PONE-D-22-22633Geographic Access to Hospital-Based Telehealth for Cancer CarePLOS ONE

Dear Dr. Shalowitz,

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.

I have now received reports from three reviewers. Based on the assessment and taking into consideration the feedback, I would like to invite you to revise your manuscript and provide a point-by-point rebuttal to all the comments.

Please submit your revised manuscript by Jan 12 2023 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,

Sonu Menachem Maimonides Bhaskar, MD PhD

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. Please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

3. Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study. 

4. Thank you for stating the following financial disclosure: 

Dr. Shalowitz received funding via the Wake Forest Comprehensive Cancer Center NCI cancer support grant (P30CA012197), and has received consulting fees from Nimble Co, LLC (purview.net) unrelated to the current work.

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." 

If this statement is not correct you must amend it as needed. 

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

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

Dr. Shalowitz received funding via the Wake Forest Comprehensive Cancer Center NCI cancer support grant (P30CA012197), and has received consulting fees from Nimble Co, LLC unrelated to the current work. 

Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests).  If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. 

Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

6. 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.

7. Please include a caption for figure 1.

8. We note that Figure 1 in your submission contain [map/satellite] images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright.

We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figure 1 to publish the content specifically under the CC BY 4.0 license.  

We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text:

“I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.”

Please upload the completed Content Permission Form or other proof of granted permissions as an "Other" file with your submission.

In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].”

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

The following resources for replacing copyrighted map figures may be helpful:

USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/

The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/

Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html

NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/

Landsat: http://landsat.visibleearth.nasa.gov/

USGS EROS (Earth Resources Observatory and Science (EROS) Center) (public domain): http://eros.usgs.gov/#

Natural Earth (public domain): http://www.naturalearthdata.com/

9. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

Additional Editor Comments:

I have now received reports from three reviewers. Based on the assessment and taking into consideration the feedback, I would like to invite you to revise your manuscript and provide a point-by-point rebuttal to all the comments.

[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: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: Yes

Reviewer #3: Yes

**********

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

Reviewer #3: 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: This manuscript provides an interesting overview of the telehealth and oncology services in US hospitals prior to the pandemic. The authors are to be commended for the readable and logical organization of the manuscript. A few comments relating to the methods and certain key design decisions are noted below.

1. It is not clear if the availability of telehealth services correlate with the quality of the care provided at a given hospital. Could the authors comment on the quality of the services provided by these hospitals?

2. Do the hospitals that provide telehealth services, use telehealth to provide oncology care? Are there data to show what the telehealth services in these hospitals were used for in the pre-pandemic era?

3. It is difficult to assess policy/clinical implications of this work without knowing how the lack of availability of services/care relate to cancer outcomes--how do the differences in availability of services translate to disparities in cancer outcomes?

4. The results show that larger hospitals are 37 times more likely to provide oncology services among those hospitals that provide telehealth. Most of the smaller/rural hospitals are less likely to provide oncology care or access to telehealth services—perhaps these hospitals are more likely to refer cancer patients to nearby larger hospitals for cancer care? If that is true, the availability of telehealth services in larger hospitals that provide oncology services could perhaps help reduce cancer care deficiencies.

Overall, it is not clear if the greatest improvement in health outcomes depend on increasing oncology and telehealth services in rural hospitals OR further increasing the telehealth capacity in existing larger hospitals. It is not clear how a policy-maker could use this study to improve care for the population.

Reviewer #2: Reviewer name: Alma Nurtazina

Geographic Access to Hospital-Based Telehealth for Cancer Care

Corresponding author: David Shalowitz, M.D.. MSHP

Wake Forest University School of Medicine

Winston-Salem, NC UNITED STATES

The authors present the results of a cross-sectional study based on the data from three main surveys conducted in 2013-2019 in the USA. In total, data from 4540 hospitals were analyzed for telehealth and oncology services.

The title is expected to contain a place of study because of the high variability of telehealth services across different countries. The abstract describes the essential information in the work. The paper’s goal is within the scope of the journal. The introductory section adequately explains the framework of the research. The importance of the research idea is evident. The authors have applied an appropriate methodology to their research and clearly described it. The presentation of the study is complete for a scientific paper. The results are described and analyzed adequately. The article is written clearly and logically consistently. The conclusion is logically supported by the obtained results.

There are a few minor limitations:

1. The title does not contain the place of the study.

2. The authors did not mention study design which is a cross-sectional.

3. There are several errors in the tables’ design and data presentation.

4. The reference list is incomplete.

Reviewer #3: Thank you for giving me the opportunity to review this research, which evaluates US hospitals’ ability to provide equitable access to oncology services via telehealth. This is an important study that highlights the number of Americans with cancer who had to attend all cancer appointments in person prior to the pandemic. This is a well-written manuscript. However, considering that the data for telehealth utilization are pre-pandemic (and therefore of limited utility to today’s researchers and policymakers), the authors need to ensure that they are appropriately contextualizing the research to highlight its relevance. Please see below for specific areas for improvement.

Major

1. Thank you for acknowledging that these data are pre-pandemic and therefore likely do not represent the current use of telemedicine in hospitals. This is a significant limitation given what we know about the uptake of telemedicine in the US since 2020, and should be reflected in the title. Further, in order to make this relevant to today’s researchers and policy makers, the authors should consider bringing this limitation to the forefront of the discussion-- currently it is not mentioned until late in the discussion. For example, in the first discussion paragraph, when you discuss increasing rurality being associated with lower telehealth rates, I suggest you discuss how this disparity is likely still the case today (some data should be available to support this), even though your analysis is pre-COVID.

2. In the second discussion paragraph, the authors write about how it is “crucial to encourage hospitals caring for cancer patients” to adopt telehealth. Again, this needs to be framed in the understanding that this may have already happened. Further, there should be more specifics included. For example, what do the authors mean by “encourage?” Through national policy? Medicare reform? There is a robust discussion currently around making certain telemedicine reimbursement waivers permanent beyond the Public Health Emergency, and this might be a good place to bring in some of these arguments to describe how hospitals would be encouraged to adopt these technologies.

3. The authors point out that only 8% of telehealth claims were for oncology in 2021. This statement needs to be contextualized in comparison to other specialties, and regarding what percent is appropriate for oncology. For example, my understanding is that an initial visit for a cancer diagnosis needs to be done with an in person exam. Are there initial visits that are appropriate for telemedicine? Further, rural patients who are on active treatment typically have their visits stacked on the same day as infusion, radiation, or radiology visits (see: DeGuzman et al, (2015). Identifying barriers to navigation needs of cancer survivors in rural areas. Journal of Oncology Navigation & Survivorship, 6, 34-42), so a telehealth visit may not make sense in these cases.

4. It may be worthwhile to consider discussing that even as telehealth becomes more ubiquitous in hospitals, those living in rural areas often lack broadband, which raises its own set of challenges. Since COVID-19, alternative origination sites (such as public libraries), and the need to extend federal regulations that support reimbursement for telemedicine services.

Minor

1. In the section on Data Sources (page 4), it would be clearer to list the data sources in the same order that you explain them in that section (i.e. switch #2 and #3)

2. On page 5, line 133, it would be clearer to state what the outcomes are before explaining you they were derived: “Thus study has two primary outcomes: x and y.”

3. On page 5 lines 140-141, it would be clearer to put the statement “per their self-reported telehealth and oncology services provisions” in parenthesis

4. On page 8, line 199, although I was able to figure out where you got the number 2326 from in your table (hospitals providing cancer care), it took a while to figure it out and I wonder if this could be explained clearer.

**********

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: Alma Nurtazina

Reviewer #3: No

**********

[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.

Pre-Pandemic Geographic Access to Hospital-Based Telehealth for Cancer Care in the United States

PONE-D-22-22633R1

Dear Dr. Shalowitz,

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,

Sonu Bhaskar, MD PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for submitting the revised version of your manuscript. I am pleased to accept the manuscript in its current form. Thank you for submitting your work to PLOS One.

Reviewers' comments: