Designing a Patient Outcome Clinical Assessment Tool for Modified Rankin Scale: “You Feel the Same Way Too”

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

As recommendations with regards to the review of the manuscript informatics-3687105 titled “Designing a Patient Outcome Clinical Assessment Tool for Modified Rankin 2 Scale: “You feel the same way too”, the suggestions to be considered might be found hereinafter,

1. The manuscript addressed a new design to improve the modified Rankin Scale (mRS) currently used to grade patient care within stroke research care delivery for clinical decision making. The current uses and challenges of the modified Rankin Scale (mRS) was first analyzed with questionnaires, then a new detailed clinical assessment tool (CAT) was developed. The contribution is relevant to the field of health service and quality assessment, as well as, decision sciences.
2. Were the participant and question set widths statistically sufficient to represent the general population? What statistical tests were used to prove this adequacy?

 

3. The explanation of the application of proposed approach and the developed method sounds vogue and inadequately described. These could be emphasized more clearly with a more traceable and net sound for scientific researchers as well as the field practitioners.
4. A more detailed comparison with existing model of mRS and developed CAT model might be presented in the discussion and conclusion sections. Add a comparative discussion how the proposed model differs from or improves upon existing framework.
5. The authors are suggested to detail the limitations and future research sub-section.

 

Author Response

comment 1: The manuscript addressed a new design to improve the modified Rankin Scale (mRS) currently used to grade patient care within stroke research care delivery for clinical decision making. The current uses and challenges of the modified Rankin Scale (mRS) was first analyzed with questionnaires, then a new detailed clinical assessment tool (CAT) was developed. The contribution is relevant to the field of health service and quality assessment, as well as, decision sciences

response 1: Thank you for this comment, I appreciate you taking the time acknowledge and summarize the paper. My hope is that this is the first paper of a series that’s ends up in real world implementation of a new modified Rankin Scale. 

comment 2: Were the participant and question set widths statistically sufficient to represent the general population? What statistical tests were used to prove this adequacy?

Response 2: I agree, thank you for acknowledging this and bringing it to my attention, there was a lack of explanation for the methods of the online survey. There have been modifications made to provide clarity.

Two short paragraphs were added to gain clarity on the methods of the online survey. On page five and page six both in the online survey: methods section. The additions are as follows:

“The content of the anonymous online survey was designed to gather insights on clinician’s current use of the modified Rankin Scale (mRS). Questions focused on issues identified in literature and current challenges, opinions, and uses of the mRS.  No formal psychometric validation was done as the aim of the survey was to gather exploratory qualitative insights to help inform design principles.”

“This survey was exploratory and targeted clinicians who are familiar with the mRS in Canada. The sample size was 20, which covers potentially~80% of the 25 hospitals who participate in stroke trials nationally. The aim of the survey was to gather qualitative inferences and design input rather than deductive conclusions; no formal calculations were conducted.”

comment 3: The explanation of the application of proposed approach and the developed method sounds vogue and inadequately described. These could be emphasized more clearly with a more traceable and net sound for scientific researchers as well as the field practitioners

Response 3: Thank you for this important comment.  I agree the explanation of the methods and design principles were vague, this is one of the most critical parts of the paper and deserves more attention and specificity.  A modified version of the design principles have been completed to create more clarity and understanding for readers.

Changes can be seen in section 5: Design Principles for a Clinical Assessment Tool for the modified Rankin Scale starting on page 9-11.

“Domains

  Incorporating more domains into the design of a clinical assessment tool (CAT) specifically for the modified Rankin Scale (mRS) will be useful in getting a more accurate grade. The mRS currently only focuses on mobility with a secondary focus on basic daily tasks. The research shows cognition and communication are highly affected post-stroke which is why they should be considered when administering the 90-day mRS. In the mRS CAT, having four domains such as mobility, daily tasks, communication, and cognition will help gain a better understanding of the patient's outcomes 90 days post stroke while maintaining the current scales focus of mobility and daily tasks. Furthermore, including a more holistic approach to what encompasses an mRS score is at the forefront of accessibility and inclusion, adding in categories such as cognition or communication in the CAT would help capture a more realistic understanding of outcomes post stroke. These domains are underrepresented in the current mRS scoring but impact a patient's function and recovery, making their inclusion in the assessment critical for equity and accuracy. This would in turn allow for a more meaningful and accurate mRS score. 

Images 

   The Clinical Assessment Tool (CAT) should incorporate simple, clear visuals alongside text cues for each option. These images should be easily interpreted, for example using consistent basic black-and-white icon-style illustrations representing people and actions described in textual cues. Providing clear and intuitive visual representations will enhance clarity and reduce cognitive load through accelerating decision-making by allowing quick, accessible visual cues that guide users in selecting the appropriate option with minimal cognitive load. Having images in the CAT also increases accessibility and inclusivity by making the options more approachable and understandable to users with varying cognition or language abilities.  

Phrasing 

    Phrasing within the CAT should be simple and at a rudimentary reading level to accommodate the diverse demographic of users. Design decisions should prioritize readability by using clear, direct language that minimizes ambiguity. Using a first-person perspective in all phrasing options will further support comprehension by enabling users to identify with options more easily and efficiently during the assessment process. This design principle highlights accessibility and clarity for the user, which in turn creates a more efficient decision-making process.  

Providing Examples 

    Including examples for more ambiguous options is important to reduce cognitive load and support accurate decision-making. Examples should focus on typical daily tasks and activities relevant to users’ lives, thereby providing context that enhances understanding and allows users to make selections confidently.  Examples should be easy to understand and applicable to a vast demographic. Specifically for the modified Rankin Scale having example that are relatable and firsthand perspective for example if the option was for mobility and said “I have mobility restrictions” the example could be “I have issues with balance, distance or speed when moving independently” this indicates a person is independently mobile and has some slight mobility issues. This will help with efficiency and clarity by allowing the user a deeper and more relatable understanding of the choices which may help decrease cognitive load, creating a more efficient tool.  

Number of Options 

   The number of options provided within each section is critical to avoid overwhelming the user. Maintaining a concise set of distinct and meaningful options will reduce cognitive load, create efficient decision-making, and improve the overall usability of the tool. Having enough information and choice on the page is crucial to getting an accurate score without creating a time burden or having too many options that will overload the user. Having between three to six options per domain and having them read from upper left to bottom right to align with how majority of users read on and offline is an important step for minimal cognitive load, and easy scanning [14]. For a clinical assessment tool (CAT) for the modified Rankin Scale (mRS) if adding in new domains we suggest keeping mobility and daily tasks which are the current focus as primary domains in the CAT allowing them more options and heavier scoring weights than any new domains being added. For example, adding in cognition and communication, they could have three to five options and mobility, and daily tasks could have four to six. This way the tool is still recognizable to clinicians using it who are used to only focusing on mobility and daily tasks.  

Visual Aesthetics 

    The overall visual aesthetic of the CAT should be clean, minimalistic, and uncluttered to reduce distractions and cognitive load. Consistent use of images, spacing, and style will contribute to an intuitive and user-friendly interface, supporting focus and enhancing the assessment experience. Having a clear visual hierarchy is important, breaking down the information into distinct sections such as title, question, options will allow users to instantly separate and understand the relevant information of each section on the page allowing for easier focus [14]. Each page or section should discuss one area of disability at a time, so there is no overlap and reduces confusion when gathering information, such as separating daily tasks and mobility into separate sections. Similarly, structuring the CAT questions in ascending order from least to most severe disability will support more deliberate decisions making to choose the most appropriate response; this will allow users to move on faster to the next question. 

User Satisfaction & Engagement 

    Making sure the Clinical Assessment Tool (CAT) creates a positive user experience will increase usability. The CAT should be designed to feel intuitive to use making the user feel in control during the process. Making the CAT familiar will help with ease of use, following an intuitive route will lessen the need for attention and short-term memory use creating a more pleasant and comfortable user experience [14]. Ensuring the CAT is responsive is key for user satisfaction, making sure to have ways to keep the user informed such as adding in page numbers, and progress indicator are a good way to show active responsiveness to the user [14]. Having a progress indicator to help reduce uncertainty and show users their progress in the CAT is important while having an intuitive flow that makes users feel in control will increase user satisfaction and autonomy while using the tool. Having an immediate scoring and an explanation of results will reinforce trust in the CAT while ensuring users understand their outcomes. Having a thank you message with a simple intuitive layout will also help contribute to a more satisfying user experience. “

Comments 4: A more detailed comparison with existing model of mRS and developed CAT model might be presented in the discussion and conclusion sections. Add a comparative discussion how the proposed model differs from or improves upon existing framework

Response 4: I Agree, thank you for bringing this to my attention, this is a critical point to bring importance to for the reader to help the reader understand why this paper is so important. There lacked an explicit comparison of the current mRS and the CAT mRS. a paragraph has been added with a direct comparison of both tools.

A paragraph was added to the discussion as a comparison which can be found on page 12. The added paragraph is as follows:  

“The comparison of the current modified Rankin Scale (mRS) and the proposed Clinical assessment tool (CAT) for the mRS is vast. The current mRS assessment method allows for open-ended interpretation by clinicians, whereas the CAT would be structured using binary questions and predefined options to get a more precise and reproducible grade. The standardization of the current mRS varies based on administrator and at times, setting. The CAT is designed to have high standardization with automated scoring to minimize subjective judgement. The Cognitive load of the current mRS can be seen as high due to the ambiguity and lack of prompts creating the need for subjective decision making on the scoring, whereas the newly proposed CAT offers reduced cognitive load through having a clear guide for decisions making. Lastly, the current mRS focuses mainly on mobility with a slight secondary focus on basic daily tasks, the new proposed CAT suggests adding domains such as cognition and communication to gain a more global understanding of disability post stroke.”

Comments 5: The authors are suggested to detail the limitations and future research sub-section

Response 5: I agree, the limitation section was missing, and the future directions required more specificity.

The following has been added to the discussion as subsections and expanded on the future directions section. the following changes were made and added into the discussion on page 13.  

Future Directions

    Next steps and future directions are to take the design principles and create a low fidelity first iteration of a user interface for the modified Rankin Scale (mRS) Clinical Assessment Tool (CAT).  This will be the first step of validation and standardization of the new tool. Once the first iteration of the tool is developed there will be a user study with stroke survivors and clinicians done to gain insights into the efficacy and validity of the new tool. The aim is to elevate the CAT to become a benchmark tool across healthcare settings.  The user-interface of this tool will eventually aim to complement existing electronic health records and tools while providing guidance throughout the assessment, helping gather information and decision-making.

Limitations  

    The limitations in this paper were the sample size of the online survey, we had 20 participants which sufficed and helped gain valuable data. Having more participants could have upheld more data for our study. Having the survey anonymous was important and allowed for opinions to be shared more readily, although adding more details for the demographic portion of the survey could have added value so we could have had an idea of where the participants were working, this could have added concrete data to assure we had participants from across Canada

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript explores an important topic: improving the reliability and usability of the Modified Rankin Scale (mRS) through the design of a Clinical Assessment Tool (CAT) informed by human-computer interaction principles. The question is well worth investigating, particularly given the long-standing concerns over inter-rater variability in mRS scoring. However, in its current form, the manuscript reads more like a conceptual outline than a completed research study. The structure is loosely organized, several key components are underdeveloped, and some of the claims are presented without adequate supporting detail.

My comments:

1) The abstract is too general. It should summarize the main contributions of the paper more clearly, especially any specific design insights or empirical findings.

2) In my opinion, the research goal of this MS is not very clear. It is not obvious whether the primary goal is to introduce a new digital tool, to present data from a clinician survey, or to combine both. If the intention is to do both, the manuscript needs to articulate the connection between these components more clearly.

3) Given the central role of the clinician survey in the study, more information is needed on how it was constructed. Were any items based on existing validated tools? Was the questionnaire piloted? How were participants selected, and how representative are they of clinicians who regularly use the mRS in clinical settings?

4) All figures should be accompanied by concise and informative captions explaining their relevance to the study.

5) Terminology should be used consistently. The terms “CAT,” “tool,” and “system” appear to be used interchangeably, which may confuse readers.

6) The MS repeatedly refers to the proposed Clinical Assessment Tool but offers no specific details about its structure or interface. A few conceptual visuals—such as screen mockups or logic diagrams—would help readers grasp what is being proposed and how it might address the limitations of existing approaches.

7) The MS contains noticeable repetition in both vocabulary and ideas. Phrases like “user-friendly” and “easy to use” are used frequently but remain undefined and unsupported. These descriptors should be replaced with more precise terminology, possibly drawing from established usability metrics.

8) The list of abbreviations at the end of the manuscript disrupts the narrative flow. It would be better placed in a footnote or as supplementary material.

Author Response

Comments 1: The abstract is too general. It should summarize the main contributions of the paper more clearly, especially any specific design insights or empirical findings

Response 1: Thank you for the comment. I agree, there lacked specificity in the aim of the paper within the abstract, it has been modified to add some more depth into the methods.

The Modified Rankin Scale (mRS) is a widely used outcome measure for assessing disability in stroke care; however, its administration is often affected by subjectivity and variability, leading to poor inter-rater reliability and inconsistent scoring. Originally designed for hospital discharge evaluations, the mRS has evolved into an outcome tool for disability assessment and clinical decision-making. Inconsistencies persist due to a lack of standardization and cognitive biases during its use. This paper presents design principles for creating a standardized clinical assessment tool (CAT) for the mRS, grounded in human-computer interaction (HCI) and cognitive engineering principles. Design principles were informed in part by an anonymous online survey conducted with clinicians across Canada to gain insights into current administration practices, opinions, and challenges of the mRS. The proposed design principles aim to reduce cognitive load, improve inter-rater reliability, and streamline the administration process of the mRS. By focusing on usability and standardization, the design principles seek to enhance scoring consistency and improve the overall reliability of clinical outcomes in stroke care and research. Developing a standardized CAT for the mRS represents a significant step toward improving the accuracy and consistency of stroke disability assessments. Future work will focus on real-world validation with healthcare stakeholders and exploring self-completed mRS assessments to further refine the tool. 

Comments 2: In my opinion, the research goal of this MS is not very clear. It is not obvious whether the primary goal is to introduce a new digital tool, to present data from a clinician survey, or to combine both. If the intention is to do both, the manuscript needs to articulate the connection between these components more clearly.

Response 2:  thank you for bringing this to my attention. I Agree, there was no clear aim or objective of the paper stated which will help guide the reader in the paper. I have modified the introduction by adding a few sentences about the aims of the paper to emphasize this point.

The added information was added to the last paragraph of the introduction which can be found on page two. The following was added:

“This paper has two objectives, one, to analyze clinician use and experiences with the current modified Rankin Scale (mRS) administration through an anonymous online survey and second, to propose design principles for a new clinical assessment tool (CAT) for the mRS informed by these findings and current literature grounded in human-computer interaction (HCI) principles to improve inter-rater reliability and the standardization of the mRS.”

Comments 3: Given the central role of the clinician survey in the study, more information is needed on how it was constructed. Were any items based on existing validated tools? Was the questionnaire piloted? How were participants selected, and how representative are they of clinicians who regularly use the mRS in clinical settings?

Response 3:  I Agree, thank you for pointing this out, it is important for the reader to understand the aim, and methods of the online survey, and there lacked clarity on the methods for the online survey.

 Two short paragraphs were added to gain clarity on the methods of the online survey. On page five and page six both in the online survey: methods section. The additions are as follows:     

“The content of the anonymous online survey was designed to gather insights on clinician’s current use of the modified Rankin Scale (mRS). Questions focused on issues identified in literature and current challenges, opinions, and uses of the mRS.  No formal psychometric validation was done as the aim of the survey was to gather exploratory qualitative insights to help inform design principles.”

“This survey was exploratory and targeted clinicians who are familiar with the mRS in Canada. The sample size was 20, which covers potentially~80% of the 25 hospitals who participate in stroke trials nationally. The aim of the survey was to gather qualitative inferences and design input rather than deductive conclusions; no formal calculations were conducted.”

Comments 4: All figures should be accompanied by concise and informative captions explaining their relevance to the study.

Response 4: I agree, figure captions were vague. It is important to give the reader more context for what the figures represent within the paper.

All figure captions were modified to include more information on why they are in the paper and how they relate to the study.

Page 3: figure 1. modified Rankin Scale (mRS) from the ESCAPE stroke trial [7]. This mRS was used as an outcome measure approximately 90-days post stroke. This figure shows one of the versions of the mRS that was administered to stroke survivors. This version has the scores and grades bolded with further guidelines italicized below.

page 4:  Figure 2. modified Rankin Scale from ESCAPE-NA1 Stroke trial [9]. This mRS was used as an outcome measure approximately 90-days post-stroke. This figure shows one version of the mRS that was administered to stroke survivors. This version of the mRS goes in descending order of scores starting with six and working down to zero.

Page 7: Figure 3. Results from our anonymous online survey looking at reported challenges in administering the current modified Rankin Scale (mRS), the questions asked was” What are the main challenges you face when administering the mRS (select all that apply)”.  This figure is based on responses from 20 Canadian clinicians.

Page 8: Figure 1. Results from our anonymous online survey looking at Proposed improvements to the modified Rankin Scale (mRS), the questions asked was” In your opinion, how do you think the mRS could be improved for both clinicians and patients? (select all that apply)”.  This figure is based on responses from 20 Canadian clinicians.

Comments 5: Terminology should be used consistently. The terms “CAT,” “tool,” and “system” appear to be used interchangeably, which may confuse readers.

Response 5: I agree, thank you for pointing that out- I went ahead and changed “system” and “tool” to clinical assessment tool (CAT)

The changes were made on the following pages:

Changed system to CAT on page 11, 12

Changed tool to CAT on page 9, 11,12

Comments 6:  The MS repeatedly refers to the proposed Clinical Assessment Tool but offers no specific details about its structure or interface. A few conceptual visuals—such as screen mockups or logic diagrams—would help readers grasp what is being proposed and how it might address the limitations of existing approaches.

Response 6: I agree, the design principles were quite vague and non-specific to the modified Rankin Scale (mRS). In response to this a new design principles section was made in hoped the reader will understand the potential for the proposed clinical assessment tool (CAT) please see changes below.

Changes can be seen in section 5: Design Principles for a Clinical Assessment Tool for the modified Rankin Scale starting on page 9-11.

“Domains

  Incorporating more domains into the design of a clinical assessment tool (CAT) specifically for the modified Rankin Scale (mRS) will be useful in getting a more accurate grade. The mRS currently only focuses on mobility with a secondary focus on basic daily tasks. The research shows cognition and communication are highly affected post-stroke which is why they should be considered when administering the 90-day mRS. In the mRS CAT, having four domains such as mobility, daily tasks, communication and cognition will help gain a better understanding of the patient's outcomes 90 days post stroke while maintaining the current scales focus of mobility and daily tasks. Furthermore, including a more holistic approach to what encompasses an mRS score is at the forefront of accessibility and inclusion, adding in categories such as cognition or communication in the CAT would help capture a more realistic understanding of outcomes post stroke. These domains are underrepresented in the current mRS scoring but impact a patient's function and recovery, making their inclusion in the assessment critical for equity and accuracy. This would in turn allow for a more meaningful and accurate mRS score. 

Images 

  The Clinical Assessment Tool (CAT) should incorporate simple, clear visuals alongside text cues for each option. These images should be easily interpreted, for example using consistent basic black-and-white icon-style illustrations representing people and actions described in textual cues. Providing clear and intuitive visual representations will enhance clarity and reduce cognitive load through accelerating decision-making by allowing quick, accessible visual cues that guide users in selecting the appropriate option with minimal cognitive load. Having images in the CAT also increases accessibility and inclusivity by making the options more approachable and understandable to users with varying cognition or language abilities.  

Phrasing 

Phrasing within the CAT should be simple and at a rudimentary reading level to accommodate the diverse demographic of users. Design decisions should prioritize readability by using clear, direct language that minimizes ambiguity. Using a first-person perspective in all phrasing options will further support comprehension by enabling users to identify with options more easily and efficiently during the assessment process. This design principle highlights accessibility and clarity for the user, which in turn creates a more efficient decision-making process. 

Providing Examples 

Including examples for more ambiguous options is important to reduce cognitive load and support accurate decision-making. Examples should focus on typical daily tasks and activities relevant to users’ lives, thereby providing context that enhances understanding and allows users to make selections confidently.  Examples should be easy to understand and applicable to a vast demographic. Specifically for the modified Rankin Scale having example that are relatable and firsthand perspective for example if the option was for mobility and said “I have mobility restrictions” the example could be “I have issues with balance, distance or speed when moving independently” this indicates a person is independently mobile and has some slight mobility issues. This will help with efficiency and clarity by allowing the user a deeper and more relatable understanding of the choices which may help decrease cognitive load, creating a more efficient tool.  

Number of Options 

The number of options provided within each section is critical to avoid overwhelming the user. Maintaining a concise set of distinct and meaningful options will reduce cognitive load, create efficient decision-making, and improve the overall usability of the tool. Having enough information and choice on the page is crucial to getting an accurate score without creating a time burden or having too many options that will overload the user. Having between three to six options per domain and having them read from upper left to bottom right to align with how majority of users read on and offline is an important step for minimal cognitive load, and easy scanning [14]. For a clinical assessment tool (CAT) for the modified Rankin Scale (mRS) if adding in new domains we suggest keeping mobility and daily tasks which are the current focus as primary domains in the CAT allowing them more options and heavier scoring weights than any new domains being added. For example, adding in cognition and communication, they could have three to five options and mobility, and daily tasks could have four to six. This way the tool is still recognizable to clinicians using it who are used to only focusing on mobility and daily tasks.  

Visual Aesthetics 

The overall visual aesthetic of the CAT should be clean, minimalistic, and uncluttered to reduce distractions and cognitive load. Consistent use of images, spacing, and style will contribute to an intuitive and user-friendly interface, supporting focus and enhancing the assessment experience. Having a clear visual hierarchy is important, breaking down the information into distinct sections such as title, question, options will allow users to instantly separate and understand the relevant information of each section on the page allowing for easier focus [14]. Each page or section should discuss one area of disability at a time, so there is no overlap and reduces confusion when gathering information, such as separating daily tasks and mobility into separate sections. Similarly, structuring the CAT questions in ascending order from least to most severe disability will support more deliberate decisions making to choose the most appropriate response; this will allow users to move on faster to the next question. 

User Satisfaction & Engagement 

Making sure the Clinical Assessment Tool (CAT) creates a positive user experience will increase usability. The CAT should be designed to feel intuitive to use making the user feel in control during the process. Making the CAT familiar will help with ease of use, following an intuitive route will lessen the need for attention and short-term memory use creating a more pleasant and comfortable user experience [14]. Ensuring the CAT is responsive is key for user satisfaction, making sure to have ways to keep the user informed such as adding in page numbers, and progress indicator are a good way to show active responsiveness to the user [14]. Having a progress indicator to help reduce uncertainty and show users their progress in the CAT is important while having an intuitive flow that makes users feel in control will increase user satisfaction and autonomy while using the tool. Having an immediate scoring and an explanation of results will reinforce trust in the CAT while ensuring users understand their outcomes. Having a thank you message with a simple intuitive layout will also help contribute to a more satisfying user experience. “

Comments 7:  The MS contains noticeable repetition in both vocabulary and ideas. Phrases like “user-friendly” and “easy to use” are used frequently but remain undefined and unsupported. These descriptors should be replaced with more precise terminology, possibly drawing from established usability metrics.

 Response 7: Agreed, the phrases are vague and unsupported, as per response six the design principles along with the language have been modified

Comments 8:   The list of abbreviations at the end of the manuscript disrupts the narrative flow. It would be better placed in a footnote or as supplementary material.

Response 8: I agree, this was the original MDPI template it is unnecessary as all abbreviations in the paper are explained. It will be removed.

Abbreviations 

The following abbreviations are used in this manuscript: 

mRS	Modified Rankin Scale
CAT	Clinical Assessment Tool

 

This abbreviation list has been removed from paper on page 14.  

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The assessment of revised manuscript could be seen hereinafter

 

The authors answered all the critics of previous assessment, thanks for their effort and attention. 

The sample size of participants should be tested statistically and/or should be justified based on the existing literature. 

The presentation of findings are improved. 

The developed approach might be represented with a illustration to better presentation and help readers to track the information flow through application. 

Author Response

comment 1: The sample size of participants should be tested statistically and/or should be justified based on the existing literature. 

Response 1: I agree, there needed to be clearer justification of the sample size 20. After researching other exploratory qualitative studies i have found a more clear justification for the sample size. 

the changes can be found in the online survey methods section on page 6.

"This sample size follows the established norms for exploratory qualitative research where we can find meaningful insights with smaller yet targeted samples that can reach saturation, for qualitative research using interviews it has been found saturation can be reached with between 9-17 participants with homogenous populations such as our online survey [11] [12]."

comment 2: The developed approach might be represented with a illustration to better presentation and help readers to track the information flow through application. 

Response 2: I agree, there needed to be a more clear process flow of the CAT.

A Process Flow Diagram of the Clinical Assessment Tool (CAT) outlining the process to complete the CAT and get a modified Rankin Scale (mRS) Score has been added with a figure caption on page 11. Please see attached updated paper and figures. 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

No comments

Author Response

thank you kindly for your help, and feedback for this paper. I appreciate your knowledge and work on reviewing my paper. All the best.