Comparison of G8 and ISAR Screening Results in Geriatric Urology
Round 1
Reviewer 1 Report
Thank you for permitting me to review this manuscript
Introduction Line 2: I would add other types of surgeries
Line 41 please add an erratum or appendix or even in the methods the description of the G8 and ISAR score
Please explain why you use the G8 score which is mainly an oncologic frailty score in patients with benign disease , if you have reference that this score can be used in patients with non oncologic disease please cite it otherwise please exclude patients not having malignities
The same problem exist with the ISAR score which is an emergency room score please cite reference confirming the possibility of using this score in non emergency patients
0.77 correlation is not very significant please explain
The discussion is confusion it needs some shake up
for instance the authors cite themselves that a comprehensive geriatric assessment is the current gold standard why this was not assessed by a geriatrician?
the authors also write that both test equally measure geriatric risk factors please elaborate
Again please justify the clinical use of these test in non oncologic and an non emergency patients
Author Response
Dear Reviewer, thank you for your valuable remarks.
We made the changes according to your remarks. In the following section we give a point by point statement/answer to your remarks and explain the changes we made in the manuscript.
1. Remark: Introduction Line 2: I would add other types of surgeries
Answer: Hopefully we understood your remark correctly. We added: „and their subsequent medical, surgical and/or radio oncologic treatment”to put clear that treatment decisions have to be taken in the geriatric population.
2. Remark: Line 41 please add an erratum or appendix or even in the methods the description of the G8 score and the ISAR score.
Answer: We moved the description off both scores to methods. Additionally, we made an appendix of both scores/questionnaires
3. Remark: Please explain why you use the G8 score which is mainly an oncologic frailty score in patients with benign disease, if you have reference that this score can be used in patients with non-oncologic disease please cite it otherwise please exclude patients not having malignities
Answer: Thank you for this valuable key remark. We changed the introduction and added / modified the following section. As requested it includes a reference of the G8 score in non-oncologic patients.
„The G8 score was chosen in the present study because it is intensively discussed in geriatric oncology [9], because it is recommended by urogeriatric guidelines [10], and because it has also shown its value in the screening of patients with benign conditions [11]. Cavusoglu et al. recently described a strong concordance between their G8 screening results and a complete geriatric assessment (CGA) in 200 non-oncologic patients and therefore proposed its use also in these patients [11].!
4. Remark: The same problem exists with the ISAR score which is an emergency room score please cite reference confirming the possibility of using this score in non-emergency patients
Answer: Thank you again for this valuable key remark: Please note that the ISAR Score is a mandatory screening for all geriatric hospitalized patients and at least in our region not reserved only for emergency patients. Even if its origin is from emergency units it is already now used in many non-emergency patients in our region. We added the following section in methods:
The ISAR score was chosen because it has become a mandatory screening tool for all hospitalized patients of 75 years and above in our region of North Rhine Westphalia, Germany in 2015 [12]. Even though it was primarily designed for geriatric emergency patients [13] it has also been evaluated in oncological patients [14] [15] and in non-emergency patients [16] . In our region it is therefore considered as a standard routine test for all patients.
The following citation was added in which the score was used in a non-emergency unit.: (16) Scharf AC, Gronewold J, Dahlmann C, Schlitzer J, Kribben A, Gerken G, Rassaf T, Kleinschnitz C, Dodel R, Frohnhofen H et al: Health outcome of older hospitalized patients in internal medicine environments evaluated by Identification of Seniors at Risk (ISAR) screening and geriatric assessment. BMC Geriatr 2019, 19(1):221.
5. Remark: The correlation of 0.77 is not very significant. Please explain
Answer: Eventually there is a misunderstanding: - 0.77 is the Sperman correlation coefficient (ranging from -1 - 0 ) and not the p-value. In our eyes -0.77 however it is quite a good correlation. The p value for significance is <0.0001. Please see tab. 2 for the value.
6. Remark: The discussion is confusion it needs some shake up. For instance, the authors cite themselves that a comprehensive geriatric assessment is the current gold standard why this was not assessed by a geriatrician?
Answer: The discussion was rewritten in many parts (please see the marked changes), Hopefully it now meets your expectations and is more clear to the reader.
The fact that we could not compare our test results to the results of a comprehensive geriatric assessment (CGA) is a limitation of our study. Due to resource restrictions CGAs were and are not performed systematically in our hospital. This is a limitation and it is openly addressed in the paper. However, data were instead compared to clinical data that are known to be related to frailty and geriatric risk factors. This still shows valuable results in our eyes.
Please see in discussion: This interpretation, however, has to be handled with care, because the results of both tests were not verified by a comprehensive geriatric assessment, which is the current golden standard for geriatric frailties [4, 5]. Because until know comprehensive geriatric assessments are not part of our clinical hospital routine, they were unfortunately not available in the present study. This is a major limitation of our study.
7. Remark: The authors also write that both test equally measure geriatric risk factors please elaborate.
Answer: Thank you for this remark. Yes, it is true that we state that we have evidence that both tests almost equally measure geriatric risk factors. This is on the one hand due to the almost similar correlation to clinical data (Charlson score, Number of diagnosis, length of stay etc.) of both tests (see table 2) and on the other hand due to the fact that nobody oft ISAR positive patients had normal G8 score.
Please see our text in discussion:
Even though highly different in their rate of positive – and negative test results, both tests had a significant negative correlation with each other. They also revealed a significant and equal correlation to important clinical parameters: length of stay, Charlson comorbidity index, number of coded diagnosis and the Braden score (tab. 2). The latter factors are all known to be related to geriatric risk factors and frailties[12]. Together with the fact, that none of the patients who were ISAR positive were G8 negative, these correlation data give us evidence that both tests equally measure geriatric risk factors and frailty in our population.
8. Remark: Again please justify the clinical use of these test in non-oncologic and in non-emergency patients
Answer: Thank you for your clear point and this valuable remark. To justify the use of both tests in our study more clearly we not only changed the introduction but also added the following sentence in discussion.
„In the present study we compared the results of the G8 and the ISAR score in an unselected group of urogeriatric patients of our department and compared both to clinical data. The reason for that is that both tests are already-as mentioned above (in the introduction)- used for general screening and not only in cancer patients in case of the G8 score and in emergency patients in case of the ISAR score. “
Reviewer 2 Report
I had the pleasure to review this revised manuscript submitted to the Journal of Clinical Medicine.
The revised version improved in some parts, however still exists some parts to be much improved.
abstract
The background for selecting the G8 and ISAR screening test in the retrospective study setting : must be added to the abstract for the readers to understand this study aim.
Introduction
The redundant introduction must be re-described to clear manifestation of the study design. The last part of the introduction cannot clearly explain the reason for the choosing the two questionnaires in this study.
Results
Tables must be edited for scientific formatting and clarify the meaning of the study results. Table 1 should be divided to express the baseline characteristics of the study participants (split the table from the G8 score~)
the abbreviations used in the tables should be added at the footnotes of the tables.
Discussion
The clinical usefulness of this study results must be clarified for the right interpretation.
Author Response
Dear Reviewer, thank you for your valuable remarks.
We made the changes accordingly. In the following section we give point by point statements/answers to your remarks and explain the changes we made in the manuscript.
- Remark: Abstract: The background for selecting the G8 and ISAR screening test in the retrospective study setting: must be added to the abstract for the readers to understand this study aim.
Answer: Thank you for your remark: We changed the abstract accordingly and added the following sentences:
„Purpose: The G8 and ISAR scores are two different screening tools for geriatric risk factors and frailty. Aim was to compare G8 and ISAR screening results in a cohort urogeriatric patients to help clinicians to better understand and choose between both tests. Methods: We retrospectively evaluated 100 patients at the age of 75 and above who were treated for different urological conditions. All routinely and prospectively underwent a G8 and an ISAR screening “
Please note that the tests of course were not performed retrospectively but in clinical routine.
- Remark: Introduction: The redundant introduction must be re-described to clear manifestation of the study design. The last part of the introduction cannot clearly explain the reason for the choosing the two questionnaires in this study.
Answer: Thank you for this remark. The introduction was changed. The reason for choosing the two questionnaires was newly addressed and the description of both tests was put into methods. Please look at the marked changes in the text.
- Remark: Results: Tables must be edited for scientific formatting and clarify the meaning of the study results. Table 1 should be divided to express the baseline characteristics of the study participants (split the table from the G8 score~), the abbreviations used in the tables should be added at the footnotes of the tables.
Answer: Thank you for this remark. We looked through the tables, we simplified table 1 and added the meaning of the abbreviations to the legends. Table 1 was spitted. Please state if you propose additional changes.
- Remark: Discussion: The clinical usefulness of this study results must be clarified for the right interpretation
Answer: The discussion was changed in many passages. The reason/rational for this study namely to compare results of both tests in a clinical day to day setting was more intensively stressed throughout the paper, especially in the discussion. Please see:
„Both the G8 score and the ISAR score are recommended as screening tests for geriatric risk factors [12, 23, 24]. Until now reports and comparisons between them in the literature are rare but important to evaluate their applicability in clinical routine and to make a choice between them.“
and
„In the present study we compared the results of the G8 and the ISAR score in an unselected group of urogeriatric patients of our department and compared both to clinical data. The reason for that is that both tests are already – as mentioned above- used for general screening and arte not only used in cancer patients in case of the G8 score and in emergency patients in case of the ISAR score.“
Round 2
Reviewer 1 Report
The authors have significantly improved the manuscript
the appendix 2 needs better resolution as it is difficult to read
Author Response
Dear reviewers thank you for your remarks.
We added the ISAR score in a better resolution.
Reviewer 2 Report
Abstract: Purpose: The G8 and ISAR scores are two different screening tools for geriatric risk factors and frailty. Aim was to compare G8 and ISAR screening results in a cohort urogeriatric patients to help clinicians to better understand and choose between both tests.
==> Purpose and Aim were duplicated. Please consider to get an English grammar correction by professional editing service.
Author Response
Dear reviewers thank you for your remarks.
We sent the paper to english editing. Please see the attached manuscript.
Best regards
