Advanced imaging and trends in hospitalizations from the emergency department

Shih-Chuan Chou; Justine M. Nagurney; Jeremiah D. Schuur; Scott G. Weiner

doi:10.1371/journal.pone.0239059

Peer Review History

Original SubmissionFebruary 13, 2020
6 Jul 2020 Decision Letter - Steve Lin, Editor PONE-D-20-04321 Advanced Imaging and Trends in Hospitalizations from the Emergency Department PLOS ONE Dear Dr. Chou, 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 September 4, 2020. 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. 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Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [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: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 ****** 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 ****** 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: This manuscript is very well-written and addresses an important topic regarding healthcare resource utilization. Having said that, this issue is complex and I have a few suggestions that would potentially help the paper reflect this complexity. 1. Hypothesis I think your hypothesis - that advanced ED imaging would lead to a decline in admission rates - needs a bit more rationale earlier in the paper. Intuitively, and as you later mention in the discussion, advanced imaging could instead lead to an increase in hospitalization if more subtle but possibly dangerous pathology was identified. Although your paper did not show any statistical difference for imaging vs. hospitalization in either direction, I think some justification for your hypothesis would help the reader follow the paper. 2. Confounding variables There are several variables that affect the decision to admit a patient to hospital. Of course, the disposition of patients at either end of the spectrum are obvious (ie. a fractured toe vs. a patient in septic shock), but much of emergency medicine operates in a grey area where two different providers could make two different, and equally justifiable, decisions. This is difficult to capture in a binary "admitted vs. discharge" outcome measure. Additionally, admission can sometimes be a product of patient preference or lack of outpatient supports. I think that you have done a good job explaining some of these variables in the conclusion ("outpatient clinical pathways, and policy factors...") but can better underscore the many factors which are at play in the decision to admit a patient to hospital, and include this is a major limitation to your study. 3. Methods How were patients who were seen in the ED and then discharged with a plan/appointment to return the next day for advanced imaging dealt with? Was this information reflected in the database? This is a relatively common practice in the EDs I have worked at for patients seen in the evening/overnight without critically emergent differential diagnoses. 4. Results No further suggestions here - I was happy to see you include relevant high-level results for subgroups (ie. excluding observation admissions and excluding ultrasound) - I think this adds credence to the arguments brought forth in the paper. 5. Conclusion You suggest that advanced imaging may not play a substantial role in the decline of admission rates. Despite your well-executed study, I am still not convinced of this, largely because of the many confounding variables, and so I think it would be more appropriate to state that more research is needed. ****** 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: Yes:** Shaun Mehta [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.0239059.r001
Revision 1
5 Aug 2020 Author Response Reviewer #1: This manuscript is very well-written and addresses an important topic regarding healthcare resource utilization. Having said that, this issue is complex and I have a few suggestions that would potentially help the paper reflect this complexity. 1. Hypothesis I think your hypothesis - that advanced ED imaging would lead to a decline in admission rates - needs a bit more rationale earlier in the paper. Intuitively, and as you later mention in the discussion, advanced imaging could instead lead to an increase in hospitalization if more subtle but possibly dangerous pathology was identified. Although your paper did not show any statistical difference for imaging vs. hospitalization in either direction, I think some justification for your hypothesis would help the reader follow the paper. Thank you for this suggestion, we reorganized the introduction to refocus the study’s emphasis on examining the value of increased advanced imaging through reduction in hospital admissions. 2. Confounding variables There are several variables that affect the decision to admit a patient to hospital. Of course, the disposition of patients at either end of the spectrum are obvious (ie. a fractured toe vs. a patient in septic shock), but much of emergency medicine operates in a grey area where two different providers could make two different, and equally justifiable, decisions. This is difficult to capture in a binary "admitted vs. discharge" outcome measure. Additionally, admission can sometimes be a product of patient preference or lack of outpatient supports. I think that you have done a good job explaining some of these variables in the conclusion ("outpatient clinical pathways, and policy factors...") but can better underscore the many factors which are at play in the decision to admit a patient to hospital, and include this is a major limitation to your study. In this revision, we acknowledge the limitation of our data to account for the complex decision of admitting a patient more explicitly. “Furthermore, we acknowledge that the decision of whether hospitalize after an ED evaluation is complex may not be fully accounted for in our analysis.” 3. Methods How were patients who were seen in the ED and then discharged with a plan/appointment to return the next day for advanced imaging dealt with? Was this information reflected in the database? This is a relatively common practice in the EDs I have worked at for patients seen in the evening/overnight without critically emergent differential diagnoses. We are not aware that planned return ED visits is a commonplace practice, at least in the community sites where we work. Nevertheless, the NHAMCS data is consisted of a cross-sectional sample of ED visits from EDs that were surveyed annually. The patients are thus not followed longitudinally across visits. Therefore, NHAMCS is unable to identify visits that may be “return” or “repeat” visits. We additionally noted this limitation as considerations for imaging use would certainly be different for repeat or return visits. “The cross-sectional nature of the dataset also does not allow us to discern whether visits may be return or repeat ED visits where decisions to pursue advanced imaging would be different from initial ED visits.” 4. Results No further suggestions here - I was happy to see you include relevant high-level results for subgroups (ie. excluding observation admissions and excluding ultrasound) - I think this adds credence to the arguments brought forth in the paper. Thank you. 5. Conclusion You suggest that advanced imaging may not play a substantial role in the decline of admission rates. Despite your well-executed study, I am still not convinced of this, largely because of the many confounding variables, and so I think it would be more appropriate to state that more research is needed. We adjusted our tone in the CONCLUSION section to be more align our finding as preliminary and needs further replication. However, we do believe that our study design is stronger exploratory compared to studies that simply observed that the decline in admission rates and the increase in advanced imaging occurred concurrently. Attachments Attachment Submitted filename: Reviewer comments and response.docx https://doi.org/10.1371/journal.pone.0239059.r002
31 Aug 2020 Decision Letter - Steve Lin, Editor Advanced Imaging and Trends in Hospitalizations from the Emergency Department PONE-D-20-04321R1 Dear Dr. Shih-Chuan Chou, 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. 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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 Reviewer #2: 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 Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes 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 #1: Yes Reviewer #2: 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 Reviewer #2: Yes ****** 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 #1: Thank you for taking the time to address my comments. I feel that you have addressed everything comprehensively and that this paper adds value to the body of scientific literature as it relates to emergency medicine. Reviewer #2: This is a well designed study on a relevant topic. This observational study has a strong analytical methods to answer the question of whether increases in imaging use may have resulted in decreased hospital admissions. The comments of the reviewers were addressed. A few outstanding comments: 1. There is an issue with the wording here: "we acknowledge that the decision of whether hospitalize after an ED evaluation is complex may not be fully accounted for in our" 2. The conclusion does not need to suggest a specific type of study such as a "replication study". "Replicate" could be changed for "support". ****** 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 #1: Yes: Shaun Mehta Reviewer #2: Yes:** Samuel Vaillancourt https://doi.org/10.1371/journal.pone.0239059.r003
Formally Accepted
4 Sep 2020 Acceptance Letter - Steve Lin, Editor PONE-D-20-04321R1 Advanced Imaging and Trends in Hospitalizations from the Emergency Department Dear Dr. Chou: 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. Steve Lin Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0239059.r004

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