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PLoS One
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PLOS ONE
1932-6203
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10.1371/journal.pone.0309821
PONE-D-23-41704
Research Article
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Knowledge, attitude, and practice towards enhanced recovery after surgery among patients underwent thoracoscopy surgery
KAP towards ERAS
https://orcid.org/0009-0006-8990-2845
Huang Yinping Conceptualization Investigation Methodology Resources Software Validation Writing – original draft Writing – review & editing *
Wang Xingbang Data curation Funding acquisition Investigation Project administration Supervision Writing – original draft Writing – review & editing
Li Jiajia Conceptualization Data curation Investigation Project administration Supervision Writing – original draft Writing – review & editing
He Qing Formal analysis Methodology Project administration Supervision Visualization Writing – original draft Writing – review & editing
Wang Rui Data curation Investigation Methodology Project administration Software Visualization Writing – original draft Writing – review & editing
Lu’ an People’ s Hospital General thoracic surgery, Lu’ an, China
Ahmed Sirwan Khalid Editor
Ministry of Health, General Health Directorate of Raparin and University of Raparin, IRAQ
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: 292325807@qq.com
4 9 2024
2024
19 9 e030982118 12 2023
19 8 2024
© 2024 Huang et al
2024
Huang et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Objective

Thoracoscopy has gained extensive utilization in managing pleural disorders, and enhanced recovery after surgery (ERAS) can improve patients’ prognosis and expedite post-surgical recovery. This study aimed to investigate the knowledge, attitudes, and practices (KAP) towards ERAS among patients underwent thoracoscopy surgery.

Methods

This cross-sectional study was conducted between September 2022 and August 2023, among patients underwent thoracoscopy surgery in 6 Secondary or Tertiary hospitals in the author’s area. Demographic characteristics and KAP scores were collected by questionnaires, and clinical data were extracted from medical records.

Results

A total of 309 valid questionnaires were collected, with 165 (53.40%) males and 202 (65.37%) aged ≤65 years old. The mean scores for KAP were 28.92±7.21 (possible range: 9–45), 53.60±6.73 (possible range: 13–65), and 43.45±5.50 (possible range: 10–50), respectively. SEM confirmed the positive associations between knowledge and attitude (β = 0.108, P = 0.019), knowledge and practice (β = 0.096, P = 0.004), and attitude and practice (β = 0.438, P<0.001). However, the KAP were found not associated with prognosis.

Conclusion

Patients underwent thoracoscopy surgery showed moderate knowledge, positive attitude, and appropriate practice towards ERAS. Preoperative education, personalized counseling, peer support groups, peer support groups, and follow-up care were recommended in further clinical practice.

The author(s) received no specific funding for this work. Data AvailabilityAll relevant data are within the manuscript and its Supporting Information files.
Data Availability

All relevant data are within the manuscript and its Supporting Information files.
==== Body
pmcIntroduction

Thoracoscopy, a minimally invasive surgical approach facilitating visualization and treatment within the pleural cavity, has garnered significant prominence in modern healthcare [1]. This technique has revolutionized diagnostic and therapeutic approaches for various thoracic conditions [2]. Through the utilization of thoracoscope introduced via minor incisions, this method offers reduced invasiveness, shorter hospitalization, and faster recovery compared to traditional open surgeries [3]. Globally, the escalating adoption of thoracoscopy is attributed to its effectiveness and patient-centric benefits [4]. Notably in China, thoracoscopy has been widely used for addressing pleural diseases, including tuberculous pleural effusion, malignant pleural effusion, and spontaneous pneumothorax [5]. This trend accentuates the need to explore factors impacting patients’ experiences and outcomes after undergoing thoracoscopy. Nonetheless, beyond its surgical advantages, thoracoscopy can also lead to postoperative discomfort, physical limitations during recovery, and psychological stress due to surgery-related anxiety [6]. Therefore, these complications can detrimentally affect patients’ quality of life and mental well-being, which highlighted the importance of appropriate support and management strategies.

Enhanced Recovery after Surgery (ERAS) represents a comprehensive approach aimed at optimizing patient outcomes and expediting post-surgery recovery [7]. This multifaceted strategy spans preoperative preparation to postoperative care, and is collectively designed to mitigate stress responses, promote rapid functional recovery, and reduce complications. Currently, the integration of ERAS protocols has demonstrated remarkable success across surgical specialties, including thoracoscopy [8]. Tailoring ERAS for thoracoscopy holds potential for shorter hospital stays, fewer complications, and heightened patient satisfaction. Furthermore, knowledge of ERAS among patients, coupled with their attitudes toward thoracoscopy implementation, can substantially influence its adoption. Therefore, the knowledge, attitudes, and practices (KAP) study serves as a suitable methodology to explore the acceptance of ERAS and determine areas of interventions. However, KAP studies of ERAS have mainly focused on medical personnel. For instance, a Chinese study revealed knowledge deficiency among pediatric surgical nurses regarding postoperative recovery and preoperative preparation [9]. Additionally, health professionals exhibited positive attitude toward ERAS but acknowledged its complexity and challenges [10]. However, the dearth of KAP study of ERAS among patients undergoing thoracoscopy still exists in China.

Therefore, this study aimed to explore the KAP towards ERAS among patients underwent thoracoscopy surgery. It was hypothesized that: 1) participants’ knowledge could positively influence their attitudes; 2) participants’ knowledge could positively influence their ERAS practice; and 3) participants’ attitudes could positively influence ERAS practice.

Methods

Study design and participants

This cross-sectional study was conducted between September 2022 and August 2023, among patients underwent thoracoscopy surgery in 6 Secondary or Tertiary hospitals in the author’s area. Patients who underwent thoracoscopy surgery and received perioperative nursing on the concept of ERAS were included. Inclusion criteria included: 1) Inpatients scheduled for thoracoscopy surgery; 2) Willingness to participate and signed informed consent; 3) Age ≥ 18 years. Exclusion criteria included: 1) Patients discontinuing surgery for various reasons; 2) Patients necessitating open surgery due to medical conditions; 3) Patients with severe liver, kidney, or hematological diseases; 4) Patients with concurrent psychiatric disorders; 5) Patients directly transferred to ICU postoperatively. Ethical approval was granted by the Medical Ethics Committee of the author’s Hospital, and all participants provided informed consent.

Questionnaire

The questionnaire was designed based on previous studies [11–14]. And revisions were made based on feedback from five senior experts, the similar or repeated questions were deleted and questions that were not clearly formulated were refined to guarantee content validity. And a pilot study among 50 participants was conducted, with Cronbach’s α coefficient of 0.9359, indicate a good internal consistency.

The final questionnaire was in Chinese, and comprised four dimensions: demographic characteristics, knowledge, attitude, and practice (supplementary materials). The demographic characteristics included 11 items, including age, gender, residence, education, occupation, monthly income, marital status, smoking, alcohol consumption, underlying medical conditions, and medical insurance. The knowledge, attitude, and practice dimensions employed a five-point Likert scale. In the knowledge dimension, 9 questions were posed, with 5 points assigned to "Very familiar", 4 points to "Familiar", 3 points to "Recognizable", 2 points to "Unfamiliar", and 1 point to "Very unfamiliar". The total score of the knowledge dimension ranged from 9 to 45 points. The attitude dimension encompassed 13 questions, with 5 points indicating "Strongly agree", 4 points for "Agree", 3 points for "Neutral", 2 points for "Disagree", and 1 point for "Strongly disagree". The total score of attitude dimension ranged from 13 to 65 points. The practice dimension consisted of 11 questions, with the 6th question analyzed descriptively only. For the remaining 10 questions, 5 points corresponded to "Always", 4 points to "Frequently", 3 points to "Sometimes", 2 points to "Occasionally", and 1 point to "Never". The total score of the practice dimension ranged from 10 to 50 points. The overall KAP scores were categorized according to modified Bloom’s cutoff: respondents scoring between 80–100% were deemed to possess good knowledge, positive attitude, and appropriate practice; 60–79% as moderate; and less than 60% as poor knowledge, negative attitude, and inappropriate practice [15].

Data collection

The electronic questionnaire was generated by the “Sojump” platform (www.wjx.cn), and were distributed via QR codes. The questionnaires were disseminated to patients when they had received ERAS education before thoracoscopy surgery. In instances where elderly patients lacked smartphones, access to paper-based surveys or assistance from family members using smartphones was facilitated. During the survey, research aides were present to aid participants grappling with comprehension. For individuals encountering difficulties with responses, staff members facilitated question presentation and response recording.

The clinical characteristics were also collected, including patients’ surgery type, surgery durations, intraoperative blood loss, ASA. Surgery type was categorized into pulmonary lobectomy and others (including fracture fixation, exploratory thoracotomy, and drainage). And the prognosis data were also collected, including postoperative bed rest time, hospital stay, and complications (including pneumonia, lung collapse, anastomotic leakage, wound infection, and wound dehiscence).

Statistical analysis

Statistical analysis was conducted by SPSS 26.0 (IBM, Armonk, NY, USA) and AMOS 23.0 (IBM, Armonk, NY, USA) software. Continuous variables were presented as means ± standard deviation (SD), and compared by ANOVA or Student’s t test. And the categorical variables were expressed as n (%). Pearson’s correlation analysis and structural equation modeling (SEM) were conducted to explore correlation among KAP. Univariate and multivariate logistic and linear regressions were conducted to explore the association between KAP and prognosis. Statistical significance was considered as a two-sided P <0.05.

Results

A total of 389 questionnaires were gathered. Following exclusions of 37 questionnaires due to insufficient response time, 32 due to incomplete data, and 11 due to logical inconsistencies, 309 valid questionnaires was retained. The majority of participants were male (53.40%), ≤65 years old (65.37%), rural residents (64.40%), educated up to middle school (74.76%), married (92.23%), categorized as ASA classification II (81.88%), and received pulmonary lobectomy (76.05%). Additionally, 39.48% were civil servants, and 41.10% had a monthly income <2,000 yuan (Table 1).

10.1371/journal.pone.0309821.t001 Table 1 Demographic characteristics of participants and KAP score distribution.

Characteristics	N (%)	Knowledge (mean ± SD)	P	Attitude (mean ± SD)	P	Practice (mean ± SD)	P	
Total		28.92±7.21		53.60±6.73		43.45±5.50		
Gender			0.911		0.252		0.201	
    Male	165 (53.40)	28.87±7.41		54.01±6.44		43.82±5.07		
    Female	144 (46.60)	28.97±7.01		53.13±7.04		43.02±5.93		
Age, years			0.140		0.968		0.399	
    ≤65	202 (65.37)	29.36±7.21		53.58±±7.05		43.26±5.86		
    >65	107 (34.63)	28.08±7.18		53.62±6.10		43.81±4.74		
Residence			<0.001		0.785		0.940	
    Rural	199 (64.40)	27.71±7.43		53.52±6.94		43.47±5.54		
    Urban or suburban	110 (35.60)	31.09±6.27		53.74±6.35		43.42±5.45		
Education			<0.001		0.823		0.183	
    Middle school or below	231 (74.76)	27.74±7.27		53.55±6.90		43.21±5.61		
    High school or above	78 (25.24)	32.38±5.83		53.74±6.22		44.17±5.13		
Occupation			<0.001		0.864		0.188	
    Production worker	77 (24.92)	31.40±6.17		53.86±6.59		44.43±5.07		
    Civil servant	122 (39.48)	29.26±6.57		53.35±6.74		43.23±5.75		
    Others	110 (35.60)	26.79±7.96		53.68±6.86		43.01±5.46		
Marital status			0.618		0.698		0.666	
    Married	285 (92.23)	28.21±6.53		53.08±6.06		43.92±5.60		
    Unmarried/divorced/widowed	24 (7.77)	28.98±7.28		53.64±6.79		43.41±5.50		
Monthly income, yuan			0.015		0.238		0.136	
    <2,000	127 (41.10)	28.08±6.71		52.68±6.39		43.24±5.55		
    2,000–5,000	120 (38.83)	28.47±7.83		54.28±6.80		42.96±5.37		
    5,000–10,000	42 (13.59)	31.76±6.32		54.40±6.69		44.52±5.45		
    >10,000	20 (6.48)	30.95±6.79		53.60±8.22		45.50±5.63		
Smoking			0.351		0.625		0.354	
    Yes	36 (11.65)	27.86±7.47		54.11±6.91		43.43±5.52		
    No	273 (88.35)	29.05±7.18		53.53±6.71		44.25±5.32		
Alcohol consumption			0.036		0.282		0.568	
    Yes	69 (22.33)	30.52±6.09		52.83±6.49		43.12±5.28		
    No	240 (77.67)	28.45±7.45		53.82±6.79		43.55±5.56		
Underlying medical conditions			0.045		0.874		0.520	
    Yes	140 (45.31)	28.01±7.55		53.53±6.57		43.23±5.17		
    No	169 (54.69)	29.66±6.86		53.65±6.88		43.63±5.76		
Medical insurance type			0.162		0.004		0.121	
    Yes	303 (98.06)	29.00±7.22		53.75±6.61		43.52±5.44		
    No	6 (1.94)	24.83±6.18		45.83±8.91		40.00±7.72		
ASA classification			0.301		0.270		0.364	
    I	22 (7.12)	31.27±6.85		52.68±8.19		43.36±5.09		
    II	253 (81.88)	28.65±7.27		53.66±6.69		43.62±5.35		
    III	32 (10.35)	29.25±7.03		53.44±5.94		42.16±6.73		
    IV	2 (0.65)	31.50±4.95		58.50±9.19		43.50±9.19		
Surgery			0.850		0.626		0.659	
    Pulmonary lobectomy	235 (76.05)	28.93±7.35		53.48±6.81		43.49±5.64		
    Others	74 (23.95)	28.88±6.80		53.97±6.5		43.34±5.07		
*: including fracture fixation, exploratory thoracotomy, and drainage

The participants had an average knowledge score of 28.92±7.21 (possible range: 9–45). Urban and suburban residents (P<0.001), individuals with a high school education or above (P<0.001), those engaged as production workers (P<0.001), participants with monthly income ranging between 5,000–10,000 yuan (P = 0.015), individuals who consumed alcohol (P = 0.036), and those without underlying diseases (P = 0.045) were likely to achieve higher knowledge scores (Table 1). In the knowledge section, the rates of "Very familiar" and "Familiar" ranged from 29.45% to 52.10%. Specifically, 52.10% possessed knowledge about the early postoperative activity requirements within ERAS (K6). In contrast, a mere 29.45% of participants were acquainted with ERAS, encompassing its definition and primary research content (K1). Additionally, only 30.74% of participants were informed about the requisites for implementing ERAS (K3) (S1 Table).

The participants had an attitude score of 53.60±6.73 (possible range: 13–65). Participants with medical insurance displayed significantly higher attitude scores (P = 0.004) (Table 1). In the attitudes section, the rate of positive responses varied between 66.34% and 90.30%. A substantial proportion (90.30%) of participants showcased a positive attitude towards prioritizing the timely seeking of healthcare experts’ assistance in case of postoperative incisional pain, instead of enduring the discomfort (A10). Conversely, the smallest proportion of participants (66.34%) concurred with the sentiment that surgical procedures trigger emotional anxiety within them (A1). Similarly, a mere 73.14% agreed that unless it affects the surgical procedure, minimizing the fasting duration before the operation takes precedence (A4) (S2 Table).

The participants displayed a mean practice score of 43.45±5.50 (possible range: 10–50) (Table 1). There was variability in practice adherence among participants, with rates ranging from 89.32% to 94.17%. The highest proportion (94.17%) of participants adhered to prescribed fasting and abstention from drinking before surgery under medical guidance (A4), as well as collaborated with healthcare professionals to discontinue smoking and alcohol intake prior to the procedure when applicable (A6). In contrast, the lowest proportion of participants (89.32%) engaged with medical personnel for participation in preoperative respiratory exercises (A3). Similarly, 89.32% of participants endorsed the use of relaxation techniques and prompt nursing assistance in case of postoperative incisional pain (A10) (S3 Table).

Pearson’s correlation analysis revealed significantly positive correlations among knowledge and attitude (r = 0.127, P = 0.026), as well as knowledge and practice (r = 0.222, P<0.001). Furthermore, attitude was positively correlated with practice (r = 0.489, P<0.001) (Table 2). The SEM results confirmed that knowledge was positively associated with attitude (β = 0.108, P = 0.019) and practice (β = 0.096, P = 0.004). Moreover, attitude was positively associated with practice (β = 0.438, P<0.001), which was consistent with the main findings from Pearson correlation analysis (Table 3, Fig 1).

10.1371/journal.pone.0309821.g001 Fig 1 Structural equation model showing the associations between demographic characteristics and KAP.

All variables are observed variables. Direction of causality is indicated by single-headed arrows. The standardized path coefficients are presented alongside the arrows.

10.1371/journal.pone.0309821.t002 Table 2 Pearson correlation analysis of KAP scores among participants.

	Knowledge	Attitude	Practice	
Knowledge	1			
Attitude	0.127 (P = 0.026)	1		
Practice	0.222 (P<0.001)	0.489 (P<0.001)	1	

10.1371/journal.pone.0309821.t003 Table 3 The estimates of SEM.

Model paths	Estimate	Standard error	P	
Knowledge → Attitude	0.108	0.046	0.019	
Attitude → Practice	0.438	0.053	<0.001	
Knowledge → Practice	0.096	0.034	0.004	

The mean intraoperative blood loss was 96.22±8.13 ml, the mean postoperative bed rest time was 25.47±0.89 hours, the mean postoperative hospital stay was 9.15±0.33, and 105 (33.98%) patients experienced postoperative complications. And the most frequently complication was lung infection (52 [16.83%]), followed by the hypoproteinemia (36 [11.65%]), and pneumothorax (25 [8.09%]) (S4 Table). However, the multivariate logistic and linear regression revealed that the KAP were not associated with postoperative bed rest time, hospital stay, or complications after adjusted for factors including alcohol consumption, ASA classification, surgery duration, and surgery types (S5–S7 Tables).

Discussion

The study demonstrated that patients undergoing thoracoscopy displayed moderate knowledge, positive attitudes, and appropriate practice to ERAS. Moreover, positive associations were identified among KAP scores. These findings might offer valuable insights for designing healthcare interventions and educational campaigns for enhancing ERAS-related KAP.

This study firstly explored the KAP towards ERAS among patients underwent thoracoscopy surgery. The previous KAP studies towards ERAS mainly focus on the medical professionists. Specifically, a study from China demonstrated knowledge gaps in preoperative preparation and postoperative recovery among surgical nurses [9]. Similarly, another research in Pakistan revealed that the majority of surgical residents struggled to identify and implement ERAS protocol [16]. In contrast, patients underwent thoracoscopy surgery exhibited heightened KAP levels in our study. This improvement might stem from heightened awareness, better training, and enhanced healthcare provider-patient communication, as well as heterogeneity in study design and questionnaire items. The findings potentially underscored the positive influence of healthcare education strategies, which could contribute to a more informed patient population regarding ERAS practices.

In the knowledge dimension, 52.10% of participants was knowledgeable about the early postoperative requirements of ERAS. This finding indicated a relatively robust understanding of the importance of postoperative activities among patients underwent thoracoscopy surgery. In contrast, only 29.45% of participants were acquainted with the overall definition and primary research content of ERAS. This lack of awareness might stem from inadequate dissemination of enhanced recovery in the preoperative and postoperative settings [17]. Given that ERAS involves a holistic strategy encompassing preoperative, intraoperative, and postoperative phases, such a disparity in knowledge underscored the need for targeted educational initiatives to elucidate the core principles and objectives of ERAS [14]. Furthermore, the acknowledgment of requisites necessary for the effective implementation of ERAS was evident in only 30.74% of participants. This lack of awareness could potentially hinder the effective implementation of ERAS protocols, leading to suboptimal surgical outcomes and prolonged recovery periods. Targeted patient education should be developed to provide training on ERAS protocols and address related misunderstandings through doctor-patient communications.

The majority of participants (90.30%) demonstrated positive attitude towards promptly seeking the guidance of healthcare professionals when confronted with postoperative incisional pain, rather than enduring the discomfort. This finding aligned with the principles of patient-centered care, and emphasized the importance of addressing postoperative pain in a proactive and efficient manner [18]. The positive attitude held the potential to contribute to improved patient outcomes and enhanced overall satisfaction with the surgical process. Conversely, the smallest proportion of participants (66.34%) expressed concurrence with the notion that surgical procedures evoke emotional anxiety within them. While surgical anxiety is a common sentiment, the comparatively lower agreement rate suggested that a significant portion of participants either had effective coping mechanisms or viewed the surgical process from a more objective standpoint [19]. This insight prompted further exploration into preoperative psychological preparation, and supported strategies to alleviate anxiety for patients undergoing thoracoscopy. Besides, a modest proportion (73.14%) of participants acknowledged the significance of minimizing fasting periods unless it directly impacted the surgical procedure. Since ERAS emphasized the importance of preoperative nutrition to facilitate postoperative recovery, educational efforts towards rationale behind fasting guidelines and their implications for surgical outcomes were necessary [20].

The highest proportion (94.17%) of participants adhered to prescribed fasting and abstention from smoking and alcohol intake in the practice dimension. This underscored participants’ recognition of the detrimental effects of these habits on surgical outcomes. It was worth noting that cessation of smoking and alcohol consumption is vital in mitigating postoperative complications and fostering conducive environment for recovery [21]. Conversely, a comparatively lower adherence rate (89.32%) was observed in participants’ engagement with medical personnel in preoperative respiratory exercises. Given the significance of such exercises in maintaining optimal lung function postoperatively, addressing potential barriers to engagement in these practices could be beneficial [22]. Similarly, the endorsement of relaxation techniques and the prompt seeking of nursing assistance was reported by 89.32% of participants, suggestive of proactive management in postoperative incisional pain.

In contrast to a prior study where patients undergoing thoracoscopic surgery lobectomy were discharged within 4 days [23], patients in our study experienced a longer postoperative hospital stay (9.15±0.33 days). Several factors may contribute to this extended duration. Firstly, a majority of patients underwent pulmonary lobectomy, which is a treatment modality for severe lung diseases. Additionally, the management of potential complications such as lung infection, pneumothorax, and hypoproteinemia could have prolonged hospitalization. However, direct comparisons of hospital stay lengths are challenging due to variations in discharge criteria among studies. The positive associations among KAP scores highlighted the necessity of targeted interventions and educational programs to augment ERAS-related KAP among patients undergoing thoracoscopy. This observation could be ascribed to the influence of knowledge on attitudes and practices of ERAS, in accordance with the theory of planned behavior, where attitudes and practices were shaped by the perception of behavioral consequences [24]. Besides, the lack of significant associations between KAP scores and clinical outcomes was found. One plausible explanation was that the effectiveness of ERAS might not be contingent upon the patients’ KAP. Instead, it might rely more heavily on the implementation of ERAS by healthcare providers, such as optimized anesthesia, minimal incision techniques, and early mobilization. Besides, all patients completed the questionnaire after receiving education about ERAS, which contributed to the elevated KAP scores and thus masked their relationships with clinical outcomes. This underscored the importance of integrating ERAS education into preoperative care for patients undergoing thoracic surgery and similar surgeries. Standardization of ERAS education may also facilitate comparisons across different patient populations, enabling researchers to evaluate the impact of education on patient outcomes more rigorously in future studies.

This study had several limitations. Firstly, its confined scope to a single region with limited sample size restricted the generalizability of the findings. Nonetheless, the findings provided valuable insights into the present KAP status of patients undergoing thoracoscopy towards ERAS. Secondly, the KAP scores could be influenced by social desirability bias, possibly leading to an overestimation of the scores. Participants might tend to provide responses that aligned with social norms rather than accurately reflecting their behaviors and knowledge [25]. Thirdly, the limited items of early postoperative outcomes (postoperative complications, postoperative bed rest time and duration of hospital stay) were collected, which cannot comprehensively grasp the relationships between KAP and early postoperative outcomes. Therefore, the observed findings should be taken with caution. Fourthly, several variables, such as previous surgical procedure, nutritional status and duration of pleural drainage, were not included in the questionnaire. The missing information can impede the investigation into the determinants of clinical outcomes, highlighting the need for future studies involving a larger cohort of phenotyped individuals.

Conclusions

In conclusion, patients underwent thoracoscopy surgery showed moderate knowledge, positive attitudes, and appropriate practice towards ERAS. Based on the identified gaps in KAP items, we recommend further development of preoperative education, personalized counseling, peer support groups, and follow-up care to enhance the prognosis and quality of life for individuals undergoing thoracoscopy.

Supporting information

S1 Checklist STROBE statement—checklist of items that should be included in reports of cross-sectional studies.

(DOC)

S1 Table Distribution of knowledge dimension responses.

(DOCX)

S2 Table Distribution of attitude dimension responses.

(DOCX)

S3 Table Distribution of practice dimension responses.

(DOCX)

S4 Table The patients’ prognosis characteristics.

(DOCX)

S5 Table Univariate and multivariate logistic regression analysis of postoperative complications.

(DOCX)

S6 Table Univariate and multivariate linear regression analysis of postoperative bed rest time.

(DOCX)

S7 Table Univariate and multivariate linear regression analysis of duration of hospital stay.

(DOCX)

S1 Data (XLSX)

S1 Questionnaire (DOC)

10.1371/journal.pone.0309821.r001
Decision Letter 0
Guerrera Francesco Academic Editor
© 2024 Francesco Guerrera
2024
Francesco Guerrera
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
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PONE-D-23-41704Knowledge, Attitude, and Practice towards Enhanced Recovery after Surgery among Patients Underwent Thoracoscopy SurgeryPLOS ONE

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors reported an interesting paper on the knowledge of patients regarding ERAS.

The manuscript is of potential interest, but I have some comments:

- Did the authors analyze the impact of knowledge on early postoperative outcomes

- Did the authors analyze the influence of a previous surgerical procedure (even of not thoracic) on the knowledge of patients?

- When the questionnaire was administered?

- Based on the results, did you change your clinical practice?

Reviewer #2: Congratulations to the authors for their contribution in the topic of ERAS. I appreciated the patient centered analysis. The methodology is clear, and the questionnaire employed is appropriate. The paper has a transverse interest, all the medical workers (surgeons, nurses and physiotherapist) are involved in ERAS strategy. Like in surgery, an deep understanding of the theoretics basis could translate in a perfect practice.

although I suggest few improvements before to publish the paper.

I hope that this review will make a good contribution to your work.

Major Revisions

- Provide the aim of thoracoscopy in the clinical parameters. VATS for pleural biopsy benign/malign, empyema, pneumothorax, lung resections? The type of surgery can influence in the clinical outcome.

- Other clinical parameters important for the analysis are: smoking status and nutritional status (obese/cachexia).

- Did KAP affected the duration of pleural drainage?

Minor Revisions

- The length of hospital stay is long. Can you explain that?

- Line 193. Medical “professor”. Do you mind professionist?

- Discussion. Did you suggest any strategies to improve KAP?

- Discussion. The results shown moderate knowledge parameter. Any suggestions to improve it?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Giovanni Bocchialini

**********

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10.1371/journal.pone.0309821.r002
Author response to Decision Letter 0
Submission Version1
17 Apr 2024

Title: Knowledge, Attitude, and Practice towards Enhanced Recovery after Surgery among Patients Underwent Thoracoscopy Surgery

Journal: PLoS One

Response to Reviewers' comments

Dear Editor,

We thank you for your careful consideration of our manuscript. We appreciate your response and overall positive initial feedback and made modifications to improve the manuscript. After carefully reviewing the comments made by the Reviewers, we have reorganized the literature data, modified the manuscript to improve the presentation of our results and their discussion, therefore providing a complete context for the research that may be of interest to your readers.

We hope that you will find the revised paper suitable for publication, and we look forward to contributing to your journal. Please do not hesitate to contact us with other questions or concerns regarding the manuscript.

Best regards,

Additional Editor Comments:

Dear Authors,

I read your manuscript with great interest,

Nevertheless, some improvement must be accomplished, and several points must be addressed in order to consider it for publication.

In particular, as the reviewers pointed out, the indication of surgical procedures and the practical implication of your results should be elucidated.

Response: Thanks for the valuable comments. We added information and analysis about surgical types, and added limitations about lack of collection for outcomes and variables such as previous surgical procedure, nutritional status and duration of pleural drainage.

Thirdly, the limited items of early postoperative outcomes (postoperative complications, postoperative bed rest time and duration of hospital stay) were collected, which cannot comprehensively grasp the relationships between KAP and early postoperative outcomes. Therefore, the observed findings should be taken with caution. Fourthly, several variables, such as previous surgical procedure, nutritional status and duration of pleural drainage, were not included in the questionnaire. The missing information can impede the investigation into the determinants of clinical outcomes, highlighting the need for future studies involving a larger cohort of phenotyped individuals.

The practical implications were added to Conclusion in brief.

“In conclusion, patients underwent thoracoscopy surgery showed moderate knowledge, positive attitudes, and appropriate practice towards ERAS. Based on the identified gaps in KAP items, we recommend further development of preoperative education, personalized counseling, peer support groups, and follow-up care to enhance the prognosis and quality of life for individuals undergoing thoracoscopy.”

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors reported an interesting paper on the knowledge of patients regarding ERAS.

The manuscript is of potential interest, but I have some comments:

Comments1- Did the authors analyze the impact of knowledge on early postoperative outcomes

Response: Thanks for the valuable comments.

Univariate and multivariate logistic and linear regressions were conducted to explore the association between KAP and prognosis. The associations of KAP scores with postoperative complications, postoperative bed rest time and duration of hospital stay were detailed in Supplementary Tables 5-7. However, no significant associations between KAP scores and early postoperative outcomes were observed. The possible explanation has been added in the Discussion.

Besides, the lack of significant associations between KAP scores and clinical outcomes was found. One plausible explanation was that the effectiveness of ERAS might not be contingent upon the patients' KAP. Instead, it might rely more heavily on the implementation of ERAS by healthcare providers, such as optimized anesthesia, minimal incision techniques, and early mobilization. This underscored the multifaceted nature of clinical outcomes, suggesting that KAP scores might not be the determinant.

Since we only collected limited information of early postoperative outcomes, it is possible that the findings could be biased. The contents have been added to limitation.

Thirdly, the limited items of early postoperative outcomes (postoperative complications, postoperative bed rest time and duration of hospital stay) were collected, which cannot comprehensively grasp the relationships between KAP and early postoperative outcomes. Therefore, the observed findings should be taken with caution.

Comments 2- Did the authors analyze the influence of a previous surgical procedure (even of not thoracic) on the knowledge of patients?

Response: Thanks for the valuable comments. Due to not collecting information on previous surgical procedures of participants, we did not analyze their influence on KAP scores. We acknowledge that this is one of limitations of our study, and the related contents has been added to the limitations section.

Fourthly, several variables, such as previous surgical procedure, nutritional status and duration of pleural drainage, were not included in the questionnaire. The missing information can impede the investigation into the determinants of clinical outcomes, highlighting the need for future studies involving a larger cohort of phenotyped individuals.

Comments 3- When the questionnaire was administered?

Response: Thanks for the valuable comments. The detailed procedure was added in the Methods

The electronic questionnaire was generated by the “Sojump” platform (www.wjx.cn), and were distributed via QR codes. The questionnaires were disseminated to patients when they had received ERAS education before thoracoscopy surgery. In instances where elderly patients lacked smartphones, access to paper-based surveys or assistance from family members using smartphones was facilitated. During the survey, research aides were present to aid participants grappling with comprehension. For individuals encountering difficulties with responses, staff members facilitated question presentation and response recording.

Comment4- Based on the results, did you change your clinical practice?

Response: Thanks for the valuable comments. The clinical practice has not changed yet, but we have incorporated additional clinical practice implications based on the survey results in discussion section.

“Targeted patient education should be developed to provide training on ERAS protocols and address related misunderstandings through doctor-patient communications.”

“This underscored the importance of integrating ERAS education into preoperative care for patients undergoing thoracic surgery and similar surgeries. Standardization of ERAS education may also facilitate comparisons across different patient populations, enabling researchers to evaluate the impact of education on patient outcomes more rigorously in future studies.”

We believe that implementing these measures in future clinical practice would be helpful in improving patients’ KAP on ERAS.

In addition, we have included practical implications in the Conclusion.

“In conclusion, patients underwent thoracoscopy surgery showed moderate knowledge, positive attitudes, and appropriate practice towards ERAS. Based on the identified gaps in KAP items, we recommend further development of preoperative education, personalized counseling, peer support groups, and follow-up care to enhance the prognosis and quality of life for individuals undergoing thoracoscopy.”

Reviewer #2: Congratulations to the authors for their contribution in the topic of ERAS. I appreciated the patient centered analysis. The methodology is clear, and the questionnaire employed is appropriate. The paper has a transverse interest, all the medical workers (surgeons, nurses and physiotherapist) are involved in ERAS strategy. Like in surgery, an deep understanding of the theoretics basis could translate in a perfect practice.

although I suggest few improvements before to publish the paper.

I hope that this review will make a good contribution to your work.

Major Revisions

Comments 1- Provide the aim of thoracoscopy in the clinical parameters. VATS for pleural biopsy benign/malign, empyema, pneumothorax, lung resections? The type of surgery can influence in the clinical outcome.

Response: Thanks for the valuable comments. The majority of patients underwent pulmonary lobectomy, while a minority underwent procedures such as fracture fixation, exploratory thoracotomy, and drainage. Due to the relatively low frequency of these alternative surgical interventions, our analysis categorized the data as "pulmonary lobectomy vs. other procedures". The associations between type of surgery and clinical outcomes were added in the Supplementary Table 5-7. The KAP scores were compared between different surgeries, but no significant differences were observed. The related contents were added.

Surgery type was categorized into pulmonary lobectomy and others (including fracture fixation, exploratory thoracotomy, and drainage).

However, the multivariate logistic and linear regression revealed that the KAP were not associated with postoperative bed rest time, hospital stay, or complications after adjusted for factors including alcohol consumption, ASA classification, surgery duration, and surgery types (Supplementary Tables 5-7).

Table The comparisons of KAP scores

Knowledge Attitude Practice

N(%) n±mean P n±mean P n±mean P

Surgery 0.850 0.626 0.659

pulmonary lobectomy 235 (76.05) 28.93±7.35 53.48±6.81 43.49±5.64

Others* 74 (23.95) 28.88±6.80 53.97±6.51 43.34±5.07

*: including fracture fixation, exploratory thoracotomy, and drainage

Comments 2- Other clinical parameters important for the analysis are: smoking status and nutritional status (obese/cachexia).

Response: Thanks for the valuable comments. The association of demographic data and clinical parameters with postoperative outcomes were detailed in Supplementary Table 5-7. For example, smoking status was not significantly associated with postoperative outcomes (OR=0.053-1.452, all P>0.05). However, considering the studying feasibility, only variables deemed to have perceived impacts on outcomes by experts were included in the questionnaire. Accordingly, nutritional status and other parameters were not collected, which was a limitation of our study. The related contents were added in the limitation section.

Fourthly, several variables, such as previous surgical procedure, nutritional status and duration of pleural drainage, were not included in the questionnaire. The missing information can impede the investigation into the determinants of clinical outcomes, highlighting the need for future studies involving a larger cohort of phenotyped individuals.

Comments 3- Did KAP affected the duration of pleural drainage?

Response: Thanks for the valuable comments. The duration of pleural drainage was not collected during the design of questionnaire. The impacts KAP on the duration were thus not explored. The related contents were added in the limitation section.

Fourthly, several variables, such as previous surgical procedure, nutritional status and duration of pleural drainage, were not included in the questionnaire. The missing information can impede the investigation into the determinants of clinical outcomes, highlighting the need for future studies involving a larger cohort of phenotyped individuals.

Minor Revisions

Comments 1- The length of hospital stay is long. Can you explain that?

Response: Thanks for the valuable comments. The postoperative hospital stay of thoracoscopy surgery is 9.15±0.33. Possible reasons for the extended hospital stay may include the need for close postoperative monitoring, and the management of potential complications, including lung infection, pneumothorax and hypoproteinemia (Supplementary Table 4). Besides, the majority underwent pulmonary lobectomy, which is a treatment modality for severe lung diseases. The contents were added.

In contrast to a prior study where patients undergoing thoracoscopic surgery lobectomy were discharged within 4 days, patients in our study experienced a longer postoperative hospital stay (9.15±0.33 days). Several factors may contribute to this extended duration. Firstly, a majority of patients underwent pulmonary lobectomy, which is a treatment modality for severe lung diseases. Additionally, the management of potential complications such as lung infection, pneumothorax, and hypoproteinemia could have prolonged hospitalization. However, direct comparisons of hospital stay lengths are challenging due to variations in discharge criteria among studies.

Comments 2- Line 193. Medical “professor”. Do you mind professionist?

Response: Thanks for the valuable comments. The phrase was corrected into “medical professionists”.

Comments 3- Discussion. Did you suggest any strategies to improve KAP?

Response: Thanks for the valuable comments. The contents were added in the Discussion.

This underscored the importance of integrating ERAS education into preoperative care for patients undergoing thoracic surgery and similar surgeries.

Based on the gaps in KAP items, preoperative education, personalized counseling, peer support groups and follow-up care can be further developed to facilitate prognosis and life quality of individuals undergoing thoracoscopy.

Comments 4- Discussion. The results shown moderate knowledge parameter. Any suggestions to improve it?

Response: Thanks for the valuable comments. The contents were added in the Discussion.

Targeted patient education should be developed to provide training on ERAS protocols and address related misunderstandings through doctor-patient communications.

________________________________________

Attachment Submitted filename: Response letter-R1.docx

10.1371/journal.pone.0309821.r003
Decision Letter 1
Ahmed Sirwan Khalid Academic Editor
© 2024 Sirwan Khalid Ahmed
2024
Sirwan Khalid Ahmed
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
30 Jul 2024

PONE-D-23-41704R1Knowledge, Attitude, and Practice towards Enhanced Recovery after Surgery among Patients Underwent Thoracoscopy SurgeryPLOS ONE

Dear Dr. Huang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Sirwan Khalid Ahmed

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear Esteemed Authors,

We appreciate your diligent efforts in editing the manuscript. However, it is necessary to restructure the entire paper to adhere to the STROBE checklist guidelines. Please complete the checklist and submit it as a supplementary file.

Please ensure that all subheadings in the text precisely align with those specified in the STROBE checklist. Additionally, carefully review the journal's guidelines to accurately revise references and include the DOI for each citation.

It is also vital to address all reviewer remarks from the previous round comprehensively. Lastly, please submit the English version of the questionnaires and raw data (Excel) as a supplemental file.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

********** 

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

********** 

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

********** 

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

********** 

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

********** 

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Tha authors replied to all the points that have been raised. I think the paper is now more clear.

I have no further comments.

********** 

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Reviewer #1: Yes: Pietro Bertoglio

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10.1371/journal.pone.0309821.r004
Author response to Decision Letter 1
Submission Version2
10 Aug 2024

Title: Knowledge, Attitude, and Practice towards Enhanced Recovery after Surgery among Patients Underwent Thoracoscopy Surgery

Journal: PLoS One

Response to Reviewers' comments

Dear Editor,

We thank you for your careful consideration of our manuscript. We appreciate your response and overall positive initial feedback and made modifications to improve the manuscript. After carefully reviewing the comments, we have modified the manuscript, therefore providing a complete context for the research that may be of interest to your readers.

We hope that you will find the revised paper suitable for publication, and we look forward to contributing to your journal. Please do not hesitate to contact us with other questions or concerns regarding the manuscript.

Best regards,

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We thank the requirement. We have meticulously checked our reference list to ensure it is both complete and correct. All references have been cross-verified for accuracy, and we have updated any incomplete information. We also have conducted a thorough review of all references to ensure their relevance and timeliness, making sure that our manuscript is supported by the most current and authoritative sources. Besides, each citation now includes the DOI for easy access.

Additional Editor Comments:

Dear Esteemed Authors,

We appreciate your diligent efforts in editing the manuscript. However, it is necessary to restructure the entire paper to adhere to the STROBE checklist guidelines. Please complete the checklist and submit it as a supplementary file.

Response: We thank the Editor. We have thoroughly checked the manuscript to align with the STROBE checklist and Journal guideline. Each section and subheading in the text now corresponds to those specified in the STROBE checklist. The completed STROBE checklist is included as a supplementary file with our revised submission.

Please ensure that all subheadings in the text precisely align with those specified in the STROBE checklist. Additionally, carefully review the journal's guidelines to accurately revise references and include the DOI for each citation.

Response: We thank the Editor. We have carefully reviewed all subheadings in the manuscript to ensure they match the STROBE checklist guidelines. This ensures clarity and consistency throughout the paper.

In accordance with the journal’s guidelines, we have meticulously reviewed all references for accuracy and completeness. We have revised the reference list to ensure that it adheres to the journal’s formatting requirements. Each citation now includes the DOI.

It is also vital to address all reviewer remarks from the previous round comprehensively.

Response: Thank you for your detailed feedback and for the opportunity to further improve our manuscript. We are pleased to note that Reviewer #1 acknowledged that all comments have been addressed in the previous round. In the first round of revision, we comprehensively addressed all comments from Reviewer #2. Specifically, we clarified methodological details, expanded on the discussion points, and provided additional references as requested.

Lastly, please submit the English version of the questionnaires and raw data (Excel) as a supplemental file.

Response: We thank the Editor. As requested, we have prepared the English version of the questionnaires used in our study. These are submitted as a supplemental file. Additionally, we have compiled and submitted the raw data in Excel format as a supplemental file, ensuring transparency and reproducibility of our findings.

Attachment Submitted filename: Response letter-R2.docx

10.1371/journal.pone.0309821.r005
Decision Letter 2
Ahmed Sirwan Khalid Academic Editor
© 2024 Sirwan Khalid Ahmed
2024
Sirwan Khalid Ahmed
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version2
20 Aug 2024

Knowledge, Attitude, and Practice towards Enhanced Recovery after Surgery among Patients Underwent Thoracoscopy Surgery

PONE-D-23-41704R2

Dear Dr. Yinping Huang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Sirwan Khalid Ahmed

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

10.1371/journal.pone.0309821.r006
Acceptance letter
Ahmed Sirwan Khalid Academic Editor
© 2024 Sirwan Khalid Ahmed
2024
Sirwan Khalid Ahmed
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
23 Aug 2024

PONE-D-23-41704R2

PLOS ONE

Dear Dr. Huang,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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on behalf of

Dr. Sirwan Khalid Ahmed

Academic Editor

PLOS ONE
==== Refs
References

1 Lee P , Folch E , editors. Thoracoscopy: advances and increasing role for interventional pulmonologists. Seminars in Respiratory and Critical Care Medicine; 2018: Thieme Medical Publishers.
2 Mangam NP , Chavan AR , Bodade R , Dhurve A . Study of diagnostic and therapeutic utility of video assisted thoracoscopic surgery. International Surgery Journal. 2018;5 : 2751–2759.10.18203/2349-2902.isj20182955
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