PONE-D-24-37526A retrospective evaluation of access equity in Virtual Care during the COVID-19 pandemicPLOS ONE

Dear Dr. Mondoux,

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 Mar 03 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,

Pasyodun Koralage Buddhika Mahesh

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.  Please note that PLOS ONE has specific guidelines on code sharing for submissions in which author-generated code underpins the findings in the manuscript. In these cases, we expect all author-generated code to be made available without restrictions upon publication of the work. Please review our guidelines at https://journals.plos.org/plosone/s/materials-and-software-sharing#loc-sharing-code and ensure that your code is shared in a way that follows best practice and facilitates reproducibility and reuse.

3. Thank you for stating the following financial disclosure:

“Declaration of Interest: SM was the recipient of the Juravinski Research Institute grant which paid for the costs of administrative data use. SM was also the recipient of the Graham Farquharson Knowledge Translational Fellowship, administered by PSI, which created protected time for research. NC was a paid research coordinator as part of this project. SM, FB, CL, PM, AP, AD and KG are all clinicians providing clinical care using both virtual and in-person modalities throughout the pandemic. AG is a paid employee of the Institute of Clinical Evaluative Sciences (ICES). “

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

4. Please expand the acronym “PSI” (as indicated in your financial disclosure) so that it states the name of your funders in full.

This information should be included in your cover letter; we will change the online submission form on your behalf.

5. Please upload a copy of Figure 1, to which you refer in your text on page 5. If the figure is no longer to be included as part of the submission please remove all reference to it within the text.

6. Please include a copy of Tables 1 and 2 which you refer to in your text on page 7.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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: The manuscript discusses an important timely topic. However, there are some areas that you need to pay attention to improve the clarity of the manuscript.

Title: A retrospective evaluation of access equity in virtual care during the COVID-19 pandemic (EVOQUe - equity)

The manuscript addresses an important and timely topic.

Suggestions for improvement: The study sample has to be mentioned in the title. Do not use statements within brackets in the title.

Introduction: The introduction provides a clear background on the growing use of virtual care in Canada, emphasizing its accelerated adoption during the pandemic and the challenges of equitable access. The authors have identified the gap in the availability of quantitative data addressing virtual care disparities.

However, the manuscript will further benefit from a clear definition for the word ‘Virtual care’. What type of virtual care were you referring to? Is this research question only relevant to the health programs carried out in virtual platforms or any other?

The background of the available literature on and around the topic should be elaborated. What made you think that virtual platforms do not support equitable access?

Please state the research question explicitly. What specific aspects of equity have you prioritized in this study? (e.g. socio-economic, geographic, ethnic etc.) What do you mean by marginalized population?

Are the results generated from this study only relevant to the pandemic times or address broader implications for future virtual care policy?

Methods

Why were some of these groups excluded from the study? Won’t that create any bias to the final result?

Discussion

Provides a good interpretation of the study findings. This part of the manuscript can benefit from critically analysing the present findings with the findings from previous literature from both international and Canadian setting.

Reviewer #2: Introduction

The authors have provided a clear rationale for conducting the current study, in a context where there is limited availability of studies assessing the equity in virtual care access quantitatively, despite the availability of qualitative data. It is suggested to also provide a brief justification for selecting the ONMARG scores for the purposes of the current study.

The aim of the study has been given as ‘to explore factors influencing the accessibility virtual care and disparities faced by various population groups’ in the introduction. This is somewhat in contrast to what is mentioned in the abstract, which mentions, ‘a comparison of healthcare utilization between virtual care and in-person care in the province of Ontario across all dimensions of the Ontario Marginalization Index and compared the rates of use within each’, which is evident as the methodology that has been followed. This difference in the depiction of the objective of the study might create some confusion to the reader initially in the text. Hence, it is suggested to mention the aim/ objective of the study in a consistent way throughout the manuscript.

Methods

Setting and population

The setting and the timeframe of analysis have been clearly defined. Exclusion criteria have been defined in the manuscript. It has been mentioned that patients without a valid Ontario health card have been excluded from the analysis. It is worth mentioning the rationale for this exclusion, how much of a proportion this category was out of the total visits, and whether excluding them would have created any bias in the study.

It is stated that there was a very high proportion of ‘undefined’ location codes within the ICES billing data. It is not very clear whether these visits were excluded or whether they were included following review. Suggest elaborating it to give a clear idea.

Suggest including a brief rationale for conducting the analysis on a per-visit basis rather than on a per-patient basis, for the clear understanding of the reader.

Data sources

The different databases linked for extracting the data required for the analysis have been well-explained.

Outcome measures and analyses

The outcome measure has been given as the mean visit rate per 1000 residents within the dissemination area. It would be clearer to the reader if it was specified as the ‘in-person or virtual’ visit rate. Further, it is not very clear whether each dissemination area has been taken as the unit measure in the analysis. Hence, it is suggested to clearly mention it. Further, It would be good to mention the number of dissemination areas included in the study altogether. Furthermore, the analysis method that has been carried out in comparing the mean visit rate (either in-person or virtual) in the dissemination areas belonging to different marginalization categories is not clear. It is suggested to explain this further for the benefit of the reader.

Ethics and approval

The rationale for not requiring informed consent and ethics approval have been explained.

Results

Study population

Table 1 and 2 were not available in the manuscript, for review. Hence, it is not possible to comment on this section. Suggest including the tables.

Access equity

An elaborated explanation has been provided on the comparison of utilization of virtual care (and in-person care) across different levels of marginalisation. However, it is not clear if these interpretations of the results are based on the comparison of descriptive mean values obtained as mean visit rates, or whether further analytical methods have been used for the comparison. Suggest presenting the available data values of the data analysis that has been carried out. Figure 1 was not available in the manuscript, for review, hence it is not possible to comment on the results/ data analysis. Suggest including Figure 1.

Interpretation

The results obtained in the study have been interpreted considerably in terms of the differences observed in virtual and in-person visits at different levels of marginalisation. However, in my view, saying that ‘Patients who used virtual care during the pandemic were fundamentally different than individuals who were seen in-person’ would require a more robust analysis of data to justify it.

The explanation given paragraphs 3 and 4 mention about the healthy immigrant effect and the likelihood of increased baseline health of less marginalized patients, as one of the causes/ explanations for seeking virtual care in contrast to in-person care. In my view, it would be good to mention the other possible causes suggested for the differences as well, to provide the reader a more comprehensive interpretation.

Limitations

Limitations of the study have been well-identified and explained.

Conclusion

It would be good to provide some recommendations for future research and elaborate some more on the policy considerations mentioned.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

**********

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

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

A retrospective evaluation of access equity in Virtual Care during the COVID-19 pandemic

PONE-D-24-37526R1

Dear Dr. Mondoux,

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,

Pasyodun Koralage Buddhika Mahesh

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 #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The study is conducted on an interesting topic and has followed a technically sound methodology. Authors have addressed all the comments made during the previous review. The manuscript is now suitable for publication.

Reviewer #2: The comments given for the previous version of the manuscript have been satisfactorily addressed by the authors.

**********

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: No

Reviewer #2: No

**********

Attachments

Attachment

Submitted filename: Comments (2).docx