Use of a decision support system for benchmarking analysis and organizational improvement of regional mental health care: Efficiency, stability and entropy assessment of the mental health ecosystem of Gipuzkoa (Basque Country, Spain)

Carlos R. García-Alonso; Nerea Almeda; José A. Salinas-Pérez; Mencía R. Gutiérrez-Colosía; Álvaro Iruin-Sanz; Luis Salvador-Carulla

doi:10.1371/journal.pone.0265669

Peer Review History

Original SubmissionSeptember 21, 2021
5 Jan 2022 Decision Letter - Majid Soleimani-damaneh, Editor PONE-D-21-30492 Use of a decision support system for benchmarking analysis and organizational improvement of regional mental health care: The case of Gipuzkoa (Basque Country, Spain) PLOS ONE Dear Dr. Almeda, 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 Feb 17 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. 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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. Thank you for stating in your Funding Statement: “This study was partially funded by a Carlos III Health Institute grant (PI18/01521) and the Regional Government of Andalusia (PY18-RE-0022) with European Union FEDER teams. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.” Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf. 3. Thank you for stating the following in the Acknowledgments Section of your manuscript: “We would like to thank the Mental Health Network of Gipuzkoa, especially Álvaro Iruin and Andrea Gabilondo, for providing data and supporting this study. We also acknowledge the Mental Health Network of Bizkaia, especially Carlos Pereira and José Juan Uriarte, for supporting this research.” 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 partially funded by a Carlos III Health Institute grant (PI18/01521) and the Regional Government of Andalusia (PY18-RE-0022) with European Union FEDER teams. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. [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: I Don't Know ****** 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: The manuscript is not well organized. The explanation of the manuscript contribution should be stronger, especially for a wider range of readers. Think about how readers' access to the statistics and information you used. Are decision support systems suitable for all decisions? I think you should make a logical argument (not just referring to other sources) as to why the decision support system is useful for your case. Reviewer #2: This is an interesting manuscript offering the readers a good and thorough analysis to develop an analytical process for (i) assessing the performance of Mental Health in Gipuzkoa (Basque Country, Spain) and identifying benchmark and target-for-improvement catchment areas. According to the authors, the main conclusion of the study is that no catchment area could be reference in its three main types of care. The article has interesting content, although I have highlighted some issues below: I suggest indicate the study’s design in the title or the abstract. The manuscript can still be improved by including a more in-depth discussion (including direction and magnitude ) of potential bias, imprecision or confounders. ****** 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.0265669.r001
Revision 1
28 Jan 2022 Author Response Response to reviewers Journal 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" Many thanks for your assistance, we have ensured that the manuscript meets PLOS ONE’s style. 2. Thank you for stating in your Funding Statement: “This study was partially funded by a Carlos III Health Institute grant (PI18/01521) and the Regional Government of Andalusia (PY18-RE-0022) with European Union FEDER teams. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.” Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf. Thank you very much for your assistance. We have corrected the mistake and follow the instructions according to Plos One journal. We have also included the updated Funding Statement in the cover letter: This study was funded by the Instituto de Salud Carlos III (grant number: PI18/01521; author who received the award: CGA) https://www.isciii.es/Paginas/Inicio.aspx and Junta de Andalucía con Fondos FEDER (Unión Europea) (grant number: Y18-RE-0022; author who received the award: CGA) https://www.juntadeandalucia.es/economiaconocimientoempresasyuniversidad/fondoseuropeosenandalucia/feder. There was no additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. 3. Thank you for stating the following in the Acknowledgments Section of your manuscript: “We would like to thank the Mental Health Network of Gipuzkoa, especially Álvaro Iruin and Andrea Gabilondo, for providing data and supporting this study. We also acknowledge the Mental Health Network of Bizkaia, especially Carlos Pereira and José Juan Uriarte, for supporting this research.” 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 partially funded by a Carlos III Health Institute grant (PI18/01521) and the Regional Government of Andalusia (PY18-RE-0022) with European Union FEDER teams. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. We are sorry for the mistakes; we have updated the Funding Statement in the cover letter as follow and we would like this paragraph to appear in the Funding Statement: This study was funded by the Instituto de Salud Carlos III (grant number: PI18/01521; author who received the award: CRGA) https://www.isciii.es/Paginas/Inicio.aspx and Junta de Andalucía con Fondos FEDER (Unión Europea) (grant number: Y18-RE-0022; author who received the award: CRGA) https://www.juntadeandalucia.es/economiaconocimientoempresasyuniversidad/fondoseuropeosenandalucia/feder . There was no additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We have also updated the Acknowledgement Section (in yellow in the manuscript): We would like to thank Álvaro Iruin and Andrea Gabilondo (Mental Health Network of Gipuzkoa) as well as Carlos Pereira and José Juan Uriarte (Mental Health Network of Bizkaia) for sharing your knowledge and improving this research. Reviewers' comments Reviewer #1: The manuscript is not well organized. Thank you very much for your suggestion. We have modified the “aims” paragraph in the introduction adding the following explanation (in yellow in the manuscript). According to this, the paper is organised in the following sections: (i) Methods, to firstly describe the real system structure and the available dataset (variables) and secondly to set the basic indicator definitions and briefly analyse the usability of the DSS in supporting the analysis of real interventions and policies, (ii) Results, analysing the MH system performance (relative technical efficiency, stability and entropy) and identifying potential interventions on “target for improvement areas” considering the structure of “benchmarking” ones and, finally, (iii) this paper ends with the discussion and conclusion sections. We have also re-structured the Method section by including a new section at the end “Potential usability of the DSS in real complex systems” where we have included the following paragraph: DSSs systems are considered appropriate tools for guiding operational (basically resource allocation and use) evidence-informed planning and management. DSSs allow decision makers and policy makers to increase their knowledge about how the organization of the ecosystem (divided in comparable organizational units) manages scarce resources in order to produce mensurable and positive results, in the end: the ecosystem performance. Commonly, decisions and policymaking are based on the manager’s experience, external opinions, historical facts, etc., and they need new evidence-based tools for increasing their knowledge when organizational interventions or policies must be assessed in advance. The DSS proposed in this paper allows them to have an objective assessment about the ecosystem performance including relative technical efficiency, stability and entropy, everything from different points of view. In addition, this computer-based tool can identify new improvement strategies once the proposed changes had been potentially taken in the real ecosystem, aiming at improving MH care provision. Also, in the Method section we have modify the second subsection to “Indicator definitions”. Finally, the “Results” section has been revised by adding four new subsections trying to clarify its content, on one hand to emphasized relative technical efficiency, stability and entropy results and, on the other, to identify both “benchmarking” and “target for improvement” areas in order to propose potential interventions in order to reach better mental health care. The explanation of the manuscript contribution should be stronger, especially for a wider range of readers. Many thanks, we have carried out this change in the Conclusions section (highlighted in yellow in the manuscript): This research has contributed to the development of evidence-informed policymaking by including scientific findings to deal with the inner uncertainty of the environment as well as context information (expert knowledge for interpreting data under a theoretical paradigm). The formal integration of evidence (data) and expert knowledge is the most powerful strategy to increase expert knowledge, and expert knowledge is the unique tool to deal with uncertainty in a real and complex ecosystem. The proposed DSS has allowed firstly to assess both the individual (decision units) and global performance of the MH system of Gipuzkoa and secondly to identify new potential improvement strategies prior its potential implementation in the real environment, this process decreases operational risks. This article can be considered a guide for informing experts, managers and policy makers on how real MH systems are really working (performance) and how they could be improved to provide better MH care. Think about how readers' access to the statistics and information you used. Many thanks for your suggestion. We have included this modification in the text (Methods> Study area and data): Data set is available at the Dryad digital repository (https://datadryad.org/stash/share/cFD5jA5F3odtAhZqUARiPBTo_yj8lKvQ9GWAGrauPnE) and processed datasets that feed the DSS are available upon request. Are decision support systems suitable for all decisions? I think you should make a logical argument (not just referring to other sources) as to why the decision support system is useful for your case. Many thanks, we have carried out this suggestion (Methods > Potential usability of the DSS in real complex systems, in yellow): DSSs systems are considered appropriate tools for guiding operational (basically resource allocation and use) evidence-informed planning and management. DSSs allow decision makers and policy makers to increase their knowledge about how the organization of the ecosystem (divided in comparable organizational units) manages scarce resources in order to produce mensurable and positive results, in the end: the ecosystem performance. Commonly, decisions and policymaking are based on the manager’s experience, external opinions, historical facts, etc., and they need new evidence-based tools for increasing their knowledge when organizational interventions or policies have to be assessed in advance. The DSS proposed in this paper allows them to have an objective assessment about the ecosystem performance including relative technical efficiency, stability and entropy, everything from different points of view. In addition, this computer-based tool can identify new improvement strategies once the proposed changes had been potentially taken in the real ecosystem, aiming at improving MH care provision. Reviewer #2: This is an interesting manuscript offering the readers a good and thorough analysis to develop an analytical process for (i) assessing the performance of Mental Health in Gipuzkoa (Basque Country, Spain) and identifying benchmark and target-for-improvement catchment areas. According to the authors, the main conclusion of the study is that no catchment area could be reference in its three main types of care. The article has interesting content, although I have highlighted some issues below: I suggest indicate the study’s design in the title or the abstract. Many thanks for your suggestion, we have modified the title as follow: Use of a decision support system for benchmarking analysis and organizational improvement of regional mental health care: efficiency, stability and entropy assessment of the Mental Health ecosystem of Gipuzkoa (Basque Country, Spain) The manuscript can still be improved by including a more in-depth discussion (including direction and magnitude) of potential bias, imprecision or confounders. Many thanks for this suggestion, we have carried out the proposed change (in yellow in the manuscript). The original dataset given by the Mental Health system of Gipuzkoa is completely reliable, but the main bias source is population. In order to calculate the corresponding availability and resource’s use rates the most reliable source for population is the official census, that is relatively outdated. In order to deal with this problem, uncertainty, a Monte-Carlo simulation engine has been developed to manage statistical distributions rather than raw data. On the other hand, data on MH systems are dynamic and change frequently the analysis showed in this paper corresponds to a specific transversal cut in the time but the DSS can analyse new datasets very easily. The Monte-Carlo simulation engine offers a sensitivity analysis to take relative small data changes into control by multiplying the number of observation artificially (21). 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. Thank you very much for your assistance. We have upload the figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool and they meet PLOS requirements. https://doi.org/10.1371/journal.pone.0265669.r002
7 Mar 2022 Decision Letter - Majid Soleimani-damaneh, Editor Use of a decision support system for benchmarking analysis and organizational improvement of regional mental health care: efficiency, stability and entropy assessment of the Mental Health ecosystem of Gipuzkoa (Basque Country, Spain) PONE-D-21-30492R1 Dear Dr. Almeda, 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, Majid Soleimani-damaneh 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 Reviewer #2: 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 Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know 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: No Reviewer #2: Yes ****** 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 ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The use of decision support systems in such a case requires more reasoning and mere citation is not enough. In addition, more reasoning is needed to determine the operational value-added of the output. Unfortunately, when we look at the results, we see that the results are not something that is unknown without doing this research, while the topic you have chosen potentially has much deeper and newer consequences. Reviewer #2: (No Response) ****** 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.0265669.r003
Formally Accepted
14 Mar 2022 Acceptance Letter - Majid Soleimani-damaneh, Editor PONE-D-21-30492R1 Use of a decision support system for benchmarking analysis and organizational improvement of regional mental health care: efficiency, stability and entropy assessment of the Mental Health ecosystem of Gipuzkoa (Basque Country, Spain) Dear Dr. Almeda: 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. Majid Soleimani-damaneh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0265669.r004

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