PONE-D-22-11005Cost Effectiveness of Temporary Isolation Rooms in Acute Care Settings in AsiaPLOS ONE

Dear Dr. Graves,

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 [No grant funding was used for this project. NG was paid consulting fees by GAMA Healthcare to develop a model and prepare a first draft of the manuscript.] 

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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: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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Reviewer #1: Yes

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: The paper is well written. The data analysis for cost effectiveness is appropriate. However, the analyses was mainly based on the hypothesis to reduce HAIs at 30% from the previous studies and the cost was based on the retrospective data, which leads to the lack of reality.

Reviewer #2: The paper analyzes the cost-effectiveness of a decision to adopt temporary isolation rooms in acute care settings in Asia. The paper is technically sound using publicly available data and seeking to offer an alternative low-cost strategy for managing healthcare-associated infections, but not without some infractions. To improve the manuscript for publication, the authors must resolve the following:

1. Title and Abstract

The title suggests a broader spatial context, but the analysis is limited to one country Singapore and not Asia in general, as portrayed in the title. Compare sentence lines 3 and 4 of the abstract to the title.

The method in the abstract should be re-written for clarity. For example, we performed a model-based cost-effectiveness analysis to evaluate ………………. Outcome measures include……………….. OR We measured outcome XXX by doing ABCD and outcome XXX2 by doing MNOP. Etc.

Again, the conclusion that the intervention is cost-effective for Singapore acute care hospitals is misleading because Figure 1 shows that the cost per life-year gain with the intervention may be positive or negative. Thus, about a 50% chance of cost-saving, meaning the intervention is not a dominant strategy.

2. Methodology

In Table 1, the HAI cases reported were inconsistent with the figures documented in citation No.14. Moreso same reference did not categorically state the number of survival and deaths attributable to HAIs as referenced in Table 1 of the manuscript. Since this paper is a model-based paper, one will expect that the cited reference reports the cited baseline figures, and where they are not, provide an explanation for clarity. For instance, the supplementary file attached to the published citation clarified how the paper authors measured some variables but not for mortality attributable to HAI. (Check Table 2 of citation No.14 to resolve the inconsistencies or provide an explanation for clarity).

The authors decided to limit the study horizon to 1 year and attributed the same for not using a preference utility weight to show QALY. In my opinion, it is the author’s discretion not to expand the study horizon, but to attribute the same for not doing additional analysis is misplaced.

3. Scenario analysis.

“The attributable mortality is unadjusted for other factors that can affect mortality”. The authors believed by halving the estimated HAI-attributable mortality, they have ensured robustness, how? They should provide a reference to justify that statement. In the first place, I did not find the mortality figures in the referenced citation used in Table 1 and the explanation of how HAI mortality was arrived at should be provided.

No mention of heterogeneity characterization. It is obvious that the study subjects vary by type of HAIs with different baseline characteristics or observed variabilities which may affect the study conclusion. An aggregated probability risk of HAIs and mortality with 95% uncertainty intervals should be explored in a deterministic sensitivity analysis (DSA) and the result presented in a Tornado graph to offer more explanation.

At baseline, I assume the mean cost per bed day of SDG 823 is an aggregated mean for all the reported HAI cases (Table 2). How about exploring the HAI case-specific mean cost in the scenario analysis to show which contributes more to the cost of HAIs and consequently the cost savings per LYG? I think the same may apply to the length of stay. Obviously, the mean cost of managing surgical site infection is different from the mean cost of managing either CLABSI, Sepsis, etc.

An alternative will be to collapse Table 2 and present only the aggregated mean parameter values, i.e., Mean cost of HAIs, LOS, risk of HAI, etc. with their 95%CI explored in a scenario analysis.

4. Results and discussion

It is the norm that all parameter values, especially those contributing significantly to the study outcome should be captured in the result and discussion section under both scenarios.

Limiting the cost to only the provider perspective results in underestimation of the potential cost associated with HAIs and this must be discussed. In paragraph two of the discussion, the authors align the strength of their paper to doing a full economic evaluation. The statement is not true because the study perspective is limited, and the methodology is not rigorous enough.

5. General comment

The use of study reporting guidelines is highly recommended for quality reporting assurance. In this case, following the CHEERS checklist is a better way to improve the methodology, results, and discussion sections, and it must be stated clearly in the methods the reporting guideline used in this study.

Reference list No 17 is incomplete and others must be checked for proper formatting.

The title of Table 1 should be checked for type error “with and with HAI”

Also, resolve the formatting of the Abstract and figure in line with the Journal requirements.

Reviewer #3: This is a good piece of work that is more relevant to the current resource management of many countries. Most of the countries prepared temporary isolation rooms in their hospitals to isolate COVID 19 patients. Therefore this is a good idea to reduce cost of managing hospital acquired infections using these temporary isolation rooms. At the same time this cost effectiveness study is a technically sound study . Therefore this is a valuable timely performed study.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Cost Effectiveness of Temporary Isolation Rooms in Acute Care Settings in Singapore

PONE-D-22-11005R1

Dear Dr. Graves,

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,

Monika Pogorzelska-Maziarz

Academic Editor

PLOS ONE