Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: Results of an international Delphi study

Jesse J. Aarden; Mel E. Major; Claartje M. W. Aghina; Martin van der Esch; Bianca M. Buurman; Raoul H. H. Engelbert; Marike van der Schaaf

doi:10.1371/journal.pone.0283545

Peer Review History

Original SubmissionOctober 14, 2022
5 Jan 2023 Decision Letter - Jean-Philippe Regnaux, Editor PONE-D-22-27730Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: results of an international Delphi studyPLOS ONE Dear Dr. Aarden, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Feb 19 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Jean-Philippe Regnaux, Ph.D, PT Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments (if provided): Dear Authors, Your submission has been carefully read by reviewers. Their outputs are positifs. They have adressed minors comments which , i think , will improve the quality of your manuscript. Few minor changes or clarifications need to be done before it can be accepted for the publication. I hope to have the pleasure to reading you soon. [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: I Don't Know ****** 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: No ****** 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 ****** 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: Thank you for the opportunity to review this really important Delphi study looking at exercise interventions and core outcomes for older people after hospital discharge. My questions/responses are probably more thoughts about how the results of the Delphi might work in practice (particularly in a UK setting). Abstract: A clear overview of the study. Introduction: A good background and rationale for the study. I was just wondering though if you anticipate that the recommendations that you produce will be generalisable to healthcare systems across the world or was your focus on transitions from hospital to home in The Netherlands? Methods: Paragraph 1 - line 5: I am not clear what location AMC means or how it fits into this sentence? You say there is a case description of an acutely hospitalized older adult and information from open questions in the supplementary material but I cannot find this information or am I missing something obvious? Can you just clarify that by handover information you mean the information that is passed onto the healthcare professional/other who will be working with the older person in the community? Not information directly for the patient? Results: Clear and concise Discussion: Paragraph 2 - I totally agree that exercise and physical activity are not continued because of a lack of stimulus and self-discipline but there are also other factors including lack of community staff/support to follow-up these people (at least this is the case in the UK - hence my question about the scope of these results in countries other than the Netherlands) - so, by stimulus do you mean a person their to motivate the older person? Conclusion: I really appreciate that you have stated that this is a starting point and I really commend you on carrying out this work as a very important starting point Reviewer #2: Manuscript review for: Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: results of an international Delphi study. Many thanks for the opportunity to review the above-named manuscript. Whilst the aims and objectives for study were clear, I feel there are a few methodological and analytical points of note that may need to be addressed. My comments are noted below. Abstract You added the keyword « resistance exercise training ». This term was only used in your abstract! It was not identified neither in the introduction nor in the results « exercise intervention » and figure 2. So, I am confused about the utility of this term. Please clarify The authors mentioned in their abstract, line 6 “an internal panel of experts n=16” practically only 15 members responded so I think better to mention the number of responders instead. Introduction Further consideration is needed about this section and the order of the paragraphs and there needs to be a stronger rationale for the research. Perhaps there needs to give some context to “acute hospitalization” (description and duration). Provide more context about exercise intervention (different types and programs) and its influence on functional decline with few examples and references. You mentioned that practical guidelines on FITT of home-based exercise intervention after hospitalization exists but are lacking! Citing the existing guidelines and giving more details about the content and its limitation could be helpful. Providing this sort would help to set the scene for the study more clearly and give significance to the results. The authors mentioned in their introduction, line 9 “In this study, in-hospital exercise programs to prevent functional decline were performed twice per day”. Which study? The context is not clear! This part should be addressed. Further information /details are needed to describe the need for this study. Methods A stronger narrative on the scoping literature review approach is required. What were the search keywords used for the scoping literature review? The search was limited on the last 10 years! Please justify this choice Expert Panel. Selection criteria, homogeneity and panel size (minimum number of experts) were not mentioned in the “expert panel” part. More details are required Panel members were identified as “experts”, how did you consider or measure experience? Based on years of clinical experience maybe! or number of publications in PubMed? (Cited in table 1) If yes, this should be included in the corresponding paragraph The authors mentioned in the expert panel part, line 5 “Because no patients were included in this study, approval of the medical committee was not required.” Unsure if this is really useful, I prefer to delete this sentence. Delphi rounds. How expert opinions were collected? Was it based on anonymous survey rounds, face-to-face or group encounters? Please clarify How did you decide on the number and type of questions? I would like to have a look on supplementary material on case description and additional questions used in this study. Delphi round 3. The authors mentioned that “If an individual panel member’s scores differed from the panel’s median scores, they were asked to consider re-ranking the statement towards the median to reach consensus.” Not clear. Please explain more the procedure. Was it based on a panel discussion? Results Why did the authors contact only 16 experts and mainly physical therapists? Theme 1. Daily exercise interventions, line 7 “1–2 times weekly interventions in the sub-acute phase” There is a disagreement with figure 2 where you mentioned that 2-3 times/week is required in sub-acute phase! Please clarify The panel agreed on level intensity “70-80%” of the maximal heart rate. This requires elaboration about progressive training. The authors presented the results regarding the consensus but what about the stability of responses between successive rounds? This information would be very interesting to explore Figure 3 presents measurement tools across ICF domains. How do you explain the choice of these measurement tools knowing that other reliable scales exist in the literature? Discussion The discussion point about high-intensity exercise interventions. This requires elaboration. I wonder if the novel finding of this study is “the expert consensus that exercise interventions should be tuned to the specific needs and goals of the patient.” Why was this information not identified in the results part? Finally, its required to highlight what makes this research novel or unique. ****** 6. 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 #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: Review Plos one paper- FA.docx https://doi.org/10.1371/journal.pone.0283545.r001
Revision 1
18 Feb 2023 Author Response Additional Editor Comments (if provided): Response to PLOS ONE Dear Authors, Your submission has been carefully read by reviewers. Their outputs are positifs. They have adressed minors comments which , i think , will improve the quality of your manuscript. Few minor changes or clarifications need to be done before it can be accepted for the publication. I hope to have the pleasure to reading you soon. Author response Thank you for the positive feedback and the possibility to improve the manuscript. We are grateful that we can response to the comments. The responses of the author are written in italics. Reviewers' comments to the author: Reviewer #1: Thank you for the opportunity to review this really important Delphi study looking at exercise interventions and core outcomes for older people after hospital discharge. My questions/responses are probably more thoughts about how the results of the Delphi might work in practice (particularly in a UK setting). Abstract: A clear overview of the study. Introduction: A good background and rationale for the study. I was just wondering though if you anticipate that the recommendations that you produce will be generalisable to healthcare systems across the world or was your focus on transitions from hospital to home in The Netherlands? Author response The starting point of the Delphi study was to include an international panel of experts. Thereforet the outcomes our generalizable to healthcare systems across the world. In the end, we included experts from seven different countries with five experts from the Netherlands. Primary reason that we included more experts from the Netherlands was that we wanted experts with practical expertise who still work in the field of geriatrics rehabilitation. In the end we think that the results will be generalizable although this should be adjusted to the different healthcare settings across the world. Methods: Paragraph 1 - line 5: I am not clear what location AMC means or how it fits into this sentence? Author response The Amsterdam UMC has 2 locations (AMC and VU) and we understand that this could be confusing. We deleted location AMC in the revised manuscript in the Methods section on page 6. You say there is a case description of an acutely hospitalized older adult and information from open questions in the supplementary material but I cannot find this information or am I missing something obvious? Author response We included the case description in the supplementary material. Can you just clarify that by handover information you mean the information that is passed onto the healthcare professional/other who will be working with the older person in the community? Not information directly for the patient? Author response Handover information is the information that is passed onto the healthcare professional from Hospital towards the primary care. We added ‘from hospital on to healthcare professionals in primary care.’ in the methods section on page 6. Results: Clear and concise Discussion: Paragraph 2 - I totally agree that exercise and physical activity are not continued because of a lack of stimulus and self-discipline but there are also other factors including lack of community staff/support to follow-up these people (at least this is the case in the UK - hence my question about the scope of these results in countries other than the Netherlands) - so, by stimulus do you mean a person their to motivate the older person? Author response We added the suggestion to the discussion on page 11: ‘After discharge from hospital, exercises and physical activity are often not continued because stimulus by staff or community21 and/or self-discipline17 are lacking.’ Conclusion: I really appreciate that you have stated that this is a starting point and I really commend you on carrying out this work as a very important starting point Author response Thank you very much for all your feedback and we fully agree. Reviewer #2: Manuscript review for: Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: results of an international Delphi study. Manuscript review for: Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: results of an international Delphi study. Many thanks for the opportunity to review the above-named manuscript. Whilst the aims and objectives for study were clear, I feel there are a few methodological and analytical points of note that may need to be addressed. My comments are noted below. Abstract You added the keyword « resistance exercise training ». This term was only used in your abstract! It was not identified neither in the introduction nor in the results « exercise intervention » and figure 2. So, I am confused about the utility of this term. Please clarify Author response Thanks for the comment because the resistance exercise training is not correct. We changed in the abstract on page 4 resistance exercise training in exercise intervention as used in the rest of the manuscript: ‘The results of this Delphi study can assist physical therapists to provide a tailored exercise intervention for older patients with complex care needs after hospital discharge, to prevent functional decline and/or restore physical function.’ The authors mentioned in their abstract, line 6 “an internal panel of experts n=16” practically only 15 members responded so I think better to mention the number of responders instead. Author response We agree with the reviewer that describing the responders is clearer. We changed the abstract on page 4: ‘An internal panel of experts in the field of exercise interventions for acutely hospitalized older adults were invited to join the study.’ Later in the abstract it is described that there are fifteen responders. Introduction Further consideration is needed about this section and the order of the paragraphs and there needs to be a stronger rationale for the research. Perhaps there needs to give some context to “acute hospitalization” (description and duration). Author response In the first sentence of the introduction a short description and duration is added: For older adults, an acute hospitalization for multiple days due to an acute illness is a high-risk event with poor health outcomes, including functional decline, readmission, and mortality.1 Provide more context about exercise intervention (different types and programs) and its influence on functional decline with few examples and references. You mentioned that practical guidelines on FITT of home-based exercise intervention after hospitalization exists but are lacking! Citing the existing guidelines and giving more details about the content and its limitation could be helpful. Providing this sort would help to set the scene for the study more clearly and give significance to the results. Author response We added information to second paragraph of the introduction with reference: ‘International exercise recommendations in older adults are reported,18,19 These recommendations indicate that exercise improve physical function and quality of life and exercise is essential to older adults. However, practical guidelines on the frequency, intensity, time, and type (FITT) of home-based exercise interventions specifically for older patients after hospitalization are lacking.’ The authors mentioned in their introduction, line 9 “In this study, in-hospital exercise programs to prevent functional decline were performed twice per day”. Which study? The context is not clear! This part should be addressed. Author response Accidently, the number of the reference was not included. We added reference 14 to the introduction: In this study14, in-hospital exercise programmes to prevent functional decline were performed twice per day. Further information /details are needed to describe the need for this study. Author response At the end of the introduction on page 5, we added information to emphasize the novelty of this study: ‘In the absence of practical guidelines and high-quality randomized controlled trials focusing on acute hospitalized older adults, the Delphi methodology is often applied to obtain expert consensus on interventions for different populations.23,24’ Methods A stronger narrative on the scoping literature review approach is required. What were the search keywords used for the scoping literature review? Author response The scoping review was based on a search in Pubmed, Cinahl and Cochrane with MESH keywords such as aged, frail, hospitalization, hospital medicine, exercise therapy, resistance training, physical therapy modalities, diagnostic tests. Also, other keywords from key articles were used in the search. Snowballing was performed on relevant article to retrieve a complete overview of the literature. The search was limited on the last 10 years! Please justify this choice Author response The choice for the last 10 years is arbitrary and was based on the changing healthcare in the last decade with shorter length of stay of patients after an acute hospitalization. Expert Panel. Selection criteria, homogeneity, and panel size (minimum number of experts) were not mentioned in the “expert panel” part. More details are required Panel members were identified as “experts”, how did you consider or measure experience? Based on years of clinical experience maybe! or number of publications in PubMed? (Cited in table 1) If yes, this should be included in the corresponding paragraph Author response We wanted to select an international panel with a combination of expertise in this specific field of geriatric care. Eligibility of the expert panel was based on the field of expertise, geographical location, years of clinical expertise and the number of publications indexed in PubMed. The authors mentioned in the expert panel part, line 5 “Because no patients were included in this study, approval of the medical committee was not required.” Unsure if this is really useful, I prefer to delete this sentence. Author response Based on the feedback of the reviewer we removed this sentence. Delphi rounds. How expert opinions were collected? Was it based on anonymous survey rounds, face-to-face or group encounters? Please clarify Author response Expert opinions were collected by a digital anonymous survey. We added to the Delphi rounds in the Methods section: ‘A digital survey was sent to generate ideas and to rank statements on a 9-point Likert scale, as per Delphi methodology recommendations.20‘ How did you decide on the number and type of questions? I would like to have a look on supplementary material on case description and additional questions used in this study. Author response The case description has been added to the supplementary material Delphi round 3. The authors mentioned that “If an individual panel member’s scores differed from the panel’s median scores, they were asked to consider re-ranking the statement towards the median to reach consensus.” Not clear. Please explain more the procedure. Was it based on a panel discussion? Author response In the third round, individual panellists were asked if they were willing to adjust the score to the rest of the group. It was not possible to organize a physical meeting because of the international composition of the group Results Why did the authors contact only 16 experts and mainly physical therapists? Author response The authors of this article wanted to focus on therapists who are working with older adults and have expertise in the field of exercise. Although most of the panel is (also) physical therapist, six out of fifteen of the included panel have another profession. Theme 1. Daily exercise interventions, line 7 “1–2 times weekly interventions in the sub-acute phase” There is a disagreement with figure 2 where you mentioned that 2-3 times/week is required in sub-acute phase! Please clarify Author response The manuscript is adjusted in Theme 1 in the Results section: ‘Regarding training frequency, daily exercise interventions in the acute phase (up to 7 days post-discharge), 2–3 times weekly interventions in the sub-acute phase (up to 12 weeks post-discharge) and 1-12 times weekly in the long-term phase (>12 weeks post-discharge) were consensually ranked as essential for preventing functional decline.’ The panel agreed on level intensity “70-80%” of the maximal heart rate. This requires elaboration about progressive training. Author response It is interesting to elaborate more on the level of intensity of the maximal heart rate, however, this falls outside the scoop of the results of this Delphi study. In the discussion we added information to this finding (see author response in discussion). The authors presented the results regarding the consensus but what about the stability of responses between successive rounds? This information would be very interesting to explore Author response The statements were ranked in the second round of the Delphi study and individual panellist were asked to reconsider their ranking to join the rest of the group and reach consensus. Therefore, for most of the panellist the responses did not change. Figure 3 presents measurement tools across ICF domains. How do you explain the choice of these measurement tools knowing that other reliable scales exist in the literature? Author response The presented measurement tools are based on the input of the expert panel. Apparently, these measurement tools are frequently used in practice. It might be conceivable that other measurement tools are more used in research or academic setting. We added to the limitations of the discussion: ‘This might have influenced the choice of the selected measurement tools or exercise intervention.’ Discussion The discussion point about high-intensity exercise interventions. This requires elaboration. Author response We agree that high-intensity training is an important discussion point. In the discussion we added: ‘Therefore, high intensity exercises can certainly be considered to restore physical function in line with the international exercise recommendation18’ I wonder if the novel finding of this study is “the expert consensus that exercise interventions should be tuned to the specific needs and goals of the patient.” Why was this information not identified in the results part? Author response In the results section it is described as tailor-made exercise intervention. We added tailored in the discussion: ‘A novel finding of our study is the expert consensus that tailored exercise interventions should be tuned to the specific needs and goals (such as independent self-care, cooking or gardening) of the patient.’ Finally, its required to highlight what makes this research novel or unique. Author response In line with previous comments of the reviewers, we added information to the introduction to emphasize the novelty of this research. The novelty of this Delphi study is that this information was not available for older patients after discharge from hospital and can support healthcare providers in their daily practice. Attachments Attachment Submitted filename: Response to Reviewers.pdf https://doi.org/10.1371/journal.pone.0283545.r002
12 Mar 2023 Decision Letter - Jean-Philippe Regnaux, Editor Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: results of an international Delphi study PONE-D-22-27730R1 Dear Dr. Aarden, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Jean-Philippe Regnaux, Ph.D, PT Academic Editor PLOS ONE Additional Editor Comments (optional): I am pleased to inform you that your submission has been accepted for publication. Your study is very interesting. I am sure that the results will be useful to readers. Reviewers' comments: https://doi.org/10.1371/journal.pone.0283545.r003
Formally Accepted
15 Mar 2023 Acceptance Letter - Jean-Philippe Regnaux, Editor PONE-D-22-27730R1 Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: results of an international Delphi study Dear Dr. Aarden: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Mr Jean-Philippe Regnaux Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0283545.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .