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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.
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Reviewer’s Comment
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.
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.
DISABLEMENT PROCESS MODEL
(p. 4): Please add definitions for key
concepts (pathologies, impairments, and
functional limitations).
Response
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We have rewritten our statistical
methods to provide justification
for our approach.
Section: Methods
- Analysis
Pages: 8-9
Paragraph #4
Lines 21-23, 113
We have made the recommended
word choice.
Section:
introduction
Page 2
Paragraph 1
Line 7
We have added the definitions for
key concepts.
Section:
Introduction
Page 4
Paragraph 2
Line 9-17
Section: Methods
METHODS SECTION: Please add
headings.
We have added headers to the
Methods Section
RESULTS: Please submit the
correlation matrix as Supplemental
Digital Content (SDC). For more
information find Author Checklist for
Supplemental Digital Content here:
https://sites.google.com/site/lwwsdcauth
orchecklist/.
DISCUSSION: recommendation for
targeting walking, standing, sitting, etc
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.
We had revised the discussion
section to incorporate the editor’s
Supplemental
table
Section: Results
Page 11
Paragraph 2
Lines 7-11
Section:
Discussion
3
Reviewer’s Comment
Response
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.
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.)
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)?"
recommendations.
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Page 12
Paragraph 2
Lines 6-11
We have revised the table based
on this recommendation.
Section: Table 1
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 have not
changed our
definition of
toileting
disability and we
kept urinary
incontinence as a
factor to
investigate.
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
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Reviewer’s Comment
Response
Location of
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Manuscript
toileting disabilities.
2. Background Literature: The rationale We think it is common
No revision
supporting the statement in line 4-5 (p.2) knowledge that toileting disability made
could be added.
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.
The prevalence of toileting disability
reported by Kane et al. in lines 14-15
(p.2) could be specified more clearly.
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.
Section:
Introduction
Page(s) 2
Paragraph(s) 2
Line(s) 14
Please recheck the prevalence numbers
reported in the references of Lee et al.
and Carey et al.(lines 17-19, p.2).
We have confirmed that the
prevalences we reported are
consistent with that reported in
these articles.
No revision
made
Address more literature on the
importance of preventing or managing
toileting disability properly to elders
without UI.
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.
No revision
made
Please recheck the relevance between
statements in p.4 to p.5 (lines 17 to 2),
and the topic.
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
No revision
made
Statements now
appear in
Section:
Introduction
Page 5
Paragraph 2
Lines 5-10
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Reviewer’s Comment
3. Theoretical framework: Authors have
modified the original conceptual model
"The disablement process." Please be
aware the confounders such as "intraindividual factors" and "co-existing
disabilities" might influence the results.
How to reduce their effects by statistical
manipulation?
Response
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.
We controlled for confounders
including intra-individual factors
and co-existing disabilities by
including them as independent
variables in the analysis.
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No revision
made
The hypothesis could be revised to
improve its clarity.
We have rewritten the hypothesis
to improve its clarity.
Section:
Introduction
Page(s) 4
Paragraph(s) 3
Line(s) 18-21
No revision
made
Statements now
appear in
Section:
Introduction
Page 5
Paragraph 3
Lines 15-22
4. Methods: The descriptions in lines 512 (p.5) could be shortened and
addressed the main information only.
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.
Please add the number of post hoc
power analysis by using the subset
sample or provide rationale support to
assuring adequate sample power?
We do not think it is necessary to
do post-hoc power analysis when
we obtained statistical
significance in our results.
No revision
made
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 have revised the description
of our statistical approach to
describe that we calculated the
outer limit of independent
variables for predicting the
Section: Methods
Page(s) 9
Paragraph(s) 1
Line(s) 10-11
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Reviewer’s Comment
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.
Response
occurrence of 398 events and we
did not exceed that limit.
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.
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.
6. Discussions: Based on results, what is
the implication to those having toileting
disability without UI?
We have added a note to table 1
to clarify what N/A represents.
The comparisons made in lines 6-8
(p.10) could be revised to improve its
appropriateness.
We have taken the reviewer’s
suggestion and removed the
comparisons about the prevalence
of toileting disability and that of
other chronic diseases.
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Throughout
paper and tables
Table 1
Again, we appreciate the
No revision
reviewer’s observation that not all made
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.
Is the hypothesis stated in lines 11-12 (p. We have revised the hypothesis to
10) consistent with the previous
ensure it is consistent between the
statement (lines 9-12, p.4)?
introduction and discussion
section.
Section:
Discussion
Page(s) 11-12
Paragraph(s) 4
Lines 21-23, 1-2
Section:
Discussion
Page(s) 12
Paragraph(s) 2
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Reviewer’s Comment
Response
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Line(s) 3-6
Please consider the relevance between
statements in lines 20-23 (p.10) and the
results.
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
acknowledge this cross-sectional,
descriptive work does not imply
causality and future studies would
need to investigate the effect of
interventions.
No revisions
made, but text
reviewer is
referring to can
be found at
Section:
Discussion
Page(s) 13
Paragraph(s) 1
Line(s) 8-11
Significant variables including resident
health, facility size, for-profit facility,
and visual or hearing impairment should
be addressed --their applications or
implications in discussions.
We have added a discussion of
these variables in the discussion
section.
Section:
Discussion
Page(s) 12
Paragraph(s) 3
Line(s) 12-21
Is the design "cross sectional" or
"secondary analysis" (lines 4-5, p.11)?
We have clarified that the
National Survey of Residential
Care Facilities survey is a crosssectional study in the methods
section.
Section: Methods
Page(s) 5
Paragraph(s) 3
Line(s) 15-16
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.
7. Conclusions: The statements in lines
4-5 and 13-14 (p.12) could be deleted to
improve relevance and clarity.
We had added additional
comments on the limitations of
the study in the discussion
section.
Section:
Discussion
Page(s) 14
Paragraph(s) 3
Line(s) 11-20
Section:
Conclusions
Page(s) 15
Paragraph(s) 1
Line(s) 2-3, 13
REVIEWER 2 Comments
We have taken the reviewers
recommendation and deleted
these two statements.
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Reviewer’s Comment
Response
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).
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 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.
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 ABiological Sciences & Medical
Sciences, 62(7), 722-727.
Additionally, we created the
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Section:
MethodsAnalysisdescriptive
statistics.
Page(s) 6
Paragraph(s) 3
Line(s) 15
Section:
MethodsAnalysis
Page 8
Paragraph 4
Lines 17-18
We have not
changed the
impairment
variable in the
manuscript.
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Reviewer’s Comment
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.
Response
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 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.
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Section: Methods
- Analysis
Pages: 8-9
Paragraph 4
Lines 21-23, 113
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:
MethodsStatistical
Software
Page(s) 9
Paragraph(s) 2
Line(s) 17-19
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.
Also on page 11, the authors do an
adequate job of describing the
limitations of using an existing dataset.
We have added additional
information in the discussion
section discussing this limitation
Section:
Discussion
Page(s) 14
Paragraph(s) 3
Line(s) 13
Section:
Discussion
Page(s) 14
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Reviewer’s Comment
Response
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?
with using subgroup analysis.
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Paragraph(s) 3
Line(s) 14-20
The footnote on Table 1 should be
We have clarified this note on
clarified slightly to say that frequencies
table 1.
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).
Section: Table 1
Foot note
Finally, on page 5, line 18 - the word
"data" is plural - the statement should
read "Data were?".
Section: Methods
Page(s) 6
Paragraph(s) 2
Line(s) 6
We have corrected this
grammatical error