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PONE-D-21-26799Disparities by Race and Insurance-Status in Declines in Pediatric ED Utilization During the COVID-19 Pandemic.PLOS ONE

Dear Dr. Sen,

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 Nov 08 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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We look forward to receiving your revised manuscript.

Kind regards,

Jingjing Qian

Academic Editor

PLOS ONE

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 [The authors were partially supported through an internal grant by the School of Public Health, University of Alabama at Birmingham. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.]

  

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[The authors were partially supported through an internal grant by the School of Public Health, University of Alabama at Birmingham. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.]. 

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: Yes

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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: No

Reviewer #2: 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

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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: This study evaluates the trends in pediatric emergency department visits in 2019 and 2020 (during the COVID-19 pandemic). The authors evaluate these trends in subgroups based on race, ethnicity, and insurance status. In addition, the study addresses an important topic given the well-known racial disparities further revealed by COVID, especially in the southern United States. Some issues with the methods and results reporting need to be clarified/addressed. Please see below for more specific comments by section:

Introduction:

• More references are needed to support a few of the statements made in the introduction.

o The 4th sentence ending in “…higher rates of ED use compared to the rest of the nation pre-pandemic” needs more support.

o Additionally, the penultimate sentence in that section needs more detail regarding vaccination rates and disparities specific to the region, perhaps as it compares to the Northeastern states mentioned earlier.

Methods:

• Study site: Please provide some more detail about the study site including annual patient volume, tertiary/teaching, etc. to help the audience draw conclusions regarding generalizability of the results.

• Study dates: I suspect the study periods were chosen to compare pre- and peri-pandemic data in a full 12 month period, however, please clarify rationale for selecting these dates.

• While the variables provided are laid out clearly, some more detail is necessary to develop a better picture of the dataset. If available, some more demographic data would be helpful to compare the 2019 and 2020 groups, specifically age.

• Please clarify further the 5-point acuity scale – is this ESI?

• Smoothing: Please provide some references for rationale.

Results:

• Throughout this section, please specify the years for each month mentioned for consistency and clarification.

• Consider combining the third and fourth paragraphs of this section to better incorporate the numbers (paragraph 4) alongside the text (paragraph 3).

• Table 1 – Clearly presented overall. Please provide the raw numbers alongside the percentages.

• Figure 1 – Please include the years on each graph. Per the title of the figure, the figures are comparing 2020 and 2019, but this should be clarified with labels.

• Table 2 – Very important table! Please clarify dates in the first column (All 12 months, up to March 13, after March 13) with years and specific time periods (e.g. January 1, 2020-December 31, 2020; January 1, 2020 – March 13, 2020; March 14, 2020-December 31, 2020). Additionally, please report 95% confidence intervals in this table. Worth highlighting this in the text (including abstract).

Discussion:

• The discussion here is interesting and keeps with the paper’s focus. The authors have done a good job addressing all the major points. However, parts of the discussion would benefit from some more detail and support from the literature.

• The following statements should be discussed in more detail and/or supported with findings from the literature:

o The first sentence in the discussion – “Growing literature has documented declines…” – please cite the literature here.

o Supplementary Figure 1 by Adjemian et al. was not included in the document.

o Please expand on inability to document specific health conditions. As the authors mention, this is an important limitation.

o The sentence – “…since Alabama shares several socio-demographic and economic characteristics with other Deep South states” – please support this statement as well.

Additionally, there are some minor grammatical and typographic errors (i.e. U.S. instead of United States on first use in the introduction) – please check for these throughout the document.

Reviewer #2: The authors set out to explore the differences in the utilization of the ED at a major pediatric emergency department in Alabama during the Covid-19 pandemic based on racial and socioeconomic factors. The authors found a significantly larger decline in ED utilization by the African-American and publicly insured or self-insured patients in comparison to non-Hispanic white and privately insured patients, respectively. These findings inform the reader of the further worsening of healthcare disparities in the pandemic environment and suggest an exacerbation of unmet healthcare needs of vulnerable populations.

1. Parts of the manuscript are somewhat difficult to read. I recommend reviewing the revised manuscript for grammar and syntax errors.

2. It appears that the authors chose to group publicly- and self-insured patients together. What was the breakdown of those groups? Are those populations truly comparable enough to be considered together?

3. The age range of the patients was not defined. Was there a difference among groups? This could be another variable relevant for analysis.

4. Was there an overlap in the two sets of groups (AA and NHW and between PUBLIC-SELF and

PRIVATE)? In other words, for instance, was there a difference in the AA + PUBLIC-SELF and AA + PRIVATE? Is possible that the difference is more related to the race or the insurance status?

5. Results Section, paragraph 2, last sentence: the statement is somewhat ambiguous, as it appears to imply that the groups were combined (AA and PUBLIC vs. NHW and PRIVATE)

6. Page 7, Discussion, sentence starting with: While this paper’s findings of steep declines… is unclear the way it is written.

7. The authors make a great point discussing the lower rates of utilization of telemedicine among African American and low income children. However, is there any data on urgent care use? Is it possible that the people were more likely to take their children to urgent care facilities due to shorter lines and more predictable wait times, especially for low-severity visits?

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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: No

Reviewer #2: No

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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.

PONE-D-21-26799R1Disparities by Race and Insurance-Status in Declines in Pediatric ED Utilization During the COVID-19 Pandemic.PLOS ONE

Dear Dr. Sen,

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 30 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: https://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,

Jingjing Qian

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:

Thanks the authors for addressing most of the reviewers' comments. In the next revision, please:

1) edit text to clarify the comparisons between AA and NHW, and between Public-self and Private throughout to avoid any confusions as suggested by Reviewer 2. For example, the last sentence in the 2nd paragraph of the Results section, "Percentage declines were consistently larger for AA and PUBLIC-SELF than NHW and PRIVATE." This is confusing and you did not revise as suggested by Reviewer 2. This is one example but please read the entire manuscript to improve clarify of writing.

2) the author's response to Reviewer 2's question regarding the overlap between AA+Public-self and AA+Private is not convincing. Please provide results for the direct comparison between these 2 subgroups in table and in text.

3) please giving the manuscript another read through for grammar and syntax prior to final submission as suggested by Reviewer 1.

[Note: HTML markup is below. Please do not edit.]

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

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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

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

Reviewer #1: (No Response)

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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

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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

**********

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 addressed the initial concerns. I would recommend giving the manuscript another read through for grammar and syntax prior to final submission.

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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

[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.

Disparities by Race and Insurance-Status in Declines in Pediatric ED Utilization During the COVID-19 Pandemic.

PONE-D-21-26799R2

Dear Dr. Sen,

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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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,

Jingjing Qian

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you!

Reviewers' comments: