- Email: [email protected]
Age and the treatment gap in the use of statins
COMMENTARY
However, WHO makes an exception for the “mind”, with its own administrative department, while dividing its substrate, the brain, into different departments—to the disadvantage of neurological patients and the confusion of all, professionals and public alike. These divisions between brain and mind have deep historical roots, reinforced by the separate emergence of neurologists and psychiatrists with overlapping territorial interests. However, the separation of neurology and psychiatry largely on the basis of brain lesions, which occurred mainly in the late 19th and early 20th centuries, is fallacious.2 Neurological and psychiatric patients with or without brain pathology have complex cerebral and mental processes that influence each other within additional important social and cultural settings.2,6 The brain and mind function as a unity, but neurologists and psychiatrists do not.7 One unfortunate consequence is that neurologists and neuroscience nongovernmental organisations (eg, the World Federation of Neurology) wish to destigmatise neurological disorders by dissociating them from mental illness,5,8 while psychiatrists are attempting to destigmatise mental illness with little or no reference to the brain.9 WHO wishes to destigmatise both, but mainly mental and behavioural disorders under the banner of “mental health”.3 The present structure and function of WHO is heavily weighted towards mental health and psychiatric disorders with little neurological input or investment. WHO should integrate public-health aspects of brain and mental illness in a more logical and balanced way to reflect the unity of action and interaction of brain and mind, and the relative contributions of neurological and psychiatric disorders to the global burden of disease. There is a need for greater professional and public awareness of the role of the brain in mental illness and the mind in brain illness, based on modern knowledge of brain and mental function arising from the neurosciences and the psychological and social sciences.1,6,10 Such an understanding, especially if led by WHO, would greatly facilitate a breakdown of the barriers of misunderstanding and stigma surrounding these common diseases, which already amount to about a quarter of the global burden of disease. EHR is a former president of the International League against Epilepsy (ILAE) and a former chairman of the ILAE/IBE/WHO Global Campaign against Epilepsy (Out of the Shadows).
E H Reynolds Institute of Epileptology, King’s College Denmark Hill Campus, London SE5 9PJ, UK (e-mail: [email protected]) 1
Ramachandran VS. The emerging mind. Reith lectures, 2003: http://www.bbc.co.uk/radio4/reith2003 (accessed May 15, 2003). 2 Reynolds EH. Structure and function in neurology and psychiatry. Br J Psychiatry 1990; 157: 481–90. 3 The World Health Report 2001. Mental health: new understanding, new hope. Geneva, WHO. 4 ICD-10: the international statistical classification of diseases and related health problems, 10th revision. 2002: http://www.who.int/ whosis/icd10 (accessed May 15, 2003). 5 Bogousslavsky J, Aarli J, Kimura J. Stroke and neurology: a plea from the WFN. Lancet Neurol 2003; 2: 212–13. 6 Eisenberg L. The social construction of the human brain. Am J Psychiatry 1995; 152: 1563–75. 7 Reynolds EH, Trimble MR, eds. The bridge between neurology and psychiatry. Edinburgh: Churchill Livingstone, 1989. 8 Baker M, Menken M. Time to abandon the term mental illness. BMJ 2001; 322: 937. 9 Crisp A, Gelder M, Rix S, Meltzer H, Rolands O. Stigmatisation of people with mental illnesses. Br J Psychiatry 2000; 177: 4–7. 10 Kendell, RE. The distinction between mental and physical illness. Br J Psychiatry 2001; 178: 490–93.
THE LANCET • Vol 361 • June 7, 2003 • www.thelancet.com
Age and the treatment gap in the use of statins Coronary heart disease accounts for more than a quarter of all deaths in the UK. The disease is estimated to cost the National Health Service and personal social services £3·8 billion and private industry more than £3 billion each year, and account for some 35 million working days annually.1 The National (UK) Service Framework for Coronary Heart Disease1 recommends the use of lipid-lowering drugs to achieve total cholesterol concentrations in the plasma below 5 mmol/L for secondary prevention. Despite this recommendation, a recent article by S DeWilde and colleagues,2 based on data collected from 142 general practices across England and Wales in patients with treated coronary heart disease, concludes that many either do not receive lipid-lowering drugs or are probably under-dosed (a treatment gap). With the caveat that plasma cholesterol concentrations were not available in the report, we concur with the overall analysis that these patients, and particularly the elderly, were underprescribed statins. As an indication, in 1996 (the DeWilde paper covers 1994–2001), over three-quarters of patients with coronary disease in the UK were recorded as having cholesterol concentrations above 5·2 mmol/L.3 As in the UK, current guidelines about coronary heart disease in Europe4 recommend total cholesterol below 5 mmol/L (LDL-cholesterol <3 mmol/L), while more rigorous values of below 4 mmol/L (LDL-cholesterol <2·5 mmol/L) are recommended in Australia5 and the USA.6 Although the question of the optimum concentration of plasma cholesterol for secondary prevention of coronary heart disease is interesting,7 the argument in favour of “the lower, the better” is somewhat irrelevant when even the present conservative targets are seldom met. The key question that arises instead is why underprescription of lipid-lowering drugs, and statins in particular, is still an issue despite strong decade-old evidence-based data demonstrating their efficacy in secondary cardiovascular prevention.8 Implicit in DeWilde and colleagues’ study2 is that statins are indicated in all patients with coronary heart disease irrespective of age. The data, however, indicate a clear bias against such treatment in the elderly. Discontinuation of treatment does not seem to be a major factor,2 although discontinuation has been observed before.9 Because clinical practitioners will all want the best outcome for their patients, the findings suggest that many are not persuaded that statin treatment is required to achieve this goal. The ambivalence about treating the elderly with lipid-lowering drugs, an ambivalence which is also found in official guidelines,6 might be due to a perceived lack of evidence favouring cholesterol reduction in this group of patients. The association between plasma cholesterol concentrations and all-cause mortality diminishes with age.10 In addition, most of the evidence base for treatment has accrued from trials in middle-aged men.11 However, two recent major trials have examined the effects of statin treatment in elderly patients with (or at high risk of) vascular or coronary disease, or both. PROSPER,12 targeted at patients aged over 70 years old, showed a significant fall in coronary disease. The Heart Protection Study (HPS), which included almost 6000 patients over 70, showed a reduction in both all-cause mortality and that from coronary heart disease in this, and other, age groups. Although new cancer diagnoses were more frequent with statin treatment in PROSPER, this finding was unsubstantiated by a metaanalysis of all statin trials.12 In HPS, there were no adverse effects on cancer incidence nor on other mortality unrelated to coronary heart disease. Even in non-elderly patients, De Wilde and colleagues show that the use of statins in secondary prevention is less 1925
For personal use. Only reproduce with permission from The Lancet Publishing Group.
COMMENTARY
than optimum.2 Strategies to improve this situation could include the use of interventions after discharge from hospital that prompt the primary-care physician in the use of secondary prevention measures, including the use of lipid-lowering drugs. Simple low-cost interventions can be successful,13,14 and would address issues of poor adherence to statin therapy, including in the elderly.9 *Jaye P F Chin-Dusting, Anthony M Dart Alfred and Baker Medical Unit, Wynn Domain, Baker Heart Research Institute and Alfred Hospital, Melbourne 3004, Victoria, Australia (e-mail: [email protected]) 1
2
3
4
5
6
7
8
9
10
11
12
13
14
National Service Framework on Coronary Heart Disease—emerging findings report. London: Department of Health, 1998: http://www.doh. gov.uk/pub/docs/doh/coronary.pdf (accessed May 15, 2003). DeWilde S, Carey IM, Bremner SA, Richards N, Hilton SR, Cook DG. Evolution of statin prescribing 1994–2001: a case of agism but not sexism? Heart 2003; 89: 417–21. Bowker TJ, Clayton TC, Ingham J, et al. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention Reduce Events). Heart 1996; 75: 334–42. Management of stable angina pectoris. Recommendations of the Task Force of the European Society of Cardiology. Eu Heart J 1997; 18: 394–413. Reducing risk in heart disease. Guidelines for preventing cardiovascular events in people with coronary heart disease. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand, 2003. http://www.heartfoundation.com.au/prof/index_fr.html (accessed May 30, 2003) American Heart Association. Cholesterol lowering drugs. 2003: http://www.americanheart.org/presenter.jhtml?identifier=557 (accessed May 15, 2003). Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360: 7–22. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383–89. Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002; 288: 462–67. Weverling-Rijnsburger AW, Blauw GJ, Lagaay AM, Knnok DL, Meinders AE, Westendorp RG. Total cholesterol and risk of mortality in the oldest old. Lancet 1997; 350: 119–23. Bartlett C, Davey P, Dieppe P, Doyal L, Ebrahim S, Egger M. Women, older persons, and ethnic minorities: factors associated with their inclusion in randomised trials of statins in 1990 to 2001. Heart 2003; 89: 327–28. Shepherd J, Blauw GJ, Murphy MB, on behalf of the PROSPER study group. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised trial. Lancet 2002; 360: 1623–30. Vale MJ, Jelinek MV, Best JD, et al. Coaching patients on achieving cardiovascular health (COACH): a multicenter randomised trial in patients with coronary heart disease. Arch Intern Med (in press). Hilleman DE, Monaghan MS, Ashby CL, Mashni JE, Woolley K, Amato CM. Physician-prompting statin therapy intervention improves outcomes in patients with coronary heart disease. Pharmacotherapy 2001; 21: 1415–21.
Appealing to editors? Biomedical journals aim to publish papers of high quality and integrity. Editors attempt to achieve this goal by means of rigorous clinical and statistical peer review. If editorial decision-making leads to the best and most relevant papers being published in the best possible form, the journal will ultimately gain the trust of readers, authors, reviewers, and the public. Almost every aspect of this process involves important scientific and ethical principles and decisions that are rarely explicitly stated and even less often shared with the readership.1 Correspondence columns in all journals show that this process is by no means perfect and mistakes do happen.2 Therefore, feedback and criticism by readers is recognised 1926
Number of appealed papers % of all rejected papers Accepted for further review Appeal rejected Finally accepted for publication Rejected after further peer review Number of papers with corresponding author from: UK USA Netherlands Germany
2001
2002
246 4·8% 143 102* 32 109†
249 5·3% 114 135 26 83‡
90 34 23 14
79 35 25 22
*1 withdrawn by authors; †2 withdrawn by authors; ‡5 still under review.
Appeals received in 2001 and 2002
by most journals and editors as an important principle of biomedical publishing.3 Equally important however, and rarely allowed, is feedback and dialogue with authors whose papers have been rejected after editorial assessment or after peer review. Most journals will give authors the main reasons for not publishing a paper after peer review; less often so, if the paper was not peer reviewed but rejected by editors. But feedback to authors usually stops at that point, sometimes causing much frustration. Recognising the subjective nature of editorial decision-making and the limitations of peer review—ie, that editors make mistakes—we introduced a formal appeals process in 2001. An appealed paper is initially assessed by the editor who saw the paper originally, in the light of the authors’ arguments as to why it should not have been rejected. The final decision whether to accept the appeal and send the paper for re-review is made in conjunction with the Editor. We thought it might be helpful to readers, reviewers, and authors to share the information on what has happened to these appealed papers. Authors of 246 rejected articles (4·8% of all rejected articles) appealed our decision in 2001. We received a similar number of appeals in 2002 (249, 5·3%) (table). In 2001, 143 appeals were accepted for further peer review and 102 rejections were upheld (one paper was withdrawn by the authors); and 114 appeals were accepted and 135 rejected in 2002. 32 of the accepted appeals (13% of all appealed papers, or 22% of accepted appeals) were finally accepted for publication in 2001, and 26 (10%, 23%) in 2002, with five papers still under review. Where did most appeals came from? Mirroring the overall pattern of submissions by country, most appeals came from a corresponding author based in the UK, followed by USA, Netherlands, and Germany (table). With close to 8000 submissions and space to publish about 650 papers per year, we do have to make decisions not only on validity and novelty, but also on what we judge to be a priority for a general readership. These decisions are perhaps the most difficult, and in some ways the most subjective, for editors to make and for authors to understand. With our appeals process we hope to have achieved a fairer, more transparent, and more accountable approach for authors. We welcome readers’ opinions on, and experience with, this process. Toralf Sperschneider, *Sabine Kleinert, Richard Horton c/o The Lancet, London NW1 7BY, UK 1 2 3
Callaham ML. Journal policy on ethics in scientific publication. Ann Emerg Med 2003; 41: 82–89. Williamson A. What will happen to peer review? Learned Pub 2003; 16: 15–50. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. The role of the correspondence column. 2001: http://www.icmje.org/ index.htm#column (accessed June 2, 2003).
THE LANCET • Vol 361 • June 7, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
However, WHO makes an exception for the “mind”, with its own administrative department, while dividing its substrate, the brain, into different departments—to the disadvantage of neurological patients and the confusion of all, professionals and public alike. These divisions between brain and mind have deep historical roots, reinforced by the separate emergence of neurologists and psychiatrists with overlapping territorial interests. However, the separation of neurology and psychiatry largely on the basis of brain lesions, which occurred mainly in the late 19th and early 20th centuries, is fallacious.2 Neurological and psychiatric patients with or without brain pathology have complex cerebral and mental processes that influence each other within additional important social and cultural settings.2,6 The brain and mind function as a unity, but neurologists and psychiatrists do not.7 One unfortunate consequence is that neurologists and neuroscience nongovernmental organisations (eg, the World Federation of Neurology) wish to destigmatise neurological disorders by dissociating them from mental illness,5,8 while psychiatrists are attempting to destigmatise mental illness with little or no reference to the brain.9 WHO wishes to destigmatise both, but mainly mental and behavioural disorders under the banner of “mental health”.3 The present structure and function of WHO is heavily weighted towards mental health and psychiatric disorders with little neurological input or investment. WHO should integrate public-health aspects of brain and mental illness in a more logical and balanced way to reflect the unity of action and interaction of brain and mind, and the relative contributions of neurological and psychiatric disorders to the global burden of disease. There is a need for greater professional and public awareness of the role of the brain in mental illness and the mind in brain illness, based on modern knowledge of brain and mental function arising from the neurosciences and the psychological and social sciences.1,6,10 Such an understanding, especially if led by WHO, would greatly facilitate a breakdown of the barriers of misunderstanding and stigma surrounding these common diseases, which already amount to about a quarter of the global burden of disease. EHR is a former president of the International League against Epilepsy (ILAE) and a former chairman of the ILAE/IBE/WHO Global Campaign against Epilepsy (Out of the Shadows).
E H Reynolds Institute of Epileptology, King’s College Denmark Hill Campus, London SE5 9PJ, UK (e-mail: [email protected]) 1
Ramachandran VS. The emerging mind. Reith lectures, 2003: http://www.bbc.co.uk/radio4/reith2003 (accessed May 15, 2003). 2 Reynolds EH. Structure and function in neurology and psychiatry. Br J Psychiatry 1990; 157: 481–90. 3 The World Health Report 2001. Mental health: new understanding, new hope. Geneva, WHO. 4 ICD-10: the international statistical classification of diseases and related health problems, 10th revision. 2002: http://www.who.int/ whosis/icd10 (accessed May 15, 2003). 5 Bogousslavsky J, Aarli J, Kimura J. Stroke and neurology: a plea from the WFN. Lancet Neurol 2003; 2: 212–13. 6 Eisenberg L. The social construction of the human brain. Am J Psychiatry 1995; 152: 1563–75. 7 Reynolds EH, Trimble MR, eds. The bridge between neurology and psychiatry. Edinburgh: Churchill Livingstone, 1989. 8 Baker M, Menken M. Time to abandon the term mental illness. BMJ 2001; 322: 937. 9 Crisp A, Gelder M, Rix S, Meltzer H, Rolands O. Stigmatisation of people with mental illnesses. Br J Psychiatry 2000; 177: 4–7. 10 Kendell, RE. The distinction between mental and physical illness. Br J Psychiatry 2001; 178: 490–93.
THE LANCET • Vol 361 • June 7, 2003 • www.thelancet.com
Age and the treatment gap in the use of statins Coronary heart disease accounts for more than a quarter of all deaths in the UK. The disease is estimated to cost the National Health Service and personal social services £3·8 billion and private industry more than £3 billion each year, and account for some 35 million working days annually.1 The National (UK) Service Framework for Coronary Heart Disease1 recommends the use of lipid-lowering drugs to achieve total cholesterol concentrations in the plasma below 5 mmol/L for secondary prevention. Despite this recommendation, a recent article by S DeWilde and colleagues,2 based on data collected from 142 general practices across England and Wales in patients with treated coronary heart disease, concludes that many either do not receive lipid-lowering drugs or are probably under-dosed (a treatment gap). With the caveat that plasma cholesterol concentrations were not available in the report, we concur with the overall analysis that these patients, and particularly the elderly, were underprescribed statins. As an indication, in 1996 (the DeWilde paper covers 1994–2001), over three-quarters of patients with coronary disease in the UK were recorded as having cholesterol concentrations above 5·2 mmol/L.3 As in the UK, current guidelines about coronary heart disease in Europe4 recommend total cholesterol below 5 mmol/L (LDL-cholesterol <3 mmol/L), while more rigorous values of below 4 mmol/L (LDL-cholesterol <2·5 mmol/L) are recommended in Australia5 and the USA.6 Although the question of the optimum concentration of plasma cholesterol for secondary prevention of coronary heart disease is interesting,7 the argument in favour of “the lower, the better” is somewhat irrelevant when even the present conservative targets are seldom met. The key question that arises instead is why underprescription of lipid-lowering drugs, and statins in particular, is still an issue despite strong decade-old evidence-based data demonstrating their efficacy in secondary cardiovascular prevention.8 Implicit in DeWilde and colleagues’ study2 is that statins are indicated in all patients with coronary heart disease irrespective of age. The data, however, indicate a clear bias against such treatment in the elderly. Discontinuation of treatment does not seem to be a major factor,2 although discontinuation has been observed before.9 Because clinical practitioners will all want the best outcome for their patients, the findings suggest that many are not persuaded that statin treatment is required to achieve this goal. The ambivalence about treating the elderly with lipid-lowering drugs, an ambivalence which is also found in official guidelines,6 might be due to a perceived lack of evidence favouring cholesterol reduction in this group of patients. The association between plasma cholesterol concentrations and all-cause mortality diminishes with age.10 In addition, most of the evidence base for treatment has accrued from trials in middle-aged men.11 However, two recent major trials have examined the effects of statin treatment in elderly patients with (or at high risk of) vascular or coronary disease, or both. PROSPER,12 targeted at patients aged over 70 years old, showed a significant fall in coronary disease. The Heart Protection Study (HPS), which included almost 6000 patients over 70, showed a reduction in both all-cause mortality and that from coronary heart disease in this, and other, age groups. Although new cancer diagnoses were more frequent with statin treatment in PROSPER, this finding was unsubstantiated by a metaanalysis of all statin trials.12 In HPS, there were no adverse effects on cancer incidence nor on other mortality unrelated to coronary heart disease. Even in non-elderly patients, De Wilde and colleagues show that the use of statins in secondary prevention is less 1925
For personal use. Only reproduce with permission from The Lancet Publishing Group.
COMMENTARY
than optimum.2 Strategies to improve this situation could include the use of interventions after discharge from hospital that prompt the primary-care physician in the use of secondary prevention measures, including the use of lipid-lowering drugs. Simple low-cost interventions can be successful,13,14 and would address issues of poor adherence to statin therapy, including in the elderly.9 *Jaye P F Chin-Dusting, Anthony M Dart Alfred and Baker Medical Unit, Wynn Domain, Baker Heart Research Institute and Alfred Hospital, Melbourne 3004, Victoria, Australia (e-mail: [email protected]) 1
2
3
4
5
6
7
8
9
10
11
12
13
14
National Service Framework on Coronary Heart Disease—emerging findings report. London: Department of Health, 1998: http://www.doh. gov.uk/pub/docs/doh/coronary.pdf (accessed May 15, 2003). DeWilde S, Carey IM, Bremner SA, Richards N, Hilton SR, Cook DG. Evolution of statin prescribing 1994–2001: a case of agism but not sexism? Heart 2003; 89: 417–21. Bowker TJ, Clayton TC, Ingham J, et al. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention Reduce Events). Heart 1996; 75: 334–42. Management of stable angina pectoris. Recommendations of the Task Force of the European Society of Cardiology. Eu Heart J 1997; 18: 394–413. Reducing risk in heart disease. Guidelines for preventing cardiovascular events in people with coronary heart disease. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand, 2003. http://www.heartfoundation.com.au/prof/index_fr.html (accessed May 30, 2003) American Heart Association. Cholesterol lowering drugs. 2003: http://www.americanheart.org/presenter.jhtml?identifier=557 (accessed May 15, 2003). Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360: 7–22. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383–89. Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002; 288: 462–67. Weverling-Rijnsburger AW, Blauw GJ, Lagaay AM, Knnok DL, Meinders AE, Westendorp RG. Total cholesterol and risk of mortality in the oldest old. Lancet 1997; 350: 119–23. Bartlett C, Davey P, Dieppe P, Doyal L, Ebrahim S, Egger M. Women, older persons, and ethnic minorities: factors associated with their inclusion in randomised trials of statins in 1990 to 2001. Heart 2003; 89: 327–28. Shepherd J, Blauw GJ, Murphy MB, on behalf of the PROSPER study group. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised trial. Lancet 2002; 360: 1623–30. Vale MJ, Jelinek MV, Best JD, et al. Coaching patients on achieving cardiovascular health (COACH): a multicenter randomised trial in patients with coronary heart disease. Arch Intern Med (in press). Hilleman DE, Monaghan MS, Ashby CL, Mashni JE, Woolley K, Amato CM. Physician-prompting statin therapy intervention improves outcomes in patients with coronary heart disease. Pharmacotherapy 2001; 21: 1415–21.
Appealing to editors? Biomedical journals aim to publish papers of high quality and integrity. Editors attempt to achieve this goal by means of rigorous clinical and statistical peer review. If editorial decision-making leads to the best and most relevant papers being published in the best possible form, the journal will ultimately gain the trust of readers, authors, reviewers, and the public. Almost every aspect of this process involves important scientific and ethical principles and decisions that are rarely explicitly stated and even less often shared with the readership.1 Correspondence columns in all journals show that this process is by no means perfect and mistakes do happen.2 Therefore, feedback and criticism by readers is recognised 1926
Number of appealed papers % of all rejected papers Accepted for further review Appeal rejected Finally accepted for publication Rejected after further peer review Number of papers with corresponding author from: UK USA Netherlands Germany
2001
2002
246 4·8% 143 102* 32 109†
249 5·3% 114 135 26 83‡
90 34 23 14
79 35 25 22
*1 withdrawn by authors; †2 withdrawn by authors; ‡5 still under review.
Appeals received in 2001 and 2002
by most journals and editors as an important principle of biomedical publishing.3 Equally important however, and rarely allowed, is feedback and dialogue with authors whose papers have been rejected after editorial assessment or after peer review. Most journals will give authors the main reasons for not publishing a paper after peer review; less often so, if the paper was not peer reviewed but rejected by editors. But feedback to authors usually stops at that point, sometimes causing much frustration. Recognising the subjective nature of editorial decision-making and the limitations of peer review—ie, that editors make mistakes—we introduced a formal appeals process in 2001. An appealed paper is initially assessed by the editor who saw the paper originally, in the light of the authors’ arguments as to why it should not have been rejected. The final decision whether to accept the appeal and send the paper for re-review is made in conjunction with the Editor. We thought it might be helpful to readers, reviewers, and authors to share the information on what has happened to these appealed papers. Authors of 246 rejected articles (4·8% of all rejected articles) appealed our decision in 2001. We received a similar number of appeals in 2002 (249, 5·3%) (table). In 2001, 143 appeals were accepted for further peer review and 102 rejections were upheld (one paper was withdrawn by the authors); and 114 appeals were accepted and 135 rejected in 2002. 32 of the accepted appeals (13% of all appealed papers, or 22% of accepted appeals) were finally accepted for publication in 2001, and 26 (10%, 23%) in 2002, with five papers still under review. Where did most appeals came from? Mirroring the overall pattern of submissions by country, most appeals came from a corresponding author based in the UK, followed by USA, Netherlands, and Germany (table). With close to 8000 submissions and space to publish about 650 papers per year, we do have to make decisions not only on validity and novelty, but also on what we judge to be a priority for a general readership. These decisions are perhaps the most difficult, and in some ways the most subjective, for editors to make and for authors to understand. With our appeals process we hope to have achieved a fairer, more transparent, and more accountable approach for authors. We welcome readers’ opinions on, and experience with, this process. Toralf Sperschneider, *Sabine Kleinert, Richard Horton c/o The Lancet, London NW1 7BY, UK 1 2 3
Callaham ML. Journal policy on ethics in scientific publication. Ann Emerg Med 2003; 41: 82–89. Williamson A. What will happen to peer review? Learned Pub 2003; 16: 15–50. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. The role of the correspondence column. 2001: http://www.icmje.org/ index.htm#column (accessed June 2, 2003).
THE LANCET • Vol 361 • June 7, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.