Impact of COVID-19 on In-Patient and Out-Patient services in Bangladesh

Ridwana Maher Manna; Md Hafizur Rahman; Tasnu Ara; Nasimul Ghani Usmani; K. M. Tanvir; M. Sabbir Haider; Ema Akter; Mohammad Sohel Shomik; Aniqa Tasnim Hossain

doi:10.1371/journal.pone.0315626

Peer Review History

Original SubmissionAugust 19, 2024
19 Aug 2024 Author Response https://doi.org/10.1371/journal.pone.0315626.r001
4 Oct 2024 Decision Letter - Rajib Chowdhury, Editor PONE-D-24-34344Impact of COVID-19 on the utilisation of in-patient and out-patient healthcare services in Bangladesh: analysis of routine healthcare system dataPLOS ONE Dear Dr. Manna, 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 Nov 18 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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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. Thank you for stating the following in your Competing Interests section: None Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state ""The authors have declared that no competing interests exist."", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now This information should be included in your cover letter; we will change the online submission form on your behalf. 3. In the online submission form, you indicated that data for this analysis were sourced from the DHIS2 Bangladesh database, dedicated to health-related indicators for routine facility monitoring and evaluation of public healthcare facilities. This data is owned by the government of Bangladesh and only available with proper request to the government.. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [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: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know 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: 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: No 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: 1. Title: The title is quite long. A more concise version would be: “Impact of COVID-19 on Healthcare Utilization in Bangladesh: Analysis of Routine Data.” 2. Short Title: Please correct the short title to: “Impact of COVID-19 on In-Patient and Out-Patient Care.” 3. Language: The article needs to be revised by a native English writer to improve readability and clarity. Abstract: 4. Abbreviations: Abbreviations should be defined the first time they are used in the manuscript. Introduction: 5. References: Provide the reference for lines 42-45. 6. References: Provide the reference for lines 70-72. 7. Clarity: The introduction needs to be rewritten to avoid repetition and to be more concise. Methods: 8. Could you please provide a detailed paragraph outlining the assessment methods utilized in your research? This should include a description of both the direct and indirect methods employed, such as tests, surveys, interviews, or observational techniques, and how these methods contributed to the reliability and validity of your findings. Data Analysis: 9. Using the Durbin-Watson statistic to check for autocorrelation is correct. However, note that the Durbin-Watson test is typically used for linear regression models. For Poisson regression, you might consider using other methods like the autocorrelation function (ACF) or partial autocorrelation function (PACF). (line 135) 10. Clarify whether you used Poisson regression or linear regression for the final analysis. If Poisson regression was used, remove the mention of applying a linear regression model. (line 137) Results: 11. Please correct the sentence in lines 147-148 to: “The number of OPD visits fell in 2020 (34.1 million) compared to 2019 but showed an upward trend, reaching the targeted predicted value in 2021.” 12. Correct “increases” to “increased” in line 150. 13. Line 220, table 2: The confidence interval for Dhaka in 2020 is listed as (0.83-0.78), which seems incorrect because the lower bound should be less than the upper bound. Discussion: 14. Please compare your major findings to previous studies found in the literature. 15. Write a small paragraph recommending possible measures to manage such pandemics in the future, while citing experiences from previous pandemics Reviewer #2: Overall this is an interesting piece of work to validate the hypothesis that the COVID-19 pandemic impacted utilisation of outpatient and inpatient care. -The introduction is very well written and well describes the context of the study and need to better understand the problem. The materials and methods -Generally are well written and clear. PlosOne required the data to be made publicly available so please recheck this criteria/allowances. -Indicators on line 117: would be nice to highlight if certain departments were not captured in the DHIS Results -Lines147-151: Suggest a minor rewriting as at the moment not clear if difference in visits were 34.1million and 37.5million or declined to that value. -Line 158: Results should not traditionally contain any subjective statements e.g. "interesting". Would rather suggest a rephrasing to state exactly what the trend was (i.e. sudden increase etc.) as a simple statement. -Line 166-67: Again, please re-highlight this point in the discussion offering some deductions/explanations. -Line 167-8: Please double check this grammar through the document as should state "number of IPD admissions declined" and remove the word "were" from this statement. In Line 168 please also remove the word substantial and replace with something more objective. -Line 170-71: Suggest replacing "could not touch" to "did not reach the predicted values" -Line 179: remove the word "was" from "OPD visits was drastically declined". Likewise in line 180. -Line 188: See suggestion about from lines 167-8 Discussion -Line 260-261: Would be nice to offer some suggestion as to why this significant rebound was observed, do we think it's due to catch-up from backlog? Limitations: -Line 285: Please state what proportion of the population access healthcare in private facilities to understand what amount of data is missing from this analysis. Important to understand how we can apply the results to the general population of Bangladesh. -Line 290-93: Please explain why this more detailed analysis on age/departments/gender could not be assessed. Is that due to limitations with data access, limitations in the data itself or not the purpose of this study. Figures: -Minor suggestion to include commas in the y-axis to help readability of the numbers ****** 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: Batoul Ghosn, PhD 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. Attachments Attachment Submitted filename: Plos.one revision.docx https://doi.org/10.1371/journal.pone.0315626.r002
Revision 1
14 Nov 2024 Author Response Editors/Journal requirements: 1. We note that your Data Availability statement states the following: "Data for this analysis were sourced from the DHIS2 Bangladesh database, dedicated to health-related indicators for routine facility monitoring and evaluation of public healthcare facilities. This data is owned by the government of Bangladesh and only available with proper request to the government." If the data is only available upon request, please provide contact information, such as an email address, for a non-author, institutional point of contact (such as an IRB or ethics committee contact) who can field data inquiries from fellow researchers. If the data contact is an individual, please provide their title and relationship to the data as well. Please note that PLOS does not allow authors to be the sole contact for data inquiries. Response: Thank you so much for your instant feedback. Data for this analysis were sourced from the DHIS2 Bangladesh database, dedicated to health-related indicators for routine facility monitoring and evaluation of public healthcare facilities. This data is owned by the government of Bangladesh and only available with proper request to the government. For data inquiries, please contact Dr. Md Toufiq Hassan Shawon, Medical Officer at the Management Information System (MIS), Directorate General of Health Services (DGHS), at sawontheboss4@gmail.com. Dr. Shawon is responsible for managing and overseeing data access for this study. We have also updated the information in the answer box in the data availability section. 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 Response: Thank you for your feedback. We have addressed the comment according to the suggestion. 2. Thank you for stating the following in your Competing Interests section: None Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state ""The authors have declared that no competing interests exist."", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now This information should be included in your cover letter; we will change the online submission form on your behalf. Response: Thank you for the comment. We have updated the cover letter and mentioned about the competing interest in the cover letter as "The authors have declared that no competing interests exist." 3. In the online submission form, you indicated that data for this analysis were sourced from the DHIS2 Bangladesh database, dedicated to health-related indicators for routine facility monitoring and evaluation of public healthcare facilities. This data is owned by the government of Bangladesh and only available with proper request to the government.. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. Response: Thank you for your comment regarding DHIS2 data availability for more clearance. We received this data from the Director General of Health Services of Bangladesh Government, who owns the data, and we do have permission to make the data publicly available or share data with manuscript. Besides, the DHIS2 is owned by the Government of Bangladesh which is available on the DHIS2 website (https://centraldhis.mohfw.gov.bd/dhismohfw/dhis-web-commons/security/login.action). Anyone can access the data upon issuing an email request to the Director General of Health Services of Bangladesh Government. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response: Thank you for your feedback. Reviewer #1: 1. Title: The title is quite long. A more concise version would be: “Impact of COVID-19 on Healthcare Utilization in Bangladesh: Analysis of Routine Data.” Response: Thank you for your feedback. We appreciate your insights about the title. We concise the title according to your suggestion into “Impact of COVID-19 on In-Patient and Out-Patient services in Bangladesh”. 2. Short Title: Please correct the short title to: “Impact of COVID-19 on In-Patient and Out-Patient Care.” Response: Thank you for your insightful observations. We corrected the short title according to the suggestion. 3. Language: The article needs to be revised by a native English writer to improve readability and clarity. Response: Thank you for your insightful observations. We made a significant revision to the narrative of the manuscript with help of a native English writer. Abstract: 4. Abbreviations: Abbreviations should be defined the first time they are used in the manuscript. Response: Thank you for your insightful observations. We have addressed the comment regarding abbreviations in the abstract section. Introduction: 5. References: Provide the reference for lines 42-45. Response: Thank you for your feedback. We have updated the references and introduction section of the manuscript. 6. References: Provide the reference for lines 70-72. Response: Thank you for your observations. We have updated the introduction section of the manuscript and added the references. 7. Clarity: The introduction needs to be rewritten to avoid repetition and to be more concise. Response: Thank you for your comment. We have revised the introduction accordingly in a concise way. Methods: 8. Could you please provide a detailed paragraph outlining the assessment methods utilized in your research? This should include a description of both the direct and indirect methods employed, such as tests, surveys, interviews, or observational techniques, and how these methods contributed to the reliability and validity of your findings. Response: Thank you for your insightful comments. We have revised the paragraph as suggested. Our analysis primarily included data from District Health Information System (DHIS2) which aggregates healthcare utilization data from public hospitals in Bangladesh. By design, it’s a secondary analysis of health system data. To enhance the readability and clarity of the assessment method utilized during the generation and management of the data, we will include detailed explanation of how these data were recorded at the health facility, validated, and deposited into the DHIS2 system. We will also describe the data flow from the health facilities to the national database, as well as the storage and quality control process. Additionally, no direct method such as surveys or interviews were used since our study relied on existing data. DHIS2 ensures data accuracy through routine check and validation procedures at various administration levels, which contribute to the reliability of our findings. The revised paragraph is provided below and we have added the paragraph according to the suggestion in line number 79-97 highlighted in the manuscript. “The data used in this study were sourced from the District Health Information System, version 2 (DHIS2), which collects aggregated data from public healthcare facilities in Bangladesh (14). The data included inpatient admission and outpatient visits from all 64 district hospitals across all eight admirative division of Bangladesh (15). Health facilities record patient data at the facilities using paper-based or electronic systems. These data are then digitalized and uploaded to the DHIS2 platform by a designated facility staff in every facility. The uploaded data flows from the health facilities to district health offices, where it is reviewed, validated, and then sent to the national level (14). DHIS2 employs a robust data validation process, including routine data check, cross-verification, and quality control in different administrative levels to ensure the accuracy and completeness of the data (14). Although no direct methods such as surveys or interviews were employed in this study, the data was considered reliable due to the rigorous process DHIS2 implement for the quality assurance (16). These processes include standardized data entry protocols at the facility level, where healthcare staff input data on outpatient visits and inpatient admissions using electronic or paper-based forms (17). After entry, data undergoes multiple levels of review, including validation checks at district health offices, where errors or inconsistencies are flagged and corrected. Additionally, the DHIS2 platform perform automated data quality checks to ensure completeness and consistency before the data is consolidated at the national level (18).” Data Analysis: 9. Using the Durbin-Watson statistic to check for autocorrelation is correct. However, note that the Durbin-Watson test is typically used for linear regression models. For Poisson regression, you might consider using other methods like the autocorrelation function (ACF) or partial autocorrelation function (PACF). (line 135) Response: Thank you for your insightful observations. We addressed the comment according to the suggestion in the “Data Analysis” section under the Materials and Methods section (Line 118-120). 10. Clarify whether you used Poisson regression or linear regression for the final analysis. If Poisson regression was used, remove the mention of applying a linear regression model. (line 137) Response: We appreciate your feedback regarding the materials and methods section of the article. We have mentioned the Poisson regression model for this study (Line 113 to 116). Results: 11. Please correct the sentence in lines 147-148 to: “The number of OPD visits fell in 2020 (34.1 million) compared to 2019 but showed an upward trend, reaching the targeted predicted value in 2021.” Response: Thank you for your insightful observations. We addressed the comment according to the suggestion in the Result section (Line 125-126). 12. Correct “increases” to “increased” in line 150. Response: Thank you for your feedback. We updated the word according to the suggestion (Line 128). 13. Line 220, table 2: The confidence interval for Dhaka in 2020 is listed as (0.83-0.78), which seems incorrect because the lower bound should be less than the upper bound. Response: Thank you for your comment. We addressed the comment according to the suggestion in the Result section (Line 188 and table 2). Discussion: 14. Please compare your major findings to previous studies found in the literature. Response: Thanks for your valuable suggestion. We have revised the discussion portion mentioning the major findings comparing with previous literature as per your suggestion. 15. Write a small paragraph recommending possible measures to manage such pandemics in the future, while citing experiences from previous pandemics Response: Thank you for your feedback. We appreciate your insights about the management of future pandemic. We have included a paragraph in the end of Discussion section (Line 262-267). Reviewer #2: Overall, this is an interesting piece of work to validate the hypothesis that the COVID-19 pandemic impacted utilisation of outpatient and inpatient care Response: Thank you for your appreciation -The introduction is very well written and well describes the context of the study and need to better understand the problem. Response: Thanks for the valuable comment and appreciation. We have revised the introduction section and shed more light on the problem. The materials and methods -Indicators on line 117: would be nice to highlight if certain departments were not captured in the DHIS Response: We appreciate this valuable suggestion. We acknowledge that DHIS2 captures data primarily from public healthcare facilities and does not include private sector data. Moreover, the aggregated nature of the data limits the granularity, meaning that department-specific healthcare utilization could not be analyzed (Line 100-106). We will include this limitation in the manuscript. Results -Lines147-151: Suggest a minor rewriting as at the moment not clear if difference in visits were 34.1million and 37.5million or declined to that value. Response: Thank you for your insightful observations. We have addressed the comment according to the suggestion in the Result section (Line 125-129). -Line 158: Results should not traditionally contain any subjective statements e.g. "interesting". Would rather suggest a rephrasing to state exactly what the trend was (i.e. sudden increase etc.) as a simple statement. Response: Thank you for your precise feedback. We updated the wordings according to your suggestion (Line 135-136). -Line 166-67: Again, please re-highlight this point in the discussion offering some deductions/explanations. Response: We appreciate this valuable suggestion. According to your suggestion we have revised and added appropriate information to the discussion section of the manuscript. -Line 167-8: Please double check this grammar through the document as should state "number of IPD admissions declined" and remove the word "were" from this statement. In Line 168 please also remove the word substantial and replace with something more objective. Response: We appreciate this valuable suggestion. We have addressed the comment according to the suggestion (Line145-147). -Line 170-71: Suggest replacing "could not touch" to "did not reach the predicted values" Response: Thank you for your feedback. We updated the word according to the suggestion (Line 147-149). -Line 179: remove the word "was" from "OPD visits was drastically declined". Likewise in line 180. Response: We appreciate your feedback regarding the result section of the article. We addressed the comment in (Line 155 to 157) the result section of the manuscript. -Line 188: See suggestion about from lines 167-8 Response: Thank you for your insightful observations. We addressed the comment according to the suggestion in the Result section (Line 164-166). Discussion -Line 260-261: Would be nice to offer some suggestion as to why this significant rebound was observed, do we think it's due to catch-up from backlog? Response: Thank you for your insightful observations. We addressed the comment according to the suggestion in the discussion section (Line 248-252) Limitations: -Line 285: Please state what proportion of the population access healthcare in private facilities to understand what amount of data is missing from this analysis. Important to understand how we can apply the results to the general population of Bangladesh. Response: We appreciate this valuable suggestion. We acknowledge that DHIS2 captures data primarily from public healthcare facilities and does not include private sector data. Which we included in the limitation in the manuscript (Line 269-275). -Line 290-93: Please explain why this more detailed analysis on age/departments/gender could not be assessed. Is that due to limitations with data access, limitations in the data itself or not the purpose of this study. Response: Thank you for the comment. You rightly mentioned that inclusion of age/gender could provide better understanding of the findings. Additionally, this is facility level aggregated data which does not report the individual level data that can provide the information on variables like gender. However, other departments including the inpatient and outpatient are there, although, it was not possible to further segregate into departments such as pediatr Attachments Attachment Submitted filename: Response to Reviewers.docx* https://doi.org/10.1371/journal.pone.0315626.r003
28 Nov 2024 Decision Letter - Rajib Chowdhury, Editor Impact of COVID-19 on In-Patient and Out-Patient services in Bangladesh PONE-D-24-34344R1 Dear Dr. Manna, 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, Rajib Chowdhury, M.Sc.; MPH Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0315626.r004
Formally Accepted
Acceptance Letter - Rajib Chowdhury, Editor PONE-D-24-34344R1 PLOS ONE Dear Dr. Manna, 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. Rajib Chowdhury Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0315626.r005

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