PONE-D-24-44865Patient satisfaction: Insights from the regional referral hospitals in BhutanPLOS ONE

Dear Dr. Dorji,

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.

==============================

ACADEMIC EDITOR: Please address the comments of the 7 reviewers. Thank you.

==============================

Please submit your revised manuscript by Jan 13 2025 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,

Ian Christopher N Rocha, MD, MBA, MHSS

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.

3. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

Additional Editor Comments:

Please address the comments of the 7 reviewers. Thank you.

[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: No

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

**********

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: 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: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

Reviewer #6: Yes

Reviewer #7: No

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: 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: Study title:

You need to re-write study title as follows

“Evaluation of patient satisfaction in the regional referral hospitals in Bhutan: a cross-sectional study”.

Abstract:

You need to re-write the abstract in a standard format including the headings ‘Background, Methods, Results, and conclusion’.

Main text:

Introduction:

It is well-written and appreciated.

Materials and methods:

You need to re-write methods section including the following sub-headings as a separate entity:

-study design

-study site

-study duration

-study setting

-study population

-inclusion criteria

-exclusion criteria

-sample size determination

-sampling method

-study variables

-study procedures

-data management

-data analysis

Results:

In Table 1, you can compare the socio-demographic variables and clinical profiles of the respondents between Gelephu and Mongar hospital, and that will give more meaning to the table.

You have inappropriately used one-way ANOVA analysis. ANOVA can be used only if you have more than 2 groups to compare quantitative variables. So, you can delete current table 2, and construct new table 2 to compare patient satisfaction scores across seven domains between Gelephu and Mongar hospital.

You need to re-write table 3 to include univariate analysis in one column and multivariate logistic regression analysis in another column. This will give a better understanding to the reader about the factors associated with poor patient satisfaction or well satisfied patient.

Table 4 doesn’t give any scientific inferences. You can delete table 4.

Reviewer #2: Abstract

1. Rather than saying "archived patient satisfaction data," you could clarify the source or specific nature of this data.

Introduction

The introduction provides a solid contextual foundation for the study. Minor stylistic adjustments would improve readability and conciseness, particularly by condensing and refining some sentences.

1. The phrase “meeting patient’s needs is imperative” could be made more specific, and the sentence starting “Starting from the early 1980s” might benefit from a more concise phrasing.

2. Also, the lack of a universally accepted definition of patient satisfaction could be condensed to focus more on its role as a quality measure.

3. The phrase “meticulously developed tool” to describe the PSQ-18 may appear overly emphatic in a scientific context.

Materials and methods

1. Confirm whether the survey sites were called “MERRH” or “ERRH” and “GCRRH” or “CRRH”.

2. Consider adding a brief statement on the justification for modifying specific terminology in the PSQ-18 and whether there was any assessment of the adapted tool’s reliability or validity in this new context.

3. Add a sentence specifying the handling of negative items during re-scaling, as this will aid replicability and ensure clarity in interpretation.

4. Briefly explain what the Dunnett grouping is, why the Dunnett grouping was used to identify distinct groups and why a significance level of 0.005 was selected. The significance level of 0.005 is strict and unusual (more commonly 0.05), so a rationale for this choice would also improve clarity.

Result

1. Satisfaction scores vary significantly by age, with older respondents generally reporting higher satisfaction levels. This finding could be influenced by generational differences in expectations of healthcare, which might warrant a brief discussion of the interpretation.

2. The study shows a predominant representation of Sharchop ethnic group respondents (57.05%), and satisfaction scores are also the highest among them. Given Bhutan's ethnic diversity, exploring whether this reflects the general population distribution or biases in sampling might be helpful.

3. Illiterate individuals reported higher satisfaction scores than those with higher education levels, which might suggest varying expectations based on education. This could be discussed as it may reveal important insights into patient perceptions of healthcare quality across different educational backgrounds.

4. The choice of control groups (e.g., using the 18-44 age group or married status as the control) appears sound. However, mentioning why these groups were selected as the baseline for comparison could strengthen interpretability.

5. Given that significant differences in satisfaction levels were observed between MERRH and GCRRH, it may be beneficial to explore specific differences in facilities, staff interaction, or procedural efficiency between the two. These insights could further contextualize why one center reports higher satisfaction levels.

Discussion

1. The authors astutely highlight Buddhism's influence on Bhutanese healthcare interactions, leading to positive patient responses. However, there may be potential biases, as indicated, that result from cultural expectations of politeness and contentment, particularly when surveys are administered by quality units. It may be valuable to propose alternative assessment methods, such as third-party evaluators or anonymous surveys, to better gauge satisfaction independently of cultural expectations.

2. The potential for satisfaction surveys to affect provider performance and motivation is a valid concern. The authors might expand this discussion by considering how Bhutan could develop a model where satisfaction surveys are used solely for improvement and not linked to individual compensation or evaluations, thus mitigating potential professional dissatisfaction and unintended care implications.

Conclusion

1. The authors could suggest areas for further research, such as longitudinal studies or comparative studies with similar healthcare systems in culturally similar countries. This would aid policymakers in anticipating and addressing shifts in patient expectations and satisfaction.

Recommendations

1. If the paper could discuss the limitations explicitly if any would strengthen the conclusions.

2. Qualitative follow-up with respondents could add depth to the quantitative findings, helping to contextualize why specific groups, such as the illiterate population, report higher satisfaction.

Reviewer #3: Abstract:

Good abstract

L32-33: you may just mention one test

L36- mention all the ethnic groups which are significant not just others, significant by how much?

L35-41: please mention the findings in figures (% or numbers, etc) in brackets.

L42-46: rephrase it and make it clear, seems sentences are diluting and repeating.

L47-49: What makes you conclude this, it should be related to your research findings not just hypothetical talk, what do you mean by high-end services, there was no finding on healthcare workforce but how come you conclude on this. Please be very specific, just mention what you get from your research.

Introduction:

General comment- keep citation number in sequence, and so does write the flow accordingly.

L87-88: rephrase the sentence to make more urging need than just saying not utlized.

L88-90: are you sure this hampers the healthcare delivery service, if yes please support by evidence.

Materials and Methods:

L94-98: Why only Mongar and Gelephu hospital, mention what is the reason for choosing these two hospitals. Why JDWNRH national referral hospital was not selected? Data says more than 60% of country's patient visit this hospital, I guess you have lost good amount of data.

L98-99: procedure is not clear, how the patient is being enrolled. Please mention in between these two lines. Showing in flowchart would be great though.

L125-126: I think you dont have to mention about the waiver for consent, this is feedback survey anyways.

RESULTS:

L146- are you sure about the clinical variables, I cant see in the table.

L148-166: Just keep few important ones, no need to describe all the variables in sentence, tables speaks.

L167-168: no need to mention

Table 4: is not good table, lot of data into it and it speaks less about it. You may delete the table or modify it. Define and show the satisfaction level, how much is dissatisfied, which score is moderate and which score is satisfied, please mention either in method section or along with the table 4.

DISCUSSION:

General comment- need to refine it more clearly. Be specific with your results and support it with previous studies.

L194-197: rephrase the sentence, i dont think so, please support by findings, what is the proportion of the patient seen and the population of these two region when you say it represents.

L213-215: How?? need more data to support

Please mention about limitations and the strength of the study before conclusion.

CONCLUSION:

L334-341: no need to reflect, those are less significant to mention

Please mention the overall satisfaction level of the patients in the conclusion, so that readers take away the message.

Reviewer #4: Thank you for the opportunity to review this work on patient satisfaction, which is quite a young but very important indicator of quality healthcare services.

Here are my comments;

Abstract

Indicate the level of patient satisfaction as found in your study

Consider including p-values for variables that are statistically significantly associated with patient satisfaction.

Introduction.

Strengths. The introduction is well structured with relevant literature capturing the concept of patient satisfaction. The authors clearly indicate the different factors that influence satisfaction and they also note that there is scarcity of published literature on the subject in Bhutan.

Criticism & suggestions. The researchers need to clearly indicate the role of patient satisfaction in healthcare highlighting the potential contribution of the study to practice. In lines 81-86, authors mention about the transition towards quality oriented care in their setting. More literature to capture the interventions from the Bhutan authorities implemented to improve patient satisfaction should be added. Authors should also add more evidence regarding patient satisfaction from other settings especially preceding the description on the factors influencing satisfaction.

What are different domains of satisfaction assessed in other settings and how do these assessment link into the assessments in Bhutan?

Materials and methods

The current structure of the methods section does not allow for smooth transition by the reader. The authors should consider structuring the section into subsections such as study design, study population, study setting, data collection tools, data collection procedures etc....

The targeted population in this study is not clear.

Was the data collected secondary or primary? Lines 99-100 seem to indicate the latter but from previous statements, one could infer that the data was secondary. This needs to be clarified in your writeup. If this was secondary data, discuss the possible biases.

The authors need to indicate the time points/periods from which the data was obtained. Do you think this affects satisfaction?

If this was secondary data, did the authors design a data abstraction? Was this informed by the PSQ18? Has the PSQ18 been utilized in other research studies? Is it a valid and reliable tool for establishing patient satisfaction? What was the internal consistency in this current study? The researchers should provide the tool used in this assessment as a supplementary material for replicability of the study in other settings.

Line 177 describes how the researchers quantified patient satisfaction by getting the average scores across 7 domains of the tool. Is this the standard approach or this was adapted?

Results

Presenting the results with subsections as per the meaning of the findings would improve the flow of information in this section.

Author need to revise the use of some words such as control group, comparison group as these could mean different parameters in different study designs.

Were the odds ratios presented in table 3 crude or adjusted? You need to consider including both.

According to the authors, the variables ethnic group and occupation were significantly associated with satisfaction. What was the rationale for creating the categories under these two variables? Are the individuals under the same group having similar characterization? and if not, could it be a biased assignment? For instance, in the category of occupation, why are students in the same group as civil servants?

Based on your analysis plan, you need to indicate in the results section the proportion of those patients who are satisfied and dissatisfied.

Discussion

The researchers have done a great job in discussing and linking their findings to the already existing body of knowledge and the implications of the findings are clear. This section can be improved by;

Providing a detailed discussion of the limitations associated with methodological weaknesses, highlighting their impact on the generalizability of the study findings.

The structuring of the discussion should be changed. The level of satisfaction should be discussed first followed by the factors associated with satisfaction.

Reviewer #5: I feel that the paper is well written and its findings are very significant to health policy maker and also for the country, this study will serve as a baseline on patient satisfaction level for future researches.

Reviewer #6: This manuscript presents a timely and relevant study on patient satisfaction in Bhutan, a country with a developing healthcare system. The study's findings, particularly the identification of ethnicity, occupation, and education level as significant predictors of patient satisfaction, offer valuable insights for healthcare policymakers and professionals in Bhutan and other countries with similar healthcare systems.

Strengths

The research addresses the important question of patient satisfaction within the Bhutanese healthcare system, which is undergoing a transition towards a quality-oriented culture. This is particularly relevant given the global emphasis on patient-centered care and the need to understand the factors that influence patient satisfaction in diverse healthcare settings.

The study adds to the existing body of literature by providing empirical evidence on patient satisfaction within the specific context of Bhutan. This is a valuable contribution as there is limited research on this topic in Bhutan, and the study's findings offer unique insights into the factors that influence patient satisfaction in a developing healthcare system

The conclusions are consistent with the evidence and arguments presented in the study. The authors have accurately summarized the key findings and their implications for healthcare policy and practice

Areas for Improvement

The authors mention the influence of Bhutan's cultural context on patient satisfaction, they could expand this discussion to provide a more nuanced understanding of how cultural factors, such as the emphasis on compassion and the role of Buddhism, may influence patient expectations and perceptions of healthcare services.

“This study retrospectively analysed patient satisfaction survey responses collected from Mongar Eastern Regional Referral Hospital (MERRH) and Gelephu Central Regional Referral Hospital (GCRRH). The routine paper-based surveys were conducted throughout April 2024.” The manuscript lacks a detailed description of the data collection process, including the sampling method. Providing this information would strengthen the study's methodology and enhance the credibility of the findings

The manuscript could benefit from a more specific and actionable recommendations for healthcare policymakers and professionals. For instance, the authors could provide concrete examples of targeted interventions to address the anticipated decline in patient satisfaction due to changing socio-demographic characteristics.

Writing Quality

The paper is well-written, with clear and easy-to-read text. The authors have used appropriate language and style for an academic audience.

Reviewer #7: General Comments

Dorji K et al. attempted to provide valuable insights into patient satisfaction levels at two referral hospitals in Bhutan, using retrospective data and exploring socio-demographic predictors of satisfaction. This research addresses an important gap in understanding healthcare quality in Bhutan. However, there are areas where further clarity would strengthen the findings. Enhancing transparency in the methodology, particularly around sample size, sampling methods, and survey administration, would strengthen this study. Addressing potential biases and improving the contextual richness of the discussion would also benefit readers and support the study’s practical implications for healthcare policy in Bhutan.

Abstract

1. Specificity in reporting results (Lines 22-49): The abstract provides a clear summary but could benefit from additional specificity. Including exact figures for satisfaction levels or effect sizes of significant predictors would make the results more informative for the reader.

Introduction

1. Bhutan’s health system (Lines 69-70): While the introduction discusses patient satisfaction broadly, it could be enhanced by offering more context on Bhutan’s healthcare system. For e.g., more emphasis on free healthcare, and the challenges associated with rural accessibility and workforce shortages would provide readers with a clearer understanding of why patient satisfaction is critical in this setting.

2. Cite BHSQA (Lines 75-76)

Materials and Methods

1. Study design and sampling method (Lines 93-128): Clarify the sampling method, especially whether it was a convenience sample or if random sampling was applied. Sampling methods are essential to understanding potential biases, as convenience sampling can limit generalizability. The use of a retrospective cross-sectional design is appropriate for the data available, but its limitations should be noted, as this design cannot capture temporal changes in satisfaction or causality. Future studies could benefit from a longitudinal approach to observe changes in satisfaction over time, especially with healthcare reforms.

2. Inclusion of western region hospitals (Lines 93-128): The study’s sample is limited to hospitals in eastern and southern Bhutan, which may not capture the full demographic diversity of the population. Including a referral hospital from the western region, such as JDWNRH, would enhance representativeness, as patients in the west may have different expectations and healthcare perceptions.

3. Mode of survey administration (Lines 99-100): If health professionals conducted surveys for illiterate patients, this could introduce interviewer bias, leading patients to feel pressured to respond positively. The manuscript should clarify who administered the surveys and acknowledge any potential interviewer effects. A more consistent survey administration mode, such as anonymous or third-party administration, could reduce response bias, especially among illiterate respondents.

4. Sample size (Lines 93-128): The study does not provide a power analysis or sample size calculation. Although 915 respondents seem more than adequate, a statistical justification would add methodological correctness. Reporting a power analysis based on effect sizes would strengthen the credibility of the sample size in capturing true effects across socio-demographic groups.

5. The method could benefit from greater transparency regarding the survey modification process for PSQ-18. Provide additional information on the survey's adaptation process and provide the modified PSQ-18 as supplementary file (Lines 100-107).

6. Multiple comparisons correction in ANOVA (Lines 114-115): The authors used one-way ANOVA with Dunnett grouping for multiple comparisons across socio-demographic groups, but it lacks a correction for multiple comparisons. Given the numerous factors compared, using a method like Bonferroni or Holm correction would reduce the likelihood of Type I error. This correction would ensure that significant differences between groups are robust and not due to chance alone.

7. Significance levels (Line 121): The manuscript uses a significance level of p < 0.005, which is stricter than the conventional p < 0.05. This could strengthen findings by reducing the risk of Type I errors, but it would be good to clarify why this threshold was chosen. If a multiple-comparisons correction (such as the Bonferroni correction) was applied to account for repeated testing across multiple domains, mentioning this would add more detail.

Results

1. Visual summaries (Lines 129-187): While the tables are comprehensive, adding visualizations (e.g., bar charts or histograms) for key socio-demographic variables and satisfaction levels across domains would improve accessibility and make trends easier to interpret. These visuals could also help in identifying outliers or skewness that might affect parametric assumptions in ANOVA.

2. Wide confidence intervals in logistic regression (Lines 171-175): Some odds ratios show wide confidence intervals, indicating limited precision, possibly due to small subgroup sizes or inherent variability. Briefly acknowledging this limitation and its potential impact on the reliability of estimates would add transparency to the findings.

Discussion

1. Cultural factors and contextual influences on satisfaction: The discussion effectively ties findings to existing literature but could benefit from a more in-depth look at Bhutan-specific cultural factors that might influence satisfaction. For instance, the cultural respect for authority figures and the potential for social desirability bias in survey responses could influence satisfaction ratings, particularly among illiterate respondents.

2. Explanation of higher satisfaction among illiterate participants (Lines 199-218): The significantly higher satisfaction among illiterate patients is noteworthy but could partly reflect interviewer influence if surveys were administered by healthcare professionals. Discussing this potential interviewer effect here would provide insight into how survey mode might impact satisfaction scores across education levels.

3. Limitations in regional representation (Lines 188-327): The findings from Mongar ERRH and Gelephu CRRH may not fully represent national patient satisfaction trends in Bhutan, as the absence of data from the west (e.g., Thimphu) could exclude urban patient perspectives and include more representation of ngalops. Acknowledge this limitation in the discussion and suggest that future research include hospitals from multiple regions for a more balanced national representation.

4. Policy implications and recommendations (Lines 278-350): The authors have provided valuable recommendations for improving patient satisfaction including enhancing accessibility and convenience. Strengthening this section with specific, immediate actions, for e.g., implementing a pilot program for anonymous feedback collection, could make the policy implications more actionable for health administrators in Bhutan.

**********

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: Yes: Kinley Gyem

Reviewer #3: No

Reviewer #4: Yes: Businge Alinaitwe

Reviewer #5: No

Reviewer #6: No

Reviewer #7: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Reviewers comments.docx

PONE-D-24-44865R1Patient satisfaction in regional referral hospitals of Bhutan: Insights from a cross-sectional study.PLOS ONE

Dear Dr. Dorji,

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.

==============================

ACADEMIC EDITOR: Please address the remaining minor comments of the reviewers.

==============================

Please submit your revised manuscript by Apr 17 2025 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,

Ian Christopher N Rocha, MD, MBA, MHSS

Academic Editor

PLOS ONE

Journal Requirements:

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.

Additional Editor Comments:

Please address the comments of the 9 reviewers.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

Reviewer #7: All comments have been addressed

Reviewer #8: All comments have been addressed

Reviewer #9: 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: Partly

Reviewer #4: (No Response)

Reviewer #5: Yes

Reviewer #7: Yes

Reviewer #8: Yes

Reviewer #9: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: (No Response)

Reviewer #5: Yes

Reviewer #7: Yes

Reviewer #8: Yes

Reviewer #9: 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: No

Reviewer #4: (No Response)

Reviewer #5: No

Reviewer #7: Yes

Reviewer #8: No

Reviewer #9: 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

Reviewer #4: (No Response)

Reviewer #5: Yes

Reviewer #7: Yes

Reviewer #8: Yes

Reviewer #9: 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: Authors have addressed all the comments though few are clarified why they have mentioned and can't be modified further. Just one comment to author: Reflect the overall findings in conclusion of the abstract, so that your takeaway key message is heard by readers of policy makers of Bhutan.

Reviewer #4: (No Response)

Reviewer #5: Definitely this study will provide a baseline for many more studies that can be carried out in the future.

Reviewer #7: (No Response)

Reviewer #9: All comments of the reviewers have been addressed. Please also read this and cite in the discussion: https://www.taylorfrancis.com/chapters/oa-edit/10.4324/9781003187462-17/negotiating-covid-19-bhutan-mary-grace-pelayo-ian-christopher-rocha-jigme-yoezer

**********

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: Yes: Kinley Gyem

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

Reviewer #7: No

Reviewer #8: Yes: Mary Grace Pelayo Arellano

Reviewer #9: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Reviewers comment.docx

Patient satisfaction in regional referral hospitals of Bhutan: Insights from a cross-sectional study.

PONE-D-24-44865R2

Dear Dr. Dorji,

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,

Ian Christopher N Rocha, MD, MBA, MHSS

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

**********

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

**********

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

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 #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 #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 #2: Thank you for inviting me to review this manuscript again. I have reviewed the revisions and the authors' responses to my previous comments. At this stage, I have no further substantive feedback to add, as my earlier concerns have been adequately addressed.

If there are specific aspects the journal would like me to re-evaluate, please let me know. Otherwise, I defer to the editorial judgment on whether the manuscript is now suitable for publication.

**********

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: Yes: Kinley Gyem

**********

Attachments

Attachment

Submitted filename: Acceptance letter.docx