PDIG-D-22-00238

Optimizing cardiovascular risk assessment and registration in a developing cardiovascular learning health care system: women benefit most

PLOS Digital Health

Dear Dr. Bots,

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Apologies for the delay in reviewing this manuscript. Upon receipt of the review I am recommending minor revision.

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Reviewers' comments:

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Comments to the Author

1. Does this manuscript meet PLOS Digital Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

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

Reviewer #1: Yes

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Reviewer #1: No

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Reviewer #1: Yes

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5. Review Comments to the Author

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Reviewer #1: This is an interesting manuscript that demonstrates a real-world application of the learning healthcare system (LHS) applied in the context of cardiovascular risk assessment and management. Grohenhof et al. clearly state the problem definition. Notably, they present LHS as a solution to what they define as the science-to-care gap.

The authors conducted a prospective cohort study comparing the measurement of cardiovascular risk factors before and after the implementation of the UCC-CVRM, an infrastructure implemented in the EHR allowing for standardized collection of cardiovascular-related health data. To demonstrate the benefits of this infrastructure, the authors compared the proportion of measured risk factors before and after its implementation. The other outcomes measured by the authors were the proportion of patients with an indication of treatment for a given cardiovascular condition and an estimation of the proportion of patients with potentially missed severe cardiovascular-related conditions.

The results are interesting as they have shown an increase in the registration of all risk factors after implementing UCC-CVRM (see S1 Table and S2 Table). The authors extrapolate their results a little bit further by estimating the likelihood of missing uncontrolled risk factor in patients who would have otherwise required treatment (S4 Table).

I have the following comments :

Major issues

Abstract and Introduction

1) No explicit mention of similar LHS initiatives in the cardiovascular space. Notably, there seem to have other examples in the literature that have implemented LHS in this space, and it would be essential to cite and explain how your initiative differs. In the cited article of Maddox et al., multiple examples are discussed.

Methods

2) Please add p-values to show the significance of the multiple statistical tests conducted (S1 Table, S2 Table

3) I don’t agree with the calculation of the likelihood of missing hypertension: in the context of EHR documentation, not being reported does not equate not being measured. Moreover, your calculation implies a uniform distribution among unmeasured variables, which is also incorrect. I like the idea you explored with those calculations, but I would like to see a few sentenced conceding the limitation of the methodology.

Figures

4) Figure 5 and 6 do not allow for easy comparison of the pre/post CVRM implementation. I would suggest using side-by-side bar chart or use the S1 and S2 tables instead.

Minor issues

1) Minor grammar issues and sentence structures could benefit from some touch-up.

i.e. lines 48-50 could be rewritten for simplicity «Healthcare is challenged by a growth in patient numbers, patients of higher age, patients with multiple diseases and medications, and a higher level of chronicity of disease. »

2) Clarification of the statement line 275. Please clarify how CDSS relates or complements the work you presented in this manuscript. The last paragraph was not so clear to me.

3) Add a discussion regarding the interaction of CVRM initiation and female sex. Notably, elaborate on the potential reasons for which the results are significant for eGFR, A1c and not for SBP and smoking.

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Reviewer #1: Yes: Eric Yamga

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Optimizing cardiovascular risk assessment and registration in a developing cardiovascular learning health care system: women benefit most

PDIG-D-22-00238R1

Dear prof Bots,

We are pleased to inform you that your manuscript 'Optimizing cardiovascular risk assessment and registration in a developing cardiovascular learning health care system: women benefit most' has been provisionally accepted for publication in PLOS Digital Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow-up email from a member of our team. 

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

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Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Digital Health.

Best regards,

Leo Anthony Celi, MD MS MPH

Editor-In-Chief

PLOS Digital Health

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Reviewer Comments (if any, and for reference):