Use of hospital care services by chronic patients according to their characteristics and risk levels by adjusted morbidity groups

Jaime Barrio Cortes; María Martínez Cuevas; Almudena Castaño Reguillo; Mariana Bandeira de Oliveira; Miguel Martínez Martín; Carmen Suárez Fernández

doi:10.1371/journal.pone.0262666

Peer Review History

Original SubmissionApril 9, 2021
27 Oct 2021 Decision Letter - Sandra C. Buttigieg, Editor PONE-D-21-11752Use of hospital care services in chronic patients according to their characteristics and risk levels by Adjusted Morbidity Groups.PLOS ONE Dear Dr. Barrio-Cortes, 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 11 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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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [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 Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 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 ****** 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 ****** 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: Thank you for this paper on predicating hospital care utilization in a region in Spain using a AMG grouper. Your paper is well structured and the analysis is presented in full detail. In your abstract I do miss the research gap that is being addressed by you research, why was it relevant to study the relationship between the AMG grouper and hospital care utilization? You do explain this to some degree in the discussion lines 315 through 318. In your introduction you may also consider to add more background information on how the results of your study will be used in addressing the problems that come with greater consumption of healthcare services (line 52-53). My other comments are: 1. I would recommend that you may include more or other literature, many of the studies that are now referred to were performed in Spain or written in Spanish. A suggestion would be to look at relevant studies conducted in the United States, Canada and Australia. 2. Also the role of not just hospital but also care utilization outside of the hospital by patients with chronic conditions should be discussed. You do mention that primary care utilization has been studied by other researchers. Perhaps you could make recommendations on what to do next now that the AMG grouper has been studied in relation to both primary and hospital care. Again the policy and/or clinical relevance of your findings are not directly clear from the paper. 3. I miss the reporting of missing data, was there missing data in your dataset. If yes, how was this handled? 4. To what degree are your results generalizable to other regions in Spain or other countries in Europe? From your discussion I understand the Ministry of Health in Spain may use your findings to apply national policies, however data are now derived from one single area in Madrid. 5. Did you consider not only calculating contacts per risk group but also the estimated costs of each contact? If it would be the aim of the Ministry of health to look at interventions to reduce or redistribute spending among risk groups? It would be helpful for the reader to have an better understanding what the ‘chronic patient treatment and related interventions’ mentioned in line 318 are precisely? 6. Furthermore please also consider to specify what ‘more studies’ in line 318 would be necessary to ‘clarify this matter’ in line 317-318, what do you mean exactly? Reviewer #2: A very interesting paper and rigorously managed study. A very pertinent subject. Mostly well written. However, the writing style started to deteriorate along the way and needs to be thoroughly reviewed and edited especially from the Discussion onwards to improve its readability and flow. ****** 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 [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.0262666.r001
Revision 1
23 Nov 2021 Author Response Academic Editor: Thank you very much for the Academic Editor comments. We have made the minor essential revisions your reviewers suggested us and we have submitted the items required (Response to Reviewers, Revised Manuscript with Track Changes and Manuscript) into the PLOS ONE Editorial Manager Platform. In case you need anything more please let us know. Best regards, Reviewer #1: - Thank you for this paper on predicating hospital care utilization in a region in Spain using a AMG grouper. Your paper is well structured and the analysis is presented in full detail. In your abstract I do miss the research gap that is being addressed by you research, why was it relevant to study the relationship between the AMG grouper and hospital care utilization? You do explain this to some degree in the discussion lines 315 through 318. We would like to thank the reviewer #1 for his/her comments. We are pleased that he/she thinks the paper is well structured and the analysis is presented in full detail. We have included in the abstract more information to fill the research gap about why this study was relevant to study the relationship between the AMG grouper and hospital care utilization: “Adjusted morbidity groups (AMG) is a population stratification tool which is currently being used in Primary Care but not in Hospitals”. - In your introduction you may also consider to add more background information on how the results of your study will be used in addressing the problems that come with greater consumption of healthcare services (line 52-53). Thank very much for the suggestion. We have added in our introduction more background information on how the results of our study will be used in addressing the problems that come with greater consumption of healthcare services: “This study could help to prove this grouper is adequate to be used in the Hospital for stratifying the chronic patients at different risk levels to individualize their care and to improve the use efficiency of available resources”. - My other comments are: 1. I would recommend that you may include more or other literature, many of the studies that are now referred to were performed in Spain or written in Spanish. A suggestion would be to look at relevant studies conducted in the United States, Canada and Australia. Thank very much for the recommendation. Following the reviewer #1 suggestion we have erased studies performed in Spain or written in Spanish and we have added more references in order to show relevant studies written in English and performed in Europe[1–7], the United States[1,2,8–12], Canada[1,2,13,14] and Australia [1,2,15]. 2. Also the role of not just hospital but also care utilization outside of the hospital by patients with chronic conditions should be discussed. You do mention that primary care utilization has been studied by other researchers. Perhaps you could make recommendations on what to do next now that the AMG grouper has been studied in relation to both primary and hospital care. Again the policy and/or clinical relevance of your findings are not directly clear from the paper. We would like to thank the reviewer #1 for his/her comments. We have discussed the role of not just hospital but also care utilization outside of the hospital by patients with chronic condition taking in consideration primary care utilization that has been studied by other researchers. Besides, we have made some recommendations on what to do next now that the AMG grouper has been studied in relation to both primary and hospital care in the discussion section. We have tried to clarify policy and/or clinical relevance of our findings by stating in the discussion that “Hospital health professionals could benefit with this stratification of the chronic population at different risk levels based on AMG to offer a more individualized, coordinated and specific care and to improve the use efficiency of available resources. The utilization of AMG in Hospital settings would facilitate the coordination between the two main levels of care, a priority in chronic patients, as a means of achieving continuity of care, reducing costs and improving the quality of care”. 3. I miss the reporting of missing data, was there missing data in your dataset. If yes, how was this handled? No, there was no missing data in our dataset so there was no need to handle this matter. 4. To what degree are your results generalizable to other regions in Spain or other countries in Europe? From your discussion I understand the Ministry of Health in Spain may use your findings to apply national policies, however data are now derived from one single area in Madrid. The “Report of the Stratification of the Population by adjusted morbidity groups project in the National Health System” listed in the Introduction section of the manuscript [16]” provides some results regarding the use of AMG in Primary Care Settings, which proves our results could be generalizable to other regions in Spain because similar results in different regions of Spain are shown. We have included this reference again in the discussion section and we have stated: “this grouper has been developed and studied in different regions in Primary Care settings in Spain” [16]. In order to show it could be generalizable to other countries in Europe we have remarked in the discussion that: “AMG and its implementation by the Ministry of Health in the different regions of Spain, has recently been selected by the WHO European Region as an example of good practice in the management of chronic patients by the health system so it could also be used in other European regions as well[16]. We apologized if in the discussion it has been misunderstood that the Ministry of Health in Spain may use our findings to apply national policies. As the reviewer wisely stated, data are derived from one single area in Madrid so it´s not enough to apply national policies based only on this data. This is why we recommend that more studies focused in AMG in Hospital Care should be made to add more information regarding this matter, because this grouper has been only developed and studied in different regions in Primary Care settings in Spain. 5. Did you consider not only calculating contacts per risk group but also the estimated costs of each contact? If it would be the aim of the Ministry of health to look at interventions to reduce or redistribute spending among risk groups? It would be helpful for the reader to have an better understanding what the ‘chronic patient treatment and related interventions’ mentioned in line 318 are precisely? No, we didn´t consider the estimated costs of each contact because we only had access to the number of contacts per risk group per year with no possibility to estimate the costs of these contacts. However, to address this matter, we have added in the discussion that “It is estimated that 80% of the interventions performed in hospitals are directly related to chronicity, which also generates 77% percent of health expenditure. This is not an isolated event, it is a generalized problem and a rising challenge because two out of three deaths are directly related to these types of conditions” [17]. The Health Ministry take in account very seriously the number of interventions to reduce or redistribute spending among risk groups. The Project "Stratification of the Population of the SNS" is framed within the Strategy for Addressing Chronicity in the National Health Service, with the aim of providing a technological tool like AMG that allows the identification of population subgroups with different levels of need and risk, which can facilitate the provision of specific interventions to each need for chronic care, so that health care is adequate and efficient and the continuity of care is guaranteed. The “chronic patient treatment and related interventions” mentioned are specified with more detailed in the the strategies for addressing patients with chronic diseases in the different regions of Spain. In order to help the reader to have a better understanding, we have created a Supplementary S1 Figure in which appears all the health professionals, health tools and health services that the chronic patients ideally would need according to their risk levels. This is based on the Kaiser Pyramid care model and it is already explained in the introduction section: • Low-risk patients are patients with chronic conditions that are still in incipient stages. The goal for this level is to slow the progression of the disease and prevent the patient from reaching higher levels of risk. To this end, the self-management of the disease and the education of a preventive nature and healthy habits are supported and to avoid healthcare utilization. • Medium-risk patients are patients who present chronic conditions that need a more disease-based approach. The goal, as at the intermediate level, is to slow progression by planning and managing the disease that combines self-management and professional care. • High-risk patients are highly complex patients, with multimorbidity and a multidisciplinary care approach with an increase healthcare services utilization. The objective at this level is to reduce flare-ups and hospital admissions through comprehensive case management, with mainly professional care. 6. Furthermore please also consider to specify what ‘more studies’ in line 318 would be necessary to ‘clarify this matter’ in line 317-318, what do you mean exactly? Thank you very much for this comment. In that sentence we exactly mean that as this grouper has been only developed and studied in the Primary Care Settings, it is necessary more research like ours to have more evidence regarding the usefulness and applicability of AMG in Hospital Care. We have clarified this sentence in the discussion adding the sentence: “because this grouper has been only developed and studied in the Primary Care Settings”. Reviewer #2: - A very interesting paper and rigorously managed study. A very pertinent subject. Mostly well written. However, the writing style started to deteriorate along the way and needs to be thoroughly reviewed and edited especially from the Discussion onwards to improve its readability and flow. We would like to thank the reviewer #2 for his/her comments. We are pleased that he/she thinks the paper is interesting and rigorously managed and with a very pertinent subject. As we are not native speakers, to improve the writing style, we have sent the paper again to America Journal Experts (AJE) to be thoroughly reviewed and edited especially from the Discussion onwards to improve its readability and flow. Also, we have tried to simplify some sentences to make it easier to understand and to facilitate its reading. The changes we have made and the ones suggested by the editors from AJE are remarked in the tracked changes version along the manuscript. We have attached the new AJE Editorial Certificate for English language, grammar, punctuation, spelling and overall style by highly qualified native English-speaking editors. References 1. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev. 2011;10: 430–439. doi:10.1016/j.arr.2011.03.003 2. Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of Multimorbidity and Morbidity Burden for Use in Primary Care and Community Settings: A Systematic Review and Guide. Ann Fam Med. 2012;10: 134–141. doi:10.1370/afm.1363 3. Glynn LG, Valderas JM, Healy P, Burke E, Newell J, Gillespie P, et al. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract. 2011;28: 516–523. doi:10.1093/fampra/cmr013 4. Brilleman SL, Salisbury C. Comparing measures of multimorbidity to predict outcomes in primary care: A cross sectional study. Fam Pract. 2013;30. doi:10.1093/fampra/cms060 5. Sullivan CO, Omar RZ, Ambler G, Majeed A. Case-mix and variation in specialist referrals in general practice. Br J Gen Pract. 2005;55: 529–33. Available: http://www.ncbi.nlm.nih.gov/pubmed/16004738 6. Prinsze FJ, Van Vliet RCJA. Health-based risk adjustment: Improving the pharmacy-based cost group model by adding diagnostic cost groups. Inquiry. 2007;44: 469–480. doi:10.5034/inquiryjrnl_44.4.469 7. Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ. 2017;356: j84. doi:10.1136/bmj.j84 8. United States Census Bureau. Projections of the Population by Sex and Selected Age Groups for the United States: 2015 to 2060. [cited 2021 November 20]. Available: https://www.census.gov/data/tables/2014/demo/popproj/2014-summary-tables.html.. 9. Adams EK, Bronstein JM, Raskind-Hood C. Adjusted clinical groups: predictive accuracy for Medicaid enrollees in three states. Health Care Financ Rev. 2002;24: 43–61. Available: http://www.ncbi.nlm.nih.gov/pubmed/12545598 10. Winkelman R, Mehmud S. A Comparative Analysis of Claims-Based Tools for Health Risk Assessment. Schaumburg; 2007. 11. Dueñas-Espín I, Vela E, Pauws S, Bescos C, Cano I, Cleries M, et al. Proposals for enhanced health risk assessment and stratification in an integrated care scenario. BMJ Open. 2016;6: e010301. doi:10.1136/bmjopen-2015-010301 12. Shelton P, Sager MA, Schraeder C. The community assessment risk screen (CARS): identifying elderly persons at risk for hospitalization or emergency department visit. Am J Manag Care. 2000;6: 925–933. Available: http://www.ncbi.nlm.nih.gov/pubmed/11186504 13. Street M, Berry D, Considine J. Frequent use of emergency departments by older people: a comparative cohort study of characteristics and outcomes. Int J Qual Heal Care. 2018;30: 624–629. doi:10.1093/intqhc/mzy062 14. Nicholson K, Terry AL, Fortin M, Williamson T, Bauer M, Thind A. Prevalence, characteristics, and patterns of patients with multimorbidity in primary care: a retrospective cohort analysis in Canada. Br J Gen Pract. 2019;69: e647–e656. doi:10.3399/bjgp19X704657 15. Harrison C, Henderson J, Miller G, Britt H. The prevalence of diagnosed chronic conditions and multimorbidity in Australia: A method for estimating population prevalence from general practice patient encounter data. Ramagopalan S V., editor. PLoS One. 2017;12: e0172935. doi:10.1371/journal.pone.0172935 16. Ministerio de Sanidad, Servicios Sociales e Igualdad. Informe del proyecto de estratificación de la población por grupos de morbilidad ajustados (GMA) en el Sistema Nacional de Salud (2014-2016). [Internet]. 2018 [cited 2021 March 26]. Available from: https://www.mscbs.gob.es/biblioPublic/publicaciones/recursos_propios/resp/revista_cdrom/VOL94/ORIGINALES/RS94C_202007079.pdf 17. Bengoa R. Empantanados. Rev Innov Sanit y Atención Integr. 2008;1: 1–7. Available: http://pub.bsalut.net/risai/vol1/8 Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0262666.r002
3 Jan 2022 Decision Letter - Sandra C. Buttigieg, Editor Use of hospital care services by chronic patients according to their characteristics and risk levels by adjusted morbidity groups. PONE-D-21-11752R1 Dear Dr. Barrio-Cortes, 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. 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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) ******** 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: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: (No Response) ****** 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: (No Response) ****** 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: (No Response) ****** 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: Thank you for adressing all of my remarks in your revised manuscript. Adding more information on the study's clinical and/orpolicy implications and adding figure 1 has clearified the paper. I think the paper can be accepted for publication in its' current form. Reviewer #2: Thanks you for the revision. In my view you answered and/or addressed all recommendations submitted by the 2 reviewers ****** 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 https://doi.org/10.1371/journal.pone.0262666.r003
Formally Accepted
25 Jan 2022 Acceptance Letter - Sandra C. Buttigieg, Editor PONE-D-21-11752R1 Use of hospital care services by chronic patients according to their characteristics and risk levels by adjusted morbidity groups. Dear Dr. Barrio Cortes: 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 Professor Sandra C. Buttigieg Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0262666.r004

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