Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: A real-time observational study

Stefan Morreel; Hilde Philips; Veronique Verhoeven

doi:10.1371/journal.pone.0237629

Peer Review History

Original SubmissionMay 20, 2020
15 Jun 2020 Decision Letter - Wen-Jun Tu, Editor PONE-D-20-15141 Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study PLOS ONE Dear Dr. Morreel, 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. Please submit your revised manuscript by Jul 30 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Wen-Jun Tu Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for including your competing interests statement; "I have read the journal's policy and the authors of this manuscript have the following competing interests:All authors have completed the ICMJE uniform disclosure form and declare: Stefan Morreel is an unpaid Board member of one of the participating General Practice Cooperatives and is paid by the Belgian ministry of help to coordinate the response of this cooperative to the COVID-19 pandemic. Veronique Verhoeven has participated at the same GPC by handling telephone calls in a fee-for-service model. All authors are board members of iCAREdata as part of their academic position, the database used in this study. " Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf. Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests [Note: HTML markup is below. Please do not edit.] 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: Yes ******** 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: No Reviewer #2: No ****** 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 study's strength lies in the massive data that allows health care system and policy makers to understand more about the nature of out-of-hours primary care during COVID19. However the data is limited in the sense that it only provides a descriptive analysis and lacking in in-depth discussion about how this data might have larger consequences to changing health care system in Belgium during pandemic, and compared with other countries' out-of-hours primary care. I suggest to expand the analysis to make connection to the larger/global implication. Reviewer #2: The authors present an interesting case study on out-of-hours primary care in Belgium during the COVID-19 pandemic. Overall, the paper is well-written, but a proper copyediting should be performed before publication. I have a few remarks that authors should address in a revised version: Page 5 (Sec Methods): how are the other 77% of the Flemish population covered? It seems to be quite a large number of GPs per centre, are they all on duty in shifts? Do they otherwise work full time as GPs and cover the same population? Page 7 / Fig 1: the representation and explanation of the process during the pandemic should be clearer. All patients are advised to call first? What happens to those who just show up? It is stated on page 10, for example, that 30% did not have a telephone consultation. Please explain in more detail how you differentiate triage from consultation. How and when where patients informed about the new process? Do you have time stamps / durations for the call handling and different consultation types? Did the durations differ in the two years? Are telephone consultations significantly faster than physical consultations? What was the staff utilisation in the two periods? Page 8 (Sec Characteristics, first paragraph): What were the remaining 3%? Page 10, Table 2: Why weren’t there any telephone consultations last year? Was it not possible to call the centre before the pandemic? Was everyone seen who called the centre? Page 10, Table 2: could you provide some numbers on the pandemic for the 5 weeks you studied to get a better idea about the situation in Belgium during that time? From the news we got the impression that Belgium was hit comparatively hard by the virus. Page 10, last sentence: do you have any explanation why ear-related diagnoses are on the list of those with the highest decline? From my experience, I would have imagined something like back pain or headaches etc. to be on that list. From your findings, would you conclude that the centres should keep telephone consultations as an option even after COVID-19? Can you make conclusions based on your findings and your data? Can you make any remarks on other European countries that also provide out-of-hours care by GPs like Germany? Did you find any papers or comments on that? Would you say that the care process should be transferable to other countries and would you suggest to use it? I am missing an outlook at the end of the paper. What should follow-up research study? How can the results be used in future research? ****** 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. If you choose “no”, your identity will remain anonymous but your review may still be made public. 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: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] 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. https://doi.org/10.1371/journal.pone.0237629.r001
Revision 1
25 Jun 2020 Author Response We thank the reviewers for their generous comments on the manuscript and have edited the manuscript accordingly. For your convenience we have made a table with the suggestions of the reviewers and our adaptations/comments in the rebuttal letter. Change competing interests statement We have added the suggestion to the cover letter. For clarity we have also copied our data availability statement to the cover letter. Lacking in in-depth discussion about how this data might have larger consequences to changing health care system in Belgium during pandemic This suggestion is similar to more specific critics of the second reviewer so we have commented those Page 5 (Sec Methods): how are the other 77% of the Flemish population covered? It seems to be quite a large number of GPs per centre, are they all on duty in shifts? Do they otherwise work full time as GPs and cover the same population? We have added the requested information. We have clarified that the studied GPCs cover 23% of the Flemish population. The remaining 77% is covered by GPCs we could not include or have the old system of rota groups for on call duties. We believe adding information about the large amount of included GPs would make the methodology section to long but provide it here for your interest: Belgium has got a rather large amount of GPs per capita and the included GPCs have a lot of part-time working GPs and trainees because of the proximity of two academic departments. GPs with a chronic illness or above 65 years of age are not obliged to work in the GPCs, all the others are. Page 7 / Fig 1: the representation and explanation of the process during the pandemic should be clearer. All patients are advised to call first? We have entirely rewritten this paragraph and simplified Fig 1. It is now more clear that all patients need to call (but some will only speak with a call taker). It is stated on page 10, for example, that 30% did not have a telephone consultation. We clarified this statement: 433 (30%) only spoke with a call taker Please explain in more detail how you differentiate triage from consultation. New sentence: “In two GPCs, the call takers refer selected patients directly to the ED (using a local triage protocol) while all other GPCs do not perform any kind of triage.” How and when where patients informed about the new process? Added to the introduction: The government’s recommendation to always call a doctor prior to going to a practice or ED was omnipresent in the media. Do you have time stamps / durations for the call handling and different consultation types? Did the durations differ in the two years? Are telephone consultations significantly faster than physical consultations? We do not have this data, added to limitations. What was the staff utilisation in the two periods? The GPCs definitely increased their staff (GPs and call takers/receptionists) but we do not have data proving this, neither was it part of our questionnaire. We have added this to the limitations. Page 8 (Sec Characteristics, first paragraph): What were the remaining 3%? There is not remaining 3%, we have clarified this sentence. Page 10, Table 2: Why weren’t there any telephone consultations last year? Was it not possible to call the centre before the pandemic? Was everyone seen who called the centre? Added to the introduction and to the footnote of this table: “Before the pandemic, remote consultations were neither reimbursed nor deontologically allowed.” Page 10, Table 2: could you provide some numbers on the pandemic for the 5 weeks you studied to get a better idea about the situation in Belgium during that time? From the news we got the impression that Belgium was hit comparatively hard by the virus. We have extended the epidemiological information in the introduction. Belgium surely was hit hard but we have chosen not to compare these data to other countries or regions because Belgium is one of the few countries including many suspected cases to the total number of cases. Currently there are no peer reviewed publications available about the comparison of the burden of this pandemic to individual countries or regions. It would be more correct to compare Belgium to New-York or Northern Italy then to compare the numbers to bigger countries. Page 10, last sentence: do you have any explanation why ear-related diagnoses are on the list of those with the highest decline? From my experience, I would have imagined something like back pain or headaches etc. to be on that list. There was a decline for back pain (included in the ICPC-chapter Musculoskeletal) and headache (chapter Neurological) but similar to the overall decline so we do not discuss them separately. Added to the discussion: “The more pronounced decline of ophthalmological and digestive diagnoses is probably due to the reduced amount of other infections caused by the lock-down.” From your findings, would you conclude that the centres should keep telephone consultations as an option even after COVID-19? Can you make conclusions based on your findings and your data? Our data do not allow for definitive conclusions but are an interesting starting point. Added to discussion: “The successful implementation of telephone consultations opens new possibilities for the post COVID-19 era but should be studied more profoundly, especially regarding patient’s safety.” Can you make any remarks on other European countries that also provide out-of-hours care by GPs like Germany? Did you find any papers or comments on that? Would you say that the care process should be transferable to other countries and would you suggest to use it? We have entirely rewritten the first paragraph of the Discussion with additional references. This study alone does not allow for a recommendation on the transfer of this care process to other countries although is surely brings in one argument. I am missing an outlook at the end of the paper. What should follow-up research study? How can the results be used in future research? Such an outlook has been added to the final paragraph of the discussion. We hope that the manuscript is now suitable for publication in Plos One. Sincerely, The authors Attachments Attachment Submitted filename: Rebuttal letter.docx https://doi.org/10.1371/journal.pone.0237629.r002
20 Jul 2020 Decision Letter - Wen-Jun Tu, Editor PONE-D-20-15141R1 Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study PLOS ONE Dear Dr. Morreel, 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. Please submit your revised manuscript by Sep 03 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Wen-Jun Tu Academic Editor PLOS ONE Additional Editor Comments (if provided): 1. In order to provide a more complete information to our readers on the topic, we would like to emphasize the importance to cross referencing very recent material on the same topic published in "PLoS ONE ". Therefore, it would be highly appreciated if you would check the contents published in the last two years of "PLoS ONE" (https://journals.plos.org/plosone/) and add all material relevant to your article to the reference list. 2. add “Clinical features and short-term outcomes of 102 patients with corona virus disease 2019 in Wuhan, China. Clinical Infectious Diseases.” in the revision text [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions 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 #2: (No Response) ******** 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: 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 #2: No ****** 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 #2: (No Response) ****** 6. 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 #2: I think the authors did a good job revising the manuscript. I just have a few minor comments: - The information and references about other countries that were added to the discussion might be better moved to the intro section as part of the relevant literature. - The last sentence of the added outlook should be revised. - The paper needs final proofreading. ****** 7. 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. If you choose “no”, your identity will remain anonymous but your review may still be made public. 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 #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] 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. https://doi.org/10.1371/journal.pone.0237629.r003
Revision 2
27 Jul 2020 Author Response Dear editor, We thank the reviewers for their additional comments on the manuscript and have edited the manuscript accordingly. We believe this paper is now ready for publication and will contribute to the wide diversity of knowledge about COVID-19 distributed by PLoS ONE as it is the first study within the COVID-19 collection with a primary care perspective. For your convenience we have made a table with the suggestions of the reviewers and our adaptations/comments. Comment Our adaptation and/or comment In order to provide a more complete information to our readers on the topic, we would like to emphasize the importance to cross referencing very recent material on the same topic published in "PLoS ONE ". We have added a recent PLoS ONE study to the Methodology section (Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): A systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020;15(6):e0234765. Published 2020 Jun 23. doi:10.1371/journal.pone.0234765) Editor: add “Clinical features and short-term outcomes of 102 patients with corona virus disease 2019 in Wuhan, China. Clinical Infectious Diseases.” in the revision text We have added this reference to the introduction The information and references about other countries that were added to the discussion might be better moved to the intro section as part of the relevant literature. We have moved this paragraph as requested The last sentence of the added outlook should be revised. This sentence was indeed incomplete and has been corrected The paper needs final proofreading. We have proofread the entire article and made some improvements here and there We hope that the manuscript is now suitable for publication in Plos One. Sincerely, The authors Attachments Attachment Submitted filename: Second Rebuttal letter.docx https://doi.org/10.1371/journal.pone.0237629.r004
31 Jul 2020 Decision Letter - Wen-Jun Tu, Editor Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study PONE-D-20-15141R2 Dear Dr. Morreel, 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. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Wen-Jun Tu Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0237629.r005
Formally Accepted
4 Aug 2020 Acceptance Letter - Wen-Jun Tu, Editor PONE-D-20-15141R2 Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study Dear Dr. Morreel: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Wen-Jun Tu Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0237629.r006

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .