Continuity of care in general practice in Norway

Lamija Delalic; Mari Grøsland; Geir Godager; Henning Øien

doi:10.1371/journal.pone.0305164

Peer Review History

Original SubmissionFebruary 25, 2024
27 Mar 2024 Decision Letter - Rizwan Shahid, Editor PONE-D-24-03545Continuity of Care in General Practice in NorwayPLOS ONE Dear Dr. Delalic, 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 May 11 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. 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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: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No 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. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The study was designed to examine the continuity of care in Norway over a 15 year period (2006-2021). The authors used two continuity of care indices, the St. Leonard’s Index of Continuity of Care (SLICC) and the Usual Provider of Care (UPC), and stratified the data by geographical level (national, high, moderate, and low centrality). They found the SLICC and UPC were relatively stable over the time period at the national level but varied widely depending on the geographical level. Overall, I found the paper well-written, with the purpose clearly articulated. Calculating continuity of care over this time period would be valuable addition to the literature. However, I found the methods section lacking detail in many areas. For example: - I am assuming the continuity of care indexes were calculated each year, and their year was defined as a calendar year (January – December) versus fiscal year (April-March). This point should be made more explicit. - The authors do not mention any exclusion or inclusion criteria applied to their data. What did the authors do about patients who only had one visit to a GP? Continuity of care indices typically need at least two visits to be calculated accurately. A single visit within a year would positively skew the indices result. Were patients who did not have a visit within a year included as well? - The total annual number of patients and physicians included in the study should also be provided. - Since the indices were calculated over a 15 year time period, the authors should provide some type of adjustment to account for the change in the population and the physician supply. It is probable that the indices (and patient behaviour) will be impacted by the number of physicians available as well as changes in the population, and therefore, could impact the interpretation and conclusion of the study. - The authors state on page 4 “Typically, the most visited physicians aligns with the patient’s regular GP”, however there was no correlation calculated in the methods section and no numerical value provided in the results section. In fact, that sentence and the one following “However, then the regular GP is absent….”may be better suited to the discussion section rather than the methods section. - On both Figure 1 & 2, the solid line is labeled as Total. Is Total the results at the National level? If that is a correct assumption, the authors need to provide that explanation, or change Total to National. Also, the y-axis is not labelled on either figure. - The continuity of care indices for each year are displayed in Figure 1 and 2. There is no mention in the methods section or on the graphs as to whether the indices are a mean, median, or something else. I am assuming the data point on the graphs are the means for each year. If so, the standard deviation or standard error of the mean should be available. Thank you for the opportunity to review your paper. I look forward to reading and citing your paper in the future. Reviewer #2: Methods There is no mention of those who might not have a primary care visit in the respective year, and if they were excluded from the study population. It might be beneficial to give more context on how centrality is defined, for instance, distance from metro cities. Results Results fail to mention the drop in continuity, both SLICC and UPC, until 2019 and then the sudden increase starting 2020. Discussion Although, the discussion talks about the increase in continuity indices in the recent year, the authors do not speculate on what can be the reasons for this increase. Authors suggests that were was only two percent variation in continuity since 2006, however supplementary data shows UPC doing down to 67%, indicating greater variation. Conclusion The conclusion seems to be from be from the perspective of the patients, i.e. comparing continuity for patients in less central areas to more central areas. However, based on the methods centrality was defined based on GP’s location. If the authors suggest using the findings to reduce geographical disparities, perhaps it is important to examine continuity from the patient’s location as well. ****** 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: Yes: Lisa L. Cook 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.0305164.r001
Revision 1
15 May 2024 Author Response Dear reviewers, Thank you for reviewing our study and for providing us with your valuable feedback and insightful suggestions. This has truly improved our article, and we are grateful for your contributions. All changes to your reviewing comments are tracked in the document, according to the line numbers provided under each review, labeled “our action”. Please see our response below. Reviewer #1: The study was designed to examine the continuity of care in Norway over a 15 year period (2006-2021). The authors used two continuity of care indices, the St. Leonard’s Index of Continuity of Care (SLICC) and the Usual Provider of Care (UPC), and stratified the data by geographical level (national, high, moderate, and low centrality). They found the SLICC and UPC were relatively stable over the time period at the national level but varied widely depending on the geographical level. Overall, I found the paper well-written, with the purpose clearly articulated. Calculating continuity of care over this time period would be valuable addition to the literature. However, I found the methods section lacking detail in many areas. For example: - I am assuming the continuity of care indexes were calculated each year, and their year was defined as a calendar year (January – December) versus fiscal year (April-March). This point should be made more explicit. Our response: It is true that the years are defined as a calendar year (January-December). Our action: We have made a clear point of out this in the Methods section, see line 77. - The authors do not mention any exclusion or inclusion criteria applied to their data. What did the authors do about patients who only had one visit to a GP? Continuity of care indices typically need at least two visits to be calculated accurately. A single visit within a year would positively skew the indices result. Were patients who did not have a visit within a year included as well? Our response: Thak you for this important feedback. We agree that more information about methods, including any exclusion or inclusion criteria, should be included. In this paper all in-person consultations and electronic consultations at a GP office and at the emergency medical office are included, including consultations for individuals with only one consultation in a given year. Our SLICC and UPC measures report on the proportion of consultation delivered by the regular GP and the most visited provider, determined by dividing the number of consultation conducted by the regular GP/most visited physician a given year by the total number of consultations with any doctor the same year. The unit of study in our paper is thus consultations, and the proportion of consultations provided by the patients’ GP and most visited physician. The reported measures characterize differences at the supply side between different areas. Our action: We have included the following information about our calculations of the two measures in the method section, please see line 95 to 103. - The total annual number of patients and physicians included in the study should also be provided. Our response: Thank you for your comment. We agree that we should include some more information on patients and consultations. Our action: We have provided a table in the appendix containing details on the number of patients who had at least one consultation each year, as well as the number of doctors who conducted at least one consultation each year (see table S1 in the appendix). We have also addressed these numbers in the Results section of our article, please see line 115-120. - Since the indices were calculated over a 15 year time period, the authors should provide some type of adjustment to account for the change in the population and the physician supply. It is probable that the indices (and patient behaviour) will be impacted by the number of physicians available as well as changes in the population, and therefore, could impact the interpretation and conclusion of the study. Our response: Thank you for stating this. Our action: We have made a clear point out of this in the “Discussion” section, please see line 189-194. - The authors state on page 4 “Typically, the most visited physicians aligns with the patient’s regular GP”, however there was no correlation calculated in the methods section and no numerical value provided in the results section. In fact, that sentence and the one following “However, then the regular GP is absent….”may be better suited to the discussion section rather than the methods section. Our response: Thank you for pointing this out. We agree that the original text was most suitable for a discussion. However, we have opted to rephrase it slightly and follow your suggestion by incorporating a numerical value to indicate the strength of the correlation. We believe the new formulations fit better within the methodology section. Our action: We have added a sentence stating the share of which a patient’s most visited physician aligns with the patient’s regular GP, please see line 94-95 of the Methods section. - On both Figure 1 & 2, the solid line is labeled as Total. Is Total the results at the National level? If that is a correct assumption, the authors need to provide that explanation, or change Total to National. Also, the y-axis is not labelled on either figure. Our response: Thanks for pointing this out. Our action: We have now accounted for all these suggestions, as total is changed to nationally and the y-axis in the figures are named “SLICC” and “UPC”. - The continuity of care indices for each year are displayed in Figure 1 and 2. There is no mention in the methods section or on the graphs as to whether the indices are a mean, median, or something else. I am assuming the data point on the graphs are the means for each year. If so, the standard deviation or standard error of the mean should be available. Our response: Thank you for your feedback. Our SLICC and UPC measures in Figure 1 and 2 report on the proportion of consultation delivered by the regular GP and the most visited provider, determined by dividing the number of consultation conducted by the regular GP/most visited physician a given year by the total number of consultations with any doctor the same year. We agree that this should be clearer in the text. Our action: We have elaborated on this in the method section to describe our measures more clearly, please see line 95-101. In addition, we specify the standard deviation in table S2 and S3 in the appendix. Thank you for the opportunity to review your paper. I look forward to reading and citing your paper in the future. Our response: Thank you again for your time and effort in providing such constructive feedback. We greatly appreciate your contributions. Reviewer 2 It might be beneficial to give more context on how centrality is defined, for instance, distance from metro cities. Our response: Statistics Norway (2024) gives the following definition of centrality “Centrality is a measure of a municipality's geographical position seen in relation to a centre where higher order of functions (central functions as bank, post office) is found.” Høydahl (2020) provides the most recent documentation of the centrality index for Norwegian municipalities. Our action: We have elaborated on the centrality measure in the Methods section, please see line 107-112. Results Results fail to mention the drop in continuity, both SLICC and UPC, until 2019 and then the sudden increase starting 2020. Our response: The increase in continuity observed in 2020 is likely caused by a substantial increase in e-consultations during the covid 19 pandemic. According to Pedersen et al. (2022), more than 470 000 e-consultations were delivered in March 2020 whereas the corresponding number was less than 50 000 e-consultations during February 2020. The system for e-consultations were set up to link regular GP and patient. Our action: The information in our response is also included in the Results section of the manuscript, please see line 149-153. Discussion Although, the discussion talks about the increase in continuity indices in the recent year, the authors do not speculate on what can be the reasons for this increase. Our response: As our aim is to contribute to the literature by providing two indices that reflect upon the continuity of care at a descriptive level, as well as to evaluate difference among centrality levels over time, our analysis lay no basis for speculations about the reasons behind this trend. However, we certainly agree that there is a need for more research to learn about the causes of this development in continuity, as well as other knowledge on how continuity may differ across different patient groups. Our action: We have elaborated on this point in the “Discussion” section, please see line 186-197. Authors suggests that were was only two percent variation in continuity since 2006, however supplementary data shows UPC doing down to 67%, indicating greater variation. Our response: Thank you for stating this mistake in the manuscript. Our action: We have now corrected this, please see line 162-163 of the Discussion section. Conclusion The conclusion seems to be from be from the perspective of the patients, i.e. comparing continuity for patients in less central areas to more central areas. However, based on the methods centrality was defined based on GP’s location. If the authors suggest using the findings to reduce geographical disparities, perhaps it is important to examine continuity from the patient’s location as well. Our response: Thank you for your comment, adding valuable elaboration on how to understand the measure of centrality in our analysis. The Norwegian Regulation on the General Practitioner Scheme in Municipalities, section 2-3 states: "The municipality shall ensure that individuals residing in the municipality are offered necessary general practitioner services, cf. the Health and Care Services Act section 3-1 and section 3-2, first paragraph." This requires, among other things, the location of the general practitioner's office to be accessible to the municipality's residents. Therefore, the location of most of the general practitioner's office are in the municipality where the resident is residing, or by other means close to the resident. Our action: We have added clarification on this in the Methods section of the manuscript, in line with the existing information on the classification of centrality. Please see line 109-112. References Høydahl, E. (2020). Sentralitetsindeksen. Oppdatering med 2020-kommuner, Statistisk sentralbyrå. English translation: Sentrality Index. Update with 2020-municipalities. Statistics Norway. https://www.ssb.no/en/klass/klassifikasjoner/128/om webpage accessed 25 April 2024 Pedersen K, Godager G, Rognlien HD, Tyrihjell JB, Værnø SG, Iversen T, Holte J, Abelsen B, Pahle A, Augestad L, Sæther EM (2022) Evaluering av handlingsplan for allmennlegetjenesten 2020–2024: Evalueringsrapport I. English translation: Evaluation of action plan for general praction services 2020-2024. Evaluation report I. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0305164.r002
27 May 2024 Decision Letter - Rizwan Shahid, Editor Continuity of care in general practice in Norway PONE-D-24-03545R1 Dear Dr. Delalic, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. 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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 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: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: 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 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: I am satisfied with the changes the authors have made based on the review. The manuscript is well written and will be welcomed addition to the primary care continuity of care research field. Reviewer #2: Thank you for the opportunity to review the manuscript. All the comments have been sufficiently addressed. ****** 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: Yes: Lisa L Cook Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0305164.r003
Formally Accepted
30 May 2024 Acceptance Letter - Rizwan Shahid, Editor PONE-D-24-03545R1 PLOS ONE Dear Dr. Delalic, 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. Rizwan Shahid Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0305164.r004

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