Pre-Operative Anxiety Related to Major Urogynecologic Surgery: Insights from Perioperative Survey Data in Maine

Round 1

Reviewer 1 Report

Comments for author File: Comments.pdf

Author Response

Dear Reviewer 1,

Thank you very much for your thoughtful review of our manuscript. We look forward to its publication as we hope it will be of use to others.

Sincerely,

Dr Kaonga

Reviewer 2 Report

Assessing anxiety in gynecological patients is a relevant topic. The study is adequately designed, and methods are appropriate.  There's however a need to clarify the selection process, particularly lines 136-137, how were the enrolled patients selected from the 10 times bigger elligible population.

The research is about pre-operative anxiety related to major urogynecologic surgery (sacrocolpopexy, sacrospinous ligament fixation, uterosacral suspension) in a sub-specialty clinic that focuses on urogynecology.

The study was conducted to risk-stratify persons undergoing major uro-gynecologic surgery by their pre-operative anxiety levels to identify opportunities for targeted intervention.

The study has found no statistical association between variables and high pre-operative anxiety levels, nevertheless, the study provided an opportunity to better understand the patient population’s perioperative anxiety, especially related to the procedure and recovery. Findings are also consistent with more recent literature investigating anxiety and the perioperative period. Conclusions are consistent with the evidence and arguments presented and address the study question

Regarding potential improvements on the submission please refer to my commentaries made on the evaluation form regarding Patient Selection process that in my opinion should have a more detailed explanation.

As stated in the checklist on the submission form, I considered the references adequate and updated, below is a recent article on the subject not considered in the submitted article

Moss C, Pandya PR, Yanek L, Lovejoy D, Muñiz K, Chen CCG, Blomquist J, Jacobs S, Powell A, Handa VL, Patterson D. The impact of anxiety on postoperative pain following pelvic reconstructive surgery. Int Urogynecol J. 2023 Jul;34(7):1551-1557. doi: 10.1007/s00192-022-05423-y. Epub 2022 Dec 21. PMID: 36542143.

Regarding Tables and figures

Table 1 should be on a single page.

Figure 2 legend is separated from the figure.

Author Response

Thank you very much for your thorough and thoughtful review! We appreciate the feedback. Our responses are as follows:

Please see sections 2.1 and 2.2 for enrollment information in the study. That should answer the questions regarding participant selection and enrollment. At the end of line 137 we have added a line to clarify that we did not know the total actually approached as that data was not captured.

Thank you for the additional reference. This study was not published at the time we wrote and updated the manuscript. Thank you for bringing it to our attention. We have incorporated it into the discussion as follows: “However, a recent study found data that suggests that elevated pre-operative anxiety levels are associated with higher post-operative pain.21 This is particularly relevant to our population.”

Regarding table 1, we will flag this for the attention of the formatters/editors.

Regarding figure 2, Attempted to link them, but I believe the editors will be able to help with reformatting and ensuring everything is present/visible for that particular figure. Just in case, we have added a line below the figure with information on each axis.

Reviewer 3 Report

 The manuscript investigates pre-operative anxiety levels in patients undergoing major urogynecologic surgery, seeking to identify predictive variables for high anxiety. Utilizing a mixed-methods approach, the study provides a comprehensive examination of anxiety patterns, incorporating both quantitative and qualitative analyses. While the study is well-conceived and addresses an important clinical issue, certain aspects require further attention for enhanced clarity and impact.

The sample size (n=54) and the homogeneity of the participant demographic (predominantly White) might limit the generalizability of the findings. A discussion regarding how these factors impact the study’s applicability to a broader population would be beneficial.

Were there any sub-group analyses conducted, particularly focusing on participants with prior mental health conditions? Insights into how pre-operative anxiety varies across different patient sub-groups could be valuable.

The methodology, particularly the mixed-methods approach, is commendable. However, the justification for the chosen methods and their relevance to the study's aims could be more explicitly outlined. https://www.mdpi.com/2227-9032/11/19/2665, the study describes role of emotions of healthcare and triangulation of the qualitative and quantitative approach, may be a good rationale for the design.

The qualitative findings were insightful, could be strengthened with more explicit connections between the identified themes and existing literature on pre-operative anxiety.

The manuscript reports null findings regarding the association between various variables and pre-operative anxiety levels. A more thorough discussion of these null findings, including potential reasons and implications, would enhance the depth of the analysis.

A more comprehensive discussion of methodological limitations, such as the impact of self-reported measures and the potential for recall bias, would strengthen the manuscript. Exploring ways these limitations could be addressed in future research would also be beneficial. Addressing the possibility of response bias, especially considering the sensitive nature of the topic (anxiety), would strengthen the study. How might participants’ willingness to disclose anxiety or understanding of what constitutes anxiety affect the results?

Given that the study was conducted during the COVID-19 pandemic, a discussion on how the pandemic might have influenced anxiety levels and the implications for the study’s findings would be pertinent.

While the manuscript discusses the potential for interventions to mitigate pre-operative anxiety, a more detailed exploration of specific clinical strategies and how they could be implemented in practice would be valuable. This could include a discussion of barriers to implementation and how these might be overcome.

None

Author Response

Thank you very much for your thoughtful feedback. Please find our responses to your comments in bold below. Again, thank you!

** 

The manuscript investigates pre-operative anxiety levels in patients undergoing major urogynecologic surgery, seeking to identify predictive variables for high anxiety. Utilizing a mixed-methods approach, the study provides a comprehensive examination of anxiety patterns, incorporating both quantitative and qualitative analyses. While the study is well-conceived and addresses an important clinical issue, certain aspects require further attention for enhanced clarity and impact.

The sample size (n=54) and the homogeneity of the participant demographic (predominantly White) might limit the generalizability of the findings. A discussion regarding how these factors impact the study’s applicability to a broader population would be beneficial.

Our discussion (end of old paragraph 4 now new paragraph 6) already did include the limitations of homogeneity and applicability not just of our study, but also pointed out  the lack of representation in gynecologic sub-specialty [research] overall. Please advise if more sentences should be added to the pre-existing text.

Were there any sub-group analyses conducted, particularly focusing on participants with prior mental health conditions? Insights into how pre-operative anxiety varies across different patient sub-groups could be valuable.

We had conducted sub-group analyses on participants with prior mental health conditions but, interestingly, that did not change the data. Please see the results section where we had mentioned this: lines 167-169.

The methodology, particularly the mixed-methods approach, is commendable. However, the justification for the chosen methods and their relevance to the study's aims could be more explicitly outlined. https://www.mdpi.com/2227-9032/11/19/2665, the study describes role of emotions of healthcare and triangulation of the qualitative and quantitative approach, may be a good rationale for the design. 

We are not sure what is meant by this feedback. Clarification would be appreciated.

The qualitative findings were insightful, could be strengthened with more explicit connections between the identified themes and existing literature on pre-operative anxiety.

Clarification would be appreciated on this comment as well, especially given our pre-existing discussion text includes relevant information that is linked to the qualitative findings.

The manuscript reports null findings regarding the association between various variables and pre-operative anxiety levels. A more thorough discussion of these null findings, including potential reasons and implications, would enhance the depth of the analysis.

We have a paragraph in the discussion about why our findings may have not revealed any associations. Please see discussion section paragraph 2.

A more comprehensive discussion of methodological limitations, such as the impact of self-reported measures and the potential for recall bias, would strengthen the manuscript. Exploring ways these limitations could be addressed in future research would also be beneficial. Addressing the possibility of response bias, especially considering the sensitive nature of the topic (anxiety), would strengthen the study. How might participants’ willingness to disclose anxiety or understanding of what constitutes anxiety affect the results?

We have added more details in the discussion to expand on the limitations.

Given that the study was conducted during the COVID-19 pandemic, a discussion on how the pandemic might have influenced anxiety levels and the implications for the study’s findings would be pertinent.

In the discussion, we note that the data were not affected by the covid-19 pandemic. The pre- and post-covid participants were not statistically different from each other.

While the manuscript discusses the potential for interventions to mitigate pre-operative anxiety, a more detailed exploration of specific clinical strategies and how they could be implemented in practice would be valuable. This could include a discussion of barriers to implementation and how these might be overcome.

While interesting, we believe this is beyond the scope of our paper.

Round 2

Reviewer 2 Report

The revision process improved the submission, the study subject is relevant and the study design is valid. The information obtained is useful for future research on the topic

Author Response

Thank you very much

Reviewer 3 Report

The authors have attempted to address some comments. However, despite the comments being self-explanatory, most suggestions are not reflected in the manuscript.

Apart from a few sentences on qualitative analysis, which I found to be very generic, there are not many details on what was actually done. Therefore, major quality items in qualitative research/grounded theory should be well described to ensure thoroughness. How would you convince your reader about the rigor of your findings?

'Qualitative data were analyzed manually using grounded theory. Specifically, open coding techniques were used to develop themes, and as the data continued to be systematically reviewed, axial coding techniques were then applied to generate and refine categories of the qualitative data.'

Are there any qualitative findings actually included in the results? Were the two free-text responses in the survey the only qualitative components? Is this a mixed-method approach on that basis? I also suggest that the authors add the questionnaire used in the research as a supplementary material in the manuscript.

None

Author Response

Thank you again for your feedback. We have done our best to clarify the methods used (throughout the text from the title, to the abstract to the text itself) and are working with the editor to include the survey tools as supplement to better clarify the quantitative and qualitative elements analyzed.