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PONE-D-20-29947

Mortality and other outcomes of patients with coronavirus disease pneumonia admitted to the emergency department: a prospective observational Brazilian study.

PLOS ONE

Dear Dr. Marchini,

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Walter R. Taylor

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Dr. Marchini,

thankyou for your nice paper.

I have reviewed it and received comments from one excellent reviewer who makes very useful and constructive comments.

yours sincerely,

Walter Taylor

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

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

Reviewer #1: I Don't Know

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Reviewer #1: Yes

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Reviewer #1: Yes

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5. Review Comments to the Author

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Reviewer #1: Thank you for the opportunity to review this paper. It is good to read a report describing presentations with COVID-19 that does not come from one of the countries that have tended to dominate the literature on this topic. Overall, the study provides a useful addition to the emerging literature on acute presentations with COVID-19. I have the following suggestions that I hope the authors will find helpful.

Please state the aim and specific objectives of the study at the end of the introduction, ensuring that the objectives are in accordance with the analysis undertaken (i.e. to describe the characteristics of people admitted to hospital with COVID-19 pneumonia and identify independent predictors of adverse outcome).

Under study design, it would be helpful to know the population covered by the hospital. Did the hospital act as the referral centre for the whole of Sao Paulo and, if so, what is the population of Sao Paulo?

Non-invasive ventilation is not reported in the outcomes. There have been reports that non-invasive ventilation (including CPAP) can reduce the need for ventilation and suggestions that this may improve outcomes. Are you able to comment on the use of non-invasive ventilation in your hospital?

Please clarify the duration of follow up? Presumably patients were follow until death or hospital discharge, but a proportion were still in hospital at a specified date.

How were the 2219 ED attendances selected? I presume these were patients with suspected COVID-19, so how was that defined? I also assume that only those admitted were routinely tested for COVID-19, but please clarify this.

It would be interesting to compare the characteristics and outcomes of those admitted with confirmed COVID-19 to those with negative COVID-19 testing. Maybe this is planned for a separate analysis.

I recommend reporting numbers alongside the percentages in the results text.

The description of the multivariable analysis requires some more detail to allow it to be reproducible:

1. How were missing predictor variables handled (I assume those with missing outcomes were excluded from the analysis)? Were missing data assumed to be normal? This may require some more information regarding the recording of predictor variables, perhaps by providing the data collection form as an appendix.

2. How was the relationship between continuous predictor variables and outcome modelled, given that some may have non-linear relationships with outcome?

3. How many predictor variables were included in the analysis? The sample size may be insufficient for a large number of predictor variables, and including too many may lead to over-fitting.

4. Was any analysis undertaken to validate the multivariable model?

In general, I think the multivariable analysis is the weakest part of the study. The descriptive analysis is appropriate and clearly presented, allowing readers to understand the characteristics of your population and compare it to other populations. It is more difficult to draw conclusions from the multivariable analysis. The study may lack power for multivariable analysis, creating risks of important predictors being missed, while the model may be over-fitted if too many predictor variables were included. I would either drop the multivariable analysis from the paper or, if retained, ensure the analysis is clearly described and the limitations acknowledged.

Finally, PLOS ONE has reviewed a paper from my research team describing ED attendances with suspected COVID-19 across the UK. You may wish to contrast your findings with ours in your discussion. The pre-print is available here (https://www.medrxiv.org/content/10.1101/2020.08.10.20171496v1) and I am happy to share our revised paper, if this is OK with the PLOS ONE editors.

Steve Goodacre, 12 October 2020

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Reviewer #1: Yes: Steve Goodacre

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Mortality and other outcomes of patients with coronavirus disease pneumonia admitted to the emergency department: a prospective observational Brazilian study.

PONE-D-20-29947R1

Dear Dr. Marchini,

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.

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Kind regards,

Walter R. Taylor

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Dr. Marchini,

thankyou for the revision of this paper.

I am happy to accept it for publication.

yours sincerely,

Walter Taylor.

Reviewers' comments: