PONE-D-21-05014

Access to domestic violence advocacy by race, ethnicity and gender:

The impact of a digital warm handoff from the emergency department

PLOS ONE

Dear Dr. Brignone,

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.

Thank you for submitting this manuscript on a very important topic related to IPV and racial differences in receiving and accessing advocacy services. This manuscript fills an important gap, but needs some additional editing and clarity before publication. 

Please submit your revised manuscript by Jul 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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We look forward to receiving your revised manuscript.

Kind regards,

Michelle L. Munro-Kramer, PhD, CNM, FNP-BC

Academic Editor

PLOS ONE

Additional Editor Comments:

Both of the reviewers provided detailed comments and suggestions that should be attended to prior to resubmission. I would specifically encourage the authors to pay attention to:

1) Streamlining the background section to focus specifically on the topics related to this study. Please see Reviewer #1's suggestion for how to do this.

2) Reviewer #1 & Reviewer #2's questions related to clarification in the methods section (e.g., which Danger Assessment was used - 5 versus 20 items; what EHR search program; how referral data was linked; how are repeat visits handled; measurement/definitions used for race and gender).

3) Discussion - As noted by Reviewer #2 - the study included a high proportion of Black patients. How did this impact the results? Please provide more details/discussion around the fact that about half of the sample did not receive the intervention and of those who did only 23-43% accessed services.

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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: Yes

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: Yes

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: No

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 is an important study of ED patients with DV, and their receipt of a digital warm handoff intervention called DVRR, and their receipt of advocacy services. I have several questions and comments to improve clarity.

Abstract, Methods:

1. Can you describe briefly how 1366 ED visits are related to 323 DV advocacy visits? Meaning are the DV advocacy visits from DVRR performed in ED?

2. Is the intervention DVRR? Meaning odds and predicted probability are comparing ED visits for DV where ED patients received DVRR or not? Did all ED patients with DV receive DVRR?

3. Can you explain more what predicted probabilities adds to odds ratios? Is it to show disparities by race/ethnicity of receiving DVRR?

Abstract, Results:

1. Latinx odds reference group is Black and white combined? In a logistic regression? Did you use a multinomial logistic regression with Latinx compared to Black compared to white

2. Is this odds of 2.53 for Latinx survivors who did not receive DVRR?

3. When you write compared to white, female survivors, is Black survivors’ 4.66 odds of reaching advocacy in those without DVRR? Is this a logistic regression (binary outcome) or multinomial outcome?

4. Male survivors experienced 12.8 times the odds compare to who? Female survivors with DVRR?

Manuscript text:

Introduction:

1. The section on race and ethnicity first sentences describes DV race/ethnicity differences. I would keep that. The 5 paragraphs describe differences in use of or service-provider creation of DV advocacy services and shelter. However, the length of text distracts from the focus on ED patients, DVRR those patients do or don’t receive, and eventual services those patients do or don’t use. I would remove the remaining material except for the last paragraph on “examining ED services”.

2. I would keep the section on gender as is, as it’s concise at 2 paragraphs.

3. DVRR section: can you describe more about DVRR? This in many ways is the crucial part of your introduction. I don’t know how to find reference 51, which is listed as a poster. Is it https://urapprojects.berkeley.edu/projects/detail.php?id_list=Soc0795? That describes data to collect, not data about DVRR. See my next set of questions below.

Methods

Intervention

1. I would move this paragraph to introduction. This material says DVRR is used at the discretion of the ED provider. Can you tell us more about this discretion? This gets at provider bias, and in many ways may determine if DVRR is useful or not.

2. Is the Danger Assessment the full 20 questions? Or the shorter versions like at https://pubmed.ncbi.nlm.nih.gov/28921610/? A short vs long questionnaire (5 questions vs. 20 questions) may mean providers use or don’t use DVRR, as an extra 15 questions will increase provider time in working with patients.

3. Describe more about CA mandatory reporting law. It is unlike other state mandatory reporting laws (https://www.futureswithoutviolence.org/userfiles/file/HealthCare/Compendium%20Final.pdf).

4. Do you know how many ED patients with DV receive DVRR, as opposed to provider who calls police directly to make report (for example in other states providers must make a call)?

5. Who (nurse, social worker, doctor) completes DVRR during a clinical encounter? Does that influence if DVRR is used?

6. Do patients not receive other DV assistance during DV encounter (safety planning for positive danger assessment screen) if DVRR is completed (where an advocate later may or may not call patient)?

7. Are ED’s completing DVRR without other ED visitors/potential perpetrators present?

8. Can survivors voluntarily decide not to receive DVRR? I know you may not have answers to many of my questions on DVRR, but the answers all influence how we interpret your results. DVRR is a novel process that I think is great, but it deserves explaining so that providers in other states can think about if a similar program is worth developing.

Data

1. Can we see a copy of the standardized abstraction form? Maybe put it as an appendix?

2. Tell me more about the EHR search program that identified all ED visits in which a patient screened positive for DV. What screening tool was used? Was the answer to only 1 DV question (out of however many DV questions were asked) considered a positive screen?

3. How do you define chief complaint (I recommend calling it a chief concern; providers may feel that patients are complaining, but patients express important concerns about their health) related to DV? Does the patient have to say “I am a victim of DV” to be considered having a chief concern related to DV?

4. Do ED patients with repeated visits for DV receive multiple DVRR?

5. Were visits by survivors of sexual assault by a partner considered to have experienced sexual assault or DV?

6. How is gender measured? Does it include non-binary identifying patients?

7. How is race defined? By patient or provider? What about a patient who has more than 1 race?

8. When you describe “the relationship between perpetrator and victim”, aren’t all DV cases relationships between partners? Is this referring to sexual assault cases?

9. Do you have a measure of how well DVRR was administered? Like full 20 question Danger Assessment, or 5-item Danger Assessment screen described above? Was there safety planning conducted in the ED for positive Danger Assessment screens?

10. Were there duplicates for survivor full names and hospital visit dates at DV agency?

Figure 1: How do you define known DV? What are your inclusion criteria? Do we know why some patients did not receive DVRR? Shouldn’t they all have?

Data analysis

1. Does DVRR administration mean that DVRR was documented to have occurred during the ED visit? Or that a DVRR report existed in the online system? Did patients receive multiple DVRR over multiple visits?

2. Describe more about what predicted probably adds to the logistic regression models

Characteristics of the study population

1. 74.2% had no other visits to the trauma center during the study period. Does that mean no other ED visits? Or no other visits for DV?

2. You write that survivors who experienced sexual assault were less likely to have administered DVRR. Do those providers receive a different intervention?

3. I’d recommend moving this paragraph to results.

Table 1: what are the **denoting? A level of p value? Or just a statistically significant difference in % values in that characteristic?

Results

1. Can you explain how the interaction terms increased the odds of connecting to advocacy services?

2. You write odds of accessing advocacy services, and odds of connecting to advocacy services. Are those the same things?

3. Explain what the predicted probability adds to the odds ratio analyses already presented. Isn’t it showing similar results to DVRR associated with increased odds of receiving advocacy services?

Table 2: is this a multinomial logistic regression? Of a series of logistic regressions shown in different columns? What is the reference group for Baseline odds, No DVRR white female? Why in the DVRR female white and latinx are white and latinx grouped together?

Discussion:

1. 2nd paragraph: You write that DVRR is an automatic referral. Given that only 54% of patients received it (from Methods/Characteristics of the study population), and your later description of providers choosing to administer DVRR may be more likely to connect survivors to services, I think you can describe this as a digital referral with lethality assessment.

2. Is there literature on Danger Assessment being validated in men who experienced violence?

Strengths and limitations

1. You write that “it confidentially links the hospital and advocacy records of DV survivors.” Do you mean DVRR, or this research study on DVRR?

2. Do you have data on how many identical given names (duplicates) occurred in your data? That would allow you to determine if duplicates affected intervention and non-intervention groups equally. I otherwise do not think you can conclude this.

Reviewer #2: Access to domestic violence advocacy by race, ethnicity and gender:

The impact of a digital warm handoff from the emergency department

Accept minor revisions

This study fills an important gap in our evidence base regarding intervention for IPV, and its focus on racial differences is particularly timely. It is also very nice to see an intervention that differentially and positively impacts Latinx and Black women. The intervention itself is well-conceived to address challenges in IPV referral in the ED, and in particular that the hand-off is to an advocacy organization rather than only to law enforcement (as required by CA law).

Specific comments:

1. The introduction is far too lengthy and reads more like an essay. Only the salient points for this analysis, summarized, are needed.

2. The authors state in their methods that they detected no missing or incomplete data, but with only aggregate data from the advocacy organizations, the quality of the data is impossible to verify. This should be noted.

3. The process for linking referrals to follow-up visits is not described. Linkages based on name, because of spelling variability, are particularly problematic and generally have some validity challenges.

4. Given strong evidence that BIPOC patients report challenges in their interactions with healthcare facilities, the generalizability of this study needs to be addressed. For example, many EDs might not have a majority of Black IPV patients (in this sample, 63.5%), and perhaps the staff at this hospital are particularly adept in culturally appropriate and ethnicity-centered healthcare. How would this potentially impact EDs with different patient profiles?

5. Although these findings are very promising, nearly half of the IPV victims in the ED did not receive the intervention, and even with the improved access to advocacy services with the intervention, only between 23% and 43% of those referred accessed services. The discussion should address these issues by providing some insight into why these proportions are low and how they might be improved.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-21-05014R1Access to domestic violence advocacy by race, ethnicity and gender:

The impact of a digital warm handoff from the emergency departmentPLOS ONE

Dear Dr. Brignone,

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 12 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-emailutm_source=authorlettersutm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Michelle L. Munro-Kramer, PhD, CNM, FNP-BC

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 (if provided):

Thank you for your careful attention to the previous comments and suggestions. There are a few very minor remaining comments from Reviewer #1. I look forward to accepting this manuscript after these have been addressed.

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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: (No Response)

Reviewer #2: 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

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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: 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

Reviewer #2: Yes

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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: This is an important study of ED patients with DV, their receipt of a digital warm handoff intervention called DVRR, and their receipt of advocacy services. I have several questions and comments to improve clarity.

Abstract:

1. Background: I suggest changing first sentence to “racial/ethnic minority survivors of domestic violence (DV) referred from emergency departments (Eds) face barriers connecting with advocacy services due to systemic inequalities.” Their inequities in healthcare access may not be the same as those found in advocacy services. I also suggest describing DVRR as an electronic reporting system to fulfill mandatory reporting requirements to law enforcement, with report also going to DV advocacy agency.

2. Methods: Describe time frame (2014-2018) for study. Briefly describe how DV-associated ED visits were defined. I recommend not describing sample sizes (1366, 740, 323) in methods section as those are results. You could state something like “We assessed 2014-2018 ED visit chief concern for DV, measured if DVRR occurred, and if patient names matched DV advocacy agency records of survivors using services”. I would suggest giving sample size for number used in logistic regression analyses and number used in predicted probability analyses.

Manuscript text

Introduction

1. 2nd paragraph: You write that “standard of care for DV often does not extend beyond hospital screening; when it does, it typically consists of printed educational material or a phone number to a community-based advocacy agency…”, and I think you are meaning that standard of care for DV includes identification of DV but does not necessarily include providing support and resources, or follow-up to see if patient used advocacy agency services. I would clarify this.

2. 2nd paragraph: You write “…warm handoff, in which the ED provider personally transfers the survivor’s DV care to a DV advocate.” A transfer of care in medical care more typically means physical movement of the patient location. A warm handoff might be better described as a healthcare provider describing DV advocacy agency services and possibly calling the DV advocacy agency while in the patient room. This may include a DV advocacy agency staff member coming to the patient location for an in-person provision of support and resources. I would clarify this.

3. Race and ethnicity, and Gender sections: I recommend condensing this into 1 paragraph. The focus of the paper is ED visits, DVRR and DV advocacy visit. The first 2 paragraphs describe ED visits and DV advocacy, and the last paragraph describes DVRR.

Results

1. I recommend changing “Analysis” header (between first and second paragraphs) to “DVRR and receiving advocacy services by race/ethnicity and gender”. Otherwise, the reader will think this is the methods section analysis plan

2. Last paragraph: what does likelihood difference assist reader in knowing?

Table 2:

1. I would put 95%CI with odds ratio in 1 row.

2. Why is the reference group baseline odds ratio (white, female) 0.12? Shouldn’t it be 1.0 as it’s the reference group?

Figures 1 and 2: what does statistical test for % increase add? I think you can remove it. It’s otherwise too much information. It’s obvious from the table that there is a visually large increase by DVRR.

S1 Appendix: can you explain more why this appendix is needed? Doesn’t Figure 2 adequately show differences in DVRR status by race and ethnicity?

Discussion: Paragraph 3: the authors describe how 5-question Danger Assessment “is an important step toward improving the strength of the Danger Assessment component of DVRR in reducing bias and providing culturally appropriate care.” I think the using 5-question DA will help provider time in completing the DA, and therefore completing the full DVRR assessment. It may increase DVRR administration from 54% to something higher.

Strengths and limitations: Paragraph 3: can you describe the “data restrictions that made it impossible to study additional groups that…experience heightened barriers to DV response or services”. Can you explain more about those data restrictions?

Reviewer #2: The revision addresses my original comments, and I have no further comments.

The revision addresses my original comments, and I have no further comments.

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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

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.

Access to domestic violence advocacy by race, ethnicity and gender:

The impact of a digital warm handoff from the emergency department

PONE-D-21-05014R2

Dear Dr. Brignone,

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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Kind regards,

Michelle L. Munro-Kramer, PhD, CNM, FNP-BC

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for the revisions and congratulations on the acceptance of this article. It will make a significant contribution to the literature.

Reviewers' comments: