Racial & ethnic disparities in geographic access to critical care in the United States: A geographic information systems analysis

Kendall J. Burdick; Chris A. Rees; Lois K. Lee; Michael C. Monuteaux; Rebekah Mannix; David Mills; Michael P. Hirsh; Eric W. Fleegler

doi:10.1371/journal.pone.0287720

Peer Review History

Original SubmissionJanuary 4, 2023
15 Mar 2023 Decision Letter - Jean Baptiste Lascarrou, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-23-00264Racial & Ethnic Disparities in Geographic Access to Critical Care in the United States: A Geographic Information Systems AnalysisPLOS ONE Dear Dr. Burdick, 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 Apr 28 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, Jean Baptiste Lascarrou 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. You indicated that ethical approval was not necessary for your study. We understand that the framework for ethical oversight requirements for studies of this type may differ depending on the setting and we would appreciate some further clarification regarding your research. Could you please provide further details on why your study is exempt from the need for approval and confirmation from your institutional review board or research ethics committee (e.g., in the form of a letter or email correspondence) that ethics review was not necessary for this study? Please include a copy of the correspondence as an ""Other"" file. 3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 4. We note that Figures 1, 2, S1 and S2 in your submission contain map 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 Figures 1, 2, S1 and S2 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/ 5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Additional Editor Comments: None [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: 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: The investigators present an analysis that aims to evaluate racial and ethnic disparities in access to intensive care services in the United States. The main analytic approach evaluates accessibility, using four categories of ICU bed counts per capita within a 60-minute drive from the centroid of each census block. They then calculated the proportion of adults in each racial and ethnic category within each access category. 1. The overall conclusion is that there is ICU bed availability according to geography, race, ethnicity, and urbanicity. This is not a novel finding and it diminishes my enthusiasm for the paper. 2. The numbers of intensive care unit beds, hospital beds, and hospitals are changing to a significant extent each year, so a cross sectional analysis in a single year is a less informative measure of access. 3. Not all intensive care unit beds are the same. Access to the services of a critical access hospital is not the same as access to a major medical center. A more nuanced evaluation of access to intensive care units that have full services would have been more informative. 4. Though others have used the same drive-time analysis described in this paper, an improvement that restricted driving to within-state would have more closely mirrored the behavior of EMS agencies. 5. As public health policy and Medicaid services are typically carried out at the state level, an analysis restricted to the state may have identified disparities resulting from policy. Reviewer #2: Kendall J. Burdick J. K. et al, write an interesting paper about racial and Ethnic Disparities in access to ICU beds. The article is well written and provides insights for decision policy. MINOR comments : Where does demographic data come from? Please could you specify in your article. What does ESRI demographic data mean? In the demographic data, Are Ethnicity and race self-reported? Which type of ICU beds were included in the analysis? Can you provide the definition of ICU beds? Maybe it would be interesting to stratified by the number of hospital? It's quite different in terms of disparities and equalities of access of care, if you compare for exemple 100 ICU beds of 1or2 hospitals (high volume hospital with high number of ICU beds) than 100 ICU beds of 10 hospitals (smaller hospitals but more widespread in the country). ****** 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: Richard CHOCRON ******** [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. https://doi.org/10.1371/journal.pone.0287720.r001
Revision 1
31 Mar 2023 Author Response Thank you for your thorough review of our manuscript and thoughtful comments. We have reviewed your comments, made the appropriate changes to our manuscript, and responded to your comments below. Thank you again for your consideration of our manuscript for publication in PLOS One. 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 We have updated our formatting to match the requested formatting document. 2. You indicated that ethical approval was not necessary for your study. We understand that the framework for ethical oversight requirements for studies of this type may differ depending on the setting and we would appreciate some further clarification regarding your research. Could you please provide further details on why your study is exempt from the need for approval and confirmation from your institutional review board or research ethics committee (e.g., in the form of a letter or email correspondence) that ethics review was not necessary for this study? Please include a copy of the correspondence as an ""Other"" file. Since our study did not include patient data, and the Census data through ArcGIS is publicly available, our study was deemed exempt by our IRB office. Please see the submitted IRB letter for confirmation. 3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. The population data used in the study comes from ESRI and is commercially available with a license for ArcGIS. Similar data is readily available from the Census. Our trauma center location data are owned by a third-party organization can be accessed by others through direct request to the Trauma Information Exchange Program (TIEP). Per their site, “Please email the ATS Staff at tiep@amtrauma.org if you are interested in more detailed TIEP data.” 4. We note that Figures 1, 2, S1 and S2 in your submission contain map 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. Figures 1, 2, S1 and S2 are original and were created using the ArcGIS Pro software by author, Kendall Burdick. There is no copyright to these images. 5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. As above, we have updated our file citations and added the supporting information to the end of our manuscript. Additional Editor Comments: None [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: 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: The investigators present an analysis that aims to evaluate racial and ethnic disparities in access to intensive care services in the United States. The main analytic approach evaluates accessibility, using four categories of ICU bed counts per capita within a 60-minute drive from the centroid of each census block. They then calculated the proportion of adults in each racial and ethnic category within each access category. 1. The overall conclusion is that there is ICU bed availability according to geography, race, ethnicity, and urbanicity. This is not a novel finding and it diminishes my enthusiasm for the paper. Thank you for the time spent reviewing and assessing our manuscript. While disparities are well described throughout many sectors of medicine, a national analysis of ICU access, at the population level, stratified by race, ethnicity and urbanicity has not be described in the literature before. This analysis provides detailed, population-specific analysis and a map of the US where critical care services can be provided, relative to their population. 2. The numbers of intensive care unit beds, hospital beds, and hospitals are changing to a significant extent each year, so a cross sectional analysis in a single year is a less informative measure of access. It would be desirable to evaluate these data over time instead of only a cross section analysis; however, this historic and annual data was not available to us at the time of this analysis. But we still feel that the disparities which our analysis emphases are an important contribution that will help identify not only where ICU beds are needed but also how the distribution of these beds affects people of different races and ethnicities. 3. Not all intensive care unit beds are the same. Access to the services of a critical access hospital is not the same as access to a major medical center. A more nuanced evaluation of access to intensive care units that have full services would have been more informative. There is variation in ICU bed type, for example, medical, surgical, and cardiac. In this study, we condensed the 3 types of beds into one category for our calculations. We believe that this is an appropriate methodological approach, considering that, as you mention in your previous comment, ICU beds have the ability to adapt into different types (ie surgical transforming into medical beds during the COVID surges), and this study is an assessment of critical care availability as a whole. 4. Though others have used the same drive-time analysis described in this paper, an improvement that restricted driving to within-state would have more closely mirrored the behavior of EMS agencies. We agree that the restriction to within-state analysis would mirror EMS agency support; though we did not limit our analysis to this, as care can be provided our reached through self-transport. Additionally, in the state of surges and hospital overflow, geographic analysis provides a comprehensive assessment of care regardless of state lines. It has been well documented that patients are frequently moved across state lines for ICU level care. 5. As public health policy and Medicaid services are typically carried out at the state level, an analysis restricted to the state may have identified disparities resulting from policy. We agree that the state level analysis provides interesting and unique insights into access, which is why we provided the state level variation in our supplemental material. Reviewer #2: Kendall J. Burdick J. K. et al, write an interesting paper about racial and Ethnic Disparities in access to ICU beds. The article is well written and provides insights for decision policy. MINOR comments : Where does demographic data come from? Please could you specify in your article. What does ESRI demographic data mean? In the demographic data, Are Ethnicity and race self-reported? Our data came from ArcGIS, which is provided by the company ESRI. This data is based on US Census data and the American Community Survey, and has been validated as the most accurate population data for US geographical research. We have clarified our method language to explain this. Methods: We used the 2021 population demographic estimates at the level of the census block group, provided through ArcGIS (ESRI, Redlands, CA). ArcGIS demographic data are based on US Census data and the American Community Survey, and were the most accurate population numbers across all geographies in the US, especially at the census tract and block group geography levels, compared to four other major data vendors. Which type of ICU beds were included in the analysis? Can you provide the definition of ICU beds? As mentioned in the Methods, ICU beds were described by the American Trauma Society Trauma Information Exchange Program database and included adult ICU beds, which was the sum of medical, surgical, and cardiac ICU beds. Methods: We considered a hospital with at least one adult ICU bed to be an ICU location. Bed counts included total adult ICU beds (sum of medical, surgical, and cardiac) for each location. Maybe it would be interesting to stratified by the number of hospital? It's quite different in terms of disparities and equalities of access of care, if you compare for example 100 ICU beds of 1or2 hospitals (high volume hospital with high number of ICU beds) than 100 ICU beds of 10 hospitals (smaller hospitals but more widespread in the country). We agree that this would add an interesting detail to analysis. We will be sure to include this stratification in future research. Attachments Attachment Submitted filename: PLOS One Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0287720.r002
12 Jun 2023 Decision Letter - Jean Baptiste Lascarrou, Editor Racial & Ethnic Disparities in Geographic Access to Critical Care in the United States: A Geographic Information Systems Analysis PONE-D-23-00264R1 Dear Dr. Burdick, 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, Jean Baptiste Lascarrou Academic Editor PLOS ONE Additional Editor Comments (optional): - None Reviewers' comments: - None https://doi.org/10.1371/journal.pone.0287720.r003
Formally Accepted
26 Jun 2023 Acceptance Letter - Jean Baptiste Lascarrou, Editor PONE-D-23-00264R1 Racial & Ethnic Disparities in Geographic Access to Critical Care in the United States: A Geographic Information Systems Analysis Dear Dr. Burdick: 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. Jean Baptiste Lascarrou Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0287720.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .