Is lack of health insurance a predictor of worsening of heart failure among adult patients attending referral hospitals in Northwestern Tanzania?

Bahati M. K. Wajanga; Christine Yaeree Kim; Robert N. Peck; John Bartlett; Deodatus Mabula; Adinan Juma; Charles Muiruri

doi:10.1371/journal.pone.0264352

Peer Review History

Original SubmissionAugust 31, 2021
5 Nov 2021 Decision Letter - Sreeram V. Ramagopalan, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-21-28263Is Lack Of Health Insurance Associated With The Severity Of Heart Failure In Northwestern Tanzania?PLOS ONE Dear Dr. Wajanga, 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 20 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. 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We will update your Data Availability statement to reflect the information you provide in your cover letter. 8. 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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [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: 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: The study investigates the relationship between health insurance coverage and severity of heart failure based on a sample of 418 patients enrolled at two outpatient clinics in Mwanza, Tanzania. Using multivariable logistic regression, no association was found between having health insurance and heart failure severity (NYHA classification III-IV vs. I-II). However, heart failure severity was associated with male sex, lower educational level, small scale business occupation, and treating clinic. The authors discuss how the results may reflect underlying social and biological factors contributing to clinical outcomes, however, on the question of health insurance coverage, call for further research into the impact of out-of-pocket expenses to assess what impact this has on clinical outcomes. Overall, the reporting of the article is clear, well written and the interpretation of findings are reasonable and generally supported by the data. Some points for consideration – 1.The analysis is cross-sectional in design, and the relationship between the exposure (health insurance) and outcome (heart failure severity) is considered, without mention of the temporality between the two variables. It would help to clarify – Whether patients with insurance, had insurance, before the diagnosis of heart failure, or whether its possible some patients could have taken out insurance after the diagnosis of heart failure? To what extent the population comprises patients with prevalent pre-existing heart failure or patients with incident new diagnoses of heart failure? Since heart failure is likely to progress in severity over time, I would suspect time since diagnosis might be an important confounding factor of the outcome to consider. 2.In the Data Analysis section, I would suggest providing more details on the NYHA score to assist readers who are unfamiliar with the measure i.e. the range of the score, and how it is interpreted, i.e. class I = no symptoms/limitations up to class IV= severe symptoms. 3.There is no mention of missing data, the extent and how this was handled in analysis – presume complete case analysis was used. Furthermore in table 2, ideally two columns should be added for the number of patients and events per category to assess whether null associations could be due to insufficient endpoints/power. 4.Line 149-150: “Pincus, et al observed that poor clinical outcomes resulted were better predicted by social conditions than access to care that is necessitated by health insurance coverage.” Check sentence for typo ****** 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 [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/. 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Revision 1
21 Dec 2021 Author Response 1. PLOS ONE STYLE OF MANUSCRIPT Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates Response Thank you for your feedback. We have revised the current version to meet the PLOS ONE’s style requirement. 2. CHANGING OF TITLE Please consider changing the title so as to meet our title format requirement (https://journals.plos.org/plosone/s/submission-guidelines). In particular, the title should be "Specific, descriptive, concise, and comprehensible to readers outside the field" and in this case it is not informative and specific about your study's scope, methodology, and findings Response: We appreciate your guidance and have revised the current title to read “Is lack of Heath Insurance a predictor of worsening of heart failure among adult patients attending referral hospitals in Northwestern Tanzania?” The short title is “Association of health insurance as a predictor of worsening heart failure” 3. GRANT INFORMATION We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. Response: We apologize for the mistake and have provided the correct grant number in the funding information 4. ACKNOWLEDGEMENT AND FUNDING SECTIONS We note that you have provided additional information within the Acknowledgements Section that is not currently declared in your Funding Statement. Please note that 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. Response: Thank you for feedback. We have removed the funding information in the manuscript as per your instruction. 5. ORCID ID PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager Response: Thank you for the feedback. I have included my ORCID ID, which is 0000-0002-1922-0746 6. ETHICS STATEMENT 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 move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript Response: In the current version of the manuscript, we have included the ethics statement in the methods section on line 129-131 7. DATA AVAILABILITY STATEMENT In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter Response Thank you for your feedback. The data set have been uploaded and URL included in the cover letter 8. REFERENCE LIST 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 Response: We reviewed the reference list and have an updated one in this version. Reviewer #1 The study investigates the relationship between health insurance coverage and severity of heart failure based on a sample of 418 patients enrolled at two outpatient clinics in Mwanza, Tanzania. Using multivariable logistic regression, no association was found between having health insurance and heart failure severity (NYHA classification III-IV vs. I-II). However, heart failure severity was associated with male sex, lower educational level, small scale business occupation, and treating clinic. The authors discuss how the results may reflect underlying social and biological factors contributing to clinical outcomes, however, on the question of health insurance coverage, call for further research into the impact of out-of-pocket expenses to assess what impact this has on clinical outcomes. Overall, the reporting of the article is clear, well written and the interpretation of findings are reasonable and generally supported by the data. Some points for consideration – 1.The analysis is cross-sectional in design, and the relationship between the exposure (health insurance) and outcome (heart failure severity) is considered, without mention of the temporality between the two variables. It would help to clarify – Whether patients with insurance, had insurance, before the diagnosis of heart failure, or whether its possible some patients could have taken out insurance after the diagnosis of heart failure? Response: Thank you for your feedback. For this study, we asked about insurance status at the beginning of the study. The patients in this study had insurances prior the diagnosis of heart failure. We have added the description on lines 121-122 To what extent the population comprises patients with prevalent pre-existing heart failure or patients with incident new diagnoses of heart failure? Since heart failure is likely to progress in severity over time, I would suspect time since diagnosis might be an important confounding factor of the outcome to consider. Response: We agree that time since diagnosis of heart failure might be an important confounding factor. Since we did not collect this information in this study, we have declared this limitation on page line 187-189 variable, but then this would work best in a known cohort, followed over time, which was not in our case where the subject was seen once. 2. In the Data Analysis section, I would suggest providing more details on the NYHA score to assist readers who are unfamiliar with the measure i.e. the range of the score, and how it is interpreted, i.e. class I = no symptoms/limitations up to class IV= severe symptoms. Response: We have provided more details about NYHA in the data analysis section lines 106- 118 3. There is no mention of missing data, the extent and how this was handled in analysis – presume complete case analysis was used. Furthermore in table 2, ideally two columns should be added for the number of patients and events per category to assess whether null associations could be due to insufficient endpoints/power. Response: We included a description of how we handled missing data on lines 125-127 We appreciate your feedback and added the two columns. 4. Line 149-150: “Pincus, et al observed that poor clinical outcomes resulted were better predicted by social conditions than access to care that is necessitated by health insurance coverage.” Check sentence for typo Response Thank you. We have corrected the typo. 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 Response We do not need to publish peer review history. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0264352.r002
9 Feb 2022 Decision Letter - Sreeram V. Ramagopalan, Editor Is lack of Heath Insurance a predictor of worsening of heart failure among adult patients attending referral hospitals in Northwestern Tanzania? PONE-D-21-28263R1 Dear Dr. Wajanga, 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, Sreeram V. Ramagopalan Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0264352.r003
Formally Accepted
18 Feb 2022 Acceptance Letter - Sreeram V. Ramagopalan, Editor PONE-D-21-28263R1 Is lack of Heath Insurance a predictor of worsening of heart failure among adult patients attending referral hospitals in Northwestern Tanzania? Dear Dr. Wajanga: 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. Sreeram V. Ramagopalan Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0264352.r004

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