Title: Physicians’ knowledge, attitude, and prescribing behavior regarding stress ulcer
prophylaxis in China: A multi-center study
Version: 2 Date: 26 Apr 2021
Reviewer's report:
In the Background:  you mentioned that the most well-known guideline was the National
Medical Journal of China… Did you mention the main recommendations for SUP in this
guideline? And how much it differs from the global evidence based guidelines?
In the Methods: you mentioned that the we performed a cross-sectional national survey using
questionnaires, randomly sampling 1266 physicians on their current SUP practices….How you
assess the random distribution?
In the Methods: Discuss more about the main parts of the used questionnaire and the content
of used questions
In the Methods: The current study assessed the general physicians practicing in sub-centers. Did
the authors ask the participants how many of them have been worked in the ICU and prescribed
SUP? And did the authors ask the participants who never worked in the ICU about the source
of information they got about the SUP?
In the methods: Mention the Sample size calculation
In the methods: you mentioned the use of chi square analysis test but I didn’t find the chi square
analysis data in the results
In the methods: you didn’t mention any details about the checking for normality such as
using Shapiro-Wilk test (with p-value #0.05 indicates a normally distributed continuous
variable), Checking for the absence of multicollinearity between the independent variables
before conducting multiple linear regression analysis. Checking for the Homoscedasticity
assumption such as using Breusch-Pagan test, with a p-value #0.05 indicate the absence of
heteroscedasticity.
In the Results: what do you mean by attending physician?
Also I think we need further data about the demographics of recruited physicians….how many
of them were (trainee, resident, fellows, consultant), years of experience in general, years
of experience in ICU, any continuous educational programs they got, the different ages of
them,,,, how many of recruited sub centers were governmental or private? maybe there are many
parameters play a role in this misuse of SUP
In the Results: how many ICU units there are in the recruited sub-centers?
In the Results: you mentioned that the most well-known guideline was the National Medical
Journal of China (NMJC, 42 %), but 46 % of surgeons were unaware of any guidelines…..in
the discussion you should highlight the reasons behind this result… is this weakness in the
educational process in Chinese universities or problem in the continuous educational programs?
In the Results: Figure 1. Drugs selection characteristics,,,, I think because the mentioned figure
contains just the percent of used PPIs so it's more suitable to be presented as table rather than
figure.
In the Results: The physicians also answered the questions “How often do postoperative patients
receive stress ulcer prophylaxis?” and “How often do patients discharged from the hospital
remain on SUP?”,,,, these details about the used questions should be moved to the methods part
In the Results: I think the results should be re-written to represent and to discuss the following
subtitles:
1) factors affecting the knowledge regarding stress ulcer prophylaxis overuse in China
2) factors affecting the attitude regarding stress ulcer prophylaxis overuse in China
3) factors affecting the prescribing behavior regarding stress ulcer prophylaxis overuse in China
In the Results: Table 2:  the table is very long, should be reorganized as follows:
Always Usually Sometimes Rarely Never
Acid-suppressing drugs are useful for SUP.
I worry that patients may develop gastrointestinal bleeding without SUP.
“ I worry about that the patients complaint against the doctors if develop
gastrointestinal bleeding but not SUP”
An attending physician’s request for SUP influenced my decision making
I agree that SUP is a prescribing habit
I perceive PPIs as harmless, which influences my decision making.
In the Results: Table 2: the table was not prescribed in the results paragraph
In the Results: you mentioned the Hospital discharged patients who remained on SUP,,, how
you assess that there is no other needs for the PPI s uses after discharge? Accordingly we cannot
be sure that there is absolute misuse of SUP practice
In the Results: you mentioned that a patient has developed gastrointestinal bleeding because
of not using SUP,,, this question is misleading because there is many factors could lead to GI
bleeding so how can the doctor be sure that the cause is not using SUP?
In the Results: you mentioned that worry about that the patients complaint against the doctors
if develop gastrointestinal bleeding but not SUP”…… i don’t understand exactly the meaning
of this sentence
In the Results: Table 4: I think there is a problem in the analysis here. I think the regression
should be used to test the correlation between different independent variables (in your study
you mentioned them as:  The independent variables were sociodemographic factors, including
the hospital level (secondary hospital, tertiary care hospital), sex (male, female), education
level (doctorate, master, undergraduate), job title (chief physician, attending physician, resident
physician) and the awareness of CPGs for SUP (yes, no). The physician’s attitude toward
SUP was also included in the prescribing behavior analysis) and different outcomes such as
knowledge score, attitude score and even the prescribing behavior. So this analysis should be
revised again
Title: Physicians’ knowledge, attitude, and prescribing behavior regarding stress ulcer
prophylaxis in China: A multi-center study
Version: 2 Date: 26 Apr 2021
Reviewer's report:
In the Background:  you mentioned that the most well-known guideline was the National
Medical Journal of China… Did you mention the main recommendations for SUP in this
guideline? And how much it differs from the global evidence based guidelines?
In the Methods: you mentioned that the we performed a cross-sectional national survey using
questionnaires, randomly sampling 1266 physicians on their current SUP practices….How you
assess the random distribution?
In the Methods: Discuss more about the main parts of the used questionnaire and the content
of used questions
In the Methods: The current study assessed the general physicians practicing in sub-centers. Did
the authors ask the participants how many of them have been worked in the ICU and prescribed
SUP? And did the authors ask the participants who never worked in the ICU about the source
of information they got about the SUP?
In the methods: Mention the Sample size calculation
In the methods: you mentioned the use of chi square analysis test but I didn’t find the chi square
analysis data in the results
In the methods: you didn’t mention any details about the checking for normality such as
using Shapiro-Wilk test (with p-value #0.05 indicates a normally distributed continuous
variable), Checking for the absence of multicollinearity between the independent variables
before conducting multiple linear regression analysis. Checking for the Homoscedasticity
assumption such as using Breusch-Pagan test, with a p-value #0.05 indicate the absence of
heteroscedasticity.
In the Results: what do you mean by attending physician?
Also I think we need further data about the demographics of recruited physicians….how many
of them were (trainee, resident, fellows, consultant), years of experience in general, years
of experience in ICU, any continuous educational programs they got, the different ages of
them,,,, how many of recruited sub centers were governmental or private? maybe there are many
parameters play a role in this misuse of SUP
In the Results: how many ICU units there are in the recruited sub-centers?
In the Results: you mentioned that the most well-known guideline was the National Medical
Journal of China (NMJC, 42 %), but 46 % of surgeons were unaware of any guidelines…..in
the discussion you should highlight the reasons behind this result… is this weakness in the
educational process in Chinese universities or problem in the continuous educational programs?
In the Results: Figure 1. Drugs selection characteristics,,,, I think because the mentioned figure
contains just the percent of used PPIs so it's more suitable to be presented as table rather than
figure.
In the Results: The physicians also answered the questions “How often do postoperative patients
receive stress ulcer prophylaxis?” and “How often do patients discharged from the hospital
remain on SUP?”,,,, these details about the used questions should be moved to the methods part
In the Results: I think the results should be re-written to represent and to discuss the following
subtitles:
1) factors affecting the knowledge regarding stress ulcer prophylaxis overuse in China
2) factors affecting the attitude regarding stress ulcer prophylaxis overuse in China
3) factors affecting the prescribing behavior regarding stress ulcer prophylaxis overuse in China
In the Results: Table 2:  the table is very long, should be reorganized as follows:
Always Usually Sometimes Rarely Never
Acid-suppressing drugs are useful for SUP.
I worry that patients may develop gastrointestinal bleeding without SUP.
“ I worry about that the patients complaint against the doctors if develop
gastrointestinal bleeding but not SUP”
An attending physician’s request for SUP influenced my decision making
I agree that SUP is a prescribing habit
I perceive PPIs as harmless, which influences my decision making.
In the Results: Table 2: the table was not prescribed in the results paragraph
In the Results: you mentioned the Hospital discharged patients who remained on SUP,,, how
you assess that there is no other needs for the PPI s uses after discharge? Accordingly we cannot
be sure that there is absolute misuse of SUP practice
In the Results: you mentioned that a patient has developed gastrointestinal bleeding because
of not using SUP,,, this question is misleading because there is many factors could lead to GI
bleeding so how can the doctor be sure that the cause is not using SUP?
In the Results: you mentioned that worry about that the patients complaint against the doctors
if develop gastrointestinal bleeding but not SUP”…… i don’t understand exactly the meaning
of this sentence
In the Results: Table 4: I think there is a problem in the analysis here. I think the regression
should be used to test the correlation between different independent variables (in your study
you mentioned them as:  The independent variables were sociodemographic factors, including
the hospital level (secondary hospital, tertiary care hospital), sex (male, female), education
level (doctorate, master, undergraduate), job title (chief physician, attending physician, resident
physician) and the awareness of CPGs for SUP (yes, no). The physician’s attitude toward
SUP was also included in the prescribing behavior analysis) and different outcomes such as
knowledge score, attitude score and even the prescribing behavior. So this analysis should be
revised again
Please review this paper.
user
Title: Physicians’ knowledge, attitude, and prescribing behavior regarding stress ulcer
prophylaxis in China: A multi-center study
Version: 2 Date: 26 Apr 2021
Reviewer's report:
In the Background:  you mentioned that the most well-known guideline was the National
Medical Journal of China… Did you mention the main recommendations for SUP in this
guideline? And how much it differs from the global evidence based guidelines?
In the Methods: you mentioned that the we performed a cross-sectional national survey using
questionnaires, randomly sampling 1266 physicians on their current SUP practices….How you
assess the random distribution?
In the Methods: Discuss more about the main parts of the used questionnaire and the content
of used questions
In the Methods: The current study assessed the general physicians practicing in sub-centers. Did
the authors ask the participants how many of them have been worked in the ICU and prescribed
SUP? And did the authors ask the participants who never worked in the ICU about the source
of information they got about the SUP?
In the methods: Mention the Sample size calculation
In the methods: you mentioned the use of chi square analysis test but I didn’t find the chi square
analysis data in the results
In the methods: you didn’t mention any details about the checking for normality such as
using Shapiro-Wilk test (with p-value #0.05 indicates a normally distributed continuous
variable), Checking for the absence of multicollinearity between the independent variables
before conducting multiple linear regression analysis. Checking for the Homoscedasticity
assumption such as using Breusch-Pagan test, with a p-value #0.05 indicate the absence of
heteroscedasticity.
In the Results: what do you mean by attending physician?
Also I think we need further data about the demographics of recruited physicians….how many
of them were (trainee, resident, fellows, consultant), years of experience in general, years
of experience in ICU, any continuous educational programs they got, the different ages of
them,,,, how many of recruited sub centers were governmental or private? maybe there are many
parameters play a role in this misuse of SUP
In the Results: how many ICU units there are in the recruited sub-centers?
In the Results: you mentioned that the most well-known guideline was the National Medical
Journal of China (NMJC, 42 %), but 46 % of surgeons were unaware of any guidelines…..in
the discussion you should highlight the reasons behind this result… is this weakness in the
educational process in Chinese universities or problem in the continuous educational programs?
In the Results: Figure 1. Drugs selection characteristics,,,, I think because the mentioned figure
contains just the percent of used PPIs so it's more suitable to be presented as table rather than
figure.
In the Results: The physicians also answered the questions “How often do postoperative patients
receive stress ulcer prophylaxis?” and “How often do patients discharged from the hospital
remain on SUP?”,,,, these details about the used questions should be moved to the methods part
In the Results: I think the results should be re-written to represent and to discuss the following
subtitles:
1) factors affecting the knowledge regarding stress ulcer prophylaxis overuse in China
2) factors affecting the attitude regarding stress ulcer prophylaxis overuse in China
3) factors affecting the prescribing behavior regarding stress ulcer prophylaxis overuse in China
In the Results: Table 2:  the table is very long, should be reorganized as follows:
Always Usually Sometimes Rarely Never
Acid-suppressing drugs are useful for SUP.
I worry that patients may develop gastrointestinal bleeding without SUP.
“ I worry about that the patients complaint against the doctors if develop
gastrointestinal bleeding but not SUP”
An attending physician’s request for SUP influenced my decision making
I agree that SUP is a prescribing habit
I perceive PPIs as harmless, which influences my decision making.
In the Results: Table 2: the table was not prescribed in the results paragraph
In the Results: you mentioned the Hospital discharged patients who remained on SUP,,, how
you assess that there is no other needs for the PPI s uses after discharge? Accordingly we cannot
be sure that there is absolute misuse of SUP practice
In the Results: you mentioned that a patient has developed gastrointestinal bleeding because
of not using SUP,,, this question is misleading because there is many factors could lead to GI
bleeding so how can the doctor be sure that the cause is not using SUP?
In the Results: you mentioned that worry about that the patients complaint against the doctors
if develop gastrointestinal bleeding but not SUP”…… i don’t understand exactly the meaning
of this sentence
In the Results: Table 4: I think there is a problem in the analysis here. I think the regression
should be used to test the correlation between different independent variables (in your study
you mentioned them as:  The independent variables were sociodemographic factors, including
the hospital level (secondary hospital, tertiary care hospital), sex (male, female), education
level (doctorate, master, undergraduate), job title (chief physician, attending physician, resident
physician) and the awareness of CPGs for SUP (yes, no). The physician’s attitude toward
SUP was also included in the prescribing behavior analysis) and different outcomes such as
knowledge score, attitude score and even the prescribing behavior. So this analysis should be
revised again
assistant