Responses to the reviewer 1

【COMMENT 1】Good description of PHC in China. What is the role of specialist physicians regarding medication prescribing? In our research we found that PCPs feel very uncomfortable adjusting therapies or deprescribing medications that they did not themselves prescribe. How does the PCP-specialist physician relationship impact medication management?

【RESPONSE 1】Thank you for raising this important point regarding the relationship between PCPs and specialists in medication management. We have revised the Introduction to explicitly address this dynamic, noting that clinical inertia often stems from PCPs’ hesitancy to adjust prescriptions initiated by specialists. This addition further clarifies a key contextual barrier in our study setting.

(Introduction) Numerous barriers hinder their ability to optimize treatment, including clinical inertia, patient resistance to changes in medication regimens, limited access to decision support tools, inadequate training in managing polypharmacy, and time constraints during consultations [12,13]. Specifically, clinical inertia among PCPs often stems from their hesitancy to modify specialist-initiated regimens due to deference to authority, uncertainty about prescribing rationale, and legal concerns, thus compromising medication safety and care quality [14]. Moreover, the lack of clinical guidelines and insufficient evidence for treating patients with multimorbidity make it difficult to formulate individualized medication plans [15].

References added:

[14] Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, et al. Clinical inertia. Ann Intern Med. 2001; 135(9):825-34. doi: 10.7326/0003-4819-135-9-200111060-00012.

【COMMENT 2】Thank you for providing the survey. Again, lack of inclusion about items related to adjusting therapies that the provider itself did not start is a concern since the authors conducted a literature review.

【RESPONSE 2】Thank you for raising this important point regarding the scope of our survey. We wish to clarify that the questionnaire items were designed to assess PCPs’ decision-making engagement in a broad clinical context, specifically, when initiating a new prescription or modifying an existing medication regimen for a patient, irrespective of whether the original therapy was started by the PCP or another provider (e.g., a specialist). Thus, the instrument captures participatory decision-making practices across both self-initiated and externally initiated therapies under the PCP’s ongoing management.

【COMMENT 3】Manuscript line 101: Please cite a reference for the final statement in this paragraph.

【RESPONSE 3】Thank you for your suggestion regarding the citation for the psychometric properties. We would like to clarify that the reported metrics (Cronbach’sα, ICC, and CFI) were derived from the pilot testing phase of this study, which was conducted to assess the psychometric properties of the self-developed questionnaire. This preliminary validation confirms the instrument's robustness for the main survey. In line with your advice, we have supplemented the relevant methodological literature on psychometric evaluation in this section.

(Methods－Instrument) The instrument demonstrated good internal consistency (Cronbach’s α= 0.87 for the full scale), strong test–retest reliability (intraclass correlation coefficient = 0.84 over a two-week interval) and satisfactory construct validity (χ²/df=1.98, CFI=0.93, TLI=0.91, RMSEA=0.06) [18].

References:

[18] Kline RB. Principles and practice of structural equation modeling, 3rd ed. New York: Guilford Publications, 2011.

【COMMENT 4】Why was NEVER not included in the likert type scale since ALWAYS is included.

【RESPONSE 4】We sincerely appreciate the reviewer’s insightful question regarding the response options in our questionnaire. Our decision to use a three-point scale ("always," "occasionally," "rarely") was based on methodological and practical considerations. We opted against including a "never" option to minimize potential social desirability bias and respondent discomfort, as an absolute term might be perceived as an admission of not performing a core professional activity. The term “rarely” was chosen to capture low-frequency behaviors while maintaining a constructive and less prescriptive tone. Furthermore, from an analytical perspective, we anticipated that a “never” response would be selected infrequently, potentially creating a highly skewed distribution that could complicate subsequent statistical analyses. The chosen scale provided a balanced distribution suitable for our analysis while maintaining a constructive response tone.

【COMMENT 5】Please provide n’s where you have percentages.

【RESPONSE 5】Thank you for this helpful suggestion. We have revised the manuscript to ensure that all percentages reported in the Results section are now accompanied by their corresponding absolute numbers (n). As the changes are made throughout the relevant sections, we have not listed them individually here but have implemented them comprehensively in the revised manuscript to enhance the clarity and transparency of our data presentation.

(Results－Respondent Characteristics and Work-related Information)

Regarding work-related characteristics, 63.9% (n=221) of PCPs had completed standardized residency training, and 71.7% (n=248) were responsible for family doctor contract services. Two-thirds (n=233, 67.3%) practiced in rural PHC settings. Approximately a quarter reported a daily outpatient volume exceeding 50 patients. In terms of institutional support, 64.5% (n=223) had participated in pharmaceutical training in the past year, 75.4% (n=261) reported routine prescription reviews in their facilities, and 82.7% (n=286) indicated access to electronic drug information systems. When facing challenges in medication decision-making, 42.2% of PCPs (n=146) reported collaborating with pharmacists.

【COMMENT 6 AND 7】Revise from “...nearly half...” to the majority. Revise from "...junior or intermediate professional titles..." to were resident physicians or attending physicians.

【RESPONSE 6 AND 7】Thank you for your kind reminder. We have carefully revised the wording to ensure accuracy and clarity in the manuscript. The text has been updated as suggested, specifically changing “nearly half” to “the majority” and revising “held junior or intermediate professional titles” to “were resident physicians or attending physicians”.

(Result－Respondent Characteristics and Work-related Information) Among the respondents, the majority (n=180, 52.0%) were male, with a mean age of 37.8 years (range: 24–59). The majority of participants had fewer than 15 years of practice experience (n=217, 62.7%), with most identifying as resident physicians or attending physicians (n=272, 78.7%), and had obtained a bachelor’s degree (n=284, 82.1%) (Table 1).

【COMMENT 8】Would be helpful to know how representative the sample is to the Chinese PCP population. Please revise the Methods to include some statistical comparisons and present the findings here.

【RESPONSE 8】Thank you for this valuable suggestion regarding the representativeness of our sample. In response, we have added a concise comparative statement in the Results section (following the presentation of participants’ demographic and practice characteristics). By referencing the latest national health statistics (e.g., China Health Statistics Yearbook 2024), we note that the gender, age, educational, and professional title distribution of our sample aligns closely with the documented profile of physicians in China—where, for instance, 52.1% are male, 35.2% are aged 35–44, and 78.4% hold a bachelor’s degree or higher. This addition references national statistical data and indicates that the profile of our sample aligns broadly with that of the primary care physician population in China, thereby supporting the reasonable representativeness of our cohort within the studied context.

(Result－Respondent Characteristics and Work-related Information) The majority of participants had fewer than 15 years of practice experience (n=217, 62.7%), with most identifying as resident physicians or attending physicians (n=272, 78.7%), and had obtained a bachelor’s degree (n=284, 82.1%) (Table 1). The demographic profile of our sample was largely consistent with the distribution patterns reported for primary care physicians in national health statistics, supporting its representativeness to a certain extent [27].

References added:

[27] National Health Commission of China. 2024 China Health Statistics Yearbook. Beijing: Peking Union Medical College Press, 2025.

【COMMENT 9】Is it common for PCPs not to have completed any residency training? Also, is it possible that there might be some physicians who were pharmacists or had some specialized pharmacology training prior to becoming a PCP?

【RESPONSE 9】Thank you for your questions regarding the training background of physicians in China. We would like to provide a detailed explanation regarding this matter. Approximately a decade ago, China introduced a three-year standardized residency training program, which is now generally required for medical graduates to obtain a training completion certificate before practicing independently. Regarding pharmacology training, all PCPs in China are graduates of clinical medicine programs, while pharmacists cannot transition to become physicians. The pharmacology education these physicians receive during both undergraduate study and residency training is fragmented and limited, lacking the depth of specialized pharmacy training.

【COMMENT 10】Please provide descriptive statistics for the “score” so readers can better understand where the PCPs landed in terms of medication practices.

【RESPONSE 10】Thank you for this valuable comment. We agree that descriptive statistics regarding the overall engagement scores would help readers better interpret the level of PCPs' involvement in medication decision-making. We acknowledge that this information was initially missing from the manuscript.

In response to your suggestion, we have now added a paragraph under Results section (PCPs’ Engagement of Medication Decision-making for Patients with Multimorbidity) to present the descriptive statistics of the engagement scores. We believe this addition provides a clearer and more comprehensive overview of PCPs’ medication decision-making practices.

(Results－PCPs’ Engagement of Medication Decision-making for Patients with Multimorbidity) Based on the 20-item questionnaire (total possible score: 40), the 346 PCPs had a mean engagement score of 31.8 (ranging from 21 to 38). The majority (n=227, 65.6%) scored between 31 and 35 points. All participants scored above half of the total possible score.

Before initiating treatment plans, 72.5% of PCPs (n=251) reported “always” reviewing patients’ medical and medication histories, while 68.2% (n=236) explored the purpose of the visit, and 70.2% (n=243) addressed patients’ prioritized needs.

【COMMENT 11】The sentence “...align with barriers previously reported in both...” needs to be finished.

【RESPONSE 11】Thank you for your kind reminder. We have carefully revised the wording to ensure the completeness and clarity of the sentence. The incomplete statement in the original text has been corrected by adding the missing word, specifically amending “resource-constrained” to “resource-constrained countries”.

(Discussion) The work-related factors identified in our study, such as limited access to decision-support resources, insufficient training in polypharmacy management, and time pressures during consultations, align with barriers previously reported in both high-income and resource-constrained countries [12,13,29,30].

【COMMENT 12】The sentence “...currently clinical guidelines which strongly advocate...” needs to be cited. Preferably one about polypharmacy or multimorbidity management.

【RESPONSE 12】Thank you for your thoughtful comment regarding the need to substantiate the statement about clinical guidelines. We acknowledge that the citation in our initial submission could have been more explicit. Upon review, we confirm that the recommended reference on polypharmacy and multimorbidity management (Muth et al., 2019) was already included in our manuscript’s reference list. To strengthen the support for this specific claim, we have now explicitly cited this guideline at the relevant point in the sentence.

(Discussion) This stands in contrast to current clinical guidelines, which strongly advocate for patient-centered care and shared decision-making, particularly in the management of multimorbidity [31].

References:

[31] Muth C, Blom JW, Smith SM, Johnell K, Gonzalez-Gonzalez AI, Nguyen TS, et al. Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. J Intern Med. 2019, 285(3):272-288. doi: 10.1111/joim.12842.

【COMMENT 13】The sentence "...research has demonstrated that engaging patients in decision-making processes...", has research found SDM improves medication adherence and/or disease outcomes?

【RESPONSE 13】Thank you for your valuable suggestion regarding the need to substantiate the link between SDM and patient outcomes. While our originally cited reference (Laviana et al., 2017) does state that involved patients “have better outcomes”, we acknowledge that this correlational language does not constitute direct, quantified empirical data on specific clinical endpoints. To more accurately reflect the available evidence and enhance the academic rigor of our argument, we have revised the relevant sentence. We have changed the phrasing from “...leads to better clinical outcomes...” to the more measured “...may have a positive association with clinical outcomes...” This modification aims to precisely convey the supportive yet indicative relationship suggested by the literature, rather than asserting a definitive causal link. We appreciate your guidance in prompting this clarification and are open to any further suggestions.

(Discussion) Evidence from international studies has shown that shared decision-making not only improves medication adherence and patient satisfaction but also may have a positive association with clinical outcomes in multimorbid populations [31].

【COMMENT 14】The sentence “...aligns with a well-documented limitation in current practice:...” needs to be cited.

【RESPONSE 14】Thank you for your thoughtful comment regarding the need to substantiate the statement about the well-documented limitation in current practice. We acknowledge that the citation in our initial submission could have been more explicit. Upon review, we confirm that the recommended reference (Wang et al., Ageing Res Rev, 2024), which systematically reviews the limitations of current disease-specific guidelines in addressing multimorbidity, was already included in our manuscript's reference list. To directly address your point and strengthen the support for this specific claim, we have now explicitly cited this review at the relevant point in the sentence.

(Discussion) This finding aligns with a well-documented limitation in current practice: most clinical guidelines remain disease-specific and fail to account for the complexity of managing patients with multiple coexisting conditions [34].

References:

[34] Wang Z, Zhu D, Zhang H, Wang L, He H, Li Z, et al. Recommendations and quality of multimorbidity guidelines: A systematic review. Ageing Res Rev. 2024; 102:102559. DOI: 10.1016/j.arr.2024.102559.

Responses to the reviewer 2

【COMMENT 1】The first cutoff point reported for the “number of outpatient visits per day” is high (≤50 patients per day). This seems quite striking. Considering that the question was free text (open question), I suggest exploring others range, or explaining how and why this cutoff was defined.

【RESPONSE 1】Thank you for your insightful comment and for raising this important point regarding the cutoff values for the daily number of outpatient visits. We appreciate your careful review. In our survey, which used an open-ended question, the reported daily patient volumes varied considerably, ranging from single digits to over 150 visits per day.

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