PEER REVIEW HISTORY BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. ARTICLE DETAILS TITLE (PROVISIONAL) Primary care physicians’ decision-making processes in the context of multimorbidity: protocol of a systematic review and thematic synthesis of qualitative research. AUTHORS Rodrigues, David; Sousa, Paulo; Basílio, Nuno; Antunes, Ana; Antunes, Maria da Luz; Santos, Maria Isabel; Heleno, B VERSION 1 - REVIEW REVIEWER Carol Sinnott University of Cambridge, UK REVIEW RETURNED 18-May-2018 GENERAL COMMENTS Will quality assessment be used to exclude studies? A number of cognitive reasoning models are discussed in the introduction – how will these be used in the analysis? Clarify how you will deal with studies on decision-making in the context of co-morbidity. Attention is needed with language and syntax throughout (e.g. use of dysrationalia). In your primary studies, will you extract all data for analysis or just http://bmjopen.bmj.com/ that related to decision-making? How will you delimit data on “ decision-making” as being different from any other data dealing with GPs’ views/perspectives on clinical care of patients with multimorbidity? In the discussion, page 9 paragraph 3 you mention that you are using this review to test a hypothesis. How will you use your data to test this hypothesis? Further to the last point, how do you judge “flaws” in decision on October 2, 2021 by guest. Protected copyright. making for multimorbidity? Against what benchmark can you say if decision-making for patients with multimorbidity is optimal or not? A limited numbers of terms are proposed for the primary care/general practice and the decision-making strings of the search; perhaps this is a pragmatic decision, favouring speed over breadth of search but this should be addressed in the text. For example, you mention family physicians in the methods section but this is not one of the terms in the search. Multimorbidity is a MeSH term now- it does not appear that this is included in the search. Prior work on cognitive biases in primary care is available in this review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093937/ There is a slight contradiction in the aims- you seek to understand what “primary care physicians perceive to contribute for better decision-making with patients with multimorbidity and which are the main barriers in this process”. But you are also interested in system one decision-making which is intuitive rather than conscious. Do you think PCPs will be able to describe the influences on their BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from system 1 decisions? How will this issue affect your data? REVIEWER Tim Stokes Department of General Practice & Rural Health, Dunedin School of Medicine, University of Otago, New Zealand REVIEW RETURNED 28-May-2018 GENERAL COMMENTS This paper is a study protocol. It reports a planned systematic review and thematic synthesis of qualitative research - GPs/FM/PHCPs accounts of managing patients with multimorbidity. The research question focuses on medical decision making between patient and practitioner. Overall the systematic review itself if appropriately designed and reported. The following points need addressing: 1. There is a need for more clarity on the aims and research question (objectives) and why the methods chosen can address these. (p. 5, LL1-7). The overall aim is appropriate. The specific research question, as worded, seems to be too specific and makes assumptions about what will be found in the qualitative synthesis in advance (e.g., "what info do PCPs perceive to contribute ...") 2. Related to (1) above, I am unclear exactly how system 1 and system 2 thinking (introduction) will actually be explored and synthesised during the review process. This needs more clarification both in introduction and in objectives section. http://bmjopen.bmj.com/ 3. The abstract needs re-wording to reflect fact that the research focuses on General Practitioners/Family Medicine/PC practitioners. 4. Overall the quality of the written English is acceptable. However there are instances throughout the paper of grammatical errors. on October 2, 2021 by guest. Protected copyright. REVIEWER Sophie Hill Centre for Health Communication and Participation, La Trobe University, Australia. REVIEW RETURNED 01-Jun-2018 GENERAL COMMENTS This is a protocol for a qualitative evidence synthesis (QES) that could make a very valuable contribution to literature and practice, given the severe neglect by researchers of the challenges of multimorbidity (MM) both for doctors and for patients. TITLE: When I read the title I assumed it was a QES about both doctors’ and patients’ experiences of decision making in the context of MM – but it is in fact only focussed on doctors. This is perfectly fine but I suggest a small re-phrasing the title to: ‘Primary care doctors’ decision making processes in the context of multimorbidity: protocol … ‘ etc. STRENGTHS AND LIMITATIONS: I agree that you have to note a BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from limitation but I do not think a focus on doctors treating people with multimorbidity is a limitation – it is a major strength, given the dearth of relevant research and guidance. Is there something else you could say for a limitation of method? One possible option is to say that you will only be considering doctors’ experiences of decision making for MM and that another review would be needed for patients’ experiences of MM. RATIONALE: I really liked to introduction to this protocol. METHODS – SEARCH STRATEGY: You state you will be considering all relevant studies that fit your inclusion criteria. I don’t expect this will be too large a number but had you anticipated that you may find 50-100 studies – and considered what you will then do or if you should sample from the set? Perhaps you could add a comment on this issue as sampling has been a strategy needed in some QES topics. STUDY RECORDS – OUTCOMES AND SYNTHESIS STRATEGY. I did not understand this sentence, so could you please consider explaining this a bit more, particularly the term’ textual pooling’. The sentence is ’The findings will be presented in a narrative form, where textual pooling is not possible’. OVERALL COMMENT: The protocol is written in clear English for the most part but I would recommend that you give it to a colleague with high English proficiency as there are a few terms that could be better expressed. VERSION 1 – AUTHOR RESPONSE Reviewer: 1 First, we would like acknowledge the Reviewer’s constructive comments. Please find the requested answers below. http://bmjopen.bmj.com/ Will quality assessment be used to exclude studies? No. All studies that fulfill eligibility criteria will be included for analysis. Quality assessment will be taken into account while assessing the confidence in cumulative evidence using Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach as described on page 7. The following changes were made in the manuscript: on October 2, 2021 by guest. Protected copyright. The following sentence clarifying this matter was added to Risk of bias in individual studies section: "Quality assessment will not be used to exclude studies." A number of cognitive reasoning models are discussed in the introduction – how will these be used in the analysis? The dual process theory (the model that states that decision making is the result of the integration between two cognitive systems, the intuitive and heuristic based system 1 and the analytical rational system 2) will be the theoretical lens through which thematic synthesis will be performed. Thematic synthesis will be theoretically driven by the dual process theory through a deductive approach. Moreover, the researchers will remain aware of new concepts that may emerge from the data itself. The following changes were made in the manuscript: In the introduction, page 4, line 5, the sentence "This theory has been applied in clinical decision making, underlining the relevance of physicians’ intuition and the high-level interactions between analytical and non-analytical processes(23) and proposing clinical reasoning and decision making as BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from the result of a permanent interaction between the two systems.(22)" was rephrased to: "This theory has been adapted for clinical decision making and proposes that clinical reasoning and decision making are the result of a permanent interaction between the two systems.(22) This will be the theoretical framework of this systematic review.” Also, in Outcomes and Synthesis strategy section on page 7, line 7, the following sentence has been added to the paragraph: “Analysis will be theoretically driven by literature on cognitive reasoning models such as the dual process theory (22) through a deductive approach. Moreover, the researchers will remain aware of new concepts that may emerge from the data itself.” Following the Reviewers commentaries, the authors acknowledged that too much focus was being made in cognitive biases. Particularly in the Introduction, the “The theoretical framework of