PONE-D-21-23145Understanding the experience of Veterans who require dysvascular lower limb amputation in the Veterans Health AdministrationPLOS ONE

Dear Dr. Leonard,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Surgeons performing the amputation may not have all the information as to rehab/prosthetic options. Would have been interesting to assess the surgeons' level of knowledge of life after surgery, because that may have affected their willingness to engage in meaningful discussions prior to amputation.

Reviewer #2: This study is trying to explore the experience of Veterans during the amputation in VHA. A good engagement can usually promote the participation of patients with amputation. The insufficient shared decision making (SDM) during amputation is found in this study. To improve the benefits of amputees, this find is an important step for the development of a decision support tool and can help them engage the involvement. Although only twelve patients were recruited in this study, the results still showed an implication for an obstacle for the patients with CLTI to participate in the treatment of their own. This study is qualitative research and reveals some important points for further studies. However, more investigation should be done in the future to support the finding from this research due to the small sample size and limited sampling.

There are several minor issues that need to be addressed before publication.

1. The amputation usually changes the whole lifestyle of the people, sometimes it also makes the amputees under negative emotions. Most people with amputation feel sadness, madness, or other strong and negative emotions. Is SDM or involvement affected by undergoing these emotions? Could someone who is more optimistic feel they were involved more (or less) before surgery (in contrast, the subjects under sadness might feel more helpless or out of control)?

Did you observe any correlation between their responses or feels and the emotions of the subjects?

2. The authors mentioned that most subjects with diabetes perceive the amputation might happen to them. Most subjects in this study believe that the medical team would make the best choice and they don’t need to, or they couldn’t provide any personal thoughts on the discussion. Is there any possibility that the surgery should be done in rush time so made the medical team had no time to let the patients be involved in the decision-making? During the interview, had the subjects in this study ever mentioned or suggested that the debate on the amputation level could be done earlier? Would it be better if discuss with the patients with CLTI about the possible amputation level when the condition wasn’t going so badly?

As the authors indicate in the study design, this research is a first but essential step before more extensive research to develop the patient decision aid and decision support tool.

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Reviewer #1: No

Reviewer #2: Yes: Mo, Pu-Chun

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Understanding the experience of Veterans who require lower limb amputation in the Veterans Health Administration

PONE-D-21-23145R1

Dear Dr. Leonard,

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

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Yih-Kuen Jan, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: All the comments were adequately addressed. This article is necessary to build up a good decision support tool and shows that the provided system of helping Veterans during the amputation is insufficient. Expect further studies to be done soon.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No