PONE-D-23-27005Rate of forgone care during the COVID-19 pandemic in Baltimore, MDPLOS ONE

Dear Dr. Meyer,

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.

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PLOS ONE

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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?

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

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

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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: No

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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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: Thank you for allowing me to review this paper. I have major issues with the paper in general, in particular with the methods and analytical pieces of it. I am also not convinced about the novelty and contribution of this study the way the authors frame it. Below are some of my comments:

L41: Studies using data from the Urban Institute capture exactly this question; ie Giannouchos TV, Brooks JM, Andreyeva E, Ukert B. Frequency and factors associated with foregone and delayed medical care due to COVID‐19 among nonelderly US adults from August to December 2020. Journal of evaluation in clinical practice. 2022 Feb;28(1):33-42.

L42: Or choice due to less urgent need – some rate of foregone care might actually be a good thing when patients overutilize the healthcare system. So this statement is partially true and should be revised

L38-46: There are more US studies looking into foregone/delayed care thus the authors should review the literature more careful or at least acknowledge that there is more than “limited” evidence (L43)

A short search revealed the following:

Giannouchos TV, Brooks JM, Andreyeva E, Ukert B. Frequency and factors associated with foregone and delayed medical care due to COVID‐19 among nonelderly US adults from August to December 2020. Journal of evaluation in clinical practice. 2022 Feb;28(1):33-42.

Findling MG, Blendon RJ, Benson JM. Delayed care with harmfulhealth consequences—reported experiences from national surveysduring Coronavirus Disease 2019.JAMA Health Forum. 2020;1(12):e201463

Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. TheImpact of the COVID‐19 pandemic on hospital admissions in theUnited States: study examines trends in US hospital admissionsduring the COVID‐19 pandemic.HealthAff. 2020;39(11):2010‐2017

Jeffery MM, D'onofrio G, Paek H, et al. Trends in emergency de-partment visits and hospital admissions in health care systems in 5states in the first months of the CoViD‐19 pandemic in the US.JAMA Intern Med. 2020;180(10):1328‐1333

L46: what was the estimated rate of foregone care and how higher was it in marginalized communities?

L53: You only cite 1 study here; how is the data mixed if 6-7 find the same thing and only one does not? In addition, the cited study that did not find similar association analyzed only Medicare beneficiaries who are different anyway. I would suggest reviewing these more carefully and updating the text

L53-55: This sentence should either be excluded or mentioned way earlier in the document (ie 1st paragraph)

L63: During the pandemic?

L69-71: The authors make an argument that nationally representative survey data do not employ robust sampling strategies and lack representation of such population. Please review this and rephrase. Also, add references so that the reader can judge which studies you are referring to. The study by Giannouchos et al use UI HPS data which are among the most comprehensive nationwide surveys – which the authors have missed in their search. Same throughout L71-73.

L75-79: Similar with the previous comment, I am not sure how under-resourced communities in Baltimore are nationally representative of other similar communities in New Mexico for example. I would suggest the authors rethink their contribution to the literature and the advantage of their study compared to previous work. Maybe the use of a survey with more recent data relative to what is published is a stronger argument.

L83: Adults as 18+ or 18-64?

L84 & 134: What was the rationale for using person-years? I am still not convinced by this. The question / outcome is dichotomous, they weren’t asked how many times – in which case enrollment length would matter. Did the authors consider or do a robustness check on this?

L86: Where these data collected for different studies? If so, your study is retrospective and secondary and you pulled your data from these studies. This should be made more explicit.

TABLE 1 should be an appendix; it is not a finding nor something that the researchers did for this study

L119: So how many were excluded? My understanding is that around 30% were excluded. If so, did the authors check on missingness? Was it at random?

L120: How many in each exclusion?

I see that this addressed in Figure 1 and the first section of the results. Maybe this should be moved in the methods.

L125: Is it possible to identify who skipped, missed, or delayed as separate outcomes? Skip is very different than delay.

L139-140: I don’t understand this. Do you mean stratified analyses?

L145-147: This is very problematic. The study N should be robust and justified, not change throughout.

L149: Why not chi2 or Fisher’s exact?

L139-151: The standard would be to conduct some sort of multivariable regression model to assess variation in foregone rate by various characteristics/factors. I am surprised that the authors did not do this, so I would encourage them to do so. Otherwise, descriptive findings and significances reported can be misleading. This is a serious issue.

L168: To my comment on representation above, 96% are not Hispanic – so your sample has external validity issues. Hence, I would encourage rethinking the strength and contribution of your work in the Introduction

Table2: I would suggest adding 2 columns and comparing those with and without reported foregone care and their p-values here which is how most studies present their findings as in this field

L185-188: I am concerned about this; see my comment above

TABLE 3: The Ns of Total Events are not consistent. This needs to be fixed. This table is confusing as well and suggest updating it as mentioned above

Lack of multivariable regression is a problem here. There is a need for this to explore which associations hold once adjusted for.

L219: An N of 2,000 is not large

L220-227: This might be a strength but is not suitable here. The first paragraph in the discussion should wrap up the findings and provide a comprehensive summary of the main findings. If the authors would like to highlight the strengths of the two samples, this should be mentioned later and more succinctly.

L229: First, how does the identified rate align with the available literature? That is the first big finding.

L238: I am not sure that his result will hold in a regression model

L243 & 251: Reference?

L251: Could this finding be sample specific?

L261: But you didn’t study immunocompromised nor present evidence about those. In addition, among the finding, are any of those at increased risk of mortality? Otherwise, this is a true comment, but not backed up but the study and irrelevant

L275: Isnt that shown in Table 3? If not, what are these numbers?

Limitations: Also, its not nationally representative and lacks external validity

L287: This is an assumption and cant be validated nor justified and thus must be excluded

L229-230 & 241: Were these factors associated with foregone care also before the pandemic? What have pre-pandemic studies found? If these were, then the findings are not novel.

Reviewer #2: This study examines forgone health care during the SARS-CoV-2 pandemic. This is a well-written manuscript that addresses a relevant topic, but I have several concerns, which are listed below.

First, I think the findings are not novel enough. Consequences of the pandemic on foregone care and subgroups more likely to forego care have been well described in the literature. I am not sure that a cross-sectional study can improve our knowledge on this topic.

Second, I am not sure that it is relevant to use "person-years" in a cross-sectional study. If the interest is in the pandemic period, then the study should be limited to the relevant periods. In addition, both studies missed the beginning of the pandemic, when the worst levels of missed care were likely to have occurred.

Third, recommendations on strategies to reduce the spread of the virus do not seem useful more than 3 years after the start of the pandemic and while restrictive measures are still in place.

Finally, the conclusions discuss the results, but given the design and results of the study, this should be removed from the paper.

Please include a description of covariates in the methods section.

Reviewer #3: This paper evaluates whether COVID-19 pandemic was associated with increased forgone care. The authors use two surveys on forgone care conducted among the population of adults residing in Baltimore, MD. They find that the rate of forgone care was highest among individuals with disabilities, functional limitations, financial stress, and multiple comorbidities.

Overall, I think this paper is nicely written and utilizes some novel data. I think a few additions to the analysis will strengthen the implications of this study.

1. The authors mention that they drop individuals with missing data for the key outcomes (forgone care) or inclusion criteria (did they need care during COVID). While I understand the need to remove these observations, it raises the possibility of selection bias. Can the authors say something about individuals with missing outcomes? Were they more likely to be from specific demographic groups? Perhaps this can be mentioned in the Limitations.

2. The authors mention that the study participants were sampled from across Baltimore, with oversampling for underrepresented demographic and socio-economic groups. How did the study population compare to Baltimore overall socio-economic and demographic population composition? Can the authors use Census data for Baltimore to compare their study population to Census Baltimore population? This would greatly help with interpreting the results and external validity implications.

3. The number of individuals reporting not being employed in Table 2 is really high (52.3%). This number is not explained by other characteristics reported in Table 2, such as % with disability (15.5), % with college degree (63.2), % lost housing during the pandemic (7.6), % with financial limitations (30.7), etc. Was the employment so low because it was COVID period, or was it so low for some other reason? How does this number compare to the overall unemployment rate in Baltimore in 2020, 2021, 2022? I think this goes back to my previous comment about comparing study population to the overall Baltimore population using an external data source.

4. Can functional limitations be broken down by % physical, mental, or emotional? Is this group overrepresented by physical or emotional limitations, which have different implications on the need for medical care?

5. The authors use certain diseases to calculate the number of comorbidities in Table 3 (footnote 3). Why were these comorbidities selected? Is it because of the study design? Or were these diseases more common among the study participants? How does the list of comorbidities used in the paper compare to comorbidities used to construct the typical comorbidities indices (Charlson, Elixhauser).

6. The Limitations section mentions absence of insurance status in the study. While it will be impossible to know the insurance status of study participants if it was not recorded in the survey, the authors can say something about the overall insurance rate in Baltimore using Census data. This will give the audience at least some clue into potential distribution of insured/uninsured population in Baltimore.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PONE-D-23-27005R1An Evaluation of the Impact of Social and Structural Determinants of Health on Forgone Care during the COVID-19 Pandemic in Baltimore, MarylandPLOS ONE

Dear Dr. Meyer,

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 01 2024 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,

Tae-Young Pak, Ph.D.

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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 #3: (No Response)

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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 #3: Partly

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

Reviewer #3: 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 #3: Yes

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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 #3: Yes

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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 #3: Thank you for addressing my comments. I would like to push back on authors’ claim that they cannot use Census data to compare the unemployment rate in their population with the overall Baltimore unemployment rate during the same time period. First, the authors can use both the civilian labor force participation rate and unemployment rate. Census also provides numbers for percent of individuals who might not be in the labor force because they are students or retirees. While, it is true that Census numbers include population 16 years and older, the authors do not provide evidence why the numbers for population of 16 years and older should be significantly different from the numbers for population of 18 years and older. Overall, I think a more careful look at Census numbers will allow the authors to compare their (very high) unemployment rate with Baltimore unemployment rate. There is about 20 percentage points difference between the unemployment rate in their sample and the CSA-level unemployment rate. This should be mentioned in the limitations.

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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 #3: No

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An Evaluation of the Impact of Social and Structural Determinants of Health on Forgone Care during the COVID-19 Pandemic in Baltimore, Maryland

PONE-D-23-27005R2

Dear Dr. Meyer,

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.

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Kind regards,

Tae-Young Pak, Ph.D.

Academic Editor

PLOS ONE

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