The impact of comprehensive geriatric assessment on postoperative outcomes in elderly surgery: A systematic review and meta-analysis

Lin Chen; Wei Zong; Manyue Luo; Huiqin Yu

doi:10.1371/journal.pone.0306308

Peer Review History

Original SubmissionApril 6, 2024
10 May 2024 Decision Letter - Barry Kweh, Editor PONE-D-24-12165The impact of comprehensive geriatric assessment on postoperative outcomes in elderly surgery: a systematicreview and meta-analysisPLOS ONE Dear Dr. Chen, 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 Jun 24 2024 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. 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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. Thank you for stating the following in your Competing Interests section: [ ]. Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now This information should be included in your cover letter; we will change the online submission form on your behalf. 3. We note that you have referenced (unpublished) on page 3, which has currently not yet been accepted for publication. Please remove this from your References and amend this to state in the body of your manuscript: (ie “Bewick et al. [Unpublished]”) as detailed online in our guide for authors http://journals.plos.org/plosone/s/submission-guidelines#loc-reference-style Additional Editor Comments: The authors have conducted an interesting and robust meta-analysis. There needs to be greater emphasis on inclusion and exclusion criteria as well as a more thorough risk of bias assessment using PRISMA-endorsed instruments. The discussion also requires a greater overview of the literature in both a tabulated and written format. This should demonstrate and discuss other means of risk stratification in elderly patients undergoing surgery such as the CCI or MFI. [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: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 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 ****** 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: No 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: The authors conducted a systematic review, which is an interesting topic to choose, but some issues need to be addressed before publication: 1. Don't use acronyms for the first time. It's confusing. 2. Are the methods of CGA exactly the same? In the included original studies, if not, the authors may not be able to conduct a combined analysis. 3. The reasons for publication bias and high heterogeneity should be explained in the discussion. 4. Full text language needs to be modified. Reviewer #2: The study will definitely contribute to the wealth of medical knowledge and it will impact geriatric patient management. The search was broad, the article selection was scientifically done ,methodology was good, and their distribution of the articles was wide.The data extraction was appropriate, result was well analysed and the conclusion was in tandem with the results. The references are appropriate. ****** 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: Yes: Alimi Mustapha Faiz ******** [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. https://doi.org/10.1371/journal.pone.0306308.r001
Revision 1
11 Jun 2024 Author Response Dear Editor and Reviewers: We sincerely thank the editor and all reviewers for their valuable feedback that we have used to improve the quality of our manuscript. The reviewer comments are laid out below in italicized font and specific concems have been numbered. Our response is given in normal font and changes/additions to the manuscript are given in the revised manuscript with red text. In response to the journal's requirements, we have revised and refined our manuscript, as detailed below: 1. We have meticulously reviewed the journal's layout specifications and adjusted our manuscript accordingly. 2. As per the guidelines, we have reformulated our declaration of interests and incorporated it into the cover letter. 3. We have thoroughly reviewed all references, ensuring that the sources are published, peer-reviewed articles from a variety of journals. Editor Comments: 1.There needs to be greater emphasis on inclusion and exclusion criteria as well as a more thorough risk of bias assessment using PRISMA-endorsed instruments. 2.The discussion also requires a greater overview of the literature in both a tabulated and written format. This should demonstrate and discuss other means of risk stratification in elderly patients undergoing surgery such as the CCI or MFI. The author’s responses 1. We accept the editor's remarks and have incorporated the proposed changes into the document. To enhance the article's rigor, we have added two elements to the exclusion criteria after careful consideration. 1. Studies that used CGA solely as a risk assessment tool for postoperative unfavorable outcomes; 2. Studies that did not use a comprehensive multidomain evaluation and optimization plan, but only evaluated one CGA field, such as nutritional status. The newly generated inclusion and exclusion criteria are a more specific description of our search procedure and will not change our earlier search results. Furthermore, as the editor noted, PRISMA-approved instruments are essential for a thorough bias risk assessment. We used the Cochrane Collaboration's tool to assess the risk of bias in randomized trials and followed the meta-analysis guidelines for epidemiological observational research. Details can be found in the manuscript's quality evaluation section and the PRISMA checklist in the appendix. 2. Based on the suggestions, we explored other methods for preoperative risk stratification in elderly patients, such as the CCI and MFI. We summarized these methods in a table, including their names, brief descriptions, and areas of focus. Additionally, we elaborated on their connections and differences with CGA. Below are some discussion points from the revised manuscript. Unlike CGA, these methods focus on clinical and physiological parameters that directly affect surgical risk, helping to decide whether patients should proceed with surgery and what level of care they need afterward. They provide faster evaluations but may miss subtle differences that a complete CGA can capture. CGA has a broader scope and is more widely used to assess the overall health status of patients. These aspects may not directly affect surgery but are crucial for patients' overall health and postoperative recovery. Reviewer #1 1. Don't use acronyms for the first time. It's confusing. 2. Are the methods of CGA exactly the same? In the included original studies, if not, the authors may not be able to conduct a combined analysis. 3. The reasons for publication bias and high heterogeneity should be explained in the discussion. 4. Full text language needs to be modified. The author’s responses 1. We apologize for the incorrect use of acronyms in the initial manuscript. Following the reviewer's suggestion, we have revised this section. 2. Regarding the reviewer's concerns about the heterogeneity of CGA methods, we addressed this during the literature review. CGA is a well-established multi-domain assessment that evaluates the physiological, social, psychological, and functional states of elderly patients. The approach to nursing optimization and the content addressed are consistent despite model variations. To achieve generalizable outcomes, we broadened the research criteria and decided to conduct a merger analysis. We carefully interpreted the results and acknowledged the limitations in the text, as this could introduce bias. However, recognizing and accepting the limitations of this review may encourage more scholars to conduct further research. 3. It is inevitable that bias will exist. We added the following potential sources of bias and heterogeneity to the manuscript's discussion section after summarizing them in response to reviewers' comments: First, the potential for bias increased when the same researchers were involved in both the intervention and control groups, as the included studies were single-center and could not blind investigators and participants during the CGA intervention. Second, a time gap between pre- and post-operative evaluations could introduce extraneous variables. Some studies addressed this by shortening the observation period, leading researchers to select quickly examinable items. However, this may lead to publication bias. For example, studies on immediate postoperative delirium may be published earlier than those on long-term cognitive effects. Insufficient follow-up time can also result in false-negative outcomes. Third, this review is limited to English language research, and this limitation may also lead to bias. 4. Thanks for reviewers' significant reminding. We have asked native English speakers and tried our best to polish the manuscript. These changes will not influence the content and framework of the paper. And here we did not list the changes but marked in red in the revised paper. Again, thank you for giving us the opportunity to strengthen our manuscript with your valuable comments and queries. We have worked hard to incorporate your feedback and hope that these revisions persuade you to accept our submission. With best regards, Sincerely Yours, Corresponding author: Lin Chen Corresponding address: No.10 Qingyun South Street, Jinjiang District, Chengdu City, Sichuan Province, China. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0306308.r002
17 Jun 2024 Decision Letter - Barry Kweh, Editor The impact of comprehensive geriatric assessment on postoperative outcomes in elderly surgery: a systematic review and meta-analysis PONE-D-24-12165R1 Dear Dr Chen, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Barry Kweh Academic Editor PLOS ONE Additional Editor Comments (optional): A well written article that has been amended in its methodology and discussion. Reviewers' comments: https://doi.org/10.1371/journal.pone.0306308.r003
Formally Accepted
21 Jun 2024 Acceptance Letter - Barry Kweh, Editor PONE-D-24-12165R1 PLOS ONE Dear Dr. Chen, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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 Dr. Barry Kweh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0306308.r004

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