PONE-D-21-06391

Predicting hospital readmission risk: A prospective observational study to compare primary care providers’ assessments with the LACE readmission risk index

PLOS ONE

Dear Dr. Walji,

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The manuscript has been evaluated by three reviewers, and their comments are available below.

All reviewers recommend greater clarity in the reporting of this manuscript, both in the Methods section and Results. Specifically, the reviewers note the need for greater detail and quantification of the primary tool used in the study, as well as additional analyses.

Could you please carefully revise the manuscript to address all comments raised?

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PLOS ONE

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“I have read the journal's policy and the authors of this manuscript have the following competing interests: Dr. Bell is a medical consultant to the Ontario Ministry of Health. The other authors have no competing interests to declare”

.We note that one or more of the authors are employed by a commercial company: Ontario Ministry of Health

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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: Partly

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: No

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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: No

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: The article is well written and addresses one of many challenges with hospital medicine - the rate of readmission to the hospital within 30 days of discharge and how to best predict patients who are at higher risk of readmission. This would allow high risk patients to received additional attention with the goal of preventing avoidable hospital readmissions.

Abstract well structured and clear. Reflects the content of the article.

Background - Sufficiently broad and up to date, discusses limitations and utility of current prediction systems (LACE) and frames the research question clearly.

Methods - Clearly presented, ethical approval documented. Statistics are conventional and are without controversy.

Some clarity would be useful - are the patients from one hospital or for the entire province of Ontario? Some basic information like size of hospital and location (100 beds, rural area in the Province of Ontario) or if the entire province some information about the number of hospitals and the population in the service area. Also, would be useful to document if hospital admissions at different hospitals within Ontario or in other provinces would be detected.

Results - Clearly presented and well organized. Tables are clear.

Discussion - Discuss readmission detection as mentioned in the methods section - this may be a strength or a limitation for this study. Results framed in context of other knowledge about readmission prediction.

Conclusions - Not overstated or generalized. Reasonable given methods and results.

Reviewer #2: This is an interesting study comparing the use of a PCP clinical assessment of readmission risk in comparison to a previously validated tool (the LACE index). The results if this study could be used to identify pragmatic tools in defining high risk patients for readmission.

I have the following recommendations to make:

1. My biggest concern in this study is the ambiguity of the PCP assessment. The authors describe what seems to be a qualitative tool in evaluating readmission, but the analysis made was purely quantitative. I suggest further quantifying the PCP assessment tool by showing methodically how PCPs evaluated the risk. In addition, the survey used by PCP should be included in the study and described in detail. Alternatively, I suggest using qualitative research tools to better define the PCP judgment.

2. Authors are asked to clarify if patients enrolled in the study were formally evaluated in the clinic by PCP and/or performed chart check only. Also, authors are asked to provide demographic baseline data of the patient population enrolled to enhance the generalizability of the results.

3. The sensitivity and specificity analysis in the study was calculated by summing the low and medium risk groups into one group. Authors are asked to clarify the reason of doing that as it may overestimate the specificity of the results.

4. Sampling methodology in the study is unclear. Did the authors include all the charts in the registry during the study period? If not please describe how sampling was done?

5. In the discussion section the authors confusedly referencing that 31 PCPs were included in the study. Please correct to 21 PCPs and consider omitting the number of patients in the registry (as only a sample was used).

6. Authors need to report the multivariate regression results assessing the relationship between LACE and PCP assessment. Consider including more variables known to increase risk of readmission, if available (polypharmacy, types of comorbidities…etc.).

Reviewer #3: The authors of this study do a great job of comparing the LACE tool to a physicians assessment. The findings of this study have implications for everyday practice and thus, this paper stands to be highly cited in the future. I just have a few minor concerns:

First, the results section of the abstract should contain the number of patients and years of the study. This will help facilitate future systematic reviews that include this paper.

Second, the ROC AUC comparisons, should contain a p-value. Many statistical software applications, such as MedCalc and Stata, make this value readily available. Even if the difference between the AUCs are statistically insignificant, this will still help interpret the findings of the study.

Finally, it may be beneficial to clearly state in the discussion or conclusions, the implications on future practice. For example, if the authors feel that incorporating the LACE score into the electronic medical record will save (or cost) the clinicians time, this should be clearly stated in the discussion or conclusions.

Thank you for the opportunity to review this important study.

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Reviewer #1: No

Reviewer #2: Yes: Tamer Hudali, MD, MPH, FACP

Reviewer #3: Yes: Joshua Parreco

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Predicting hospital readmission risk: A prospective observational study to compare primary care providers’ assessments with the LACE readmission risk index

PONE-D-21-06391R1

Dear Dr. Walji,

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,

Tamer Hudali

Guest Editor

PLOS ONE

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