Frailty Screening Practice in Specialized Burn Care—A Retrospective Multicentre Cohort Study

Round 1

Reviewer 1 Report

Thank you for the opportunity to review this manuscript.  It is well-written and on an important topic.  My suggestions for revision include:

Introduction

1.) Did you have a hypothesis for your study?  If so please state it in your introduction.

Methods

2.) You call the study Multicentre, but then refer to "a Dutch burn centre." Were there more than one centers involved? I think that there were 3 hospitals involved but it is a little unclear.

3.) Was the 35 admissions per year only those older than 70 or total admissions? Also was that at each hospital or for the total study?

4.) What led you to dichotomize frailty? Did you do any analysis for each additional scale being positive?

Results

5.) Did you look at the pieces of the frailty assessment separately? Did any one in particular predict outcomes better than the combined measure?

 

Author Response

Thank you for your valuable evaluation, please see the attachment. 

Author Response File: Author Response.docx

Reviewer 2 Report

The authors of, “Frailty screening practice in specialized burn care; a retrospective multicentre cohort study” aimed to “assess the feasibility and validity of frailty screening in specialized burn care”. They evaluated 515 patients admitted to the different Dutch Burn centers over an 8 year period. Using the Dutch Safety Management System (DSMS frailty screening) tool they looked at patients over the age of 70 to assess their frailty. They looked at compliance of the different institutions and looked at the validity of the results. The found that only 39.6% of the assessments were complete. Of those, 49.9%were at risk of frailty. At risk patients were “older, had more comorbidities (known group validity), a longer length of stay, and more frequently a non-home discharge (predictive validity)”. This is an interesting study. There are a few concerns:

The patients admitted to burn centers are not all patients with burn injury. This statement is unclear “Screening practice did not differ by patient’s diagnosis; 40.5% completed screening in patients with burn injuries versus 35.7 % in patients with other skin-related diseases (p=0.53). Does this mean that of the 39.6% of complete assessments, 40.5% of them were burn patients which 35.7% were skin disorder? There is no way to get to 100%.

Were patients with skin disorders included in the Revised Baux score calculations? It is unclear if they were kept separated? Were the analyses of just the burn patients not statistically significant, thus not reported? I can understand a low n, but were the analyses attempted?

The first paragraph in the discussion is overstated. Only 39.6% of patients were completely screened.

Can you comment on any potential bias that may exists in the screenings?

Can you speculate on why the results did not predict mortality? What was the mortality of the patient population included in the study? What happens when the skin disorder patients are removed?

Author Response

Please see the attachement

Author Response File: Author Response.docx

Reviewer 3 Report

Thank you for the opportunity of reviewing this paper on frailty, which is a very relevant topic given that the global population is getting older.  

The study aimed

1.      to assess the feasibility of the Dutch Safety Management System (DSMS) screening in specialized burn care,

2.      to assess predictors for complete screening,

3.      to assess the prevalence of frailty,

4.      to assess the known group validity and predictive validity of the DSMS frailty screening

Unfortunately, the study failed to analyze aims 1 (main aim) 2, and 3 since the feasibility of the DSMS screening instrument and its validity were not investigated in this study. The authors assessed how often the score was used but not the accuracy of the instrument nor how easy it was for the nurses to perform the screening. To investigate validity and feasibility and factors associated with complete screening requires another study design, as example qualitative interview or observation.

The scientific value of this paper would increase focusing only on the analysis of the frailty among patients with complete DSMS assessment and investigating the association between frailty and outcomes of interest after burn care (LOS, discharge location, in-hospital mortality).

I suggest analyzing with univariate regression the association between positive frailty score and age/ sex/ TBSA%/ Inhalation injury/ ASA> 2/ LOS/ Discharge location/ In-hospital mortality.

Furthermore, I suggest analyzing the effect of the different variables on the three outcomes of interest with multivariate regression.

Suggestion of the three models:

Model 1. Factors independently associated with LOS> 7 days, multivariate regression
	OR	95% CI	p
Age (years)
Sex (female)
Burn size (TBSA%)
Inhalation injury (yes)
ASA >2
Frailty positive

 

 

Model 2. Factors independently associated with discharge location (home), multivariate regression
	OR	95% CI	p
Age (years)
Sex (female)
Burn size (TBSA%)
Inhalation injury (yes)
ASA >2
Frailty positive

 

Model 3. Factors independently associated with in-hospital mortality, multivariate regression
	OR	95% CI	p
Age (years)
Sex (female)
Burn size (TBSA%)
Inhalation injury (yes)
ASA >2
Frailty positive

 

Finally, if the authors have access to data on mortality after 30 days from discharge, it would be very interesting to see a fourth model the show the association between the variables and tis outcome.

 

Author Response

Please see the attachment

Author Response File: Author Response.docx

Reviewer 4 Report

The authors conducted a retrospective cohort study to evaluate the feasibility and validity of frailty screening. The manuscript is overall well written. I have one major comment:

The authors acknowledged an important limitation of their study, which is that they included in their study non-burn patients admitted to their burn centers. The authors should perform a sensitivity analysis excluding these patients to see if the results of the sensitivity analysis differ from the results of the present analysis.

Alternatively, the authors should just exclude the non-burn patients from their study and redo the analysis, as the focus of the manuscript is on burn care and elderly patients with burn injuries. 

Author Response

Please see attachment

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Thank you for addressing my questions.

Author Response

Thank you for your help making this a better manuscript. 

Reviewer 2 Report

The authors of, “Frailty screening practice in specialized burn care; a retrospective multicentre cohort study” aimed to “assess the feasibility and validity of frailty screening in specialized burn care”. They evaluated 515 patients admitted to the different Dutch Burn centers over an 8 year period. Using the Dutch Safety Management System (DSMS frailty screening) tool they looked at patients over the age of 70 to assess their frailty. They looked at compliance of the different institutions and looked at the validity of the results. The found that only 39.6% of the assessments were complete. Of those, 49.9%were at risk of frailty. At risk patients were “older, had more comorbidities (known group validity), a longer length of stay, and more frequently a non-home discharge (predictive validity)”.

The authors addressed the concerns from original version. There are some minor language/syntax errors.

Author Response

Thank you for your help making this a better manuscript 

Reviewer 3 Report

The authors have declined to revise as suggested

Author Response

Please see the attachment

Author Response File: Author Response.docx

Reviewer 4 Report

The authors have conducted the sensitivity analysis but the results from the sensitivity anlaysis were not presented. I ask that the authors please include the specific results from the sensitivity analysis in their manuscript, at least as supplemental tables/figures. 

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 3

Reviewer 3 Report

I accept the new draft of the manuscript for publication.

Reviewer 4 Report

The authors have adequately addressed my comments.