Prevalence of multimorbidity in Brazilian individuals: A population-based study

Ana Daniela Silva da Silveira; Jonas Eduardo Monteiro dos Santos; Marianna de Camargo Cancela; Dyego Leandro Bezerra de Souza

doi:10.1371/journal.pone.0296381

Peer Review History

Original SubmissionNovember 15, 2022
15 Mar 2023 Decision Letter - Bruno Pereira Nunes, Editor PONE-D-22-31513Prevalence of multimorbidity in Brazilian individuals: a population-based studyPLOS ONE Dear Dr. Silva da Silveira, 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 manuscript has been reassessed by two reviewers. Their comments are appended below. The reviewers observe some major concerns about the manuscript, and in particular they feel that important methodological issues exist that affect the technical soundness of your study, and the conclusions of the paper. We request authors to conduct a detailed review of the comments. Please submit your revised manuscript by Apr 29 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, Bruno Pereira Nunes, Ph.D. 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 [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: No ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: No ****** 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: No 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: In the Methodology Section please provide the following : • Basic description of multistage sampling used and clarification at what level(s) was the National Health Survey (NHS) representative; • Detailed description of all ethical considerations of the NHS; • Explanation on how NHS data became public with unrestricted access? • Explanation why did you analyze 88,531 responses and why multimorbidity was defined by the presence of two or more NCDs and later in the text you use the term condition? • Description of all independent variables used (for example: level of education, what do working status and minutes of physical activity mean); • Description of prerequisites for and procedure of the Poisson regression used. For the Results Section please do the following: • As Prevalence Ratio (PR) and Odds Ratio (ORs) are not the same thing and logistic regression coefficient B, Exp(B) and Wald test have values with regard to p value (Sig.), perform analyses again and use clearly defined statistical marks in the presenting tables. Reviewer #2: The manuscript addresses an emerging theme in the literature. However, the rationale is very superficial. The methods need more detail and the adjusted analysis seems to me to have many flaws, there is a need to review the adjustments. There is no focus on evaluating MM associated with any specific factor and this makes the manuscript much more superficial in other points, such as the discussion that needs greater depth. Comments were made in the attached text. ****** 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: 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. Attachments Attachment Submitted filename: PONE-D-22-31513.pdf https://doi.org/10.1371/journal.pone.0296381.r001
Revision 1
18 Apr 2023 Author Response Dear reviewers, all your recommendations have been accepted. All changes were described in the documents attached on the journal's platform. We appreciate the suggestions. The authors. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0296381.r002
25 May 2023 Decision Letter - Bruno Pereira Nunes, Editor PONE-D-22-31513R1Prevalence of multimorbidity in Brazilian individuals: a population-based studyPLOS ONE Dear Dr. Silva da Silveira, 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 manuscript has been reassessed by two reviewers. Their comments are appended below. The reviewers continue to observe major concerns about the manuscript, and in particular they feel that important methodological issues exist that affect the technical soundness of your study, and the conclusions of the paper. We request authors to conduct a detailed review of the comments. Please submit your revised manuscript by Jul 09 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, Bruno Pereira Nunes, Ph.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] 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: (No Response) Reviewer #2: 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: Partly Reviewer #2: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: No ****** 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 Reviewer #2: Yes ****** 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 Reviewer #2: 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: Please provide in the Methodology section: 1. what is the total number of participants covered by the analyses? 2. description why and how did you use Incidence Rate Ratio (IRR), 3. proofs of assumptions for the use of Poisson regression, 4. detailed procedure for the use of Poisson regression. Please provide in the Results section correct interpretations for PR (in comparison to what it is high / low) Reviewer #2: The rationale of the study does not seem to me sufficient. There is already recent evidence of MM and associated factors, including a longer list of PNS morbidities. The authors also need to explain the analysis model used, it is not clear. The list of diseases must be described and not just mention the figure. Provide an explanation for these variables (measurements):physical activity, body mass index (BMI), alcohol consumption, smoking, private health insurance, and medical care in the last year. In the discussion, the mention "memory bias" should be modified. I believe it is recall bias. Furthermore, limitations should be discussed and not just cited. ****** 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: No Reviewer #2: 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. Attachments Attachment Submitted filename: Review for PONE-D-22-31513R1.docx https://doi.org/10.1371/journal.pone.0296381.r003
Revision 2
11 Oct 2023 Author Response We appreciate the new suggestions for publication. The authors carefully reviewed the manuscript "Prevalence of multimorbidity in Brazilian individuals: a population-based study". Our responses to the considerations of Reviewer n#1 and Reviewer n#2 are listed below Dear Reviewer n#1, we accepted your suggestions and made the necessary adjustments according to your guidelines. We are grateful for that and have provided the answers to your questions below: The Reviewer #1 says: "Please find below my remarks: 1. On the Page 4, Line 78 – Authors write: “We analyzed 88,531 responses about the lifestyle of Brazilian individuals corresponding to the responses of people over 18 years old.”; and, 2. on the Page 6, Line 117 authors write: “The NHS 2019 involved 88,531 individuals corresponding to an estimated 159,171,311 individuals”; and, 3. present on the Page 7, Table 1. Estimated prevalence of multimorbidity according to sociodemographic characteristics, social determinants, lifestyle factors, and use of health services, with the number of participants of 47,598,091; and, 4. write statement, as an answer to the reviewer, that “In this study, we chose to carry out the Poisson regression model, the estimated measure used was the IRR (Incidence Rate Ratio) and the Wald test was used as post-estimation of the Poisson model. We do not use logistic regression”." A: All suggestions accepted and text corrected as explained below The Reviewer #1 ask: 1. what is the number of participants covered by the authors analyses? A: The number of responses analyzed in this research was 88,531 (On page 4, line 78 and page 6, line 117), corresponding to responses from individuals aged over 18 years. The SVY module for complex statistics made it possible to estimate these values for the total number of responses (159,171,311; page 6, line 117) and, of this total, the number of people in the category "with multiborbity" (people with 2 or more chronic diseases) is 47,598,091, represented in Table 1 (Page 7, Table 1). Reviewer #1 - 2&3: • write statement, as an answer to the reviewer, that “In this study, we chose to carry out the Poisson regression model, the estimated measure used was the IRR (Incidence Rate Ratio) and the Wald test was used as post-estimation of the Poisson model. We do not use logistic regression”. and 2. why and how did authors use Incidence Rate Ratio (IRR) for data from typical prevalence study such as National Health Survey? (an incidence rate ratio allows us to compare the incident rate between two different groups, exposed vs. non-exposed). and 3. where did they present assumptions for the use of Poisson regression? (two out of four assumptions should be that the distribution of counts follows a Poisson distribution and mean and variance of the model are equal) A: The classic Poisson probability distribution is applied to count data to model rates over time and predict whether the mean and variance are equal. However, in situations of underdispersion or overdispersion of the data – in which the mean and variance are not equal – it is possible to make adaptations to the classical model, using link functions. In this case, using Poisson modeling fits the binary result data using the logarithmic function to linearize the relationship between the result and the independent variables. It's the same assumption as logistic regression, but uses the logit link function. In the classic use of the Poisson distribution, the measure of association, after beta exponentiation, is the IRR, like the incidence rate of a given event. However, in the linearization process with the logarithmic function, the classic association measure can be interpreted as a prevalence ratio, as it is cross-sectional data. Reviewer #1 - 4: 4. why they interpret obtained ratios as high not giving belonging comparison (for example if IRR Greater than 1: This indicates that the incident rate is greater in an exposed group compared to an unexposed group). A: Suggestion accepted and text corrected (Page 8, Line 127 and 135) Dear Reviewer n#2, we accepted your suggestions and made the necessary adjustments according to your guidelines. We are grateful for that. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0296381.r004
14 Nov 2023 Decision Letter - Bruno Pereira Nunes, Editor PONE-D-22-31513R2Prevalência de multimorbidade em indivíduos brasileiros: um estudo de base populacionalPLOS ONE Dear Dr. Silva da Silveira, 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 Dec 29 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, Bruno Pereira Nunes, Ph.D. Academic Editor PLOS ONE Additional Editor Comments: The manuscript has undergone a thorough reassessment by one designated reviewer, and their comments are provided below for your consideration. Some concerns have been raised regarding the manuscript's rationale and methodological aspects, which impact the overall technical robustness of your study. We kindly urge the authors to carefully review the provided comments and incorporate necessary revisions into the text. [Note: HTML markup is below. Please do not edit.] 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 #2: (No Response) ******** 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 #2: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: No ****** 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 #2: 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 #2: No ****** 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 #2: (No Response) ****** 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 #2: 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. https://doi.org/10.1371/journal.pone.0296381.r005
Revision 3
2 Dec 2023 Author Response The last revision came without any files. After contacting the PLOS ONE editorial committee, I am resending the corrections to the latest version, which follows: Dear Reviewer n#1, we accepted your suggestions and made the necessary adjustments according to your guidelines. We are grateful for that and have provided the answers to your questions below: The Reviewer #1 says: "Please find below my remarks: 1. On the Page 4, Line 78 – Authors write: “We analyzed 88,531 responses about the lifestyle of Brazilian individuals corresponding to the responses of people over 18 years old.”; and, 2. on the Page 6, Line 117 authors write: “The NHS 2019 involved 88,531 individuals corresponding to an estimated 159,171,311 individuals”; and, 3. present on the Page 7, Table 1. Estimated prevalence of multimorbidity according to sociodemographic characteristics, social determinants, lifestyle factors, and use of health services, with the number of participants of 47,598,091; and, 4. write statement, as an answer to the reviewer, that “In this study, we chose to carry out the Poisson regression model, the estimated measure used was the IRR (Incidence Rate Ratio) and the Wald test was used as post-estimation of the Poisson model. We do not use logistic regression”." A: All suggestions accepted and text corrected as explained below The Reviewer #1 ask: 1. what is the number of participants covered by the authors analyses? A: The number of responses analyzed in this research was 88,531 (On page 4, line 78 and page 6, line 117), corresponding to responses from individuals aged over 18 years. The SVY module for complex statistics made it possible to estimate these values for the total number of responses (159,171,311; page 6, line 117) and, of this total, the number of people in the category "with multiborbity" (people with 2 or more chronic diseases) is 47,598,091, represented in Table 1 (Page 7, Table 1). Reviewer #1 - 2&3: • write statement, as an answer to the reviewer, that “In this study, we chose to carry out the Poisson regression model, the estimated measure used was the IRR (Incidence Rate Ratio) and the Wald test was used as post-estimation of the Poisson model. We do not use logistic regression”. and 2. why and how did authors use Incidence Rate Ratio (IRR) for data from typical prevalence study such as National Health Survey? (an incidence rate ratio allows us to compare the incident rate between two different groups, exposed vs. non-exposed). and 3. where did they present assumptions for the use of Poisson regression? (two out of four assumptions should be that the distribution of counts follows a Poisson distribution and mean and variance of the model are equal) A: The classic Poisson probability distribution is applied to count data to model rates over time and predict whether the mean and variance are equal. However, in situations of underdispersion or overdispersion of the data – in which the mean and variance are not equal – it is possible to make adaptations to the classical model, using link functions. In this case, using Poisson modeling fits the binary result data using the logarithmic function to linearize the relationship between the result and the independent variables. It's the same assumption as logistic regression, but uses the logit link function. In the classic use of the Poisson distribution, the measure of association, after beta exponentiation, is the IRR, like the incidence rate of a given event. However, in the linearization process with the logarithmic function, the classic association measure can be interpreted as a prevalence ratio, as it is cross-sectional data. Reviewer #1 - 4: 4. why they interpret obtained ratios as high not giving belonging comparison (for example if IRR Greater than 1: This indicates that the incident rate is greater in an exposed group compared to an unexposed group). A: Suggestion accepted and text corrected (Page 8, Line 127 and 135) Dear Reviewer n#2, we accepted your suggestions and made the necessary adjustments according to your guidelines. We are grateful for that. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0296381.r006
12 Dec 2023 Decision Letter - Bruno Pereira Nunes, Editor Prevalence of multimorbidity in Brazilian individuals: a population-based study PONE-D-22-31513R3 Dear Dr. Silva da Silveira, 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. Additionally, it is necessary for you to make the following adjustments for the final version of the manuscript: 1) Line 105: review and replace (if deemed appropriate) "robust variance" with robust adjustment of variance; 2) Line 209: is it memory bias or recall bias?; 3) review the English throughout the text; 4) send figures with greater clarity and resolution. 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, Bruno Pereira Nunes, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0296381.r007
Formally Accepted
19 Dec 2023 Acceptance Letter - Bruno Pereira Nunes, Editor PONE-D-22-31513R3 PLOS ONE Dear Dr. Silva da Silveira, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Bruno Pereira Nunes Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0296381.r008

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