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Dear Editor,
We appreciate the opportunity to revise and resubmit our paper titled “Factors Associated with Toileting Disability in Older Adults without Dementia Living in Residential Care Facilities.“We want to thank the editor and reviewers for their critiques and revision recommendations. We think the revised paper is strengthened by them. We have followed the editor’s suggestion and provided a table summarizing the editor’s and reviewers’ comments, our response to the comments and the location of changes made in the manuscript. Changes to the revised manuscript are underlined using the tracked changes function of Microsoft Word. We have included the line numbers in the revised manuscript to help the reviewers identify our changes.
EDITOR’S COMMENTS
The key concern I have is regarding the two-step procedure for data analysis. Please add justification for first estimating univariate logistic regression models and then estimating a multivariate regression model; or, report a single multivariate logistic regression in the revision. Using the first step to screen variables is not compelling, particularly when weighed against the cost of conducting multiple statistical tests. / We have rewritten our statistical methods to provide justification for our approach. / Section: Methods - Analysis
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WORD CHOICE (para 1): "Frail older adults without dementia are increasingly choosing to live in residential care facilities" Reconsider the use of "choosing" in this context. It implies free selection of options, which may not really be tenable for older frail adults whose options are often restricted. It would be better to simply state that Frail older adults without dementia are increasingly living in residential care facilities. / We have made the recommended word choice. / Section: introduction
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DISABLEMENT PROCESS MODEL (p. 4): Please add definitions for key concepts (pathologies, impairments, and functional limitations). / We have added the definitions for key concepts. / Section: Introduction
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METHODS SECTION: Please add headings. / We have added headers to the Methods Section / Section: Methods
RESULTS: Please submit the correlation matrix as Supplemental Digital Content (SDC). For more information find Author Checklist for Supplemental Digital Content here: / We have created a correlation matrix of the variables included in the multivariable model and added a paragraph in the results section discussing the related findings. / Supplemental table
Section: Results
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DISCUSSION: recommendation for targeting walking, standing,sitting,etc skills. This is a good point. Make it explicit that all these more generic skills are needed for independent toileting, or prevention of toileting disability. It might also be mentioned that disability can be a function of environmental challenge; issues such as spaciousness of the bathroom, grab bars, and height of toilet seat may also contribute to prevention of disability. Although information about these extra-individual factors were not available in your dataset, they could be mentioned in the discussion as an important consideration in future work. / We had revised the discussion section to incorporate the editor’s recommendations. / Section: Discussion
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TABLE 1 CONSTRUCTION: Please use separate columns for each statistic reported (n, %). (Otherwise, the data reported do not line up straight, creating vertical waviness in the table.) / We have revised the table based on this recommendation. / Section: Table 1
REVIEWER 1 COMMENTS
1. Problem Statement: The description of the problem significance is acceptable. However, authors made the operational definition of toileting disability equal to BADL difficulty in toileting could not be optimal to result interpretations, management implications and hypothesis testing of conceptual model. One question may rise " What's the importance of toileting disability to elders without urinary incontinence (UI)?" / We agree with the reviewer that there are many ways to define toileting disability. However, we were limited in the definition we could use based on the measures available in the data set. Furthermore, the definition used in the data set is the most commonly used definition of toileting disability in national surveys.
We acknowledge that not every person with a toileting disability has urinary incontinence. However, the purpose of this study was to identify factors associated with toileting disability and the literature (as scant as it is) strongly suggests that urinary incontinence often accompanies toileting disabilities. / We have not changed our definition of toileting disability and we kept urinary incontinence as a factor to investigate.
2. Background Literature: The rationale supporting the statement in line 4-5 (p.2) could be added.
The prevalence of toileting disability reported by Kane et al. in lines 14-15 (p.2) could be specified more clearly.
Please recheck the prevalence numbers reported in the references of Lee et al. and Carey et al.(lines 17-19, p.2).
Address more literature on the importance of preventing or managing toileting disability properly to elders without UI.
Please recheck the relevance between statements in p.4 to p.5 (lines 17 to 2), and the topic. / We think it is common knowledge that toileting disability is commonly defined as having difficulty with or requiring human or mechanical assistance with toileting and therefore have not added an unnecessary citation to support this statement.
We have clarified that the review done by Kane et al., indicated that very few nationally representative studies of older adults identify the prevalence of toileting disability.
We have confirmed that the prevalences we reported are consistent with that reported in these articles.
We appreciate the reviewer’s recommendation to “address more literature on the importance of preventing or managing toileting disability properly to elders without urinary incontinence.” Unfortunately, we are not aware of any literature that addresses this issue.
We thank the reviewer for asking us to reconsider the paragraph we have describing how many people live in residential care facilities vs. nursing home and the related costs. We have decided to keep this paragraph in the manuscript, because it provides background information on the number of people likely to be impacted by toileting disability and the potential cost of preventing a transition to the nursing home. We want to provide this background because we know that not all readers in this journal are familiar with this information. / No revision made
Section: Introduction
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Section: Introduction
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3. Theoretical framework: Authors have modified the original conceptual model "The disablement process." Please be aware the confounders such as "intra-individual factors" and "co-existing disabilities" might influence theresults. How to reduce their effects by statistical manipulation?
The hypothesis could be revised to improve its clarity. / We controlled for confounders including intra-individual factors and co-existing disabilities by including them as independent variables in the analysis.
We have rewritten the hypothesis to improve its clarity. / No revision made
Section: Introduction
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4. Methods: The descriptions in lines 5-12 (p.5) could be shortened and addressed the main information only.
Please add the number of post hoc power analysis by using the subset sample or provide rationale support to assuring adequate sample power?
A particular concern is a large number of independent variables have entered to test the regression model, and a subset sample of 398 elders with toileting disability is used. / We appreciate the need to be concise with the description of the NSRCF, however, we have chosen to keep the information we previously provided describing it. The reason for doing so is that there is not agreement on how to define residential care facilities and this section clearly defines how it was defined in the survey.
We do not think it is necessary to do post-hoc power analysis when we obtained statistical significance in our results.
We have revised the description of our statistical approach to describe that we calculated the outer limit of independent variables for predicting the occurrence of 398 events and we did not exceed that limit. / No revision made
Statements now appear in
Section: Introduction
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Section: Methods
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5. Results: Be aware to do consistently in content while round the percentage number to the nearest whole number (15.1%=15%; 34.7%=35%). Similarly, the numbers of p-value in tables might keep the third digit after the decimal point consistently.
The statement in lines 1-2(p.9) could be revised to improve its clarity. The N/A in table 1 (p.3) might need to add a note. / We have corrected any inconsistencies with rounding percentage numbers to the nearest whole number and p-values to the third decimal point throughout the paper and tables.
We have added a note to table 1 to clarify what N/A represents. / Throughout paper and tables
Table 1
6. Discussions: Based on results, what is the implication to those having toileting disability without UI?
The comparisons made in lines 6-8 (p.10) could be revised to improve its appropriateness.
Is the hypothesis stated in lines 11-12 (p. 10) consistent with the previous statement (lines 9-12, p.4)?
Please consider the relevance between statements in lines 20-23 (p.10) and the results.
Significant variables including resident health, facility size, for-profit facility, and visual or hearing impairment should be addressed --their applications or implications in discussions.
Is the design "cross sectional" or "secondary analysis" (lines 4-5, p.11)?
Indicate how the limitation stated in lines 12-16 (p.11) might restrict the scope of study purpose or measure or results? It is important to readers. Please provide more justification to readers. / Again, we appreciate the reviewer’s observation that not all residents with toileting disability will have urinary incontinence. However, we have not been able to identify any literature to guide incorporating this issue into the discussion. Additionally the purpose of our paper is to identify factors associated with toileting disability and to suggest future research based on these findings. The strong statistical significance found for incontinence, suggests it’s an important consideration for toileting disability and we have elected to suggest including it in future research.
We have taken the reviewer’s suggestion and removed the comparisons about the prevalence of toileting disability and that of other chronic diseases.
We have revised the hypothesis to ensure it is consistent between the introduction and discussion section.
We believe the statements provided in lines 20-23 continue to be relevant. These statements include the recommendation to modify programs that have been done in nursing home settings for the residential care setting. We think that our findings suggest this is a reasonable next research step. Our suggestions are tentative in nature, because we acknowledgethis cross-sectional, descriptive work does not imply causality and future studies would need to investigate the effect of interventions.
We have added a discussion of these variables in the discussion section.
We have clarified that the National Survey of Residential Care Facilities survey is a cross-sectional study in the methods section.
We had added additional comments on the limitations of the study in the discussion section. / No revision made
Section: Discussion
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Section: Discussion
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No revisions made, but text reviewer is referring to can be found at Section: Discussion
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Section: Discussion
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Section: Methods
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Section: Discussion
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7. Conclusions: The statements in lines 4-5 and 13-14 (p.12) could be deleted to improve relevance and clarity. / We have taken the reviewers recommendation and deleted these two statements. / Section: Conclusions
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REVIEWER 2 Comments
First, the methods section was somewhat confusing. On page 6, line 3 the authors state that the subsample represents 34.7% of the NSRCFS sample which is apparently based on weighted results. At this point in the manuscript this is not clear and will lead to confusion among readers if they try to calculate that number. Often when describing the sample in weighted analyses, unweighted sample sizes are provided, but weighted proportions are presented. It appears that was done here, but it needs to be made clear what is being presented (e.g., unweighted Ns but weighted proportions). / We deleted the sentence “This subsample represents 35% of the NSRCFS sample” from the methods section and left the statement in the results section.
We have clarified our use of unweighted frequencies and weighted proportions in the analysis section. / Section: Methods-Analysis-descriptive statistics.
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Section: Methods-Analysis
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On page 7 the authors should state their justification for essentially dichotomizing each physical impairment to create the composite score. Using a larger range, by including all levels of the responses to the six items, might allow for a better assessment of this factor. / We selected to create a composite impairment variable that represents the number of impairments, rather than a continuous measure that would represent severity of impairment. In the latter case, the severity of impairment may represent impairment in only one area.In gerontology an “accumulation of deficits” is more highly associated with disability, than the severity of a problem in one area(Rockwood & Mitnitski, 2007). Thus, we think a count of impairments has more meaning for this descriptive study.
Rockwood, K., & Mitnitski, A. (2007). Frailty in relation to the accumulation of deficits. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 62(7), 722-727.
Additionally, we created the continuous impairment variable recommended by the reviewer to determine if this measure was operationally different from our count measure. The correlation between the count variable and the continuous variable was .67, indicating that both measures are measuring similar concepts.Thus, we think it is easier for the reader to understand that as the number of impairments increases, so does the risk of having a toileting disability. / We have not changed the impairment variable in the manuscript.
On page 8 the authors state that variables with correlations greater than 0.5 were excluded. While co-linearity is an important issue to address, the statement implies all correlated predictors were removed. Was this the case or was one retained for the analysis? This should be clarified. / We have clarified our process for selecting variables in the manuscript and included per the editor’s request a correlation matrix of variables for a supplemental table. / Section: Methods - Analysis
Pages: 8-9
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Also, on page 8 the authors provide some explanation for how the analyses account for the sampling design employed. While this is adequate, it might be useful to state that this is necessary because this type of sampling may lead to inherently correlated data. The respondents within a facility may be more similar (i.e., correlated) than those in different facilities. / We have included a statement in the methods section indicating why it is necessary to account for the sample weights in the analysis. / Section: Methods-Statistical Software
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On page 11, the authors state estimates are unreliable when cell sizes are below 30. This is true, but a brief explanation and/or a reference would be useful / We have included a citation for this issue. / Section: Discussion
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Also on page 11, the authors do an adequate job of describing the limitations of using an existing dataset. They go on to conclude though the "study's generalizability is strengthened by the use of a nationally representative sample, estimation procedures that account for the complex sampling design, and confirmation of a theory driven hypothesis." However, they should discuss the limitation of the weighting methodology a bit more. Usually, large public use datasets are weighted such that the entire sample is nationally representative. How can the authors be sure that the subsample employed is nationally representative? / We have added additional information in the discussion section discussing this limitation with using subgroup analysis. / Section: Discussion
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The footnote on Table 1 should be clarified slightly to say that frequencies reported are raw numbers but proportions are weighted ("so percentages calculated with the raw frequencies?" implies raw frequencies are reported, but this should be explicitly stated). / We have clarified this note on table 1. / Section: Table 1
Foot note
Finally, on page 5, line 18 - the word "data" is plural - the statement should read "Data were?". / We have corrected this grammatical error / Section: Methods
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