PONE-D-20-34927

Trends in heart failure-related cardiovascular mortality in rural versus urban United States counties, 2011-2018: A cross-sectional study

PLOS ONE

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Jim P Stimpson, PhD

Academic Editor

PLOS ONE

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: The manuscript is well written and deals with an area of major public health significance, there appropriately and well to a set of 3 reviewers. I would add the following comments, mostly relating to tables:

Table S2. Suggest that the entries in the “crude rate” columns all be shown to one place after the decimal point (including the whole numbers like “92” for the crude mortality rate of Black women.

Table S3. I could not understand the entries in the row for “County population, No.”, e.g what do “918,685” and “(1,559,985)” represent?

Figure 4. The scale of this figure is so small that is difficult to visually determine whether some of the lines cross “1” x-axis point. Because of this, I suggest that an additional table be created with the values shown in the graph.

Of broader and more substantive concern is the absence of consideration of the major behavior risk factors and of hypertension in these data (recognizing that reasonable data may not exist) or in the limitations section of the discussion. The specific behaviors are smoking, diet, and physical activity. Diet and physical activity may be along the causal pathway to obesity and diabetes, which show rural-urban differences in the manuscript. Smoking is a known risk factor for heart failure and is more prevalent in rural vs. urban communities. Hypertension is the major risk factor for heart failure and is also more prevalent in rural the urban areas in the U.S. I would section that a not too long section be added in the discuss for this which might just be that there were other factors (e.g., the ones noted in this paragraph) for which data were not available to include in the analysis

Reviewer #2: We thank the authors for the opportunity to rereview the manuscript entitled “Trends in heart failure-related cardiovascular mortality in rural vs urban United States counties, 2011-2018: a cross-sectional study”. The authors have responded appropriately to the prior queries. However, I have one additional concern that I would ask the authors to respond to.

1. On pg 12 line 241, the authors note that “There were no practicing cardiologists in 51.1% and 74.9% of rural counties”. Do the authors have a way of knowing whether patients are referred to practicing cardiologists who might be located in urban (or other) locations) for these rural patients? Similarly, how does the adjustment for physician density change if the authors adjust for the number of PCPS and the number of cardiologists in separate models ??

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Reviewer #1: No

Reviewer #2: No

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Trends in heart failure-related cardiovascular mortality in rural versus urban United States counties, 2011-2018: A cross-sectional study

PONE-D-20-34927R1

Dear Dr. Khan,

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,

Jim P Stimpson, PhD

Academic Editor

PLOS ONE