Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: A cohort study

Rachel Lane Socolovithc; Renata Rego Lins Fumis; Bruno Martins Tomazini; Laerte Pastore; Filomena Regina Barbosa Gomes Galas; Luciano Cesar Pontes de Azevedo; Eduardo Leite Vieira Costa

doi:10.1371/journal.pone.0243269

Peer Review History

Original SubmissionSeptember 12, 2020
28 Oct 2020 Decision Letter - Chiara Lazzeri, Editor PONE-D-20-28770 Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: a cohort study PLOS ONE Dear Dr. Fumis, 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. This is an accurate description of the epidemiologic characteristis of critically ill COVID patients in Brazil. We suggest the Authors to better clarify, in the discussion section, the peculiarity of their population and the clinical impact of their findings. Please submit your revised manuscript by Dec 10 2020 11:59PM. 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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. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Review comments Title: Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: a cohort study General comments This is a study of relevance for the global community considering the fact that the health outcomes and implications of the COVID-19 pandemic is widespread. The authors output is satisfactory. The following issues however need to be addressed by the authors: Title Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: a cohort study The letter “a” after the colon should be capitalized. Abstract The aim of the study focused on the describing clinical outcomes of patients with COVID-19 yet the methods included another group whose clinical outcomes were also described and compared with the COVID 19 patients. The conclusion section did not provide the implications of the findings of the study. Introduction Line 84 should be more specific to the COVID-19 disease and the appropriate references should be cited. The statement preceding the aim of study suggest a Brazilian regional based challenge which would have required an aim trying to address these regional variations. Therefore, a preceding statement linking the background to the aim of study should be more specific to COVID-19-related critical illness and resources/facilities in ICUs Methods 1. The methods should be sectioned for better appreciation, i.e. design, study site, participants etc etc 2. What were the attendance records like? a. how many participants per cohort? b. Were all patients during the two periods included in the study or there was some form of sampling? c. What were the inclusion and exclusion criteria? 3. Data collection tools - A detailed description of each of the study tool is required. For example, 1) what are some of the items in each tool, 2) what kind of information do they seek to obtain, 3) how are they scored? 4) how are the scores rated/categorized? Results Results reporting percentages should include the n values. For example, n (%). All ‘N’ in tables that represent each cohort should be replaced with ‘n’. Conclusion The authors after stating the main findings should provide the implications of their findings to clinical care and the current COVID-19 pandemic. ****** 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 [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.0243269.r001
Revision 1
12 Nov 2020 Author Response Reviewer #1: Review comments Title: Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: a cohort study General comments This is a study of relevance for the global community considering the fact that the health outcomes and implications of the COVID-19 pandemic is widespread. The authors output is satisfactory. The following issues however need to be addressed by the authors: Title Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: a cohort study The letter “a” after the colon should be capitalized. Authors response: The letter a was capitalized as suggested. Abstract The aim of the study focused on the describing clinical outcomes of patients with COVID-19 yet the methods included another group whose clinical outcomes were also described and compared with the COVID 19 patients. Authors response: Thank you for your comment. The reviewer is correct that the aim was primarily to describe clinical characteristics and outcomes in patients with COVID-19. A secondary aim was to assess the impact of the pandemic on the use of hospital resources. To this end, we chose to compare COVID-19 patients with critically-ill medical patients from the previous year. We are sorry that this was not clear enough in the previous version of the manuscript. The text now reads: “…and assess the impact on the use of hospital resources in comparison to the previous year”, lines 104-105 of the clean version of the revised manuscript. The conclusion section did not provide the implications of the findings of the study. Authors response: The main findings were that COVID-19 patients demanded more hospital resources but had similar clinical outcomes as compared to non-COVID-19 patients. The implications of these findings are that, even in the face of a pandemic, adaptative structural changes and preparedness might influence the outcomes. The text now reads: “There was no difference in all-cause mortality at 28 and 60 days, suggesting that health systems preparedness be an important determinant of clinical outcomes”, lines 51-53 of the clean version of the revised manuscript. Introduction Line 84 should be more specific to the COVID-19 disease and the appropriate references should be cited. Authors response: We updated the references as suggested. Line 89-90 of the clean version of the revised manuscript. The statement preceding the aim of study suggest a Brazilian regional based challenge which would have required an aim trying to address these regional variations. Therefore, a preceding statement linking the background to the aim of study should be more specific to COVID-19-related critical illness and resources/facilities in ICUs Methods 1. The methods should be sectioned for better appreciation, i.e. design, study site, participants etc etc Authors response: We performed the proposed changes. 2. What were the attendance records like? a. how many participants per cohort? Authors response: We included 185 patients in the non-COVID-19 cohort and 212 in the COVID-19 cohort. This information is in the first paragraph of the results section and also in Table 1. Lines 173-174 of the clean version of the revised manuscript. b. Were all patients during the two periods included in the study or was there some form of sampling? Authors response: All consecutive adult COVID-19 patients within the study period were included. For the non-COVID-19 cohort, consecutive adult patients admitted to the ICU due to respiratory or infectious diseases were included. The text now reads: “The COVID-19 cohort consisted of all consecutive adult patients admitted to the ICU from March 08th to June 30th, 2020. In 2020, all patients admitted to the ICU had a diagnosis of COVID-19. For the non-COVID-19 cohort, we included all adult patients admitted to the ICU due to respiratory or infectious diseases in the same period in 2019.” Lines 128-131 of the clean version of the revised manuscript. c. What were the inclusion and exclusion criteria? Authors response: In the COVID-19 cohort, we included all adult patients admitted within the study time frame. For the non-COVID-19 cohort, we included all adult patients admitted with respiratory or infectious diseases diagnosis from the same period of time in the previous year (2019). Patients under 18 years old were excluded in both cohorts. We added this information in line 132 of the clean version of the revised manuscript. 3. Data collection tools - A detailed description of each of the study tool is required. For example, 1) what are some of the items in each tool, 2) what kind of information do they seek to obtain, 3) how are they scored? 4) how are the scores rated/categorized? Authors response: We performed the requested changes. Line 141-152 of the clean version of the revised manuscript. Results Results reporting percentages should include the n values. For example, n (%). All ‘N’ in tables that represent each cohort should be replaced with ‘n’. Authors response: We performed the requested changes. Conclusion The authors after stating the main findings should provide the implications of their findings to clinical care and the current COVID-19 pandemic. Authors response: We thank the reviewer for this remark. We performed the changes as suggested. The text now reads: “COVID-19 required more hospital resources, including invasive and non-invasive ventilation, had a longer duration of mechanical ventilation, and a more prolonged ICU and hospital length of stay. There was no difference in all-cause mortality at 28 and 60 days, suggesting that health systems preparedness be an important determinant of clinical outcomes”. Line 286-290 of the clean version of the revised manuscript. . https://doi.org/10.1371/journal.pone.0243269.r002
19 Nov 2020 Decision Letter - Chiara Lazzeri, Editor Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: A cohort study PONE-D-20-28770R1 Dear Dr. Fumis, 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, Chiara Lazzeri Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0243269.r003
Formally Accepted
23 Nov 2020 Acceptance Letter - Chiara Lazzeri, Editor PONE-D-20-28770R1 Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: A cohort study Dear Dr. Fumis: 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. Chiara Lazzeri Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0243269.r004

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