PONE-D-21-16668Outreach screening to address demographic and economic barriers to diabetic retinopathy care in rural ChinaPLOS ONE

Dear Dr. Congdon,

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Additional Editor Comments (if provided):

Dear authors,

The study has important conclusions which can impact Diabetic retinopathy screening programmes. However, as pointed out by the reviewers, this study has major limitations which need strong justification, especially the fact that the the three comparison groups differ in the time period of examinations and also differ geographically.

Please find the reviewer comments below. I have recommended "major revision" for these reasons.

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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?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: Here is a list of specific comments. Note: line and page numbering are not available; line and page numbering in reviews and comments is based on those in the Editorial Manager-generated PDF.

1. Another drawback of this manuscript was the lack of health outcome comparisons.

2. Page 13 of 24, Secondary-level passive case-finding: I suggest revising “patients were drawn” as ‘patients in the passive detection cohort were drawn’.

3. Page 13 of 24, Outreach screening: Please include the description of the 185 patients in the outreach screening cohort.

4. Page 14 of 24, 1st paragraph: I suggest relocating the sentence “to create comparable inclusion criteria, . . . ” to the Study Design section.

5. Page 15 of 24, 1st paragraph: Although the goal was to compare the passive detection cohort and the outreach screening cohort to the population-based cohort, it would be necessary to provide results of chi-square tests for the distribution of socioeconomic and clinical characteristics among three cohorts; i.e., add a column of p-value for overall tests in Table 2.

6. Page 15 of 24, 1st paragraph, chi-square tests: Please confirm if Fisher’s exact tests were necessary for some characteristics with 0-count cells such as highest DR grade in either eye, DME in either eye, etc.

Reviewer #2: Abstract

Please indicate if there was a difference in the less educated between the population cohort and outreach cohort. You only mentioned there was no difference in age and women between both cohorts

Methodology

The outreach cohort is clearly cross sectional but the population and secondary level cohort is a bit confusing. Are the population cohort and the secondary level cohort retrospective with regards to this particular study in which the data were collected during the trial (for the secondary cohort) or at some time in the past for the population cohort OR were they cross sectional where all participants were re-invited, screened, and questionnaires administered? Kindly clarify

If cross sectional, did all the initial patients present for the current study? if not what proportion did not?

Discussion

Please could you explain why the outreach screening identifies more severely-affected patients than case finding in hospital. One would think that the patients presenting to the hospital would have worse disease

Reviewer #3: The authors have tried to test their hypothesis by comparing 3 cohorts of patients that were from different studies and done at different period and all in different regions.

These regions may all be rural but in a country like China, rural populations and areas are heterogeneous. The study periods range from 2014 for one cohort to 2019 in the recent cohort. Lots of progress has been made in 5 years and so it is difficult to make these conclusions.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Outreach screening to address demographic and economic barriers to diabetic retinopathy care in rural China

PONE-D-21-16668R1

Dear Dr. Congdon,

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.

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Kind regards,

Soujanya Kaup, MS DNB FPRS