PONE-D-22-31987Cost effectiveness of repeat delayed imaging for spontaneous subarachnoid hemorrhagePLOS ONE

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- https://doi.org/10.1161/CIRCOUTCOMES.119.006406

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Additional Editor Comments:

Thank you Dr. Jin et al. The manuscript nicely models a cost-effectiveness of imaging. I would recommend modifications according to the attached reviewer comments.

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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?

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Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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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: This study evaluated the cost-effectiveness of repeat delayed imaging in patients with

SAH who had a negative result during their initial imaging from a healthcare perspective.

The manuscript was very well-written and logically constructed.

I totally agree to accept for publication, while some minor revisions are needed.

1.In abstract, the control group should be clarified in the description of results.

2.Some minor grammar errors need to be revised, for example, in line 110 should say ‘were’ instead of ‘was’.

3.The time horizon ‘lifetime’ may need to be clarified in methods section.

4.Complications for patients with SAH were not explicitly modeled in this study, the authors have illustrated this as a limitation, this is acceptable.

5.Line 130-136: Sensitivity Analysis: the range of sensitivity and specificity should be clarified.

Reviewer #2: The authors investigated the cost effectiveness of using repeat delayed imaging to diagnosis unruptured aneurysms that were missed after initial imaging. To do so, the authors developed a Markov model using available data relating to costs of imaging and treatment in the UK and the utility of certain outcomes. The authors presented their results as they related to the lifetime costs and QALY that patients were estimated to experience. This paper was well-written and easily digestible; however, the below points should be considered before the work is published.

1. Given that the model was specifically designed using assumptions for 55-year-old patients, it would be prudent for the authors to explicitly note this limitation in the ability to generalize their findings to a more diverse patient population.

2. Why did the authors choose to divide the time period of the study into one year cycles? A brief description of the reasoning and a relevant citation would help ground this decision.

3. The authors do not specify what aneurysm treatment method was used in the model (i.e. clipping versus coiling), which would be helpful in determining the overall applicability of their findings. Were both treatment methods accounted for or only one? If only one was factored into the analysis, this limitation should be noted.

4. The tornado diagram was difficult to understand; a more detailed explanation of how to interpret the diagram would be helpful in parsing the key points, as well as a higher-resolution image.

5. The authors mention two studies that were conducted in the US (Jethwa et al. and Kalra et al.) but do not comment on the fundamental differences in healthcare systems and overall healthcare costs between the two countries; the authors should consider briefly discussing these differences in the estimated costs used in the US studies versus their own UK study and how these differences, if any, may account for the difference in their findings.

6. Additionally, the authors note that one of the limitations of their study includes not explicitly modeling complications due to a lack of evidence. It is not clear to me what is meant by "lack of evidence". Are the authors referring to a lack of available data about the cost of complications from SAH in the UK? Given that Jethwa et al. includes complication-associated costs in their analysis, it may be prudent to explain in more detail how this limitation came about and the possible effect its exclusion may have on the results.

7. Finally, a more detailed explanation of how to interpret the utility and mortality of functional outcome would aid in understanding the results of the model and its sensitivity. For example, what factors may influence "the utility of survived patients with a favorable outcome"?

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: ONE-D-22-31987-recommendation.docx

Cost-effectiveness of Repeat Delayed Imaging for Spontaneous Subarachnoid Hemorrhage

PONE-D-22-31987R1

Dear Dr. Jin,

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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Kind regards,

Alfred Pokmeng See, M.D.

Academic Editor

PLOS ONE