Review for 10.1186/s12876-021-01979-z (2021)

Title: Physicians’ knowledge, attitude, and prescribing behavior regarding stress ulcer
prophylaxis in China: A multi-center study
Version: 2 Date: 27 Apr 2021
Reviewer:  Muhammad Eid Akkawi
Reviewer's report:
Thank you for giving me the chance to review this manuscript. The research idea is quite
important and inadequately studied before. However, I have some concerns regarding the
methodology used to run the study.
Here are my detailed comments:
Title:
In fact, the study did not assess knowledge or attitude about SUP overuse but assessed the
practice and attitude about prescribing SUP itself. Therefore, the title is not accurately reflective.
Also, please change the word survey to study.
Introduction:
“Instead, these medications may have side effects, including an increased risk of pneumonia,
Clostridium difficile infection, fracture, and hypomagnesemia9-10” : In fact, some ADR of PPI
such as  fracture, and hypomagnesemia are usually associated with long-term use of PPI, which
is not applicable in case of SUP.
The authors stated that major surgery is a risk factor for SU. However, all the cited guidelines,
ASHP, DSAICM and EAST recommend SUP in major surgery except for major burn surgery or
organ transplantation. Actually, this assumption affected the results when the physicians asked
to identify risk factors for SU.
Methods:
Sampling and participants:
The authors claimed that this a national study. What was the sampling technique used? stratified,
cluster, multistage, others?  How was the sample size calculated? How many Chinese states/
territories the study covered? I do not believe that this is a nationwide study.
The authors also mentioned nothing about the inclusion criteria applied to recruit physicians.
One of the options for the question about the education level was “undergraduate”: was the
study involved undergraduate students? If yes, it should be clearly stated that the study involved
physicians and medical students.
The questionnaire used:
It would be beneficial and clearer to the reader if the authors elaborate about the validity and
reliability tests done before, and their results. If there is another paper for the validation of the
used questionnaire, please cite it.
Also, it is not clear whether the questionnaire used was in Chinese or English language.
Additionally, it is not clear whether the question regarding SUP prescribing was about ICU
patients or surgery patients in general.
Another important note about the questionnaire that some statements used to investigate the
attitude are should not practically being under attitude. For example, 12.7 & 12.8 are practice/
experience not attitude. Also, the responses provided for other items are not appropriate. For
instance, “I agree that SUP is a prescribing habit” the participants either agree or disagree on
this statement, so the answer should be either yes or no. Giving options as frequency (Always
b. Usually c. Sometimes d. Rarely e. Never) is meaningless.
Data analysis:
Variables such as age, sex, education level, and years of experience should be included in the
logistic regression. These factors are quite important to investigate their association with SUP
prescribing.
Results:
The authors divided the respondents based on the frequency of SUP prescribing. However, it
was not stated what was the percentage that was considered “high”; is it >40%, >60%, or > 80%?
Please give some insights about table 3 & 4 in the text.
Table 4: I think the authors mistakenly wrote “patients” instead of “physicians”.
Discussion:
“Koczka et al. and Hussain et al.14- 15 previously described the national and international
awareness and attitudes of physicians toward SUP”: why do authors mean by national and
international awareness?
“In prior surveys, the SUP agent of choice was H2RAs, ranging from 64 to 77 %18- 20” : The
cited papers are old studies. Please compare with recent studies from China instead of those.
“but prior observational studies showed that almost 20 % of survey respondents indicated
that they did not discontinue SUP until the patient was discharged from the hospital”: Your
respondents? if no, please cite the study.
“These findings are congruent with those of a recent survey by Krag et al”: it is in 2015, so it
is not a recent study.
“Although it is difficult for any survey to elucidate why physicians prescribe in a certain way,
we can hypothesize based on the results of our questionnaire.”: Hypothesize what?
“A lack of awareness of SUP CPGs correlated with higher prescribing behavior. Subjective
attitudes also affected prescribing behavior, as indicated by the responses to the questions “Acid-
suppressing drugs are useful for SUP,” “I agreed that SUP is a prescribing habit,” “ I worry about
that the patients complaint against the doctors if develop gastrointestinal bleeding but not SUP”
and “A patient has developed gastrointestinal bleeding because of not using SUP.”: Please give
explanation. Do not just repeat the results only.
“Recent studies reported low CIB frequency, with the majority of prospective studies and meta-
analyses finding little bleeding reduction with pharmacological prophylaxis”: Please, cite the
studies.
General:
the manuscript needs a profound English language editing.