Functional Profile of Older Adults Hospitalized in Rehabilitation Units of the National Network of Integrated Continuous Care of Portugal: A Longitudinal Study

Round 1

Reviewer 1 Report

Thank you for the opportunity to review the manuscript “Functional profile of older adults hospitalized in Rehabilitation units of the National Network of Integrated Continuous Care of Portugal: a longitudinal study”.

Before evaluating this article, I read the other two articles published by Ramos et al. The article is very similar to “Functional profile of older adults hospitalized in convalescence units of the National Network of Integrated Continuous Care of Portugal: a longitudinal study”. Curiously, I found the same sample (59 013) as in the current article, despite the fact that in Ramos (2022) the authors wrote:

“A longitudinal retrospective study is made with a sample of 171,414 older adults, aged 65 years and over and hospitalized in health units belonging to the NNCIHC. The Long-Term and Maintenance Units were the ones with the most hospitalized people (34.7%; N = 59,516), followed by the Medium Term and Rehabilitation Units (34.4%; N = 59,013) and, finally, the Convalescent Units (30.9%; N = 52,885).”

….maybe there is an error somewhere. The article is absolutely overlapping in both methods and much of the results, particularly the clusters, so I leave it to the editor to evaluate this.

The aim of a longitudinal, retrospective study was to assess the functional profile of older adults admitted to the rehabilitation units in Portugal and to relate the functional profile of these individuals with age, sex, education level and emotional state.

In the Introduction, I do not note any assumptions by the authors or how their work will contribute from a scientific point of view.

The Material and methods section is poor, the authors do not state the data that appear in the results and how they collected them (i.e.anxiety, depression....) or why they performed some subgroup analyses. It is not specified data collection.

Results

The authors repeat in text and table the same data on age and sex, put together level of education and professional level (what are the differences between them and why grouped education in years –no comparison is possible) and they don't comment on the last 4 categories...are they needed? have they been used?

Figures 1 and 2 are in Portuguese. I don’t understand levels of dependencia (in methods there are 4 levels…here 8..)

Clusters have variables that do not appear previously.... How were they made?

The abstract is not informative and contains an error in the cluster definition.

The list of references is not in alphabetical order and is therefore difficult to retrieve from the text.

For all these reasons I believe that the work cannot currently be evaluated favorably. I suggest that the authors work on it in depth and try to resubmit it in a new form.

Author Response

Please see attached document

Author Response File: Author Response.docx

Reviewer 2 Report

Dear authors, thank you for allowing me to revise your manuscript, analyzing the functional profile of elderly hospitalized in rehabilitation units of NNICC of Portugal longitudinally.

Even if I recognize that your study had potential, I am very concerned about the presentation of results and their support of the discussion. I found it very difficult to follow your thoughts throughout the manuscript; thus, I am suggesting some points that could improve the overall quality of this study.

Abstract:

Line 17 - please, do not use acronyms if they were not previously introduced.

Line 19 - "with a sample" is repeated twice.

Line 24 - I don't get the difference between cluster 2 and cluster 3

Line25 - Maybe it is inappropriate to examine the elderly and try to be consistent.

Introduction: 

Line 46 - I found the first sentence very difficult to understand.

Lines 54-63 - I got from the title you are referring to Portugal, but a deeper explanation of how these units are organized at a Regional level would be appropriate in understanding the context in which the study has been conducted.

Lines 67-70 - I don't understand how this sentence fits into the introduction; I would find it more appropriate in the methods section.

Generally, the introduction lacks a clear statement of the rationale for the conduction of this study.

Methods:

2.1. Study type - how the data has been collected? Locally/regionally/nationally, from what healthcare professionals? What kind of patients are in charge of the NNICC?

2.2 Instruments - how many items were present for each of such ICF dimensions? What type of questions were made? It is essential to present such information even if some paper has already shown the data collection set of instruments.

Results:

The first part of the results duplicates all the information already in the table, so they are not valuable for understanding your sample. Moreover, other characteristics you presented later in the cluster models were not shown (e.g., weight, anxiety/depression, falls). Moreover, try to be consistent with the terms you have used for dependence (sometimes it is light, and some others are mild). Another fundamental lack in the presentation of data is the absence of patients' information. What are their diagnoses? For how long have they been in charge of NNICC? Try to present your sample more representatively.

Figures are reported in Portuguese; please use English if possible. Moreover, maybe you have missed "dependence" in the title of paragraph 3.2.

Just a consideration: have you tried to explain why people with mild dependence reported more falls? In the discussion, I found no mention of this occurrence.

Discussion:

I found some parts disconnected from your results and others challenging to understand. For example, what does the use of aerobic dance do to the improvement of cognition? Do you use this kind of art-based therapy with patients in NNICC?

Lines 176-179 - I don't follow your thoughts; you have just said that dependence has decreased, but now the increase in mobility is discussed. Try to be linear in your discussion.

Lines 209-212 - I don't want to discuss findings from other colleagues, but instead of education (that in people born at least in the late 60s is not warranted by public institutions); maybe an aspect that could be discussed is the influence of the income or other economic factors on the dependency.

Falls are not discussed.

Are you sure the only limitation is the presence of data before 2017? 

Conclusions:

You have emphasized gender and age on dependency, but what about the factors you found with cluster analyses? These could be of interest in assessing how to take charge of patients with particular characteristics.

Author Response

Please see the attached document.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments to the authors:

Abstract: Remove the acronym from the NNICC abstract and complete. Cluster 2 and 3 are the same, it must be corrected. Also, the conclusions must be modified, they do not respond to the results of the study, but rather they are generic and obvious.

Introduction: The bibliographic review is incomplete and the same citations are repeated several times in this section. The citation format should also be reviewed.

Materials and Methods: The sample is large and constitutes a strength of the study. However, the authors used an instrument, the New ICF-Based Instrument, so in limitations, the authors should explain the reasons why they did not use other internationally validated instruments to measure functional level, dependence in activities of daily living or cognitive status. This makes it difficult to compare this study with other similar ones.

Regarding the data analysis, was the distribution of the variables analysed? In case the variables do not follow a normal distribution, non-parametric tests should have been carried out. I recommend reviewing these aspects and modifying if necessary.

Regarding ethical considerations, was the permission of the ethics committee obtained at the end of the data collection in 2017? Research usually begins when a positive evaluation is obtained from the ethics committee. In any case, it should be explained in limitations.

Results: In general, the results are not very precise, they should be described considering the proposed objectives and the figures are not described in English.

Discussion: Although the results are discussed comparing with others, the same thing happens, there is an excess of self-citations and probably from the same longitudinal study. The authors should review in greater depth the international bibliography on the subject.

Author Response

Please see the attached document.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

I have noted the changes made by the authors. A great deal of work was done. Unfortunately, I still have some concerns.

The aim of this study was:

1)      to evaluate the functional profile of older adults hospitalized in a Unit of the National Network of Integrated Continuous Care of Portugal;

2)      to assess the relationship between functional profile and age, gender, level of education and emotional state;

3)      typify nursing care needs by degree of dependence.

Item 3 does not seem to be present in the results.

Results section:

Line 72 “……to have access to care appropriate to their level of dependence (NNICC).” The acronym is explained after the point and so I would remove it from here.

Lines 207-209: “ The constituent variables analyzed were according to an elaborated concept map that defines self-care, suggested by the literature and statistically validated.” This sentence is unclear and does not refer to specific bibliography

Table 1 : Present marital status by sorting by frequency

Lines 313-315 “As for the level of education, most individuals do not have any type of qualification 313 (70.3%), followed by qualified individuals (23.4%), intermediate professional level (4.5%), 314 and finally, with less expression, the specialists (1.8%).” Education and professional levels are the same thing?

Figure 1 The authors seem to hypothesize that the loss of dependence is related to time and rehabilitation, but may also be subject to the starting condition. If I have a femur fracture and I'm fine, it's different than having a stroke with a permanent disability. Has this issue been considered?

3.3 Dependence Clusters: the clusters in lines 330-335 differ from clusters presented in Figure 2 in which cluster 1 seems to be the b)cluster 2 ; cluster 2 seems to be a) cluster 1 and so on….I think this is confusing to the reader.

Figure 3 : What insights does this figure bring? All clusters are equally distributed in the observed variables....does not seem to me to be informative for the reader

Discussion section

Lines 426-438 “In Medium-Duration Rehabilitation Units, within the first 90 days of hospitalization (maximum recommended length of stay), a decrease in dependence in mobility, activities of daily living and instrumental activities of daily living and an improvement in cognitive  status are observed.”

This statement should be the purpose of any rehabilitation, but how do the authors say if it happens to everyone? Or only in certain diseases? who benefits more? if, as I wrote above, we do not take into account the starting condition? For what levels of care intensity?

Answering these questions would make the paper truly innovative

Lines 439-444 “When these results are compared to those obtained in the study conducted in the NNICC Convalescence Units, we found that there was an improvement in all domains during the first 30 days of hospitalization (Ramos et al., 2021). This data is in line with the findings of some authors who show that interventions focused on the rehabilitation of hospitalized patients show improvements at the functional level, promoting independence after a 443 acute hospital admission (Kosse et al., 2013; Pils, 2016).”

Are the patients overlapping? I think not...but you are certainly going off your aims of the study

And much of the discussion does not remain centred on your goals.

Conclusion section

You have no data to make the written claims

References

84 references for this type of article is really too many, no more than half very related to the work is enough. You also self-cite many times--I would keep the self-citations when substantial for the work

Author Response

Thank you very much for agreeing to review our article. Your comments helped us to improve it. We have responded to your comments below:

We remove the aim 3.

Results section:

Line 72 “……to have access to care appropriate to their level of dependence (NNICC).” The acronym is explained after the point and so I would remove it from here.

Thanks. We remove it.

Lines 207-209: “ The constituent variables analyzed were according to an elaborated concept map that defines self-care, suggested by the literature and statistically validated.” This sentence is unclear and does not refer to specific bibliography

We clarify the sentence.

Table 1 : Present marital status by sorting by frequency

Thanks. We change it.

Lines 313-315 “As for the level of education, most individuals do not have any type of qualification 313 (70.3%), followed by qualified individuals (23.4%), intermediate professional level (4.5%), 314 and finally, with less expression, the specialists (1.8%).” Education and professional levels are the same thing?

No. Thanks for your observation. We change it.

Figure 1 The authors seem to hypothesize that the loss of dependence is related to time and rehabilitation, but may also be subject to the starting condition. If I have a femur fracture and I'm fine, it's different than having a stroke with a permanent disability. Has this issue been considered?

The deficit in self-care capacity was not studied in the correlation with diseases, but in its repercussion on people's functional capacity.

3.3 Dependence Clusters: the clusters in lines 330-335 differ from clusters presented in Figure 2 in which cluster 1 seems to be the b)cluster 2 ; cluster 2 seems to be a) cluster 1 and so on….I think this is confusing to the reader.

Thank you very much for your comment. There was an error in the chart that we have already modified

Figure 3 : What insights does this figure bring? All clusters are equally distributed in the observed variables....does not seem to me to be informative for the reader

We consider that it can be relevant to discriminate how people with more or less dependence are distributed by variables, staging groups, sex, education, body mass index, etc.

Discussion section

Lines 426-438 “In Medium-Duration Rehabilitation Units, within the first 90 days of hospitalization (maximum recommended length of stay), a decrease in dependence in mobility, activities of daily living and instrumental activities of daily living and an improvement in cognitive  status are observed.”

This statement should be the purpose of any rehabilitation, but how do the authors say if it happens to everyone? Or only in certain diseases? who benefits more? if, as I wrote above, we do not take into account the starting condition? For what levels of care intensity?

Answering these questions would make the paper truly innovative

Thank you for your comment. These questions are quite interesting, the levels of care intensity are lower than in convalescence units. The need for continuity of care, where a slower recovery profile is expected. we added this information

Lines 439-444 “When these results are compared to those obtained in the study conducted in the NNICC Convalescence Units, we found that there was an improvement in all domains during the first 30 days of hospitalization (Ramos et al., 2021). This data is in line with the findings of some authors who show that interventions focused on the rehabilitation of hospitalized patients show improvements at the functional level, promoting independence after a 443 acute hospital admission (Kosse et al., 2013; Pils, 2016).”

Are the patients overlapping? I think not...but you are certainly going off your aims of the study

Persons are not overlapped, but can be transferred from unit, but there is never a return to the previous unit

Conclusion section

You have no data to make the written claims

We change the conclusion.

References

84 references for this type of article is really too many, no more than half very related to the work is enough. You also self-cite many times--I would keep the self-citations when substantial for the work

We have revised the references, because by mistake many were duplicated.

Reviewer 2 Report

Dear authors, thank you for allowing me to revise this second version of your manuscript.

Although I found it considerably improved, some points still lack quality and should be amended. I raise my issues of concern here below.

The abstract, Introduction and Methods are OK.

Results: in table 2, please, correct the language in the last section.

I found figure 2 inconsistent with the description of clusters you precedently provided. Why the Cluster 2 has better outcomes than Cluster 3, even if it has a better functional assessment?

Discussion is better built and consistent with your results. However, you should disclose the limitations of your study at the end of the section. I have suggested adding some other limitations, not omitting them.

Conclusions should not replicate the results, you should suggest the application of your findings in the clinical practice and the future studies to be performed or research approaches to be used to expand the knowledge in this field.

Author Response

Thank you very much for agreeing to review our article. Your comments helped us to improve it.

Results: in table 2, please, correct the language in the last section.

Thanks. We made this correction.

I found figure 2 inconsistent with the description of clusters you precedently provided. Why the Cluster 2 has better outcomes than Cluster 3, even if it has a better functional assessment?

Thanks for your comment. There was an error in the caption of figure 2.

Discussion is better built and consistent with your results. However, you should disclose the limitations of your study at the end of the section. I have suggested adding some other limitations, not omitting them.

Thanks for your comment. We added limitations.

Conclusions should not replicate the results, you should suggest the application of your findings in the clinical practice and the future studies to be performed or research approaches to be used to expand the knowledge in this field.

Thanks for your comment. We improve the conclusion.

Reviewer 3 Report

We thank the authors for all the changes made, in practically all sections of the manuscript.

Observations: The authors explain in methodology that:..."Data was collected from the database of the NNICC Medium-Term care and Rehabilitation Units for the period between January 1, 2008, and February 27, 2017. These records were made by health professionals from these units at national level....."

However, in Table 1, it has been added that more than 70% were unqualified professionals... the authors should clarify this aspect since they would not be health professionals. This would also be a new limitation in data collection.

Author Response

Thank you for your revision that help us to improve the manuscript.

This data in Table 1 refers to the study participants and not to the professionals who collected the data. For the sake of clarity for the reader, we have clarified this in the text.

“As for the professional level of the sample, most individuals do not have any type of qualification (70.3%), followed by qualified individuals (23.4%).”