Embedding Physical Therapy in the Pediatric Primary Care Setting: Qualitative Analysis of Pediatricians’ Insights on Potential Collaborative Roles and Benefits

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

This revised manuscript does not resemble an academic paper, as the scientific soundness of this study is not high enough for publication. It is more like an interview recording, and there are only a few participants. To be a scientific study, this study needs a large sample size and a systematic analysis of the results. 

Comments on the Quality of English Language

English is fine. 

Author Response

• This revised manuscript does not resemble an academic paper, as the scientific soundness of this study is not high enough for publication. It is more like an interview recording, and there are only a few participants. To be a scientific study, this study needs a large sample size and a systematic analysis of the results. 

 

REPLY:  We appreciate your perspective on the nature of our qualitative research.  We would submit that our work is a scientific study with systematic analysis, aligned with published best practices for qualitative research and reporting.

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript on the interesting topic of embedding physical therapy in pediatric primary care.  The manuscript is well written and easy to understand. 

Author Response

• Thank you for the opportunity to review this manuscript on the interesting topic of embedding physical therapy in pediatric primary care.  The manuscript is well written and easy to understand. 

 

REPLY:  Thank you for your time in reviewing our manuscript.  We appreciate the feedback.

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

I have no methodological concerns regarding the research described in this manuscript.  It is in line with the requirements for qualitative research. 

I have some concerns regarding the premise of this study (as mentioned in the introduction): the supposed fact that the global prevalence and years lived with disability are increasing in the pediatric population. I can follow that in the adult and definitely in the geriatric population this is so and the part of the population that is affected is significant, yet in my assessment in the pediatric population this is still limited (only a minute fraction of the overall pediatric population). There are no references regarding this topic provided (see line 76-77).

What is claimed here for physical therapists holds true for specialized nurses and other paramedic professions.  (e.g. the necessary attributes for these professionals as mentioned in the result section).

Author Response

• I have no methodological concerns regarding the research described in this manuscript.  It is in line with the requirements for qualitative research.

REPLY:  Thank you for this appraisal, as we have sought to ensure fidelity to published qualitative research methodology.

• I have some concerns regarding the premise of this study (as mentioned in the introduction): the supposed fact that the global prevalence and years lived with disability are increasing in the pediatric population. I can follow that in the adult and definitely in the geriatric population this is so and the part of the population that is affected is significant, yet in my assessment in the pediatric population this is still limited (only a minute fraction of the overall pediatric population). There are no references regarding this topic provided (see line 76-77).

REPLY:  The Cieza et al. (2020) citation has been moved to after the sentence from line 76-77, as it was accidentally place after the sentence before.  We also revised the sentence to better hone in on the key implications from Cieza.  Years lived with disability (YLD) is defined in that review as “ [the] measure of the burden of non-fatal disease and injury…”, and the authors assert that to help better manage lifespan care for children living longer (e.g. improved quality of life, decreased total cost of care), children with developmental, cognitive, and congenital challenges need to be identified earlier for referral and treatment.  Thank you for the clarification.

• What is claimed here for physical therapists holds true for specialized nurses and other paramedic professions.  (e.g. the necessary attributes for these professionals as mentioned in the result section).

REPLY:  We agree.  Our intention is that our manuscript highlights the needs in primary care and how a collaborative team of professionals can each contribute in the medical home.  Thank you.

Reviewer 4 Report (New Reviewer)

Comments and Suggestions for Authors

In this work the authors intend to provide broad support of opinions to a hypothesis of inclusion of PTs in pediatric primary care settings.

The theoretical assumptions and possible practical implications are extensively analyzed, described and argued throughout the article also through the support of semi-structured interviews addressed to a small group of primary care pediatricians of different professional backgrounds.

Personally, I believe that the proposed hypothesis is certainly of interest for the many reasons analyzed during the discussion and that it is worth bringing to the attention of the pediatric world and of those who have to make important organizational decisions.

 

I have two main observations:

1. The arguments proposed and the motivations discussed sometimes appear repetitive and a bit verbose. Personally, I believe that all the italicized asides can be moved outside the article as additional data so as not to excessively burden the reading. Ultimately, they represent the point of view of a very small group of professionals who certainly contribute to orienting the direction of the interventions, but that cannot assume scientifically relevant significance.

2. I believe that the section relating to materials and procedures, with everything concerning the analysis and evaluation of semi-structured interviews, should be submitted to the opinion of a reviewer who has adequate experience of this investigation methodology.

Author Response

• In this work the authors intend to provide broad support of opinions to a hypothesis of inclusion of PTs in pediatric primary care settings. The theoretical assumptions and possible practical implications are extensively analyzed, described and argued throughout the article also through the support of semi-structured interviews addressed to a small group of primary care pediatricians of different professional backgrounds.

 

REPLY:  Thank you for your work in reviewing and recognizing our efforts in this.

 

• Personally, I believe that the proposed hypothesis is certainly of interest for the many reasons analyzed during the discussion and that it is worth bringing to the attention of the pediatric world and of those who have to make important organizational decisions.

 

REPLY:  We agree and appreciate the opportunity to bring the conversation forward.

 

• I have two main observations:

 

1. The arguments proposed and the motivations discussed sometimes appear repetitive and a bit verbose. Personally, I believe that all the italicized asides can be moved outside the article as additional data so as not to excessively burden the reading. Ultimately, they represent the point of view of a very small group of professionals who certainly contribute to orienting the direction of the interventions, but that cannot assume scientifically relevant significance.

 

REPLY:  We have made multiple revisions to remove verbosity and/or repetitive motivations discussed, mostly in the Discussion section.  Regarding the italicized quotes, we acknowledge that these quotes provided in the Results section do add to length in the manuscript.  Nonetheless, it is standard practice in published qualitative research to include 1-3 direct quotes from recorded transcripts in the main body text for each theme/subtheme, as these are the evidence (i.e. the data) that lead to the themes/subthemes derived from the study and support trustworthiness.  We are open to suggestions from the editors if manuscript length is an issue.

 

2. I believe that the section relating to materials and procedures, with everything concerning the analysis and evaluation of semi-structured interviews, should be submitted to the opinion of a reviewer who has adequate experience of this investigation methodology.

 

REPLY:  We are in full agreement with this, and we appreciate that the editors have sought out a wide variety of reviewers, including experts in qualitative methodology.  We have described in detail our methodology in line with published best practices, intending transparency so that readers can appraise the rigor and trustworthiness of the findings.

Reviewer 5 Report (New Reviewer)

Comments and Suggestions for Authors

Thank you for the opportunity to review your manuscript. Overall, I found this to be a very interesting and very valuable study for primary care and paediatrics. The introductory information was well formed and set the context clearly. The references were relevant and the structure was good. The approach to your study was appropriate for the information that you were wanting to gain and the methods were generally well described. I found your results to be presented clearly and the themes that were generated aligned nicely to the data and were well supported by quotations from your participants. Your discussion was generally high level and highlighted the main points, with relevance to the local context and broader transferability. I have made some specific comments below.   

Are the three themes in the abstract?  I suggest that these should be the results section in your abstract. 

Grounded theory - what approach did you follow for the analysis of data? Your language does not align with the GT approach. The paper that you have cited as the method (24) uses concurrent data collection/analysis and theoretical sampling with three levels of coding, which is usual for GT. Did you apply this? Or did you use a general inductive approach to theming as per Nowell 2017? I would suggest that you did not use GT framework for this study and so I suggest you remove the reference to it and stick with Nowell, 2017 only.  

Line 160 - you can remove the length of interviews from the methods as this is included in the results. 

It would be beneficial to include an identifier after each quote (e.g. Participant 1). This ensures that all quotes are not coming from 1 or 2 participants but shows a good spread of results. 

Figure 2 would be better as a table or a different type of image. It doesn't portray the information well in its current form. 

 The discussion seems to contain results (quotes). In the discussion you should discuss the impact of your study and how the outcomes will effect real world change (or not). Some further reference to literature in the first half of the discussion would also be beneficial. 

Author Response

• Thank you for the opportunity to review your manuscript. Overall, I found this to be a very interesting and very valuable study for primary care and paediatrics. The introductory information was well formed and set the context clearly. The references were relevant and the structure was good. The approach to your study was appropriate for the information that you were wanting to gain and the methods were generally well described. I found your results to be presented clearly and the themes that were generated aligned nicely to the data and were well supported by quotations from your participants. Your discussion was generally high level and highlighted the main points, with relevance to the local context and broader transferability. I have made some specific comments below.   

REPLY:  Thank you for your time in reviewing, and your appraisal of our methodology and reporting.

• Are the three themes in the abstract?  I suggest that these should be the results section in your abstract. 

REPLY:  We made the three themes more explicitly stated in the abstract by modifying the sentence at lines 15-18.  Good suggestion for reader clarity.

• Grounded theory - what approach did you follow for the analysis of data? Your language does not align with the GT approach. The paper that you have cited as the method (24) uses concurrent data collection/analysis and theoretical sampling with three levels of coding, which is usual for GT. Did you apply this? Or did you use a general inductive approach to theming as per Nowell 2017? I would suggest that you did not use GT framework for this study and so I suggest you remove the reference to it and stick with Nowell, 2017 only.  

REPLY: We agree and appreciate the clarity of framework that describing our approach using Nowell brings.  Yes, we did use the general inductive reasoning approach and the framework from Nowell, guiding the procedures described. We have removed reference to grounded theory (as not to imply we formally used that framework).  The first two paragraphs in Materials and Methods, and the first paragraph under Trustworthiness of Data, have been changed to reflect this, with citations updated.

• Line 160 - you can remove the length of interviews from the methods as this is included in the results. 

REPLY:  Done.  Thank you for seeing that.

• It would be beneficial to include an identifier after each quote (e.g. Participant 1). This ensures that all quotes are not coming from 1 or 2 participants but shows a good spread of results. 

REPLY:  Great catch.  This has been done now.

• Figure 2 would be better as a table or a different type of image. It doesn't portray the information well in its current form. 

REPLY:  We have reworked Figure 2 as a table, including categories and new visual layout.  Thank you for the suggestion.

• The discussion seems to contain results (quotes). In the discussion you should discuss the impact of your study and how the outcomes will effect real world change (or not). Some further reference to literature in the first half of the discussion would also be beneficial. 

REPLY: Thank you for this.  We have added to the Discussion section toward more interpretation of impact and effect on pediatric practice/outcomes, including references for those interpretations and assertions.

Round 2

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

This manuscript might not be suitable to be published as a scientific article.  

Comments on the Quality of English Language

English is fine. 

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors

 

After reviewing the document I have some points that I believe require some clarification:

 

1.- Could you please define in a greater degree of detail the triangulation system that ensures the absence of bias in the collection and analysis of the information provided.

2.- Could you please indicate and specify if you have used any software to help you in the analysis of the data extracted from the interviews?

I have not been able to find in the text information related to the approval of your project by an ethics committee, nor how you tto obtain the signature of the consent of the subjects to participate in the study. 

 

4.- Likewise, I have not found in the discussion section any reference to the limitations of the study. 

Author Response

Thank you for your review.  Please accept our responses below:

1.- Could you please define in a greater degree of detail the triangulation system that ensures the absence of bias in the collection and analysis of the information provided.

• Numbered points at the end of the Materials and Methods section have been clarified to further demonstrate how bias was minimized (lines 190-223). Phrases were added explicitly pointing out where researcher triangulation occurred for the data.

 

2.- Could you please indicate and specify if you have used any software to help you in the analysis of the data extracted from the interviews?

• This is now clarified in the Materials and Methods section (lines 175-177). No software was used in the analysis, the details of which are described in numbered points at the end of the Materials and Methods section, per procedures described in Nowell 2017.

 

3.- I have not been able to find in the text information related to the approval of your project by an ethics committee, nor how you to obtain the signature of the consent of the subjects to participate in the study.

• Specific IRB approval information was added to Materials and Methods (line 115-116).
• An informed consent statement was also added (lines 150-152).

 

4.- Likewise, I have not found in the discussion section any reference to the limitations of the study.

• Limitations are found in the final paragraph of the Discussion section (lines 663-670). Note that these lines are not highlighted in the resubmitted manuscript, as no changes from the original manuscript were made.

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript aims to integrate physical therapists into collaborative healthcare teams for pediatric primary care. To achieve this aim, the authors interviewed nine pediatricians and analyzed the recording information. Overall, this manuscript is clearly written and easy to understand for our readers. However, this manuscript might not be suitable for academic publication because this study is not scientifically robust. First, the sample size (n=9) is too small to reach solid conclusions. Although interesting, this study has no statistical significance, and thus, information obtained from participants might not be applied in a broader situation. Second, the insights from the nine participants are subjective and have not been verified using experiments. So, this study only shows the potential of embedding physical therapists into pediatric primary care settings and might not be necessary. In sum, this manuscript has a clear writing style but might not be recommended for publication as an academic paper of science.

Comments on the Quality of English Language

English is fine. 

Author Response

Thank you for your time in reviewing our manuscript.  Please see our responses below:

This manuscript aims to integrate physical therapists into collaborative healthcare teams for pediatric primary care. To achieve this aim, the authors interviewed nine pediatricians and analyzed the recording information. Overall, this manuscript is clearly written and easy to understand for our readers. However, this manuscript might not be suitable for academic publication because this study is not scientifically robust.

• Thank you for this feedback. We have added important information and references to the manuscript to support the robustness of our qualitative research approach (thematic analysis, framed in grounded theory)—one that is well-supported for exploratory investigations like our study.

 

First, the sample size (n=9) is too small to reach solid conclusions.

• We have added explanation of our literature-based approach to sampling in this qualitative study, providing two additional references supporting snowball sampling to the point of theme saturation (lines 117-129).
• Additionally, it is reiterated later in this section that recruitment was concluded when theme saturation was reached (lines 186-187).

 

Although interesting, this study has no statistical significance, and thus, information obtained from participants might not be applied in a broader situation. Second, the insights from the nine participants are subjective and have not been verified using experiments.

• We appreciate the importance of quantitative research, particularly high-quality well-controlled investigations. However, qualitative research methodology is, by definition, focused on subjective data obtained rigorously from participants and does not apply inferential statical analysis to data.
• Please see the Materials and Methods section where we have bolstered the detail around our qualitative procedures and cited further references supporting the Thematic Analysis approach employed.

 

So, this study only shows the potential of embedding physical therapists into pediatric primary care settings and might not be necessary.

• For a first-of-its-kind investigation into a novel potential service of embedding physical therapists into the pediatric primary care setting like our study, potential is all that one would expect to infer from expert opinion of pediatricians. We intend that subsequent investigations (and pilot implementations in primary care pediatrics) would further clarify what aspects of such a service might be necessary. However, this was not the aim of our study which indeed was to explore for the first time the potential of primary care pediatric physical therapy side-by-side with pediatricians. With no available research on the topic available and, as far as we can find, no existing service in pediatric primary care like this in the world, the current study was conducted as a first important step toward understanding the perspective of pediatricians who might themselves benefit, along with their patients, from such a service.

 

In sum, this manuscript has a clear writing style but might not be recommended for publication as an academic paper of science.

We hope that our additions, changes, and clarifications made to the manuscript reflect the rigor of our scientific inquiry and qualitative reporting.  Thank you again for this opportunity to resubmit for you consideration.