institute for Tumor Big Data, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian, China
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27
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Gender-related differences after acute myocardial infarction: A major global health challenge. Int J Cardiol 2020; 311:18-19. [DOI: 10.1016/j.ijcard.2020.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 11/19/2022]
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Reda A, Almahmeed W, Dobrecky-Mery I, Huang PH, Juarez-Herrera U, Ranjith N, Sayre T, Urina-Triana M. A Narrative Review and Expert Panel Recommendations on Dyslipidaemia Management After Acute Coronary Syndrome in Countries Outside Western Europe and North America. Adv Ther 2020; 37:1754-1777. [PMID: 32227306 PMCID: PMC7467479 DOI: 10.1007/s12325-020-01302-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 11/28/2022]
Abstract
Patients who have experienced an acute coronary syndrome (ACS) are at very high risk of recurrent atherosclerotic cardiovascular disease (CVD) events. Dyslipidaemia, a major risk factor for CVD, is poorly controlled post ACS in countries outside Western Europe and North America, despite the availability of effective lipid-modifying therapies (LMTs) and guidelines governing their use. Recent guideline updates recommend that low-density lipoprotein cholesterol (LDL-C), the primary target for dyslipidaemia therapy, be reduced by ≥ 50% and to < 1.4 mmol/L (55 mg/dL) in patients at very high risk of CVD, including those with ACS. The high prevalence of CVD risk factors in some regions outside Western Europe and North America confers a higher risk of CVD on patients in these countries. ACS onset is often earlier in these patients, and they may be more challenging to treat. Other barriers to effective dyslipidaemia control include low awareness of the value of intensive lipid lowering in patients with ACS, physician non-adherence to guideline recommendations, and lack of efficacy of currently used LMTs. Lack of appropriate pathways to guide follow-up of patients with ACS post discharge and poor access to intensive medications are important factors limiting dyslipidaemia therapy in many countries. Opportunities exist to improve attainment of LDL-C targets by the use of country-specific treatment algorithms to promote adherence to guideline recommendations, medical education and greater prioritisation by healthcare systems of dyslipidaemia management in very high risk patients. Video Abstract
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Affiliation(s)
- Ashraf Reda
- Department of Cardiology, Menoufia University, 127 Mohamed Fareed Street, Babellouk, Cairo, Egypt.
| | - Wael Almahmeed
- Department of Cardiovascular Medicine, Cleveland Clinic, Abu Dhabi, UAE
| | | | - Po-Hsun Huang
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | - Miguel Urina-Triana
- Cardiology Division, Faculty of Health Sciences, Simón Bolívar University, Barranquilla, Colombia
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Li M, Feng L, Li X, Gao R, Wu Y. Influences of Smoking Status on Effectiveness of Cytochrome P450 Enzyme System Metabolized Medications in Reducing In-Hospital Death in 14 658 Patients With Acute Myocardial Infarction: Data From CPACS-3 Study. J Cardiovasc Pharmacol Ther 2020; 25:418-424. [PMID: 32338045 DOI: 10.1177/1074248420921304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The benefit of cytochrome P450 (CYP450) enzyme system metabolized medications, especially clopidogrel, was reported more pronounced in smoking than nonsmoking patients, but limited evidence was available from Asian patients. We analyzed data from a large registry-based study of Chinese patients with acute myocardial infarction (AMI) to understand if the above finding could be reproduced. METHODS A total of 14 658 patients with AMI were prospectively recruited from 101 hospitals across China. Generalized estimating equation was applied to assess the association between CYP450 enzyme system metabolized medications (clopidogrel, statins, calcium channel blockers) and in-hospital death in smoking and nonsmoking patients, separately, adjusting for hospital clustering effects and propensity score of using the medication in question. RESULTS There were 86%, 93%, and 10% of study patients who received clopidogrel, statins, and calcium channel blockers during the hospitalization. Compared with patients not receiving clopidogrel, patients receiving the drug had a significantly lower risk of in-hospital death (adjusted relative risk [RR] = 0.61, 95% confidence interval [CI]: 0.40-0.91) in current smokers but an insignificant lower risk (adjusted RR = 0.85, 95% CI: 0.71-1.01) in nonsmokers, and the P for interaction was <.01. The corresponding adjusted RR was 0.45 (95% CI: 0.24-0.86) in current smokers and 0.94 (95% CI: 0.68-1.29) in nonsmokers (P for interaction <.01) for statins use and 1.00 (95% CI: 0.53-1.89) in current smokers and 0.66 (95% CI: 0.48-0.90) in nonsmokers (P for interaction = .23) for calcium channel blockers use. CONCLUSIONS Our study in a large cohort of Chinese patients with AMI found that the treatment effect in reducing risk of in-hospital death was significantly larger in smokers than in nonsmokers as for clopidogrel and statins but not for calcium channel blockers.
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Affiliation(s)
- Min Li
- Clinical Epidemiology and EBM Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lin Feng
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China.,The George Institute for Global Health at Peking University Health Science Center, Beijing, China
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30
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Feng L, Li M, Xie W, Zhang A, Lei L, Li X, Gao R, Wu Y. Prehospital and in-hospital delays to care and associated factors in patients with STEMI: an observational study in 101 non-PCI hospitals in China. BMJ Open 2019; 9:e031918. [PMID: 31712344 PMCID: PMC6858215 DOI: 10.1136/bmjopen-2019-031918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 09/23/2019] [Accepted: 10/18/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To describe the prehospital and in-hospital delays to care and factors associated with the delays among patients with ST-segment elevation myocardial infarction (STEMI) in non-percutaneous coronary intervention (PCI) hospitals in China. DESIGN, SETTING AND PARTICIPANTS We analysed data from a large registry-based quality of care improvement trial conducted from 2011 to 2014 among 101 non-PCI hospitals in China. A total of 7312 patients with STEMI were included. Prehospital delay was defined as time from symptom onset to hospital arrival >120 min, first ECG delay as time from arrival to first ECG >10 min, thrombolytic therapy delay as time from first ECG to thrombolytic therapy >10 min and in-hospital delay as time from arrival to thrombolytic therapy >30 min. Logistic regressions with generalised estimating equations were preformed to identify the factors associated with each delay. RESULTS The rates of prehospital delay, first ECG delay, thrombolytic therapy delay and in-hospital delay were 67.1%, 31.4%, 85.8% and 67.8%, respectively. Patients who were female, older than 65 years old, illiterate, farmers, onset during late night and forenoon, had heart rate ≥100 beats/m at admission were more likely and patients who had history of myocardial infarction, hypertension or SBP <90 mm Hg at admission were less likely to have prehospital delay. First ECG delay was more likely to take place in patients arriving on regular hours. Thrombolytic therapy delay rate was lower in patients who had prehospital delay or first ECG delay but higher in those with heart rate ≥100 beats/m at admission. In-hospital delay rate was lower in patients with a history of dyslipidaemia and those who arrived during regular hours. CONCLUSION Chinese patients with STEMI in low medical resource areas suffered severe prehospital and in-hospital delays to care. Future efforts should be made to improve the prehospital delay among vulnerable populations with low socioeconomic status. TRIAL REGISTRATION NUMBER NCT01398228; Post-results.
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Affiliation(s)
- Lin Feng
- Clinical Research Institute, Peking University First Hospital, Beijing, China
- Peking University Clinical Research Institute, Beijing, China
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Min Li
- Clinical Epidemiology and EBM Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing, China
| | - Wuxiang Xie
- Peking University Clinical Research Institute, Beijing, China
| | - Aihua Zhang
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Licheng Lei
- The Department of Cardiology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - R Gao
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Beijing, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Beijing, China
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
- Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
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31
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Bahiru E, Agarwal A, Berendsen MA, Baldridge AS, Temu T, Rogers A, Farquhar C, Bukachi F, Huffman MD. Hospital-Based Quality Improvement Interventions for Patients With Acute Coronary Syndrome: A Systematic Review. Circ Cardiovasc Qual Outcomes 2019; 12:e005513. [PMID: 31525081 DOI: 10.1161/circoutcomes.118.005513] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Quality improvement initiatives have been developed to improve acute coronary syndrome care largely in high-income country settings. We sought to synthesize the effect size and quality of evidence from randomized controlled trials (RCTs) and nonrandomized studies for hospital-based acute coronary syndrome quality improvement interventions on clinical outcomes and process of care measures for their potential implementation in low- and middle-income country settings. METHODS AND RESULTS We conducted a bibliometric search of databases and trial registers and a hand search in 2016 and performed an updated search in May 2018 and May 2019. We performed data extraction, risk of bias assessment, and quality of evidence assessments in duplicate. We assessed differences in outcomes by study design comparing RCTs to nonrandomized quasi-experimental studies and by country income status. A meta-analysis was not feasible due to substantial, unexplained heterogeneity among the included studies, and thus, we present a qualitative synthesis. We screened 5858 records and included 32 studies (14 RCTs [n=109 763] and 18 nonrandomized quasi-experimental studies [n=54-423]). In-hospital mortality ranged from 2.1% to 4.8% in the intervention groups versus 3.3% to 5.1% in the control groups in 5 RCTs (n=55 942). Five RCTs (n=64 313) reported 3.0% to 31.0% higher rates of reperfusion for patients with ST-segment-elevation myocardial infarction in the intervention groups. The effect sizes for in-hospital and discharge medical therapies in a majority of RCTs were 3.0% to 10.0% higher in the intervention groups. There was no significant difference in 30-day mortality evaluated by 4 RCTs (n=42 384), which reported 2.5% to 15.0% versus 5.9% to 22% 30-day mortality rates in the intervention versus control groups. In contrast, nonrandomized quasi-experimental studies reported larger effect sizes compared to RCTs. There were no significant consistent differences in outcomes between high-income and middle-income countries. Low-income countries were not represented in any of the included studies. CONCLUSIONS Hospital-based acute coronary syndrome quality improvement interventions have a modest effect on process of care measures but not on clinical outcomes with expected differences by study design. Although quality improvement programs have an ongoing and important role for acute coronary syndrome quality of care in high-income country settings, further research will help to identify key components for contextualizing and implementing such interventions to new settings to achieve their desired effects. Systematic Review Registration: URL: https://www.crd.york.ac.uk/PROSPERO/. Unique identifier: CRD42016047604.
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Affiliation(s)
- Ehete Bahiru
- Department of Medicine, University of California Los Angeles, CA (E.B.)
| | - Anubha Agarwal
- Department of Medicine (A.A., M.D.H.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mark A Berendsen
- Galter Health Sciences Library (M.A.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Abigail S Baldridge
- Department of Preventive Medicine (A.S.B., M.D.H.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tecla Temu
- Departments of Global Health (T.T.), University of Washington, Seattle
| | - Amy Rogers
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (A.R.)
| | - Carey Farquhar
- Departments of Epidemiology and Medicine (C.F.), University of Washington, Seattle
| | | | - Mark D Huffman
- Department of Medicine (A.A., M.D.H.), Northwestern University Feinberg School of Medicine, Chicago, IL.,Department of Preventive Medicine (A.S.B., M.D.H.), Northwestern University Feinberg School of Medicine, Chicago, IL.,The George Institute for Global Health, Food Policy Division, Sydney, Australia (M.D.H.)
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32
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Li X, Krumholz HM. What does it take to improve nationwide healthcare quality in China? BMJ Qual Saf 2019; 28:955-958. [PMID: 31366577 DOI: 10.1136/bmjqs-2019-009839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Xi Li
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut, USA
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