The economic burden of low back pain in KwaZulu-Natal, South Africa: A prevalence-based cost-of-illness analysis from the healthcare provider’s perspective

Morris Kahere; Cebisile Ngcamphalala; Ellinor Östensson; Themba Ginindza

doi:10.1371/journal.pone.0263204

Peer Review History

Original SubmissionJanuary 12, 2022
30 Jun 2022 Decision Letter - Steve Zimmerman, Editor PONE-D-22-00974 The economic burden of low back pain in KwaZulu-Natal, South Africa: a prevalence-based cost-of-illness analysis from the healthcare provider’s perspective. PLOS ONE Dear Dr. Kahere, 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 note that we have only been able to secure a single reviewer to assess your manuscript. We are issuing a decision on your manuscript at this point to prevent further delays in the evaluation of your manuscript. Please be aware that the editor who handles your revised manuscript might find it necessary to invite additional reviewers to assess this work once the revised manuscript is submitted. However, we will aim to proceed on the basis of this single review if possible. Please submit your revised manuscript by Aug 13 2022 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, Steve Zimmerman, PhD Associate Editor, PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. 2. Please amend your current ethics statement to address the following concerns: a) Did participants provide their written or verbal informed consent to participate in this study? b) If consent was verbal, please explain i) why written consent was not obtained, ii) how you documented participant consent, and iii) whether the ethics committees/IRB approved this consent procedure. 3. Thank you for stating the following in the Acknowledgments Section of your manuscript: “The authors would like to thank the University of KwaZulu-Natal (UKZN) for the provision of resources towards this project and the UKZN CHS Scholarship that was awarded to facilitate the research running costs.” We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: “This study was funded by the University of KwaZulu-Natal College of Health Sciences (CHS Scholarship). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. 4. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide. 5. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. 6. Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF. 7. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate ""supporting information"" files. 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: Please change "females” or "males" to "women” or "men" as appropriate, when used as a noun (see for instance https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/gender)." [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: 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 ****** 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 is an interesting paper on the cost of LBP in a low income country. It is largely well written but does need a grammar and spell check. Specific comments are: Abstract 1. Background: It may be better not to include production since this isn’t covered in the paper. 2. Results: Acronyms need to be defined at first use and used consistently - ALBP and CLBP Background 3. P4 line 81: why is the pooled lifetime estimate lower than the 12 months estimate, shouldn’t it be the other way around? 4. Were there no prior South African studies or studies from other African countries to mention in the introduction? 5. Last paragraph: This should state what this study adds over prior studies. Line 279 page 11 in the discussion says this is the first study to estimate cost of LBP in South Africa. If so this should be stated in the last paragraph of the introduction. Methods 6. P7 line 159 antidepressants are often used primarily to treat pain (often at a lower dose than for depression). Anticonvulsants are also commonly used in this way. 7. P 7 line 164 Were invasive procedures only in an emergency? Commonly surgery is recommended for chronic back pain but without an emergency situation or attendance at a hospital emergency department. 8. P 8 A paragraph at the end is needed to state ethics approval and software (and version) used to undertake the analysis (even if it is simply a spreadsheet such as Excel). Results 9. P 9 line 227 The similar cost of ALBP and CLBP is worth mentioning in the discussion as in the introduction CLBP was significantly greater in the studies cited. It would be helpful to explain why the results of this study are different – for example if outpatient services are not easily accessible or are costly for the patient Discussion 10. P10 lines 243 to 257 For each point, there needs to be a statement about what this current study found and how it compares with other studies. The differences with what is found in this study also need to be stated (e.g. ALBP and CLBP being similar is quite different to other studies that found expenditure on CLBP to be much greater than for ALBP). 11. P10 line 264: What were the differences in health care service delivery and study methodologies? 12. Line 279 page 11 in the discussion says this is the first study to estimate costs of LBP in South Africa. However lines 243-244 refers to several other studies of the economic burden on LBP in South Africa. This seems contradictory. Grammatical/spelling errors A grammar and spell check is needed. There are quite a few grammatical/spelling errors with a few examples being: P 4 line 74 “Prevalence and incidence estimate” should be “The prevalence and incidence estimates” p4 line 84 “…get completely healed” should be something like “do not make a full recovery” P5 line 93 “lasted” should be “lasting” P5 Line 110 “decision should be decisions” P5 Line 111 ”hospital” should be ”hospitals” P11 line 269 “All cases report at the outpatient ….” should this be “All cases report at the outpatient department…”? ****** 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: Deborah Schofield ******** [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.0263204.r001
Revision 1
16 Aug 2022 Author Response RESPONSE TO EDITORS’ COMMENTS Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. Response: we have addressed all formatting requirements, see the manuscript cover page 2. Please amend your current ethics statement to address the following concerns: a) Did participants provide their written or verbal informed consent to participate in this study? b) If consent was verbal, please explain i) why written consent was not obtained, ii) how you documented participant consent, and iii) whether the ethics committees/IRB approved this consent procedure. Response: This study was hospital chart review. There was no human participation, therefore no consent was required from participants. Authorisation to access the records was sought by means of gatekeeper permissions from participating hospitals. 3. Thank you for stating the following in the Acknowledgments Section of your manuscript: “The authors would like to thank the University of KwaZulu-Natal (UKZN) for the provision of resources towards this project and the UKZN CHS Scholarship that was awarded to facilitate the research running costs.” Response: All funding statements have been removed from the manuscript as suggested by the editor. We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: “This study was funded by the University of KwaZulu-Natal College of Health Sciences (CHS Scholarship). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” Response: we have removed all the funding statements from the manuscript Please include your amended statements within your cover letter; we will change the online submission form on your behalf. 4. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide. Response: We have amended that statement, to state that, data for this manuscript is not available in any published paper/article, but raw data can be accessed upon signing of disclosure agreements between the interested parties and the university of KwaZulu-Natal. 5. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. Response: We have moved the ethics statement up to the methods section and have deleted it from the declaration section. 6. Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF. Response: We have removed all figures from the manuscript and have uploaded them as separate files. Additional Editor Comments: Please change "females” or "males" to "women” or "men" as appropriate, when used as a noun (see for instance https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/gender)." Response: We have changed “females” to “women” and “males” to “men” RESPONSE TO REVIWERS COMMENTS Reviewer #1: This is an interesting paper on the cost of LBP in a low-income country. It is largely well written but does need a grammar and spell check. Specific comments are: Abstract 1. Background: It may be better not to include production since this isn’t covered in the paper. Response: We have paraphrased the background section of the abstract to exclude the production cost as it does not concern the current research question, see page 2, lines 29 – 35 2. Results: Acronyms need to be defined at first use and used consistently - ALBP and CLBP Response: We have now defined all acronyms at first mention and are all used consistently now, see page 2, lines 48, 50, 54 Background 3. P4 line 81: why is the pooled lifetime estimate lower than the 12 months estimate, shouldn’t it be the other way around? Response: This is the exact results of the study we gave reference of. You may find the article by following the DOI link: https://doi.org/10.1186/s12891-018-2075-x 4. Were there no prior South African studies or studies from other African countries to mention in the introduction? Response: We have only identified one cos of illness study that was conducted in Africa, and we have now included it in the background section, see page 5, lines 116 – 128. 5. Last paragraph: This should state what this study adds over prior studies. Line 279 page 11 in the discussion says this is the first study to estimate cost of LBP in South Africa. If so, this should be stated in the last paragraph of the introduction. Response: We thank the reviewer for this comment, and we have addressed that, see page 6, line 135 Methods 6. P7 line 159 antidepressants are often used primarily to treat pain (often at a lower dose than for depression). Anticonvulsants are also commonly used in this way. Response: We thank the reviewer for the comment. We have now added that to the literature, see page7, lines 190 – 191 7. P 7 line 164 Were invasive procedures only in an emergency? Commonly surgery is recommended for chronic back pain but without an emergency situation or attendance at a hospital emergency department. Response: We thank the reviewer for the insight. We have addressed and rephrased that sentence, see page 7&8 lines, 194, 195 8. P 8 A paragraph at the end is needed to state ethics approval and software (and version) used to undertake the analysis (even if it is simply a spreadsheet such as Excel). Response: We have deleted the ethical approval from the declaration section and inserted it as the last paragraph of the methods section, see page 8, lines 214 – 222 Results 9. P 9 line 227 The similar cost of ALBP and CLBP is worth mentioning in the discussion as in the introduction CLBP was significantly greater in the studies cited. It would be helpful to explain why the results of this study are different – for example if outpatient services are not easily accessible or are costly for the patient Response: The similarity between ALBP and CLBP was based on the fact that, there were many cases of ALBP with few presentations while the many cases of CLBP had several presentations over time, see page 12, lines 324 - 327. Discussion 10. P10 lines 243 to 257 For each point, there needs to be a statement about what this current study found and how it compares with other studies. The differences with what is found in this study also need to be stated (e.g. ALBP and CLBP being similar is quite different to other studies that found expenditure on CLBP to be much greater than for ALBP). Response: We have rephrased this section, see page 11, lines 228 – 303 11. P10 line 264: What were the differences in health care service delivery and study methodologies? Response: We have expanded on that statement to include the differences. The sentence now reads, “This difference can also be attributed to differences in healthcare service delivery systems among countries such as accessibility, affordability and availability of services, and differences in study methodologies such as the method of costing (prevalence-based, incidence-based, human capital approach, friction cost or the willingness to pay method) and/or perspective of costing (societal, patients or providers perspective)”, see page 11, lines 311 – 316 12. Line 279 page 11 in the discussion says this is the first study to estimate costs of LBP in South Africa. However lines 243-244 refers to several other studies of the economic burden on LBP in South Africa. This seems contradictory. Response: We have addressed that confusion. No study was conducted in South Africa, as this is the first one. The studies reported there are conducted elsewhere outside the African context, see page 11, lines 287 – 288 Grammatical/spelling errors A grammar and spell check is needed. There are quite a few grammatical/spelling errors with a few examples being: P 4 line 74 “Prevalence and incidence estimate” should be “The prevalence and incidence estimates” Response: We have changed “estimate” to “estimates”, see page 4, line 182 p4 line 84 “…get completely healed” should be something like “do not make a full recovery” Response: We have changed “get completely healed” to “do not make full recovery”, see page 4, line 196 P5 line 93 “lasted” should be “lasting” Response: We have changed “lasted” to “lasting”, see page 5, line 103 P5 Line 110 “decision should be decisions” Response: “decision” has now been changed to “decisions”, see page 6, line 133 P5 Line 111 ”hospital” should be ”hospitals” Response: “hospital” is now changed to “hospitals”, see page 6, line 134 P11 line 269 “All cases report at the outpatient ….” should this be “All cases report at the outpatient department…”? Response: We have added, “department” as per the reviewers comment, see page 12, line 322 Attachments Attachment Submitted filename: Response to Reviewer.docx https://doi.org/10.1371/journal.pone.0263204.r002
20 Sep 2022 Decision Letter - Kuo-Cherh Huang, Editor The economic burden of low back pain in KwaZulu-Natal, South Africa: a prevalence-based cost-of-illness analysis from the healthcare provider’s perspective. PONE-D-22-00974R1 Dear Dr. Kahere, 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, Kuo-Cherh Huang Academic Editor PLOS ONE Additional Editor Comments (optional): 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 ******** 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (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: No ****** 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: All comments have been adequately responded to and I am happy for the paper for proceed to publication now ****** 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: Yes: Deborah Schofield ******** https://doi.org/10.1371/journal.pone.0263204.r003
Formally Accepted
4 Oct 2022 Acceptance Letter - Kuo-Cherh Huang, Editor PONE-D-22-00974R1 The economic burden of low back pain in KwaZulu-Natal, South Africa: a prevalence-based cost-of-illness analysis from the healthcare provider’s perspective. Dear Dr. Kahere: 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 Dr. Kuo-Cherh Huang Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0263204.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .