Trajectories of medical care expenditure in the last year of life associated with long-term care utilization in frail older adults: A retrospective cohort study

Noriko Yoshiyuki; Takuma Ishihara; Ayumi Kono; Naomi Fukushima; Takeshi Miura; Katsunori Kaneko

doi:10.1371/journal.pone.0297198

Peer Review History

Original SubmissionSeptember 5, 2023
25 Oct 2023 Decision Letter - Ramzi Ibrahim, Editor PONE-D-23-27675Trajectories of medical care expenditure in the last year of life associated with long-term care utilization in frail older adults: a retrospective cohort studyPLOS ONE Dear Dr. Kono, 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 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. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for letting me review this clinically important paper. I agree with the initial hypothesis that end-of-life medical care expenditure trajectories for older adults can be heterogenous. In a similar vein, within a study of elderly cancer patients on home-based palliative care, several differing trajectories of healthcare utilization were also seen. [https://doi.org/10.1186/s12916-022-02513-y] These are some of my comments for consideration: 1) Long-term care is understood differently depending on country context. Suggest providing a few sentences at the Introduction section to set the stage (instead of leaving it till later within the Methods section) 2) The first paragraph talks about frailty but then frailty barely mentioned in the remaining article. Even in Table 1, there is no capture of clinical data with respect to frailty (e.g. function, frailty scale, comorbidity severity, cognition, etc). In my opinion, elderly age and presence of a chronic disease is not sufficient to characterize frailty. Suggest rewriting the first paragraph to focus on the significance of studying medical care expenditure in EOL among elderly adults and linking it subsequently to why there is a eventual hypothesis that LTC is associated with different trajectories of care expenditure. The alternative is to include more clinical data/indicators for frailty, of which perhaps what would be also of interest would be frailty predictors for medical care expenditure. 3) It is interesting that within the Minimal MCE group, the total MCE in last year of life is 0 (0-0). Numbers are also not small (56/405 of cohort). Is this truly zero utilization of medical care? Or is this due to missing data (e.g. patient was recruited into the cohort but left the healthcare coverage area? Some patients did not file insurance claims?) If this is truly due to zero utilization, the authors could provide a statement to declare the comprehensive coverage of the primary outcome measure (healthcare insurance claims). Alternative is to consider a sensitivity analysis of trajectories excluding those patients with zero MCE or imputing their MCE. - Moreover, very few patients (1 per chronic disease type) within these 56 had a known chronic disease. Hence, on deterioration (prior to death), one would expect MCE of some form for further investigations? - I note that this has been subsequently mentioned in the discussion portion (about the lacking of continuous records of medical care utilization in the claim dataset). This missingness may need to be handled or at least written clearly as a limitation. 4) Suggest to reword as associations instead of causations. E.g. “home-based long-term care utilization was associated with increased medical care expenditure in the descending medical care expenditure group. Also I believe the testing of association between long-term care and MCE within group-based trajectory modelling is an incidence rate ratio which should be mentioned? 5) The paragraphs within discussion describing the possible associations with LTC and MCE trajectories are difficult to understand and need to be revised. - For example, for those with rising/persistently high MCE trajectories, a lower incidence rate ratio of MCE is associated with use of facility-based long-term care. The hypothesized reason behind this association should be clearly spelled out. (could it be because facility-based LTC provide some degree of medical/nursing care that reduces the need for hospital MCE?) - On another note, those with descending MCE trajectories, a higher incidence rate ratio of MCE is associated with use of home-based LTC. What is the hypothesized reason behind this association? 6) Under limitations, it is mentioned that ICD-10 did not fully assess chronic disease. However, a common methodology is to compute comorbidity severity (either charlson or elixhauser) via ICD-10 codes. This could be considered as a surrogate measure of comorbidity severity since the authors have access to ICD codes 7) The fourth limitation is unclear to me. May need to be rephrased. 8) Under conclusion, the first conclusion that there are heterogenous MCE trajectories is quite clear. The subsequent sentences are unclear and I am not sure what the authors are recommending. Are you suggesting that improving on long-term care utilization may attenuate high MCE? ****** 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. 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Revision 1
15 Nov 2023 Author Response Point-by-point responses to the reviewer’s comments We appreciate the reviewer’s helpful suggestions. Our point-by-point responses to the reviewer’s comments are provided below. In addition to the changes suggested by the reviewer, we have revised some other sentences at various points to improve their flow and comprehensibility and reduce redundancy. The newly added/revised text has been highlighted yellow in the revised manuscript. Reviewer 1 1) Long-term care is understood differently depending on country context. Suggest providing a few sentences at the Introduction section to set the stage (instead of leaving it till later within the Methods section) Response According to your suggestion, we have added a few sentences to the Introduction to set the stage for non-Japanese readers to understand the context of long-term care in Japan (L100-L107). 2) The first paragraph talks about frailty but then frailty barely mentioned in the remaining article. Even in Table 1, there is no capture of clinical data with respect to frailty (e.g. function, frailty scale, comorbidity severity, cognition, etc). In my opinion, elderly age and presence of a chronic disease is not sufficient to characterize frailty. Suggest rewriting the first paragraph to focus on the significance of studying medical care expenditure in EOL among elderly adults and linking it subsequently to why there is a eventual hypothesis that LTC is associated with different trajectories of care expenditure. The alternative is to include more clinical data/indicators for frailty, of which perhaps what would be also of interest would be frailty predictors for medical care expenditure. Response As you suggested, we have rewritten the first paragraph to focus on the significance of studying medical care expenditure and long-term care utilization among older adults at the end of life(L73–L85). 3) It is interesting that within the Minimal MCE group, the total MCE in last year of life is 0 (0-0). Numbers are also not small (56/405 of cohort). Is this truly zero utilization of medical care? Or is this due to missing data (e.g. patient was recruited into the cohort but left the healthcare coverage area? Some patients did not file insurance claims?) If this is truly due to zero utilization, the authors could provide a statement to declare the comprehensive coverage of the primary outcome measure (healthcare insurance claims). Alternative is to consider a sensitivity analysis of trajectories excluding those patients with zero MCE or imputing their MCE. Response Decedents whose total MCE in the last year of life was zero were followed up until their death, meaning the zero MCE was not due to missing data. However, we could not distinguish decedents who did not use medical care genuinely from those who used publicly funded medical care or required public assistance during the follow-up period. We have mentioned this point in the limitations. We assumed that decedents who used publicly funded medical care or required public assistance had not used medical care for more than two months immediately prior to death. Therefore, as you suggested, we have added a sensitivity analysis to estimate the trajectory of medical care expenditure for this group (L200-L203) (L353-L361). - Moreover, very few patients (1 per chronic disease type) within these 56 had a known chronic disease. Hence, on deterioration (prior to death), one would expect MCE of some form for further investigations? Response As you have clearly noted, for each chronic disease type, only one decedent in the minimal MCE group had a chronic disease. These individuals may have died suddenly without medical care. We have added this explanation to the Discussion (L419–L421), as you suggested. - I note that this has been subsequently mentioned in the discussion portion (about the lacking of continuous records of medical care utilization in the claim dataset). This missingness may need to be handled or at least written clearly as a limitation. Response As you suggested, we have clarified the lack of continuous records of medical care utilization in the claims dataset in the Limitations (L429–L443). 4) Suggest to reword as associations instead of causations. E.g. “home-based long-term care utilization was associated with increased medical care expenditure in the descending medical care expenditure group. Also I believe the testing of association between long-term care and MCE within group-based trajectory modelling is an incidence rate ratio which should be mentioned? Response Thank you for your suggestion. We have reworded the explanation as association to avoid causation (L402–L405). 5) The paragraphs within discussion describing the possible associations with LTC and MCE trajectories are difficult to understand and need to be revised. - For example, for those with rising/persistently high MCE trajectories, a lower incidence rate ratio of MCE is associated with use of facility-based long-term care. The hypothesized reason behind this association should be clearly spelled out. (could it be because facility-based LTC provide some degree of medical/nursing care that reduces the need for hospital MCE?) Response Thank you for your helpful suggestion. We have added the explanation to the Discussion section (L396–L401). - On another note, those with descending MCE trajectories, a higher incidence rate ratio of MCE is associated with use of home-based LTC. What is the hypothesized reason behind this association? Response Thank you for the question. Older adults at the end of life need palliative care, including medication, fluid replacement, or tube feeding, to relieve suffering. The patients receiving home-based long-term care might also access home-based medical care through visits by physicians or nurses. We have added this point to the Discussion (L405–L407). 6) Under limitations, it is mentioned that ICD-10 did not fully assess chronic disease. However, a common methodology is to compute comorbidity severity (either charlson or elixhauser) via ICD-10 codes. This could be considered as a surrogate measure of comorbidity severity since the authors have access to ICD codes Response We appreciate your suggestion. Our previous description of this limitation was insufficient. We have revised this limitation for clarity (L446–L449). 7) The fourth limitation is unclear to me. May need to be rephrased. Response We think this limitation is not important and have deleted it. 8) Under conclusion, the first conclusion that there are heterogenous MCE trajectories is quite clear. The subsequent sentences are unclear and I am not sure what the authors are recommending. Are you suggesting that improving on long-term care utilization may attenuate high MCE? Response As you suggested, we have revised the conclusion to clarify the recommendation (L462–L464). Attachments Attachment Submitted filename: 2023-1110_Point-by-point_response_to_reviewers.docx https://doi.org/10.1371/journal.pone.0297198.r002
2 Jan 2024 Decision Letter - Ramzi Ibrahim, Editor Trajectories of medical care expenditure in the last year of life associated with long-term care utilization in frail older adults: a retrospective cohort study PONE-D-23-27675R1 Dear Dr. Kono, 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, Ramzi Ibrahim, M.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: 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 ****** 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: My queries have been addressed. No further questions. ****** 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 ******** https://doi.org/10.1371/journal.pone.0297198.r003
Formally Accepted
16 May 2024 Acceptance Letter - Ramzi Ibrahim, Editor PONE-D-23-27675R1 PLOS ONE Dear Dr. Kono, 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. Ramzi Ibrahim Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0297198.r004

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