PONE-D-20-17250

Long-Term Healthcare Provider Availability Following Large-scale Hurricanes: A Difference-in-Differences Study

PLOS ONE

Dear Dr. Bell,

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.

I concur with the methodological issues raised by Reviewer 1. Control variables should be clearly distinguished from treatment variables. Direct effects of treatment variables both with and without control variables must be reported. How do treatment effects change with the addition of control variables, and why? Standard statistical tests on multi-collinearity, misspecification, auto-corellation etc. need to be reported. The discussion section needs to elaborate model limitations  that might arise due to biases induced by model specification, multi-collinearity etc. 

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We look forward to receiving your revised manuscript.

Kind regards,

Asim Zia, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

I concur with the methodological issues raised by Reviewer 1. Control variables should be clearly distinguished from treatment variables. Direct effects of treatment variables both with and without control variables must be reported. How do treatment effects change with the addition of control variables, and why? Standard statistical tests on multi-collinearity, misspecification, auto-corellation etc. need to be reported. The discussion section needs to elaborate model limitations that might arise due to biases induced by model specification, multi-collinearity etc.

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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

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

Reviewer #1: Yes

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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

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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

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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 study examined the availability of healthcare providers following two US natural disasters: Hurricanes Sandy and Katrina. The authors used publicly available provider and county-level data. The difference-in-difference approach used is appropriate given the study design and question. The finding that counties affected by Katrina had more substantial changes in healthcare provider availability compared with counties affected by Sandy raises important questions as to how to tailor and target interventions aiming to restore access to healthcare following natural disasters. I have several questions or comments, enumerated below.

Did any of the affected counties have missing/0 providers during the study period for any of the provider categories?

How did you identify counties that had a “sizeable influx of Katrina migrants”? This was listed as an exclusion criteria for control counties.

The methods stats that control counties were randomly selected and determined not to be statistically significantly different in sociodemographics than affected counties, but in Table 1 there is a significant difference in county population between control and affected counties before the hurricane Katrina.

Why is the term parish used sometimes instead of county? Is that a meaningful distinction?

The authors hypothesize that the decrease in providers after Katrina may be due to providers migrating. A potential driver could be hospital closures, which then force providers to look elsewhere for work. They have number of hospitals by county in Table 1 – does that number change following Katrina?

Is there a threshold that is used to determine whether an area is officially determined to have a provider shortage? If so, do the declines following Katrina meet this threshold? A decline on its own does not necessarily indicate a shortage.

Given the similar results for the short term and long term DID analyses, it seems the impact of disasters on healthcare provider availability is relatively permanent/stable. Perhaps more discussion on this is warranted. Was there any targeted intervention attempted after Katrina to recruit healthcare providers back to the area?

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Reviewer #1: Yes: Erika Moen

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Long-Term Healthcare Provider Availability Following Large-scale Hurricanes: A Difference-in-Differences Study

PONE-D-20-17250R1

Dear Dr. Bell,

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.

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Kind regards,

Asim Zia, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #1: All comments have been addressed

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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

**********

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: (No Response)

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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: No