PONE-D-19-24519

Surgical Decision Making in the Setting of Severe Traumatic Brain Injury: A Survey of Neurosurgeons

PLOS ONE

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PLOS ONE

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Overall

The two scenarios are essentially treated as two separate questions for much of the paper, which brings up the point of multiple comparisons. Either the second scenario is a “control” which the authors did not anticipate would vary with providing prognostic data, or the issue of multiple comparisons needs to be addressed/taken into account appropriately during analyses for significance. Alternatively, the authors could have performed analyses while somehow removing/regressing out the effect of the patient scenario to see the global effect across the entire study. Either way, the possibility of performing multiple comparisons needs to be addressed.

Abstract

Methods – Please more clearly explain the groups in methods, else the results section is less clear to the reader.

Results – As written it is not clear that the surgery recommendation changing is only for one of the two groups.

Paper

194 – The effect was borderline and not a significant effect, therefore one can claim it at most as a trend only.

195 – Is the mediation analysis for both scenarios or just the 1st ?

203 – The results of a multivariable analysis are less convincing when independent variable A (6-month ADL) is relatively correlated with variable D (whether the participant received CRASH data). There seems to be a decent degree of multicollinearity between 6-month ADL and test version, which depending on the strength may be an argument against performing this particular analysis at all. Did the authors validate the use of multiple linear regression by testing Variance Inflation Factor values?

Figures and Tables:

Table 2 – In the trauma center hospital section the number and percent data don’t make sense. I think the percent data in row “other” for control and intervention columns should be in the “Level 1” row AND the number data for intervention “other” should be in the level 1 row.

Reviewer #2: The authors present a survey analysis from a random convenience sample of 139 neurosurgeons from the Congress of Neurological Surgeons (CNS) meeting 2017. The goal of the study was to evaluate surgical decision making in the setting of severe TBI and to determine the impact of availability of evidence-based risk estimates on prognostication and treatment recommendation. The authors found that prognostic beliefs and surgical recommendation were highly variable and could be modestly influenced by evidence-based risk estimates. The manuscript is well-written and relevant findings appropriately discussed. I have the following comments:

1. I would advise the authors to avoid beginning sentences in the results section of the abstract with a number.

2. Although neurotrauma training is pretty standard across most residency programs, did the authors collect information about the type of practice for attending neurosurgeons? Were there differences based on type of fellowship training? Were spine surgeons more or less likely to recommend craniotomy? Did having additional neuro-critical care fellowship training influence treatment recommendation? If this information was not collected, the authors should mention the possibility of residual confounding due to such factors as one of the limitations of the results.

3. In the multivariable analysis presented in Table 4, I notice the authors did not adjust for other collected demographic characteristics like surgeon race/ethnicity, age and years of experience. Can the authors comment on that or provide a revised analysis adjusted for these covariates?

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Reviewer #1: No

Reviewer #2: No

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Surgical Decision Making in the Setting of Severe Traumatic Brain Injury: A Survey of Neurosurgeons

PONE-D-19-24519R1

Dear Dr. williamson,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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With kind regards,

Panagiotis Kerezoudis, M.D., M.S.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

The authors have addressed all of the reviewers' comments and the manuscript is now ready for publication.