PONE-D-21-00107

Physician and patient concordance in reporting of appropriateness and prioritization for cataract surgery

PLOS ONE

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Additional Editor Comments:

I recommend that the Authors provide the change requested by Reviewer 2, especially answering the specific questions about Statistics.

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"I have read the journal's policy and the authors of this manuscript have the following competing interests:

Matthew B. Schlenker: honoraria from, and consultant to, Alcon (Fort Worth, TX, USA); honoraria from, and consultant to, Allergan plc (Irvine, CA, USA); consultant to Light Matter Interaction (Toronto, ON, CA); consultant to Santen Pharmaceutical Co, Ltd (Kita-ku, Osaka, Japan); honoraria from Aequus (Vancouver, BC, CA); honoraria from Johnson & Johnson (Jacksonville, FL, USA); honoraria from Thea-Labtician (Oakville, ON, CA).

Saba Samet: no financial disclosures.

Morgan Lim: no financial disclosures.

Chelsea D’Silva: no financial disclosures.

Robert Reid: no financial disclosures.

Iqbal Ike K. Ahmed: speaker’s honoraria and research support from, and consultant to, Abbott Medical Optics (Abbott Park, IL, USA); consultant to Acucela (Seattle, WA, USA); research support from, and consultant to, Aerie Pharmaceuticals (Durham, NC, USA); speaker’s honoraria and research grant support from, and consultant to, Alcon (Fort Worth, TX, USA); speaker’s honoraria and research support from, and consultant to, Allergan plc (Irvine, CA, USA); consultant to ArcScan (Golden, CO, USA); consultant to Bausch and Lomb (Rochester, NY, USA); speaker’s honoraria and research support from, and consultant to, Carl Zeiss Meditec (Jena, Germany); consultant to Centervue (Padova, Italy); consultant to Clarity Medical Systems (Pleasanton, CA, USA); consultant to ElutiMed (New Orleans, LA, USA); consultant to Envisia Therapeutics (Morrisville, NC, USA); consultant to Equinox (Newport Beach, CA, USA); consultant to Eyelight (Funo, Italy); consultant to ForSight Labs (Menlo Park, CA, USA); research support from, and consultant to, Glaukos (San Clemente, CA, USA); consultant to Gore (Newark, DE, USA); consultant to InjectSense (Emeryville, CA, USA); consultant to Iridex (Mountain View, CA, USA); consultant to iStar (Wavre, Belgium); research support from, and consultant to, Ivantis (Irvine, CA, USA); consultant to KeLoTec (Orange County, CA, USA); consultant to LayerBio (Medford, MA, USA); consultant to Leica Microsystems (Wetzlar, Germany); research support from, and consultant to, New World Medical (Rancho Cucamonga, CA, USA); consultant to Omega Ophthalmics (Lexington, KY, USA); consultant to Ono Pharma (Chuo-ku, Osaka, Japan) consultant to PolyActiva (Melbourne, VIC, Australia); consultant to Sanoculis (Kiryat Ono, Israel); consultant to Santen Pharmaceutical Co, Ltd (Kita-ku, Osaka, Japan); consultant to Science Based Health (Spring, TX, USA); consultant to SOLX (Waltham, MA, USA); consultant to Stroma (Irvine, CA, USA); consultant to TrueVision (Santa Barbara, CA, USA)."

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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?

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Reviewer #1: Yes

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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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

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: Patient prioritization refers to strategic management for access to healthcare services based on a decision process that needs to be transparent and fair with reduction of errors in the selection tool. Countries with publicly funded healthcare systems experience prolonged waiting times with potential dramatic consequences. Canada having adopted a socialist type of medicine took the lead in designing priority lists such as the Cataract Priority Criteria Score (PCS), developed by the Western Canada Waiting List (WCWL) Project to determine patient prioritization for cataract surgery (by BL Conner-Spady · 2005). The Steering Committee of the Western Canada Waiting List Project adopted the following Outcome measures: Visual Function Assessment (VFA), EuroQol (EQ-5D), and best-corrected visual acuity. The current group adopted 3 kinds of questionnaires: eCAPS Quality of Life (QoL), Catquest-9SF and EQ-5. eCAPS Quality of Life (QoL), while 313 completed the Catquest-9SF and EQ-5D questionnaires. Also innovatively, they used binary conversions of PROM scales. They found in univariate analysis that Prioritization was associated with low income, 8 clinical criteria, 9 eCAPS, 5 Catquest-9SF, and 1 EQ-5D PROMs. By multivariable regression analysis, 1 clinical criterion (study eye BCVA), 2 eCAPS QoL (night driving difficulty, ability to take care of local errands), and 2 Catquest-9SF PROMs (seeing prices, seeing to walk on uneven ground) were significantly associated. The current study took prioritization to a higher level pending the future use of artificial intelligence. The paper is well written, easy to read despite the complex statistics and the different questionnaires. The authors made the paper appear concise putting the complex tables as supplements.

Reviewer #2: General comments: This observational study examines the association between physician and patient rated preoperative factors and appropriateness and prioritization for cataract surgery in a cohort of 471 patients evaluated for cataract surgery across 7 practices in Canada. The exposures of interest include physician-rated clinical factors related to the cataract based on the eCAPS clinical criteria (e.g. anticipated complexity of surgery, anisometropia, monocular status, etc.), and patient reported measures related to activities of daily living based on the eCAPS QOL and Catquest-9SF questionnaires. The outcomes include physician-rated appropriateness and prioritization for surgery, which were both rated on a scale of 0-10. The authors conclude that certain elements on the eCAPS QOL and Catquest-9SF show concordance with physician-deemed appropriateness and prioritization for cataract surgery. This study examines an interesting subject in anticipation of future resource and workforce limitations for cataract surgery, but several aspects of the study require further analysis and explanation.

Specific comments:

1) Introduction: The foundation of the authors’ justification for doing this study is that there are anticipated scarce resources for cataract surgery and that there will be a need to prioritize patients for surgery. Are there any data for current cataract surgery wait times across different healthcare settings in different countries? How about data on the consequences of delayed surgery?

2) Methods: There are a long list of inclusion and exclusion criteria. Why were patients with multifocal lenses in one eye excluded? Why were patients over age 85 excluded?

3) Methods: What variables were controlled for in the multivariable regression models?

4) Methods/Results: The authors state that physicians rated surgery appropriateness and prioritization on a scale of 0-10. Can more detail be provided regarded this rating system? Was there any standardization of the criteria for each numerical score? Furthermore, the authors decide to use a dichotomous outcome for the appropriateness measure with a binary cutoff of 7/10 for appropriate vs not appropriate. The authors state that this is because the results demonstrated a left skew where most patients were rated either above or below 7. This seems somewhat arbitrary. Were other statistical analyses considered, such as log transformation of the appropriateness score?

5) Methods/Results: The authors analyze a long list of questions from the two patient questionnaires in their regression models. Furthermore, they perform alternative analyses with different categorization of questionnaire responses. Was any consideration given to multiple comparisons? This should be accounted for in statistical analyses and/or discussion of study limitations.

6) Results/Discussion: The one consistent significant result from the patient questionnaires is that there is an association between night driving difficulty and physician-deemed appropriateness and prioritization for surgery. I am not sure how much new information this provides in terms of clinical decision-making for cataract surgery. Are there additional ways to examine the study questionnaire or results to provide a more robust system to stratify patients preoperatively for surgery?

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Reviewer #1: Yes: Ahmad M Mansour

Reviewer #2: No

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Physician and patient concordance in reporting of appropriateness and prioritization for cataract surgery

PONE-D-21-00107R1

Dear Schlenker,

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,

Marie-Helene Errera

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: