PONE-D-24-33388Clinical, laboratory, and hospital factors associated with preoperative complications in Peruvian older adults with hip fracture.PLOS ONE

Dear Dr. Valladares-Garrido,

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Additional Editor Comments:

A well written article which requires clarification of the methodology and a broader overview of the literature including alternate means of risk stratification peri-operatively.

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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: Partly

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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: THE STUDY IS VERY RELEVANT FOR GERIATRIC ORTHOPAEDIC PRACTICE.

THE CLASSIFICATION OF THE STUDY VARIABLES IS QUESTIONABLE AND UNCLEAR . IN THIS AGE GROUP URINARY TRACT INFECTION CAN BE LIIFE THREATENING AND IT CAN BE VERY SEVERE.

THE MAIN INDEPENDENT VARIABLES ARE VERY GOOD BUT ARE THEY CLINICAL OR HOSPITAL FACTORS?

THE LABORATORY FACTORS WERE BROAD AND SOME OF THEM ARE THE SAME WITH THE CLINICAL FACTORS E.G CHRONIC KIDNEY DISEASE AND UREA,ELECTROLYTE AND CREATINE.

THE STUDY WILL HELP IMPROVE PATIENT EVALUATION FOR HIP SURGERIES TO POSSIBLY BETTER THE OUTCOME.

THE DOCUMENTED TITLE THOUGH IS NON-SPECIFIC AND BROAD WAS PARTLY ANSWERED IN THE CONCLUSION

I WAS UNABLE TO ACCESS THE DOCUMENTS ATTACHED (HENCE QUESTION 3 RESPONSE IS I DON'T KNOW)

Reviewer #2: The manuscript presents an observational retrospective cohort study that aims to identify clinical, laboratory, and hospital factors associated with preoperative complications in older adults with hip fractures. Overall, the quality of the writing and the study design is sound, and the article is suitable for acceptance. Below are the strengths of the manuscript and a few minor suggestions for improvement:

Clarification of Terms: The term "mental red cross >=3 points" could be clarified or defined in more detail, as it may not be a widely recognized metric outside specific regional or institutional practices.

Further Discussion on Gender Differences: While the manuscript notes that female gender is associated with an increased risk of preoperative complications, a deeper exploration of potential underlying causes or mechanisms would enhance the discussion section.

Minor Grammatical Revisions: Although the language is generally good, a few sentences could benefit from minor grammatical refinement for smoother readability.

Conclusion:

The manuscript is well-structured and provides important insights into preoperative complications in older adults with hip fractures. With minor revisions, I recommend this manuscript for acceptance.

Reviewer #3: Question 1: The introduction of the article is more detailed and provides relevant background information. However, its structure can be somewhat simplified. Merge similar content and consider breaking it into fewer paragraphs.

Question 2: On page 5, line 109, "2.3 Sampling and sampling" why is it so stated

Question 3: Too few variables were included in the multivariate analysis compared to the baseline data, and there may be large confounding factors. It is necessary to consider the collinearity problem, but the criterion of excluding collinearity by P < 0.2 is there any relevant literature report, please give the specific VIF value of each variable.

Question 4: The points described in the discussion part of the article are more specific, but they are not in-depth. I hope to see the author's in-depth analysis of the main conclusions of the article on the mechanism level.

Reviewer #4: The sample size calculation, although mentioned as being performed using the Cleveland Clinic online calculator, lacks detailed explanation of the parameter selection. More information should be provided on the sample size determination process, and the rationale behind the choice of parameters should be clarified, along with how the representativeness of the sample was ensured. Additionally, the use of non-random sampling limits the generalizability of the findings, which should be further emphasized in the discussion.

The exclusion criteria are not sufficiently justified. For instance, patients with voluntary discharge are excluded without discussion of whether they differ significantly from included patients in terms of health status or outcomes, potentially introducing bias. It is recommended to provide a more detailed rationale for excluding these patients and to discuss how their exclusion might impact the study’s results.

The data collection period spans from 2017 to 2019, but there is no mention of whether any changes in hospital practices occurred during this time and how these changes might have influenced the results. Given the retrospective nature of the study, the potential influence of time-related factors should be considered and discussed.

The writing style is somewhat verbose, particularly in the abstract and discussion sections. Some paragraphs could be simplified to improve clarity and conciseness. In particular, the introduction contains excessive background information that could be streamlined to focus more on the research question.

Inconsistent terminology usage is evident throughout the manuscript, particularly with the term "mental red cross," which is not clearly defined and is used inconsistently. It is recommended to ensure consistent use of terminology and to provide a detailed explanation of unfamiliar terms upon first use to avoid confusion.

Some statements in the manuscript lack precision. For example, in the multivariate analysis results, the assertion that "female sex significantly increases the risk of pre-surgical complications" is overconfident given that the p-value is 0.052, which is marginally significant. It is advised to use more cautious phrasing, such as "female sex showed a trend towards an association with pre-surgical complications."

The discussion of certain variables, such as cardiovascular disease and diabetes, lacks depth. The manuscript would benefit from a more thorough exploration of the potential mechanisms through which these variables might influence preoperative complications, adding credibility to the findings.

The use of a Poisson regression model for multivariate analysis is reasonable, but the choice of this model over others, such as logistic regression, is not explained. A brief justification of the model selection should be provided, and the handling of multicollinearity among variables should be discussed.

Confidence intervals are missing for some variables, especially in Table 3 of the multivariate regression analysis. The absence of confidence intervals limits the ability to assess the precision of the findings. It is recommended to include 95% confidence intervals for all relative risk estimates.

Some effect sizes, while statistically significant, may lack clinical significance. For instance, the effect of admission glucose levels on pre-surgical complications (RR=1.01) is statistically significant but the magnitude of the effect is small. Further discussion is needed to clarify the clinical relevance of such findings and to avoid overinterpretation of statistically significant results with minimal effect sizes.

Missing data are acknowledged but not adequately addressed. While the manuscript notes that some variables, such as sex and Barthel Index, have missing values, it does not describe how these missing data were handled (e.g., exclusion, imputation). A more detailed explanation of the approach to missing data is necessary.

The presentation of data in Table 1 is too condensed, with an overwhelming amount of information. It is recommended to split the table into multiple sections—one for demographic and clinical characteristics, and another for laboratory and complication data—to enhance readability. Additionally, the inclusion of graphical representations, such as Kaplan-Meier curves for complication occurrence, would improve the accessibility of the findings.

The structure of the discussion is somewhat disjointed, with weak logical connections between certain points. The comparison of study results with existing literature is brief, and the manuscript would benefit from a more structured and thorough analysis of how the findings align with or differ from previous studies.

The ethics section mentions approval from an ethics committee, but more detailed information on how data privacy was ensured during data collection and analysis is needed, especially given the use of personal health data. Additional information on how patient anonymity was maintained would strengthen the ethical compliance of the study.

The study claims an informed consent waiver due to its retrospective design, but more justification is needed for this waiver, including specific references to relevant ethical guidelines. Further elaboration on the justification for waiving informed consent and how the study ensured compliance with ethical standards would enhance the credibility of the ethical considerations.

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Reviewer #1: Yes: Mustapha ALIMI

Orthopaedic and Spine Surgeon

National Orthopaedic Hospital

Igbobi ,Lagos

Nigeria

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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Clinical, laboratory, and hospital factors associated with preoperative complications in Peruvian older adults with hip fracture.

PONE-D-24-33388R1

Dear Dr. Valladares-Garrido,

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.

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Kind regards,

Barry Kweh

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors have satisfactorily clarified the definition of their variables and strengthened their discussion with a broader incorporation of the literature regarding perioperative complications of patients undergoing hip fractures.