Development and validation of the Health Segment Classification of Population Encompassed within Singapore (HealthSCOPES) framework

Ian Yi Han Ang; Nabilah Rahman; Shing Hei Wong; Sheryl Hui-Xian Ng; Kyle Xin Quan Tan; Ke Xin Eh; Zheng Jye Ling; Andrea Su En Lim; Kelvin Bryan Tan; Sue Anne Toh

doi:10.1371/journal.pone.0317016

Peer Review History

Original SubmissionJune 13, 2024
19 Aug 2024 Decision Letter - Apurva kumar Pandya, Editor PONE-D-24-23865Development and validation of the Health Segment Classification of Population Encompassed within Singapore (HealthSCOPES) frameworkPLOS ONE Dear Dr. Ang, 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 Oct 03 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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Additional Editor Comments: Dear authors, first of all, let me congratulate authors for wonderful work. We received feedback from reviewers and suggest you to make minor revision to consider for publication. [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: 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: No 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: This manuscript presents an in-depth analysis of the development and validation of the Health Segment Classification of Population Encompassed within Singapore (HealthSCOPES) framework. I have several questions as below 1) Extent and Management of Missing Data: The manuscript does not explicitly mention the extent of missing data encountered during the study. Could you provide detailed information on the amount of data that was missing? Additionally, what strategies or methodologies were employed to handle the missing data? Understanding the approach to missing data is critical for evaluating the robustness and reliability of the study's findings. 2) Stability of Health Segments: It is mentioned that the health segments should be stable over time. Can you confirm if this aspect of stability was directly addressed and analyzed within the manuscript? If so, please provide insights into the methods used to assess the stability of the health segments and the results obtained from this analysis. 3) Consultation with Local Clinical Experts: The development of the HealthSCOPES framework included consultations with local clinical experts. Please elaborate on the number of clinical experts consulted during this process. Additionally, was a consensus reached among these experts regarding the classification criteria and the overall framework? Details on the consultation process and the extent of expert agreement would provide valuable context for the framework's validation. Explanation of the CHAS Scheme: 4) Given that the audience of the journal may not be familiar with the healthcare system in Singapore, particularly the Community Health Assist Scheme (CHAS), a brief explanation of the scheme and its color coding (e.g., CHAS Blue, CHAS Orange) would be highly beneficial. This context will help readers understand the socio-economic stratifications and their implications on healthcare access and utilization in Singapore. 5) Exclusion of Medifund Status: The manuscript did not mention whether Medifund status was used in the analysis. Could you provide the rationale behind the exclusion of Medifund status? Understanding the reasons for omitting this financial assistance scheme will clarify any potential biases or limitations in the socio-economic aspects of the health segmentation. 6) Obesity Classification Standards: Lastly, could you specify whether the classification of obesity in the study follows the World Health Organization (WHO) standards or the Asian Body Mass Index (BMI) criteria for high risk? Given the differences in BMI thresholds for defining obesity in various populations, this clarification is essential for interpreting the findings related to obesity and its associated health risks. Reviewer #2: The reviewed article seems to me to be very appropriate and its conclusions are based on the findings and results obtained. The methodology is coherent and in accordance with the proposed objectives, as are the conclusions obtained. It seems to me a good article that contributes and sheds light on patient classification from a multi-criteria perspective, very much to be taken into account by healthcare decision-makers and political managers. ****** 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: Ang Yee Gary Reviewer #2: Yes: AJ Garcia-Ruiz. Del Pharmacology. Health & Economics Research. School of Medicine. University of Málaga (Spain) ******** [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.0317016.r001
Revision 1
2 Oct 2024 Author Response We thank the editor and reviewers for their comments. Please find the responses to the comments below. 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: We have reviewed and ensured the style and file naming meets the requirements. 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. Response: We have updated the Data Availability statement in the submission to more clearly state that: “Data cannot be shared publicly; there are legal restrictions on sharing the de-identified data because they are national administrative data consolidated and owned by the Government of Singapore. Access to the data can be requested through the TRUST Platform with approvals from the Data Access Committee at https://trustplatform.sg/” 3. 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. Response: We have reviewed our reference list and it is complete and correct. Additional Editor Comments: Dear authors, first of all, let me congratulate authors for wonderful work. We received feedback from reviewers and suggest you to make minor revision to consider for publication. Response: Thank you. Reviewers' comments: Reviewer #1: This manuscript presents an in-depth analysis of the development and validation of the Health Segment Classification of Population Encompassed within Singapore (HealthSCOPES) framework. I have several questions as below 1) Extent and Management of Missing Data: The manuscript does not explicitly mention the extent of missing data encountered during the study. Could you provide detailed information on the amount of data that was missing? Additionally, what strategies or methodologies were employed to handle the missing data? Understanding the approach to missing data is critical for evaluating the robustness and reliability of the study's findings. Response: We have added a flowchart to illustrate how the 2016 segmentation population was created. From the master list of individuals, we excluded those without race information, who were non-residents, aged >110 in 2016, with no valid residential postal code and who died in 2015 or earlier. For the summary statistics on the segment demographics (Table 2), summary statistics on healthcare utilization (Fig 3) and validation analysis (Table 3, Fig 4 and Table 4), there was no further missing data. For each of the aforementioned results, we have since indicated in the manuscript that data was complete. Rather than missing data, the limitation of the study’s findings is lack of additional types of data to apply some of the segmentation criteria. This limitation can be found in the discussion section. 2) Stability of Health Segments: It is mentioned that the health segments should be stable over time. Can you confirm if this aspect of stability was directly addressed and analyzed within the manuscript? If so, please provide insights into the methods used to assess the stability of the health segments and the results obtained from this analysis. Response: Stability aspect of the health segments is not addressed and analyzed in this manuscript. To assess the stability aspect of the manuscript, health segments of multiple years need to be available. At the point of analysis, not all of the equivalent dataset segments used to segment 2016 population were ready and available for the following years. Hence, we were not able to assess stability well without attributing any differences to the lack of equivalent data in applying the segmentation criteria for subsequent years. This point is more clearly stated in the Limitations section, with suggestions for future work to explore the multi-year stability. 3) Consultation with Local Clinical Experts: The development of the HealthSCOPES framework included consultations with local clinical experts. Please elaborate on the number of clinical experts consulted during this process. Additionally, was a consensus reached among these experts regarding the classification criteria and the overall framework? Details on the consultation process and the extent of expert agreement would provide valuable context for the framework's validation. Response: Five clinical experts were consulted during the development of the framework. They were at the consultant level and above, and covered specialties of oncology, palliative care, pediatrics, endocrinology, and preventive medicine. The consultations were to first ensure the framework facilitated development of practical care goals, actionable care programs, and measurable outcomes for segments relevant to each clinical expert’s specialty before the quantitative data portion. As such, there were no procedures taken for the overall framework and the classification criteria to reach consensus amongst the clinical experts. We have added these details to the manuscript to clarify the process taken for the framework development. Explanation of the CHAS Scheme: 4) Given that the audience of the journal may not be familiar with the healthcare system in Singapore, particularly the Community Health Assist Scheme (CHAS), a brief explanation of the scheme and its color coding (e.g., CHAS Blue, CHAS Orange) would be highly beneficial. This context will help readers understand the socio-economic stratifications and their implications on healthcare access and utilization in Singapore. Response: We have added some description on CHAS scheme in the “Database” section. It now reads: “The datasets contained healthcare utilization data submitted through the Central Claims Processing System and data submitted for subvention purposes from (i) public sector hospitals for inpatient episodes, emergency department (ED) attendances, and specialist outpatient clinic (SOC) attendances, (ii) public sector primary care centers (polyclinics), and (iii) private sector Community Health Assist Scheme (CHAS) clinics. CHAS is a scheme introduced in 2014 aimed to make primary healthcare more accessible and affordable to lower- to middle-income Singaporean households by providing higher subsidies to these households. Before November 2019, CHAS benefits are tiered depending on household income with CHAS Blue cardholder receiving higher subsidies than CHAS Orange cardholder. From November 2019, CHAS Green was introduced for Singaporean with chronic conditions who do not qualify for CHAS Blue and Orange.” 5) Exclusion of Medifund Status: The manuscript did not mention whether Medifund status was used in the analysis. Could you provide the rationale behind the exclusion of Medifund status? Understanding the reasons for omitting this financial assistance scheme will clarify any potential biases or limitations in the socio-economic aspects of the health segmentation. Response: Medifund status was excluded due to repetition with the socio-economic status as capture in the CHAS status. Additionally, Medifund serves as a safety net only triggered in the event of an exorbitant medical bill, and so might not be adequately capturing socio-economic status if not such medical episodes exist. 6) Obesity Classification Standards: Lastly, could you specify whether the classification of obesity in the study follows the World Health Organization (WHO) standards or the Asian Body Mass Index (BMI) criteria for high risk? Given the differences in BMI thresholds for defining obesity in various populations, this clarification is essential for interpreting the findings related to obesity and its associated health risks. Response: Yes, the classification of obesity was set as having body mass index 27.5kg/m2 or higher, the criteria for Asian populations. This is now clearly stated in the manuscript. Reviewer #2: The reviewed article seems to me to be very appropriate and its conclusions are based on the findings and results obtained. The methodology is coherent and in accordance with the proposed objectives, as are the conclusions obtained. It seems to me a good article that contributes and sheds light on patient classification from a multi-criteria perspective, very much to be taken into account by healthcare decision-makers and political managers. Response: Thank you. 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. Response: The figure files have now been processed through PACE and will be reuploaded. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0317016.r002
20 Dec 2024 Decision Letter - Nenad Filipovic, Editor Development and validation of the Health Segment Classification of Population Encompassed within Singapore (HealthSCOPES) framework PONE-D-24-23865R1 Dear Dr. Ang, 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. 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If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for making the suggested changes I am happy to recommend accepting the publication in its current form. Reviewer #2: (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 #1: Yes: Dr Ang Yee Gary Reviewer #2: Yes: Antonio J Garcia-Ruiz, MD,MsC,PhD. Dep Farmacólogo & Clinical Therapeutics. Health Economics & Outcomes Research. University of Malaga. ******** https://doi.org/10.1371/journal.pone.0317016.r003
Formally Accepted
26 Dec 2024 Acceptance Letter - Nenad Filipovic, Editor PONE-D-24-23865R1 PLOS ONE Dear Dr. Ang, 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 Professor Nenad Filipovic Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0317016.r004

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