Comparison of hospitalization events among residents of assisted living and nursing homes during COVID-19: Do settings respond differently during public health crises?

Colleen J. Maxwell; Eric McArthur; David B. Hogan; Hana Dampf; Jeffrey Poss; Joseph E. Amuah; Susan E. Bronskill; Erik Youngson; Zoe Hsu; Matthias Hoben

doi:10.1371/journal.pone.0306569

Peer Review History

Original SubmissionFebruary 7, 2024
7 May 2024 Decision Letter - Mario Ulises Pérez-Zepeda, Editor PONE-D-24-03317Comparison of hospitalization events among residents of assisted living and nursing homes during COVID-19: do settings respond differently during public health crises?PLOS ONE Dear Dr. Maxwell, 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 Jun 21 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, Mario Ulises Pérez-Zepeda, M.D., 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 2. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. Please update your Data Availability statement in the submission form accordingly. 4. 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. [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: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes 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. 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 ****** 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 ****** 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: Well written. The practical problems of AL have been brought out in the first paragraph itself. The residents of the NH were frailer, had more comorbidities, cognitively worse and were dependent on ADLs, as expected. Did this approach statistical significance? Among AL residents, there was a statistically significant increase in rate of hospitalization with death during the peak of wave 2 and in January 2021, followed by a significant decrease in this outcome during the peak of wave 3. For NH residents, the only statistically significant association was for an increase in rate of hospitalization with death during wave 2 relative to historical period. This is true all over the world. Wave 2 was the worst and by wave 3 and 4 – vaccinations had been given, and others would have been exposed to the virus. But what about variants? During waves 2 and 4 the rates were higher among AL than NH residents- this could be attributed to the fact that AL patients mingled, while NH patients were bedbound and exposed to fewer people – both inmates and carers at the facilities. Did death and burden of comorbidities correlate? What about morbidity? Did the admission and discharge criteria vary between waves, and between NH and AL? Reviewer #2: The article is well constructed and gives an interesting perspective of how different settings of assisted living and nursing homes respond during health crises. Some data should be clarified and be less dispersive to ensure that readers undestand exactly the researches point of view. I did appreciate the strategies to be investigated in the conclusions and I think it worths finding out more about. ****** 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. https://doi.org/10.1371/journal.pone.0306569.r001
Revision 1
14 May 2024 Author Response Response to Reviewers: Note: Comments from Reviewers are presented verbatim using italics. The location of revised text refers to lines in the revised manuscript with track changes. Reviewer #1: 1. Well written. The practical problems of AL have been brought out in the first paragraph itself. Response: Thank you for noting these strengths of our manuscript. 2. The residents of the NH were frailer, had more comorbidities, cognitively worse and were dependent on ADLs, as expected. Did this approach statistical significance? Response: In our comparison of the characteristics of residents in AL vs NH, we reported which differences were larger than a standardized difference of 0.10 as a measure of a meaningful difference (please see footnotes used in Tables 1 and 2). We used standardized differences rather than p values given the large sample sizes involved - which would result in small differences being statistically significant but not necessarily clinically relevant. In our original manuscript, we noted the rationale for this in the Analysis section (lines 172-174) with a supporting reference (reference #42). 3. Among AL residents, there was a statistically significant increase in rate of hospitalization with death during the peak of wave 2 and in January 2021, followed by a significant decrease in this outcome during the peak of wave 3. For NH residents, the only statistically significant association was for an increase in rate of hospitalization with death during wave 2 relative to historical period. This is true all over the world. Wave 2 was the worst and by wave 3 and 4 – vaccinations had been given, and others would have been exposed to the virus. But what about variants? Response: We do acknowledge that COVID-19 case rates were most pronounced (in Alberta and globally) during the period of the pandemic prior to widespread vaccinations. This is also evident for residents in our study as illustrated in our S5 Fig. Regarding our findings for rate of hospitalization with death – a key point we wished to highlight with these statements were the differences in this outcome observed between AL and NH beyond the peak of wave 2 – i.e., during January 2021 and during the peak of wave 3 (as also emphasized in our Discussion – see lines 305-307 and lines 356-359). Related to this was our finding of considerably higher COVID-19 hospitalization rates among residents of AL vs NH during the peak of wave 2 and in the subsequent month of January 2021 (as shown in S4 Fig.). As noted throughout our manuscript, there were several notable differences in study outcomes between those in AL vs NH – including during wave 2 of the COVID-19 pandemic. We are not able to comment on the relevance of differences in specific variants of SARS-CoV-2 present throughout the study period as we did not have access to these data (we have added this statement to the limitation section of our Discussion, see lines 377-379). We do not believe that the key differences we observed in outcomes between AL and NH settings would be due to differences in the variants present, as the dominant variants would be expected to be comparable across settings at specific points in time. 4. During waves 2 and 4 the rates were higher among AL than NH residents- this could be attributed to the fact that AL patients mingled, while NH patients were bedbound and exposed to fewer people – both inmates and carers at the facilities. Response: Thank you for this comment regarding potential contributing factors to the observed differences between AL and NH settings in the monthly rates of COVID-19 hospitalizations. As we noted in our Results (lines 290-295) and Discussion (lines 309-310) sections, these differences were observed during waves 2 and 4 even though monthly rates of positive COVID-19 tests were relatively similar in ALs and NHs during these waves (as illustrated in our S5 Fig.). We do comment on possible reasons for these differences in our Discussion (including an increased likelihood for AL homes to transfer residents with COVID-19 and/or greater illness severity in AL vs NH residents) (lines 330-331). As suggested, we have added a brief comment about the potential role of less effective isolation of active cases and greater interactions among AL residents (lines 331-332); however, while more physically impaired, it would be inaccurate to state that most NH residents were bedbound. We also believe it would be misleading to assume that NH residents were exposed to fewer people than AL residents - given that similar visitor restrictions were implemented in both settings during the pandemic and the expected higher numbers of staff available in NH vs AL settings. 5. Did death and burden of comorbidities correlate? What about morbidity? Response: We believe this comment relates to the likely associations between level of resident comorbidity and the outcome of hospitalization with death. For this outcome (as with all our outcomes), our models were adjusted for several covariates, including number of chronic conditions as noted in our Analysis section (see lines 181-183) and in the footnotes provided for Table 3. 6. Did the admission and discharge criteria vary between waves, and between NH and AL? Response: Thank you for this interesting question. As would be expected, there always have been differences in the admission and discharge criteria between licensed publicly subsidized AL and NH settings in Alberta as these criteria define initial and ongoing eligibility for setting-specific care as per Alberta Health Services (as per our reference #29). There is no evidence, however, that admission and discharge criteria changed in either of the two settings with the emergence of the COVID-19 pandemic (or by pandemic wave) (Auditor General of Alberta. COVID-19 in Continuing Care Facilities, 2023. https://www.oag.ab.ca/wp-content/uploads/2023/04/oag-covid19-cont-care-facilities-feb2023.pdf ). However, we can’t be sure whether there were temporary differences in how existing admission and/or discharge criteria across AL and/or NH sites were enacted by the homes during the pandemic waves under study. It is also possible that strategies were adopted during the pandemic (e.g., increased interactions between NH sites and ED physicians or paramedic services [Wyer et al., 2024]) that differentially affected hospitalization events during the four pandemic waves. We have added a brief comment regarding the above to our Discussion along with the references noted above (lines 343-348; new references #48 & #49). Reviewer #2: 1. The article is well constructed and gives an interesting perspective of how different settings of assisted living and nursing homes respond during health crises. Response: Thank you for these positive comments regarding the strengths of our manuscript. 2. Some data should be clarified and be less dispersive to ensure that readers undestand exactly the researches point of view. Response: Thank you. We are unclear what specific data should be clarified and/or rearranged (which we think is what was meant by the suggestion to be less dispersive). We believe that our revisions made in response to comments provided by Reviewer #1 help to address this comment. 3. I did appreciate the strategies to be investigated in the conclusions and I think it worths finding out more about. Response: Thank you for this positive comment. Attachments Attachment Submitted filename: Response to Reviewers_COVID Hosp AL NH_PLOS ONE 14May2024.docx https://doi.org/10.1371/journal.pone.0306569.r002
20 Jun 2024 Decision Letter - Peng Wu, Editor Comparison of hospitalization events among residents of assisted living and nursing homes during COVID-19: do settings respond differently during public health crises? PONE-D-24-03317R1 Dear Dr. Maxwell, 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. If you have any questions relating to publication charges, 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, Peng Wu 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 #2: All comments have been addressed Reviewer #3: 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 #2: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes 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 #2: Yes Reviewer #3: 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 #2: Yes Reviewer #3: 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 #2: (No Response) Reviewer #3: (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 Reviewer #3: No ******** https://doi.org/10.1371/journal.pone.0306569.r003
Formally Accepted
2 Jul 2024 Acceptance Letter - Peng Wu, Editor PONE-D-24-03317R1 PLOS ONE Dear Dr. Maxwell, 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. Peng Wu Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0306569.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .