PONE-D-21-39908Measuring Voluntary Responses in Healthcare Utilization During the COVID-19 Pandemic: Evidence from TaiwanPLOS ONE

Dear Dr. Yang,

 Thank you for submitting your manuscript to PLOS ONE. The reviewers have commented on your manuscript and they are largely positive.  However they have some major comments/questions/concerns that need your attention before this can be considered further. 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 Apr 14 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.

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-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

M. Sohel Rahman, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional 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

2. Thank you for stating the following financial disclosure:

“No”

At this time, please address the following queries:

a)        Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b)        State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c)        If any authors received a salary from any of your funders, please state which authors and which funders.

d)        If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

3. Thank you for stating the following in your Competing Interests section: 

“NO authors have competing interests”

Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now

 This information should be included in your cover letter; we will change the online submission form on your behalf.

4. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Additional Editor Comments :

Please carefully attend to the comments of the reviewers and answer the questions raised by Reviewer 2.

[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: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: 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

Reviewer #2: 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

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 proposes some interesting findings on patient's behaviour during COVID-19 pandemic. But i have few suggestions/questions.

1. In Introduction Section, this line should be properly referenced, "Previous studies suggest that people change their behaviors voluntarily to reduce the chance of contracting diseases."

2. In Introduction Section, there is a line " We utilize a difference-in-differences design and a 2014–2020 county-by-week-level dataset from Taiwan’s National Health Insurance (NHI), covering the entire population in Taiwan.". A little description on DID and why DID is appropriate for this study should be mentioned clearly.

3. In Table 3, some of the values are missing, if the values are zeros, they should be mentioned properly.

4. Why are there different p-values were used for different tests? If authors has specific reason to do so, it should be properly mentioned with reference.

5.For mortality analysis, authors used dataset from 2008-2019 but the full analysis was done on 2014-2020. Mortality analysis also needs to be done in the same period to do comparative analysis and draw any conclusions and the corresponding discussions should be updated accordingly.

Reviewer #2: This is an important and relevant report on the assessment of health consequences attributable to the COVID-19 pandemic in Taiwan. The authors do provide a thorough background of the COVID-19 response measures during the pandemic showing a unique position Taiwan (being low COVID-19 burden possibly (i) fear and voluntary concerns, and (ii) the use of masks could be more important to reduce health care utilization in general). The authors chose to use DID (difference in differences) and found a reduction in health care utilization (for outpatient and inpatient).

However, few issues:

1. Please do review the manuscript organization to align with PlosONE guidelines (see https://journals.plos.org/plosone/s/submission-guidelines)

- Note Abstract/Introduction/Materials and methods/Results/Discussion/Conclusions: All these pieces are present in the manuscript but they are not in that sequence

- For the readers of PlosONE it is too much to have such an Introduction + Background extension (6 pages and something more). Please just make on Background and do not put results or discuss your results on it. End this section with the aims.

2. The same issue of formatting with citations. Please see the guidelines. PLOS uses “Vancouver” style.

3. For the models, the authors state that they used the Poisson regression and a multiway approach to compute standard errors clustered both at the year-week and county level. Does this address potential overdispersion so common in count data?

4. Also, the authors indicate to have applied weighted regression by population size of a county. Why this weighting?

5. Please document the software used, and if possible share the code and the data used for this analysis. This is a quite pedagogic work.

6. I could not see the figure 3.

7. Table 1: These are mean and standard deviation. I wonder if Taiwan collects population and other demographic characteristics on weekly basis and at a county level. For example, the population pre- to post-outbreak changes. Why?

8. Tables 2, 3 and similar tables in the supplements present betas as they come from the software. I would recommend presenting in the main manuscript exponentiated version (which are relative changes) and their confidence intervals. And put the betas as of now in the supplements.

**********

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: Yes: Sheikh Saifur Rahman Jony

Reviewer #2: Yes: Orvalho Augusto

[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.

Measuring Voluntary Responses in Healthcare Utilization During the COVID-19 Pandemic: Evidence from Taiwan

PONE-D-21-39908R1

Dear Dr. Yang,

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,

M. Sohel Rahman, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

There are a couple of vey minor comments from Reviewer 2. I leave up to your discretion to consider those while you upload the final version.

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: 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

**********

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: Authors has addressed all my comments properly. I think the paper can be accepted in current form.

Reviewer #2: This is a very good work and also pedagogical.

The Taiwan COVID-19 experience is unique, and the good data availability makes coupled with this analysis may teach the planet on how voluntary actions could largely change the course of an epidemic.

Few minor issues:

1. In the spirit of the pedagogy I would ask the authors, if they can, present in the appendix a snip of the year, week and the dummy indicators (for year, few for weeks). The formulas are good and clear. But remember not all people can follow this brilliant parametrization.

2. Figure 1. Please, add somewhere that this is for year 2020.

3. Lines 402 to 405 - OK for the possibility that measures lead to a "prevention effect". Isn't possible, as well, that people decided to hide they were sick?

**********

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: Yes: Orvalho Augusto

**********