The Perceived Role of Healthcare Providers and Systems in the Development of Secondary Health Conditions among Adults with Spinal Cord Injury
Round 1
Reviewer 1 Report
I was please to have the opportunity to review research on the very important topic of prevention (or development) of secondary health conditions among persons with spinal cord injury. I highly welcome the perspective on the role of health care providers and health care systems. However, I found the title of the research fosters wrong expectations and is misleading. While it suggests the research is about preventing secondary health conditions (SHC) in general (in an ageing population) it is about safety of care and medical complications. When the research includes the role of providers on prevention SHC the title would fit. However, as I understand the interview grid, the sole focus was on health care safety? However, I am not sure if this correct. If not it would puzzle me that the research suggests that the occurrence of SHC is only a matter of health care providers inducing SHC, but not that health care providers might also support the prevention of SHC. To add: The discussion also only starts about iatrogenic and nosocomial conditions, ignoring the important topics to support persons with care and in self-management to prevent SHC.
It is unclear what the research really is about and I suggest it is about patient experience.
The topic of ageing, as specifically addressed in the title, is no longer pursued in the manuscript. Also the health systems perspective is promised but not pursued in the manuscript. There is no reference to "health systems" neither in the results nor discussion section. An advice to authors is to drop systems and just focus on providers.
The works lacks a theoretical framework underpinning the qualitative analysis (recruitment, saturation, etc.).
The phrase "One of the most frequent topics that was brought up ..." suggests that a quantitative perspective was in focus and a related quantitative investigation would have been better suited. Also, the statement "identifying the association between iatrogenic factors and SHC" (Line 290) is too strong for a qualitative perspective and suggest rather a quantitative approach. See also line 347.
The narratives on the themes, as well as the various quotes are generally too sparse. E.g. Subtheme 2C: Interdisciplinary Collaboration. The quote does not really inform on the spectrum of interdisciplinary collaboration, its current situation and how it is best set up to prevent SHCs.
The motivation why hospital safety needs to be addressed differently or specifically in persons with SCI — as compared to the general population — is unclear .
The conclusion that "healthcare organizations need to recognize their role not just in the treatment but also in the prevention of SHC" is weak or too obvious. They do recognize their role and I do not think anything suggests differently.
In persons with SCI, it is unclear what the role is of the individual interview and what that of the focus group. Do the findings presented in this research come from both? There is a general confusion between these two sampling concepts and I miss a concept on how they supplement or enrich each other and how we need both to specifically address the research questions. To the reader it is confusing that some conclusions are with reference to the focus groups, other to interviews.
Are the caregivers related to a person with SCI who is also participating or are these two groups independent?
Table 1 present only the persons with SCI, but not the respective demographic information for the caregivers.
It is inconsistent that participants were sometimes named "PARTICIPANT" and sometimes with their name.
The delineation between veterans vs other non-veteran participants is drawn, where it often remains unclear from which group the quote comes and the deducted theme applies. Same for caregivers vs person with SCI.
In Line 59 it say the perspective is "as perceived by adults aging with SCI", not mentioning the caregiver's perspective.
It is difficult to draw a conclusion from the themes. The result is: there is an emerging theme. It is not obvious how to bridge from "there is a theme" to the research question "the role of healthcare providers and systems is ...". E.g. Subtheme 2C: Interdisciplinary Collaboration. What and how interdisciplinary collaboration is set up to prevent SHC? The quote says: "they all try to work together and communicate what's best for me". From this quote it is unclear whether collaboration is already in effect, whether it works well and how it is related to reduce SHC? Specifically this section should be enriched by more quotes/narratives.
Line 187ff: I am not convinced that this quote can go over "unintended consequences of medical treatment" Constipation is a chronic problems for persons with SCI per se, which may be exacerbated while using other drugs as side effect.
Please provide a short definition of "high reliability organization".
I believe the background section should focus more on high reliability organizations and its principles, instead of the prevalence of SCI and cost of treatment
Line 208: The conclusion that the MRSA is hospital acquired, in said quote, is speculative.
Line 243: The respective quote does not well match the theme of "respect".
Line 310ff: I just failed to see the differences between the VA system and the "civilians" healthcare system in the results. I am not sure based on what the authors came up with this recommendation.
Line 45: ("Higher costs are related to higher injury levels, more frequent SHC ..."). Citation is required.
Line 57: I highly doubt the assertion that the role of providers and health systems in the prevention of SHC has been hardly studied.
Line 42: is this annual incidence?
Line 44: it is unclear how lifetime costs can be specific for a certain age? Is the mentioned age the age at injury? Please clarify.
Table 1: Please specify that the numbers are percentages. No decimal place in percentages is needed with totals as small or smaller than 44. Two decimal places accuracy in years/age is outrageous.
The discussion section should present more interpretation of the findings and less definitions.
The implication should not come up with completely new topics (such as telemedicine), but conclude from the findings.
Same for "Future Research" section: intervention approaches are suddenly mentioned, which come by surprise and seem unrelated to rest of the research.
Implications: Implications are rather generals and not strongly tied to the research findings (e.g. "consistent care and service delivery are needed"). The call for more specialization is not well concluded from the findings, where many problems where induced by specialists. Also the call for specialization on one hand and consistent care along the continuum of care on the other hand, might be conflicting.
Author Response
We wish to thank the reviewer for these comments, as we have reflected upon them and made multiple changes throughout the manuscript.
Author Response File: 
Author Response.docx
Reviewer 2 Report
Dear authors, I congratulate with your work. The topic is of interest. The article is well written. However, I have some issues that may require clarification:
- do you think that the remuneration of patients and recruitment criteria may represent a selection bias?
- how were the semi-structured questions created? Were the main topics proposed by the researchers/facilitators or were the participiants free to discuss any topic? Could the selection of the main topics influence the responses?
- how did you choose the two main overlapping themes: where they the only one discussed? did you exclude other themes?
- the discussions reported are useful to understand the patient/caregiver's point of view, however they are not always completely clear; for example in the first sub-theme it is not clear if the patient is complaining about the lack of structured medical services dedicated to SCI or if he is complaining about the lack of medical attention of general medicine towards SCI; in the second sub-theme it is not clear how the medical condition could change from an urologic problem to a pancreatic and spleen disease.
- the discussion is mostly a repetition of the results and do not add much to the reader
Author Response
We wish to thank the reviewer for these comments, as we have reflected upon them and made multiple changes throughout the manuscript. Please see attachment.
Author Response File: Author Response.docx
Round 2
Reviewer 2 Report
Dear Authors,
thank you for answering to all my comments. The methodology is much more clear. The results are better presented. The discussion is much more complete in its actual form.
Author Response
Thank you.
