Healthcare utilization in children across the care continuum during the COVID-19 pandemic

Alan R. Schroeder; Alex Dahlen; Natasha Purington; Francisco Alvarez; Rona Brooks; Lauren Destino; Gayatri Madduri; Marie Wang; Eric R. Coon

doi:10.1371/journal.pone.0276461

Peer Review History

Original SubmissionMay 19, 2022
8 Jul 2022 Decision Letter - Tai-Heng Chen, Editor PONE-D-22-14626Healthcare Utilization in Children Across the Care Continuum During the COVID-19 PandemicPLOS ONE Dear Dr. Schroeder, 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 Aug 22 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 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: 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: Yes 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: Healthcare Utilization in Children Across the Care Continuum During the COVID-19 Pandemic Overall: The paper focused on the essential topic of “ utilization of pediatric services during Covid”. It is week written. Introduction: The information included in the second paragraph does not have any reference. In the second paragraph, “Major shifts in health care use and diagnosis patterns are important to describe as we monitor child health following the pandemic” needs to be rephrased. What shift the authors are referring to is unclear. How the training can help the shift has also not been clarified. The statement “how viral transmission and healthcare utilization impact the incidence and outcomes of specific diseases” is beyond the scope of this study as the source of data is insurance claim administrative data. Method The major concern is why include four years of data for comparison rather than taking previous year's data (March 2019-Feb 2020) for analysis? There was no justification given. The authors focused on primary care, urgent care, and ED visits, hospitalizations, and prescription medication claim but did not provide the operational definition of those terms. Results It would have been useful for the policymakers to show the utilization rate change according to the income quintile, race, and gender. Discussion The utilization rate over four years period might create a bias toward utilization rate. The conclusion about future policy or strategy the differentiation if any, across gender, race, and income quintile would have been helpful. Reviewer #2: This is a very well-written manuscript describing changes in healthcare utilization related to the pandemic across different sectors in a population-based sample of US children. It adds to the literature by broadening the US data to include outpatient care and prescriptions and by including emergency department and admissions to community hospitals. Given the broad nature of the outcomes, the analyses raise more questions that are relevant both for future pandemics but also to potentially extraneous patterns of health care use at baseline. The authors did an excellent job in the discussion of highlighting which findings require more investigation. I have only minor comments to potentially strengthen the manuscript. Methods: • As per RECORD guidelines, a comment on whether the dataset has ever been validated would be helpful (even if it hasn’t been – there was only a comment in the limitations in general related to ICD-10 codes). Analysis: • it would be important for the authors to justify why the models weren’t age/sex adjusted – the fact that age and sex distribution were similar amongst enrollees across the time periods doesn’t mean that there would not have potentially been effects of either across the outcomes. Discussion: • The authors cite studies from other jurisdictions (UK, Canada etc) and it would be helpful to comment that the consistencies of many findings, despite different 1) health systems, 2) levels of COVID transmission at various time points and 3) restrictions (esp school closures) is also worthy of more comparative investigation. • The inability to distinguish new vs recurrent problems (because of no ability to link across episodes) is a limitation that should be included. This is esp. true for the findings around DKA as the implications of higher rates of DKA in incident vs prevalent cases are different. For the former this is related to delays in care seeking or issues in misdiagnoses in primary care whereas for children with known diabetes, this would be related to problems with specialized care. ****** 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: Yes: Astrid Guttmann ******** [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. Attachments Attachment Submitted filename: Comments PON_ June 2022.docx https://doi.org/10.1371/journal.pone.0276461.r001
Revision 1
23 Aug 2022 Author Response Dear Editors, PLoS One: We appreciate the favorable reviews for our manuscript and thank the reviewers for their thoughtful comments and suggestions, which have strengthened the manuscript. Below is a point-by-point response to each suggestion. Reviewer #1: Comment 1: The information included in the second paragraph does not have any reference. Response: Multiple additional references were added following the first sentence. Comment 2: In the second paragraph, “Major shifts in health care use and diagnosis patterns are important to describe as we monitor child health following the pandemic” needs to be rephrased. What shift the authors are referring to is unclear. Response: The sentence has been modified and now reads as follows: “Major shifts in health care use and diagnosis patterns as we have observed are important to describe quantify as we monitor child health following the pandemic.” Comment 3: How the training can help the shift has also not been clarified. Response: The sentence has been modified and now reads: “Additionally, quantification of these shifts help to identify potential gaps in clinical exposure for students, residents, and fellows who underwent training during the pandemic.” Comment 4: The statement “how viral transmission and healthcare utilization impact the incidence and outcomes of specific diseases” is beyond the scope of this study as the source of data is insurance claim administrative data. Response: We agree that we are not analyzing outcomes in this paper. However, this paper will serve as a guide for our group (and hopefully other investigators) to know which conditions to target for these types of investigations. We have modified the sentence as follows: “Such information provides a “natural experiment” to investigate how viral transmission and healthcare utilization impact the incidence and outcomes of specific diseases, and quantifying any changes in incidence is a necessary first step.” Comment 5: The major concern is why include four years of data for comparison rather than taking previous year's data (March 2019-Feb 2020) for analysis? There was no justification given. Response: Thank you for this comment – we agree that clarification would help. We felt that we needed at least a few years of pre-pandemic data to account for trends that may have predated the pandemic (for example, SSRI prescriptions were rising steadily from 2016-2019) and to mitigate the impact that an unusual occurrence (e.g. a bad influenza year) would have if only one year were used. We did not go back further than 2016 given the ICD9 to ICD10 transition in late 2015. We have added the following sentence: “We elected to use 2016 as a starting point to allow sufficient time to account for secular trends in utilization that may have begun prior to the pandemic.” Comment 6: The authors focused on primary care, urgent care, and ED visits, hospitalizations, and prescription medication claim but did not provide the operational definition of those terms. Response: The first page of Supplementary Information describes how all of these types of utilization were defined. Comment 7: It would have been useful for the policymakers to show the utilization rate change according to the income quintile, race, and gender. Response: We agree with the reviewer that our analysis leaves open the possibility that different demographic groups were affected differently during the pandemic—heterogeneity of treatment effect. While a full analysis of this heterogeneity would be really interesting, we decided that it was outside the scope of our analysis, and would require multiple additional tables and figures, as well as potentially lengthy explanations for any notable findings. We are in the process of procuring a Medicaid database and do intend to compare and contrast utilization patterns for that. Nonetheless, given the related comment from Reviewer 2 below, we did do an additional analysis adjusting for these covariates. See comments below. We have added a sentence to limitations section after mentioning the private insurance only limitation: “Understanding how these utilization patterns differed across demographics is an important next step.” Comment 8: The utilization rate over four years period might create a bias toward utilization rate. Response: The utilization rate described is a count per 100 child years, and should not be biased by the number of years prior to the pandemic. As stated above, it is important to account for trends that predated the pandemic, and the ITS model is used precisely for that purpose. Comment 9: The conclusion about future policy or strategy the differentiation if any, across gender, race, and income quintile would have been helpful. Response: thank you for this insightful comment. Please see above responses and response to reviewer comment 2. Reviewer #2: We thank Dr. Guttman for her very kind comments and suggestions for improvement. Comment 1: As per RECORD guidelines, a comment on whether the dataset has ever been validated would be helpful (even if it hasn’t been – there was only a comment in the limitations in general related to ICD-10 codes). Response: We have added a sentence to Methods, with 3 references investigating this question: “Although deidentification of patient information makes formal validation of claims data challenging, some investigations have demonstrated encouraging reliability, though specificity of diagnostic codes is likely higher than sensitivity.22-24” The section in Limitations reads: “Although investigations into the validity of diagnostic codes in claims data have mostly been promising,22-24 there is still potential for miscoding.” Comment 2: it would be important for the authors to justify why the models weren’t age/sex adjusted – the fact that age and sex distribution were similar amongst enrollees across the time periods doesn’t mean that there would not have potentially been effects of either across the outcomes. Response: A similar comment was made by Reviewer 1, see our related response above. We focused on unadjusted differences in part because presentation in this fashion can be easier to interpret. Additionally, we wanted our data to depict actual “real world” changes. When we performed the full interrupted time series analysis for trends in demographic makeup cohort (results in the supplement), we found that no demographic variable made a step change of >1%. Nonetheless, in response to this suggestion, we’ve also added a sensitivity analysis to the Supplement where we adjust for demographic shifts, and indeed the results are pretty much the same. The Supplementary Methods now ends with: “Lastly, as a sensitivity analysis, we included demographic covariates (age, sex, and race, census region, and income quartile) in the ITS model to examine the extent to which adjustment for these variables led affected the unadjusted rates.” The Results section now has a new paragraph reading: “In our sensitivity analysis, adjusting for the demographics portrayed in Table 1 (age, sex, race, census region, and income quartile) did not have a meaningful impact on the changes in utilization in the early or mid-pandemic periods (Supplementary Figure 6).” The supplementary tables and figures now has an additional Supplementary Figure 6 portraying the results of this sensitivity analysis. Comment 3: The authors cite studies from other jurisdictions (UK, Canada etc) and it would be helpful to comment that the consistencies of many findings, despite different 1) health systems, 2) levels of COVID transmission at various time points and 3) restrictions (esp school closures) is also worthy of more comparative investigation. Response: We added the following sentence to Limitations: “Similarly, investigations comparing shifts in utilization patterns between different countries and in the context of varying states of transmission of COVID-19 (and related restrictions) may also help to inform policy.” Comment 4: The inability to distinguish new vs recurrent problems (because of no ability to link across episodes) is a limitation that should be included. This is esp. true for the findings around DKA as the implications of higher rates of DKA in incident vs prevalent cases are different. For the former this is related to delays in care seeking or issues in misdiagnoses in primary care whereas for children with known diabetes, this would be related to problems with specialized care. Response: We added the following two sentences to Limitations: “Furthermore, we did not attempt to discriminate between new versus recurrent problems. Such discrimination is important to better understand some of the changes we observed in conditions such as diabetic ketoacidosis.” Attachments Attachment Submitted filename: PLoS_Response_PUPPI_7-21-22.docx https://doi.org/10.1371/journal.pone.0276461.r002
7 Oct 2022 Decision Letter - Tai-Heng Chen, Editor Healthcare Utilization in Children Across the Care Continuum During the COVID-19 Pandemic PONE-D-22-14626R1 Dear Dr. Schroeder, 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, Tai-Heng Chen, M.D. Academic Editor PLOS ONE 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 ******** 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 ****** 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 ****** 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: All comments are addressed. There are several limitations of this study which have been acknowledged by the authors!! ****** 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: Yes: Malabika Sarker ******** https://doi.org/10.1371/journal.pone.0276461.r003
Formally Accepted
20 Oct 2022 Acceptance Letter - Tai-Heng Chen, Editor PONE-D-22-14626R1 Healthcare Utilization in Children Across the Care Continuum During the COVID-19 Pandemic Dear Dr. Schroeder: 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. Tai-Heng Chen Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0276461.r004

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