Public Health and Disability: A Real-Life Example of the Importance of Keeping Up the Good Work

Round 1

Reviewer 1 Report

The CPUP is a wildly successful program that has made a tremendous impact on reducing hip dislocation. Further, the lessons learned and disseminated by the study team also provide important information for large-scale prevention efforts that can be adopted by more than just orthopedic groups. The implications of CPUP are far reaching, such as reduced healthcare utilization, improved function, and enhanced QoL. Thank you to the study team for creating such an impactful program in which we can all learn from.

As explained below, I think the study team has a lot of really important things to say on the topic of public health and disability. As it is currently presented, the paper with the focus on research findings are rather weak, and the manuscript as a whole is rather incongruent; although, I do wish to note that the writing is excellent for each section and element presented independently, but seems to lack cohesiveness across sections/elements to make a single, focused research paper. With that said, I propose that the authors consider doing a review paper on the topic of public health and disability, and use some of the CPUP findings to provide real world evidence to support the claims that it is necessary to keep up the good work.

The title and first 2 paragraphs in the Introduction are well written, and begins to read as an exciting review article on the topic of public health and disability. The next Introduction section on CPUP is also well written, but was an abrupt transition that did not seem to coalesce very well with the title and beginning of what seemed like a review paper. Then, there were aims, which was again, a bit surprising given the flow of the title and Introduction.

The Results section is rather weak. I understand that some of the data is only available from 2017-2019, but the results were not compelling to have this paper as a standalone research article in my opinion. The reasons for the hip dislocations are given for the year 2019, but not for other years. I do think this is an important point that could supplement a review article, described below, but as a research paper, the lack of attention on other years’ for the cause of hip dislocation in relation to waiting time, for example, seems unbalanced. 9 of the 29 events were related to waiting for surgery, which would have led to ~0.5%, which is aligned with the 2010-2014 data. I can only assume since it is not stated that these 9 events in 2019 were odd and unique to the time period, as this is how the authors presented this information.

The Discussion section is well written, but seems to be incongruent with the findings. The authors make arguments explaining the increase in hip dislocation. However, as presented, it appears that the increase in hip dislocations in 2019 were uniquely due to excess waiting times longer than normal. The authors briefly mention this, but much of the Discussion is spent speculating other reasons.

I recommend two options, but as the authors know more about their own paper, program, and message from this paper than I do, I am certainly open to explanation for not changing the focus of this work.

Option #1: Reformat for a review article focused on public health and disability, and the need to continue efforts even during times of crises, such as the COVID 19 pandemic. The authors obviously have a lot of really great things to say and disseminate to the world about prevention programs for individuals with disabilities, and there is much we can all learn from them. Parts of this paper have strong elements for an impactful review. For example, the authors discuss the impact of COVD 19 and reducing medical intervention and prevention, which is going to disproportionately impact individuals with disabilities. Some of the CPUP data could provide real world evidence of the effect of extra waiting times on hip dislocations, which ~1/3 of them could have been prevented with adequate waiting times for surgeries. On the topic of public health and epidemiology, while a 0.3% increase may seem marginal, the increase in preventable burdens are likely occurring across many medical problems (e.g., fractures, cardiometabolic health, function, nutrition) and globally for CP and other populations with disabilities. The global impact stemming for several populations with disabilities of this seemingly marginal increase in preventable conditions and the long-term impact is tremendous. So, a clear focus on the need for public health and disability, especially in times where medical interventions are reduced, on many disability populations would be an impactful review. The CPUP data could provide a compelling argument of what happens when our medical systems let up and do not monitor as intensively as they should.

Option #2: The review article suggestion may not be of interest to the study team. If that is the case, then I recommend removing much of the Discussion on speculation of the increase in 2019 hip dislocations, and consider filling that space with some basic elements of what I described in Option #1 above, centered around the extra waiting time as a preventable cause, and that prevention efforts need to continue for the population with CP and other disabilities.   

Author Response

Please see attached.

Author Response File: Author Response.pdf

Reviewer 2 Report

Congratulations on this excellent paper re quality assurance of CPUP. 

It is wonderful to read about the latest cohort of children from CPUP. The authors should be congratulated on identifying this small increase in hip dislocation in the most recent cohort. Well done on highlighting the importance of constant quality assurance and the monitoring of the program - necessary to maintain the excellent results of CPUP. 

Please see some small suggestions for consideration in the attached file. 

I am interested by your statement:  It is also possible that the increased number of children during the years 2015-2019 was due to an influx of children with CP who immigrated to Sweden. These children were more likely to be in GMFCS levels IV-V and thus have a higher risk of hip dislocation. Can you perhaps describe a little more about why it is postulated that there was an increase in children with CP immigrating between 2015-2019 and why it is thought that these children may have more commonly had severe CP.  I assume the increase in immigration was in relation to asylum seekers from Syria and other countries? Is it known that this population included children with severe CP? Is there any data/references to support this? Can you explain a little more for the reader? 

It feels most likely that increased waiting times may have had the biggest impact on hip outcomes. If there was any available data to report on waiting times for surgery over time and whether this has changed over time I think it would be very interesting for the reader. 

Re the paragraph on collective memory - if there is a sense that newer staff may be less aware of the time sensitive nature of the program - are you considering increasing education or training for this group?  

Comments for author File: Comments.pdf

Author Response

Please see attached.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Wow, this paper has dramatically improved! Even the small additional transition sentences in the Intro make a big impact on the flow. The re-organization of the purpose and aims are excellent. It really sets up the focus and scope of the work, removing any lingering concerns I had about a review paper. The additional analyses provide empirical evidence to support the original claims that I thought were speculative, making this a high impact results section. I understand and appreciate the lack of data at some sections, but overall, the newly presented results outweigh the minor limitations of missing some information.

The paper is very impactful and flows very well. Thank you for considering the comments from myself and the other reviewer. The author team went above and beyond on this revision, and the paper is excellent. 

Lastly, my apologies about my assumption of COVID-19 impact. I must have been reviewing another paper at the same time and mixed that up.

Author Response

Thank you so much! And like I stated previously, thank you so much for your earlier comments. They were much needed.

Reviewer 2 Report

The success of CPUP is wonderful - it is an inspiration. This paper is not a traditional results paper nor is it a review paper, but I think perhaps instead it can be a discussion paper looking at qualitative assurance of the CPUP program. 

The authors should be congratulated on this work and for their critical review of their excellent CPUP program.  

Small suggestions:

The new sentences in p3 'Given the longevity of CPUP...' needs reworking.  Perhaps you could try something like: Given the longevity of CPUP, it can be considered an exemplar of a public health disability program and so requires quality assurance monitoring like other programs. In this instance this monitoring can be accomplished by analysing the trajectory of hip dislocations in children with CP in Sweden over almost a decade.

Page 5 – suggest ‘poor general health’ instead of ‘poor general condition’. 'Health' suggests people and 'condition' is more suggestive of objects.

P7 Thank you for the additional figures re children born in Sweden and born abroad – I think this is very helpful for the reader.

p9 Perhaps you could soften the sentence re 'Newer staff...' and add in your comments re considering future training needs?  Eg Newer staff may be unaware of the negative outcomes that can result when hip dislocations are not prevented. We intend to investigate this question further and evaluate whether there is a need for additional training or education regarding the importance of timely intervention. 

Author Response

Dear reviewer!

Thanks for your comments! I agree that your rephrasing of the two sentences improve the paper and have basically accepted them right off the bat (changes highlighted in yellow).

Many thanks!