Review for 10.1186/1471-230X-11-25 (2011)

Reviewer's report
Title:Perspectives on gastroesophageal reflux disease in primary care: the
REFLEX study of patient-physician agreement
Version: 1Date:10 October 2010
Reviewer: Christina Reimer
Reviewer's report:
This is a French study of patient-physician agreement concerning treatment
satisfaction among primary care GERD patients. Overall I think that the
manuscript is well-written and that the conclusions of the study are fair based on
the presented data. The authors should be acknowledged for this large survey
and the handling of a large amount of data.
Major revisions:
I think that important methodological information is missing and that both the
results and the discussion sections of the manuscript need shortening and major
revisions before publication can be considered. Above all I think that the tedious
reporting of numerous kappa values and what this translates to in terms of
agreement needs much tighter editing.
It is a bit unclear how the participating patients were selected. It says that the first
three adult patients with reflux symptoms who had a PPI prescription covering
the previous month were selected. Is it the first 3 that the PCP saw in his
consultation? In that case why did they consult? Because of residual symptoms
or any other cause? This could result in some selection of patients with more
severe GERD. Or is it the first 3 patients the PCP comes across in his patient
database? Did all patients agree to participate or were some asked and declined
participation? This is important missing information that makes it difficult to
interpret and extrapolate the results.
Furthermore the way symptoms and satisfaction (response options and time
frame) with therapy was assessed needs to be elaborated in the methods
section. More importantly it is unclear what the physicians were asked especially
in terms of expectations to treatment, impact of symptoms and self-medication.
Were they asked about their own beliefs or what they thought their patients felt
about these different issues?
As a general comment I think it should be remembered that the reduction of data
to a single kappa value inevitably yields answers that are not terribly meaningful
without the associated frequencies. Another problem is that kappa values
depend on the number of categories. In some cases the number of categories
could be grouped into for instance two meaningful categories (fig. 1 e.g.
Good/excellent and moderate/minimal/none to distinguish patients who are
satisfied with patients who need additional therapy or intervention).
Minor revisions
Were the participating PCPs comparable to the PCPs that were approached but
did not participate?
In table 1 I find the prevalence (77,3%) of esophagitis among the endoscoped
patients surprisingly high. This should be commented on or explained in terms of
selection of patients. Furthermore I do not think that the information on
physicians beliefs concerning use of OTC medication belongs in this table. It
would be more relevant to report the results of the patients to characterize the
participants.
Results:
I think it is unnecessary to report the proportion of patients in different categories
and the kappa-values both in the text and in figures (fig. 1 e.g.)
For other results only kappa-values are reported without the associated category
frequencies.
On page 9 the kappa values on agreement on impact on daily life etc do not
really make sense to me since it is unclear what the physicians were asked? This
goes for the associated fig. 2 as well. Were the physicians asked how many
patients they thought would expect a decrease of impact on daily life. Or how
many patients they believed would experience a decrease?
I think that the paragraph on residual symptoms could be shortened. The most
interesting information is how many continue to report characteristic reflux
symptoms despite PPI therapy. I doubt that the reporting of residual bloating for
instance characterizes a patient with insufficient response to PPI therapy and
need for PPI switching or additional OTC treatment.
Again on page 10 there is no need to report the numerous kappa values in the
text as they are already stated in the figure.
It is unclear how the frequency of residual symptoms was measured by the
physicians. Did they only rate the patients who actually experienced symptoms?
What is the time frame? In the previous week or further back? The same goes for
the rating of severity of symptoms.
I think that the discussion should be adjusted according the changes in the
results section suggested above
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I have received consultation fees from AstraZeneca in the past 5 years