Social determinants of health in lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) older adults: Impact of socioeconomic disadvantage on inpatient hospitalizations

Jennifer T. May; Devon Noonan; Susan G. Silva

doi:10.1371/journal.pone.0330612

Peer Review History

Original SubmissionJanuary 10, 2025
12 Feb 2025 Decision Letter - Harpreet Grewal, Editor Dear Dr. May, 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. ==============================<h3>Hard Recommendations </h3> Justify the Exclusion of Emergency Room Visits The Introduction references prior research on socioeconomic status and hospital/emergency room utilization. However, the Methods section does not clarify why emergency room visits were excluded. The authors must provide a strong rationale for this exclusion, as ER visits are a critical component of healthcare access, particularly in socioeconomically disadvantaged populations. Clarify the Relationship Between ADI Groups and Primary Diagnoses/Hospitalizations per Patient The Results section does not explicitly explore whether there is a correlation between ADI groups and specific health conditions or the frequency of hospitalizations per patient. If no relationships were found, this should be clearly stated. If such data exist but were not analyzed, the authors should consider including it, as it would enhance the study’s clinical relevance. Provide References for Social Support and Community Connection Claims The Discussion section states that differences in sexual orientation across ADI groups suggest differences in social support and community connection. However, no references are provided to support this claim. The authors must either cite relevant literature or provide empirical justification for these assertions. ******** <h3>Soft Recommendations </h3> Improve Writing and Grammar Throughout the Manuscript The manuscript contains multiple spelling and grammatical errors, as noted by Reviewer 2. Specific lines (99-101, 163-166, 192-193, etc.) require correction, but the entire manuscript should be reviewed for clarity and coherence. A professional language edit is strongly recommended. Clarify the Placeholder Citation ("XX et al. 2023[21]") On line 165, there is a reference to “(see XX et al. 2023[21]).” If this is an intentional blinding of author names for review purposes, it should be indicated. If it was left in by mistake, it must be corrected. Discuss the Potential for Future Comparisons to Heterosexual and Cisgender Counterparts** While the Introduction makes comparisons between LGBTQ+ individuals and their heterosexual/cisgender counterparts, the Discussion does not return to this point. The authors should consider acknowledging this as a potential future research direction. Please submit your revised manuscript by Mar 29 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. 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. 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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, Harpreet Singh Grewal 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 update the “Ethics Statement” section in the Metadata of your manuscript with the relevant information." 3. Please provide additional details regarding participant consent. 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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. [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? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: I Don't Know ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: No ****** Reviewer #1: This study conducted a secondary analysis of hospital admission records for which economic/neighborhood groups of LGBTQ+ older individuals were treated at some academic medical centers. Almost all patients were there for treatment of pulmonary symptoms. The majority of LGBTQ+ patents (66.4%) were from areas with low socioeconomic disadvantage. The authors expressed surprise about this finding. The authors discuss patient ease of access, support, insurance, and community factors facilitating their care saying policy should address LGBTQ+ patients from less affluent neighborhoods with higher social disadvantage. This is a reasonable recommendation. There is no discussion of health outcomes. Likely this information was not in the health records that they consulted. Is this a limitation? Reviewer #2: This article aims to determine if a relationship exists between LGBTQ+ older adult hospitalizations and the county-level socioeconomic conditions in which they reside, and to interpret this relationship through the lens of the SGM Health Research Framework at the individual, interpersonal, community, and societal level. This reviewer believes the authors were mostly successful in accomplishing their aims. The manuscript appears technically sound and the data supports their conclusions; this reviewer is not well-versed enough in statistical analyses to address their appropriateness or rigor; the authors do not provide access to the data, citing unspecified privacy/ethical concerns; and while most of the manuscript is intelligible and written in standard English, there are a number of spelling/grammatical errors that require correction. The major and minor issues that should be addressed prior to publication are detailed below: 1. One major area of concern is the lack of justification for the exclusion of emergency room visits. In the Introduction, the authors reference previous studies linking socioeconomic status and rates of hospitalizations, rehospitalizations, and emergency visits. It is not made clear in the Methods section why emergency room visits were not included. 2. Relatedly, another major area of concern is in the authors’ examination of “ADI Groups and Patient Characteristics” in the Results section. The authors do not mention any analyses regarding relationships between ADI groups and primary diagnoses nor hospitalizations per patient. If no relationships were found, this should be stated. 3. Another area of concern: in the Discussion section, “Interpersonal Level Factors”, on lines 268-270, the authors do not adequately provide reasoning for why differences in sexual orientation across low, moderate, and high disadvantage areas suggests differences in social support and community connection. What is the reasoning behind this claim? No references are provided for differences in social support and community connection between lesbian/gay-identified older adults and asexual older adults. 4. Of more minor concern is the writing of this article. While much of the article is perfectly intelligible and well-written, there are multiple spelling and grammatical errors, and several sentences that are unclear throughout the paper. Please see the following lines for errors that should be addressed prior to publication: 99-101, 163-166, 192-193, 194, 201, 203, 228, 260, 280, 284, 290-292, 338-339, 346, 350, 352, 354. This reviewer also recommends the entire article be reviewed for any spelling mistakes and grammatical errors, in case any were missed in the above list. 5. Of minor concern: on line 165, the article says “(see XX et al. 2023[21])”. It is unclear if this is meant as a purposeful blinding, or if it was mistakenly left in. 6. Of minor concern: while comparisons to heterosexual and cisgender counterparts are made in the introduction section, the Discussion section does not bring this up as a potential future direction of research. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0330612.r001
Revision 1
23 Apr 2025 Author Response Please find the reviewer’s comments and our responses below. Thank you for this opportunity to revise and resubmit. 1. Justify the Exclusion of Emergency Room Visits The Introduction references prior research on socioeconomic status and hospital/emergency room utilization. However, the Methods section does not clarify why emergency room visits were excluded. The authors must provide a strong rationale for this exclusion, as ER visits are a critical component of healthcare access, particularly in socioeconomically disadvantaged populations. Authors’ comments: Thank you for the comment. We agree that ED visits are a critical component of care and hope to look at this with future research studies. The focus of the study was on inpatient hospitalizations only. In the introduction the Armenia et al. (2017) article describes an observational study from the National Inpatient Sample database of the Healthcare Cost and Utilization Project (HCUP) data. The study discusses emergency surgeries of patients who are admitted as inpatient status. We have clarified throughout the manuscript by using the term “inpatient” before hospitalizations where appropriate, including the title. 2. Clarify the Relationship Between ADI Groups and Primary Diagnoses/Hospitalizations per Patient The Results section does not explicitly explore whether there is a correlation between ADI groups and specific health conditions or the frequency of hospitalizations per patient. If no relationships were found, this should be clearly stated. If such data exist but were not analyzed, the authors should consider including it, as it would enhance the study’s clinical relevance. Authors’ comments: We agree that exploring the relationship between ADI group and specific health conditions or frequency of hospitalization per patient would be useful. However, the study was not part of the information extracted from the electronic medical records. Thus, we did not conduct these analyses. 3. Provide References for Social Support and Community Connection Claims The Discussion section states that differences in sexual orientation across ADI groups suggest differences in social support and community connection. However, no references are provided to support this claim. The authors must either cite relevant literature or provide empirical justification for these assertions. Authors’ comments: We have added supporting information for this statement. The additional information reads: Pg 14, lines 267-272 - This is supported by research showing that socioeconomic status (SES) significantly impacts social support networks among LGBTQ+ individual, with higher SES individuals from higher socioeconomic backgrounds are more likely to receive support from multiple sources, including family, peers, and significant others, while those from lower socioeconomic backgrounds often lack family support and experience worse mental health outcomes.[31, 32] Soft Recommendations 1. Improve Writing and Grammar Throughout the Manuscript The manuscript contains multiple spelling and grammatical errors, as noted by Reviewer 2. Specific lines (99-101, 163-166, 192-193, etc.) require correction, but the entire manuscript should be reviewed for clarity and coherence. A professional language edit is strongly recommended. Authors’ comments: Thank you for bringing these errors to our attention. Line 57 – correction to the spelling of “identity” Line 65 - correction to the spelling of “county” Lines 97: We have added a comma after the word “model” in line 97 to now read as: “Guided by the social ecological model,[19]…”. This aligns with the Vancouver style of intext citations. Line 100 the spelling of incapsulated has been corrected to “encapsulated”. 2. Clarify the Placeholder Citation ("XX et al. 2023[21]") On line 165, there is a reference to “(see XX et al. 2023[21]).” If this is an intentional blinding of author names for review purposes, it should be indicated. If it was left in by mistake, it must be corrected. Authors’ comments: Thank you. We have inserted “blinded for review” as a placeholder and have added this to the references list. 3. Discuss the Potential for Future Comparisons to Heterosexual and Cisgender Counterparts While the Introduction makes comparisons between LGBTQ+ individuals and their heterosexual/cisgender counterparts, the Discussion does not return to this point. The authors should consider acknowledging this as a potential future research direction. Authors’ comments: Thank you for this suggestion. Pg 17, lines 330-335 reads: While some studies might benefit from comparing LGBTQ+ and non-LGBTQ+ populations, it’s equally important to conduct research that explores the rich diversity within LGBTQ+ older adult communities without necessarily using non-LGBTQ+ populations as a reference point. Longitudinal studies examining how health experiences and needs evolved over time could provide important information for developing long-term strategies to promote equity in aging populations. Attachments Attachment Submitted filename: PLOS One Response to Reviewer Comments.docx https://doi.org/10.1371/journal.pone.0330612.r002
8 Jul 2025 Decision Letter - Saima Aleem, Editor Dear Dr. May, Thank you for submitting your manuscript to PLOS ONE. 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 Aug 22 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. 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 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, Saima Aleem 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. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #2: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> 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 Reviewer #1: No Reviewer #2: No ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: No ****** Reviewer #1: The review has addressed all of the reviewers' concerns and queries. The authors did a competent job in refining this submission. Reviewer #2: A majority of the original comments were addressed. The manuscript is technically sound, the data support the conclusion, and the analyses were appropriate and rigorous. The authors indicate the data cannot be shared publicly because of data privacy, but is available upon request. However, minor revisions are recommended as there are still a large number of grammatical errors in the text that were not addressed. It is recommended the authors correct the following errors and review their manuscript carefully for any additional grammatical errors missed by the reviewer: Line 165: “…or it can be entered it in the clinical setting…” to “…or can be entered in the clinical setting…” Line 195-196: “…when there is a significant overall effect was detected.” to “…when a significant overall effect was detected.” Line 243: “…the majority of (66.4%) of hospitalized LGBTQ+…” to “…the majority (66.4%) of hospitalized LGBTQ+…” Line 276: “…backgrounds are more likely to receive support from multiple sources…” to “…backgrounds being more likely to receive support from multiple sources…” Line 287: typo—change “my” to “may” Line 291: typo—change “tavel” to “travel” Line 298: typo—change “my” to “may” Line 299: typo—change “aniti-discrimination” to “anti-discrimination” Line 350-351: “Street level data would would have…” to “Street level data would have…” Line 362: “…particularly or older…” to “…particularly for older…” Line 364: “Since the pandemic there…” to “Since the pandemic, there…” Line 366: “Depending on which disadvantage index used…” to “Depending on which disadvantage index is used…” Except for these grammatical issues, the manuscript is well-written and engaging. In particular, the Discussion, Future Directions, and Limitations sections were well executed and robust. ****** 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 https://doi.org/10.1371/journal.pone.0330612.r003
Revision 2
28 Jul 2025 Author Response Reviewer Comments Reviewer #1 1. The review has addressed all of the reviewers' concerns and queries. The authors did a competent job in refining this submission. Thank you! Reviewer #2 1. A majority of the original comments were addressed. The manuscript is technically sound, the data support the conclusion, and the analyses were appropriate and rigorous. The authors indicate the data cannot be shared publicly because of data privacy, but is available upon request. However, minor revisions are recommended as there are still a large number of grammatical errors in the text that were not addressed. Thank you! 2. It is recommended the authors correct the following errors and review their manuscript carefully for any additional grammatical errors missed by the reviewer: I appreciate the level of detail the errors are listed and the opportunity to correct these. I apologize for the oversight. We have carefully reviewed and provided an additional edit to correct the font of the reference page. Line 165: “…or it can be entered it in the clinical setting…” to “…or can be entered in the clinical setting…” Corrected. Line 195-196: “…when there is a significant overall effect was detected.” to “…when a significant overall effect was detected.” Corrected. Line 243: “…the majority of (66.4%) of hospitalized LGBTQ+…” to “…the majority (66.4%) of hospitalized LGBTQ+…” Corrected. Line 276: “…backgrounds are more likely to receive support from multiple sources…” to “…backgrounds being more likely to receive support from multiple sources…” Corrected. Line 287: typo—change “my” to “may” Corrected. Line 291: typo—change “tavel” to “travel” Corrected. Line 298: typo—change “my” to “may” Corrected. Line 299: typo—change “aniti-discrimination” to “anti-discrimination” Corrected. Line 350-351: “Street level data would would have…” to “Street level data would have…” Corrected. Line 362: “…particularly or older…” to “…particularly for older…” Corrected. Line 364: “Since the pandemic there…” to “Since the pandemic, there…” Corrected. Line 366: “Depending on which disadvantage index used…” to “Depending on which disadvantage index is used…” Corrected. 3. Except for these grammatical issues, the manuscript is well-written and engaging. In particular, the Discussion, Future Directions, and Limitations sections were well executed and robust. Thank you! Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0330612.r004
5 Aug 2025 Decision Letter - Saima Aleem, Editor Social determinants of health in lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) older adults: Impact of socioeconomic disadvantage on inpatient hospitalizations PONE-D-25-01218R2 Dear Dr. May, 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. For questions related to billing, please contact billing support . 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, Saima Aleem Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0330612.r005
Formally Accepted
Acceptance Letter - Saima Aleem, Editor PONE-D-25-01218R2 PLOS ONE Dear Dr. May, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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. Saima Aleem Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0330612.r006

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