PONE-D-21-28858Effect of COVID-19 pandemic on missed medical appointments among adults with chronic diseases conditions in Northwest, EthiopiaPLOS ONE

Dear Dr. Shitu,

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.

The reviewers have raised a number of concerns in their comments; please ensure that you address each of the reviewers' comments in revising your manuscript. Please also note the technical requests below regarding 1) participant consent, and 2) the survey or questionnaire used in this study.

Please submit your revised manuscript by Apr 30 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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Hugh Cowley

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PLOS ONE

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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

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

Reviewer #1: Yes

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: No

Reviewer #2: No

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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: Thank you for the opportunity to review this paper, which looks at pre and during Covid-19 rates of missed appointments in Ethiopia. It was very interesting to read, and is very topical and provides new and useful information on the topic, and how Covid-19 has impacted on how many appointments are missed- which is a very relevant and potentially useful area for policy and practice.

I have made a few comments, that will help to increase the readability of the paper, and some suggested additions to the discussion. There are a few instances of language needing a bit of attention (words missing or just wrong tense), and I have highlighted a few but would suggest authors have another check through.

Abstract:

Results: There seems to be a missing word where it reads ‘most (55.4%) were female.’ Suggest need to add in ‘participants’ or similar.

Conclusion: This is repetitive as it duplicates the reasons of missed appointments which is also found in results. The conclusions would be better to include more about the implications of the findings or the next steps for future research. This relates to a later comment about the conclusion in the main body of the paper.

Introduction:

The first paragraph of the introduction would benefit from more references. If the references that are provided also cover earlier points, it might be worth adding the reference number in again. Some points seem to be unreferenced so this would make it clearer. One example of this is ‘Access to health facilities was restricted due to fear of the spread of the virus from patient and health professional perspectives. Patients were scared to go to a health facility to receive their care and treatments.’ This occurs throughout the introduction.

In the second paragraph of the introduction you state that ‘Although the virus infects every individual’ this would read better as ‘potentially infects every individual’ as much is still unknown and not everyone is infected.

When you say ‘An estimated 41% of adults had delayed or avoided medical care including urgent or

emergency care (12%) and routine care (32%) because of concerns about COVID-19 in the US’ it would be helpful to define the timeframe that this covers.

It would be useful to include a statement on why looking at missed appointments is needed/ relevant/ interesting. What is the impact of missed appointments on health services and patients? (cost and time for health care professionals and unmet need/ delayed treatment for patients).

Methods:

Study design and period: ‘Two years retrospective data’ could you just briefly state what type of data this was- e.g. was it electronic patient records etc?

Study setting: Of the 9 hospitals that participated in the study, what were their demographics? (e.g were they rural/ urban etc).

Data collection methods and measurement:

This sentence would be worth rewording to make it clearer: ‘During data collection, it has been about a year since the emergence of the COVID-19 pandemic.’ Something like ‘Data collection was conducted approximately a year into the pandemic.’

On page 7 you mention patient interviews. This is the first mention, and it is not clear what this relates to. Is this a reference to the surveys that were used? It implies that there is a qualitative component to the study, so suggest rewording it.

Results:

Socio-demographic characteristics: In line with earlier comment, when you say ‘A total of 1,833 individuals with common chronic diseases were interviewed’ do you mean ‘A total of 1,833 individuals with common chronic diseases completed the survey.’ Possibly reword to make it clearer they completed the survey.

‘More than one-fourth (28.0%) of the individuals with a common chronic condition was not able to read and write’ should say ‘were’ not ‘was.’

There are a few examples in the results sections where the language would benefit from being revised to make it clearer. E.g. ‘About one in four patients (23.63%) have been following for more

than 10 years,’ (have been receiving follow-up?) and ‘However, only 33 (1.8%) diagnoses for COVID-19 and all of them were positive,’ (Diagnosed implies that they were positive) ‘Nearly one-third (33.35%) of the patients had identified co-morbid diseases in which hypertension was the commonest type of co-morbidity observed in most of the patients.’ (duplication- commonest and most- suggest just use one or the other).

Missed appointments: Again a few suggestions on improving the language. E.g. ‘About 225 (12.47% (95% CI: 11.13%, 14.20%)) of patients with common chronic diseases have missed their appointment during their follow-up before COVID 19 pandemic’ (remove ‘have’).

Discussion:

You start by discussing generally about Covid and low-income countries, but then move on to talk specifically about the country being studied. ‘There have been different strategies and non-pharmaceutical interventions implemented, however, the implementation level has been very limited due to the cultural and traditional practices in the country’. It would be good to state here when you move on to talk about one specific country to make it clear.

Again a few missed words in this section ‘the rate of COVID-19 transmission is higher United States, Singapore, Canada and Italy.’ Missing ‘in’.

Strengths and limitations: There is limited discussion of the strengths and limitations for this study. You mention a few strengths but no discussion of why they are strengths or how they strengthen the study.

I also suggest you could include a section on implications and discuss how this research can help understanding of this topic, implementation of policy or impact on practice. I also think that it would be useful to include any future research needed or [planned on the topic.

This also needs to be included in the abstract.

Reviewer #2: The authors conducted a retrospective cohort study to evaluate the impact of the COVID-19 pandemic on missed appointments among those with chronic conditions in Northwest of Ethiopia. It was important to know the scale of the impact and the risk factors that were associated with increased risk of no-show. Here are my concerns:

1. I do not know why the author called their study “chart review and cross-sectional survey”. Their data source was electronic chart. I also did not see any conventional survey was conducted. Suggest remove “chart review and cross-sectional survey” and replace it with “a retrospective cohort study”.

2. Appointment data were extracted during the COVID-19 pandemic and one year before the pandemic for the same patients. Thus, the outcome, missed appointments from these two periods were not independent. However, the authors used an independent t-test to test the difference in missed appointments before and during the pandemic. In addition, t-test may not be the right test for the number of missed appointments. A binomial test is preferred for count data, or just run the negative binomial regression model without including covariates.

3. In the Results, the authors described how they landed on negative binomial regression because of overdispersion. I recommend a) In Methods, make clear that number of missed appointment is the dependent variable in the negative binomial regression; b) consider the dependence of observations in the regression; c) consider including number of scheduled appointments as an offset in the regression model (natural log(number of scheduled appointments)); when the offset is used, they should remove “The more frequent the visits, the higher the incidence of missed appointments” in page 14, and should not include duration of follow-up because number of scheduled appointments already contained all the information needed.

4. It was not clear what criteria were used to determine that negative binomial regression model was the best. Please provide a reference in page 14.

5. These sentences in Discussion are confusing: “Still, after a year, the pandemic remains very challenging, especially for low-income countries. There have been different strategies and non-pharmaceutical interventions implemented, however, the implementation level has been very limited due to the cultural and traditional practices in the country.” We are in the third year of the pandemic. I do not know what “strategies” and “interventions” were referred to and for what purposes. Suggest removing these sentences.

6. The author did not distinguish missed appointments, cancelled appointments, and rescheduled appointments. Were cancelled and rescheduled appointments counted as missed appointments? If they were, how many of those missed appointments were cancelled or rescheduled? Please discuss this issue.

7. There were many grammar-like errors in the manuscript, some examples are: a) lower case for “No-show rate” in page 5; b) there should be a space between 1005 and (55.37%) in page 8; c) throughout the manuscript, insert a space in 95%CI (like 95% CI); d) need define abbreviations before using them (e.g., CIRR, AIRR); e) decimals were not consistence, for example, in Table 3, column 4, some numbers had two decimals and other had three decimals; also in the Table 3, some had no space between a number and left parathesis. f) it seems that the last sentence of the Results is not complete: “Nearly 40% increase in …..”. g) in page 17, “The possible reason may be because patients may fear contracting the pandemic if…” should be “The possible reason may be because patients may fear contracting the novel coronavirus if…”; h) in page 17, “experienced COVID-19 like symptom(s) sedentary lifestyle were found to ...” should be “experienced COVID-19 like symptom(s), and sedentary lifestyle were found to …”

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Reviewer #1: No

Reviewer #2: No

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PONE-D-21-28858R1Effect of COVID-19 pandemic on missed medical appointments among adults with chronic diseases conditions in Northwest, EthiopiaPLOS ONE

Dear Dr. Shitu,

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.

==============================

ACADEMIC EDITOR:

Appreciate that a conclusion was added, but it was too long, suggest the following:

The rate of missed appointment increased significantly during the COVID-19 pandemic. Older age, longer duration of follow up, more frequent follow-up, out-of-pocket expenditure for health service, history of poor follow-up, and sedentary lifestyle had positive relationship with missed appointments during the pandemic. Therefore, it is important to give special emphasis to individuals with these risk factors while designing and implementing policies and strategies for peoples with chronic diseases to ensure the continuity of care and to avoid the long-term impact on their health.

Need add the following before the last sentence of "Data Collection Methods and Measurements"

We extracted two-year’s data from medical chart (the primary data source). For those variables that were not recorded in the chart, we conducted patient interview to collect the data (the secondary data source).

It is good to see reasons for strengths and limitations. But there are some language issues. Suggest changing

“The other limitations include retrospective nature of the study might underestimate the outcome variable. Because when the date at for an appointments were not documented, we could not assured weather an individual missed the appointment or not. Moreover, this study considers both cancelled and rescheduled appointments as missed appointments. Though considering rescheduled appointments as missed appointments might overestimate the number missed appointments.”

to

“Another limitation is the retrospective nature of the study. When the date for an appointment was not documented, we could not determine whether an individual actually missed the appointment or not. Moreover, this study considered both cancelled and rescheduled appointments as missed appointments and might have overestimated the number of missed appointments.”

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Please submit your revised manuscript by Aug 06 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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• 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,

Stanley Xu

Guest Editor

PLOS ONE

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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:

thank you for addressing the comments of reviewers and the paper improved significantly. As one of the reviewers and now a guest editor, I have some remaining minor issues.

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Reviewers' comments:

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Effect of COVID-19 Pandemic on Missed Medical Appointment among Adults with Chronic Disease Conditions in Northwest Ethiopia

PONE-D-21-28858R2

Dear Dr. Shitu,

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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Stanley Xu

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

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