Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: A large observational study using electronic health record data

Sanne E. W. Vrijlandt; Daan Nieboer; Joany M. Zachariasse; Rianne Oostenbrink

doi:10.1371/journal.pone.0262432

Peer Review History

Original SubmissionJune 22, 2021
20 Oct 2021 Decision Letter - Biswadev Mitra, Editor PONE-D-21-20440Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: a large observational study using electronic health record data.PLOS ONE Dear Dr. Oostenbrink, 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 Dec 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. 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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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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: Dear authors, This is an important topic for research and incorporates a population that has not been researched frequently. The methodology is well-explained and the results are easy to follow. I have some minor comments only: Introduction 1. Best not to assume that patients with FV have unfulfilled medical needs. Please consider re-phrasing this sentence. 2. Last sentence, "Which provides..." is not grammatically correct. Results 3. There are many patients under the category of "other" in FV. Is it possible to provide a more detailed description of this subgroup? 4. Ln 266. Please reword "..you may conclude.." to we may or it can be concluded 5. Under risk factors, best not to present any interpretation of results here. 6. Under conclusions, I am not convinced that this study ahs indicated re-structuring of pathways. Suggest deleting it from the conclusion or re-wording [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know ****** 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: No ****** 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: No ****** 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: This study analyses data from a hospital centre serving a large urban population in order to characterise the factors most likely to be associated with frequent ED attendance. The tertiary care provision is for a larger area. One of the strengths is its analyses by person and by visit type. The categorisation of conditions uses a number of other study methods which gives some consistency across similar studies. The data was incomplete in a round 15% of cases and it would be useful to know if there were any systematic biases noted ( age, severity etc. compared to the included group). I would want a statistics expert to comment on the choice of tests used and their appropriateness. 36% of the visits classified as frequent attenders were in the non-urgent category and a cross tabulation against complexity would aid interpretation as other studies of large hospital populations have shown this to be possibly related to access and other demographic issues ( ethnicity, residency location etc) . It would strengthen the conclusion made that "frequent visits were not less severe than compared to non FVs" There were a number of grammatical errors which I list below :- Suggest L99 changed to read "As FVs have some sort of unfulfilled medical or social need , insight...." L149 replace "diagnose" with "diagnosis" L209 replace "allows" with "allowing us" L290 replace "hazard" with "risk" similarly on line 307 L351 replace with phrase "have expected from a clinical perspective." L352 replace " is" with "are" L353 replace "relates" with "relate" L376 suggest rephrasing This study suggest that there may be a case for restructuring health care pathways for children with co-morbidities in order to optimise patient flows....." L379 rephrase "...…contributing to supporting parents and redirecting some patients from the ED" ****** 6. 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: Yes:** Professor Mitch Blair [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. https://doi.org/10.1371/journal.pone.0262432.r001
Revision 1
17 Dec 2021 Author Response Editor’s comments: Comment 1. Best not to assume that patients with FV have unfulfilled medical needs. Please consider re-phrasing this sentence. Answer 1. Thank you for this suggestion, we have adjusted this sentence (Line 105). ‘’..as it might be possible to fulfill their medical needs in other healthcare pathways.’’ Comment 2. Last sentence, "Which provides..." is not grammatically correct. Answer 2. We have re-phrased this sentence (Line 119). ‘’This contributes to …’’ Comment 3. There are many patients under the category of "other" in FV. Is it possible to provide a more detailed description of this subgroup? Answer 3. We had chosen to group the smallest groups into a category ‘others’, in order to avoid the table being too long. However, we have now adjusted the table (table 1 page 9) to show all categories. Comment 4. Ln 266. Please reword "..you may conclude.." to we may or it can be concluded Answer 4. We have changed this (Line 275) to ‘’..it can be concluded..’’. Comment 5. Under risk factors, best not to present any interpretation of results here. Answer 5. The sentence was intended to guide the reader how to understand the meaning of the figures rather than to reflect the interpretation of the authors, we have re-phrased the sentence slightly and removed the term ‘interpreted” (Line 301) ‘’A HR of 1.17 means…’’. However, when the editor considers it redundance we can leave it out. Comment 6. Under conclusions, I am not convinced that this study has indicated re-structuring of pathways. Suggest deleting it from the conclusion or re-wording Answer 6. We understand that the editor raises this issue and we have therefor re-worded this sentence (Line 388) ‘’Identified risk factors…’’. Accordingly, we also changed the conclusion in the abstract (line 49) ‘’Healthcare pathways, including…”. Reviewer’s comments: Comment 1. The data was incomplete in a round 15% of cases and it would be useful to know if there were any systematic biases noted ( age, severity etc. compared to the included group). I would want a statistics expert to comment on the choice of tests used and their appropriateness. Answer 1. We understand this concern, and indeed, we had missings for some variables, however as shown in table 2 distribution of missing was similar among frequent visits and non-frequents visits (our outcome). In the final model only two variables with missings were included, although these missings were multiple imputed to make all data available for analysis. As we assumed the comment of the statistics experts of choice of tests was related to this remark, we added in the manuscript a reference on dealing with missings (methods section page 7, Line 197, ref 24 and 25). A statistician was involved in the analyses and has co-authored this paper, and reviewed the reviewer’s comments and the revised version (author D. Nieboer). Comment 2. 36% of the visits classified as frequent attenders were in the non-urgent category and a cross tabulation against complexity would aid interpretation as other studies of large hospital populations have shown this to be possibly related to access and other demographic issues (ethnicity, residency location etc). It would strengthen the conclusion made that "frequent visits were not less severe than compared to non FVs". Answer 2. We do not fully understand whether you would like a cross tabulation of comorbidity complexity or urgency severity against triage category. We assume you mean severity instead of (comorbidity) complexity and cross tabulated this against triage category for frequent visits as well as for non-frequent visits. This showed no difference between the frequent visits and non-frequent visits (supplemental data file 1). However, we have changed the sentence to the actual data (Line 362) ‘’not less often triaged as…’’. Comment 3 There were a number of grammatical errors which I list below : Suggest L99 changed to read "As FVs have some sort of unfulfilled medical or social need , insight....", L149 replace "diagnose" with "diagnosis", L209 replace "allows" with "allowing us", L290 replace "hazard" with "risk" similarly on line 307, L351 replace with phrase "have expected from a clinical perspective.", L352 replace " is" with "are", L353 replace "relates" with "relate", L376 suggest rephrasing This study suggest that there may be a case for restructuring health care pathways for children with co-morbidities in order to optimise patient flows.....", L379 rephrase "...…contributing to supporting parents and redirecting some patients from the ED" Answer 3. Thank you for the suggestions we have corrected the grammatical errors. We only preferred to keep the term “hazard” (Line 302 and 304) in the results section, to stay with the proper meaning of the used analysis, although it can be used as ‘risk’ in a more interpretative way, as used in the discussion (line 319). However, if the editor or reviewer consider these terms interchangeable, we are happy to change this. https://doi.org/10.1371/journal.pone.0262432.r002
23 Dec 2021 Decision Letter - Biswadev Mitra, Editor Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: a large observational study using electronic health record data. PONE-D-21-20440R1 Dear Dr. Oostenbrink, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Biswadev Mitra, MBBS, MHSM, PhD, FACEM Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0262432.r003
Formally Accepted
6 Jan 2022 Acceptance Letter - Biswadev Mitra, Editor PONE-D-21-20440R1 Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: a large observational study using electronic health record data. Dear Dr. Oostenbrink: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Prof. Biswadev Mitra Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0262432.r004

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