PONE-D-20-30890

The cost-effectiveness of a two-step blood pressure screening programme in a dental health - care setting

PLOS ONE

Dear Dr. Helen Andersson,

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.

Can you also please complete a ‘Consolidated Health Economic Evaluation Reporting Standards (CHEERS)’ Statement indicating, where in the manuscript, each element of this statement has been addressed. Can you please also structure/format the manuscript according to this statement.

Please submit your revised manuscript by 18 February 2021. 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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We look forward to receiving your revised manuscript.

Kind regards,

Billingsley Kaambwa

Academic Editor

PLOS ONE

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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

Reviewer #2: Yes

Reviewer #3: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

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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

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #2: Yes

Reviewer #3: 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: Authors developed an economic model to assess the cost-effectiveness of an opportunistic hypertension screening programme compared to no screening of people aged 40-75 attending a dental-care facility. The authors found that under the current model structure and assumptions that opportunistic screening for hypertension in a dental care setting in a country with a relatively low prevalence is unlikely to be cost-effective.

In general, the manuscript was well written and structured. The abstract provides an accurate summary of the cost-effectiveness analysis. The conduct of the economic analysis conformed to best practices, but there some queries/suggestions.

• Given that the economic analysis considers the 40-74 years old population. Would it be helpful to include in the introduction the prevalence of hypertension in this population in Sweden?

• The intervention includes blood pressure readings taken by a dental health nurse, with some requiring home blood pressure measurements. Please can the authors elaborate on if participants were supplied with blood pressure monitors?

• Please can the authors provide the reference used to convert Swedish Kronor to Euros? It appears that some costs were obtained from the literature, please can the authors reference how these were inflated to current prices?

• Please can the authors state in the methods the software program that was used to undertake the economic analysis?

• The queries here relate to Table 1. First, the authors have included a cost of 165,000 SEK for vaccine program administration. Please can the authors elaborate on this cost included? Second, the authors state ‘formal care costs: short-term model.’ However, in my copy of the manuscript I have not seen this ‘short-term model’. Apologies if I have missed it. Third, it was not clear what was the average age of the population. Fourth, what utility value is used for people in the healthy state? Please can the authors expand on the abbreviations used in table 1?

• Based on the illustrative Markov model structure, it appears that people can only experience one event (e.g. cannot experience more than one stroke). Should this assumption be highlighted?

• Figure 1 presents the results of the one-way sensitivity analysis in the form of a tornado diagram. Please can the authors include the legend?

• I presume that with the two-step screening program, this will lead to early detection of people with hypertension compared to usual practice. Hence, it would be useful to show the impact of early detection, by reporting the number of events (e.g. stroke and AMI) that would be saved if this two-step program was implemented in practice.

• The queries here relate to the probabilistic sensitivity analysis (PSA). First, it was not clear what uncertainty range and distribution were used around the prevalence. Second, if space allows, please can the authors report the PSA results in the form of a scatterplot? Third, please consider re-phrasing the PSA results to, ‘The probability that the screening programme is cost-effective is approximately 0.02 at a willingness-to-pay threshold of 500,000 SEK per QALY.’

Reviewer #2: This is a well conducted study that is relevant in its field. Requirements for an economic evaluation according to the Drummond checklist were met.

The results could be presented in a less confusing way by indicating the ICER in both currencies for each perspective sequentially as opposed to putting them in brackets (page 1 line 32-35, page 6 line 200-204). Also indicate the currency year used for the Euro conversion.

Mention the time horizon in specific terms as opposed to simply indicating short-term and long term especially at first mention and in the abstract (page 1 line 24-25, page 3 line 95, 112)

Provide references for the model assumptions, especially those that are specific to the Swedish population (e.g page 4 line 130-133)

Minor comment: Regarding the Markov model, dead is an absorbing state so you do not expect a repeat arrow

Reviewer #3: This is a well written manuscript assessing the cost-effectiveness of a screening programme for hypertension in a dental health care setting compared to the "status quo". While I find the short term analysis easier to follow, further detail is required on the long term modelling approach so that I can assess the validity of the methods and the subsequent results. I provide some more specific comments below:

Short term analysis:

- Would be helpful to provide some more details on any potential false positives in the screening programme arm (or are there assumed to be none?)

- Data on the differential identificationis based on assumptions of the control arm. Please provide more details of the data used to inform these assumptions.

- It would be helpful to comment on the incremental analysis- it is not really screening programme or status quo, it is screening programme in addition to the status quo. How would this affect your analysis?

- What is the time horizon of the short term analysis? How many of the patients not identified in the control arm in this period would go on to be identified over the longer term by routine practice? What impact would this have on your results?

Long term analysis:

- Are there separate Markov models for those with identified hypertension, non identified hypertension and no hypertension or are you taking an average? The use of a markov model approach suggests a homogenous population entering the model at the beginning, as such if may not be a suitable approach if you do not model these 3 heterogeneous groups separately.

- Can unidentified patients in the model become identified?

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: 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.]

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Attachments

Attachment

Submitted filename: Artikel cost-effectiveness 201001.docx

PONE-D-20-30890R1

The cost-effectiveness of a two-step blood pressure screening programme in a dental health - care setting

PLOS ONE

Dear Dr. Andersson,

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 Jun 04 2021 11:59PM. 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.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Billingsley Kaambwa

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Page 3 line 18-21: This belongs to the results section

Page 3 line 25-29: Sentence is very long, Split sentence into two. Indicate the actual time for short-term in years or months

Page 3 line 30: The abbreviation is preceded by the word in full

Page 4 line 2-5: Indicate the source of costing data

Page 4 line 11-16: Indicate source of costing data and how non-health care costs were obtained

Page 4 line 38: write AMI in full at first time of mention

Page 5 line 9-11: Indicate how QALYs were obtained, was an instrument used, and frequency of QoL assessment

Page 5 line 29-30: Indicate the threshold value for Sweden

Results

Page 6 line 5: First time the link between this previous study and this present study is mentioned. This needs to be clearly spelt out in the introduction that this CEA is a follow-on from that previous study

Table 2: Include a column for unit costs

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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

Reviewer #2: (No Response)

Reviewer #3: 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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #3: 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

Reviewer #3: 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: The authors have responded to the concerns raised by the authors and have made the necessary changes to the manuscript.

Reviewer #3: The authors have fully responded to my comments and made appropriate ammendments to the paper. I have no further comments.

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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

Reviewer #2: No

Reviewer #3: 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.

The cost-effectiveness of a two-step blood pressure screening programme in a dental health - care setting

PONE-D-20-30890R2

Dear Dr. Helen Andersson,

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,

Billingsley Kaambwa

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: