Assessing the validity of post-discharge readmission and mortality as a composite outcome among newborns in Uganda

Abhroneel Ghosh; Vuong Nguyen; J. Mark Ansermino; Yashodani Pillay; Angella Namala; Joseph Ngonzi; Nathan Kenya-Mugisha; Niranjan Kissoon; Matthew O. Wiens

doi:10.1371/journal.pone.0332787

Peer Review History

Original SubmissionSeptember 4, 2025
27 Oct 2025 Decision Letter - Chris Rees, Editor Dear Dr. Ghosh, 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 Dec 11 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'. 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For a list of recommended repositories and additional information on PLOS standards for data deposition, please see https://journals.plos.org/plosone/s/recommended-repositories . 5. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 6. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: -Minor point, but please change “increased” to “greater” on line 23 in the Abstract. Increase/decrease imply changes over time. -Please include the total sample size and some basic demographics in the Results of the Abstract. Additionally, as the power to assess the relationship between post-discharge mortality and readmission is predicated upon the frequency of each event, please include the numbers for each outcome in the Abstract as well. -Line 53: Access to healthcare is not “easy” for all patients and families in high-income settings. There are many documented disparities that make accessing care more challenging for certain populations. As such, please remove “easily”. -As this study really relies on which candidate variables were collected to assess the relationship between readmission and post-discharge mortality, I request that the authors include more of a description of the rationale for the candidate variable selection in the Methods. -Fig 3: please avoid increase/decrease as there is no relationship between the variables included and time in this figure. Greater and lower would be more appropriate. [Note: HTML markup is below. Please do not edit.] 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 Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 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 Reviewer #3: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** Reviewer #1: This is helpful, well written manuscript that make a clear and decisive point. The question address is important, the methods used are appropriate and the interpretation is accurate to the results. I have read the manuscript in depth and do not believe the authors need to make any changes. Reviewer #2: Check these out: Rees CA, Kisenge R, Godfrey E, Ideh RC, Kamara J, Coleman-Nekar YJ, Samma A, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP. Derivation and Internal Validation of a Novel Risk Assessment Tool to Identify Infants and Young Children at Risk for Post-Discharge Mortality in Dar es Salaam, Tanzania and Monrovia, Liberia. J Pediatr. 2024 Oct;273:114147. doi: 10.1016/j.jpeds.2024.114147. Epub 2024 Jun 13. PMID: 38878962; PMCID: PMC11415288. Rees CA, Kisenge R, Godfrey E, Ideh RC, Kamara J, Coleman-Nekar YJ, Samma A, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP. Derivation and Internal Validation of a Novel Risk Assessment Tool to Identify Infants and Young Children at Risk for Post-Discharge Mortality in Dar es Salaam, Tanzania and Monrovia, Liberia. J Pediatr. 2024 Oct;273 :114147. doi: 10.1016/j.jpeds.2024.114147. Epub 2024 Jun 13. PMID: 38878962; PMCID: PMC11415288. Kisenge RR, Godfrey E, Ideh RC, Kamara J, Coleman-Nekar YJ, Samma A, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP, Rees CA. Development and Internal Validation of a Risk Assessment Tool to Identify Neonates at Risk for 60-Day Hospital Readmission in Dar es Salaam, Tanzania, and Monrovia, Liberia. Am J Trop Med Hyg. 2025 Apr 1;112(6):1378-1384. doi: 10.4269/ajtmh.24-0648. PMID: 40168977; PMCID: PMC12139531. The discussion is shallow. there are many issues which have been breifly discussed, but not elaborated in detail. The travel time for example, may need more clarity. The reason for admission may also have various categories. The maternal mortaality as a predictor of young infant mortaloty may also be considered. Reviewer #3: This was an appropriately described analysis of composite outcome analysis in newborns in Uganda, recognizing the importance and potential utility of risk differentiation in clinical care in LMIC settings as well as the unique barriers to care. This manuscript was well written, easy to follow, with an appropriately described analysis. As a reviewer with limited knowledge of prediction modeling, I was able to follow along easily and appreciated the authors' clear writing and definitions. I also appreciated the authors recognizing the limitations of their data for interpretation and agree with the need to understanding the complex and multifaceted nature of barriers to readmission and mortality in the Ugandan (and other LMIC) context(s). ****** 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 Reviewer #3: 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.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0332787.r001
Revision 1
4 Jan 2026 Author Response We have enclosed our responses within the submitted "Response to Reviewers" rebuttal letter. We copy the same below for reference. Editor Minor point, but please change “increased” to “greater” on line 23 in the Abstract. Increase/decrease imply changes over time. Response: Thank you for your careful review of our manuscript and for the insightful comments. We have appropriately changed increased/decreased to greater/reduced. Please include the total sample size and some basic demographics in the Results of the Abstract. Additionally, as the power to assess the relationship between post-discharge mortality and readmission is predicated upon the frequency of each event, please include the numbers for each outcome in the Abstract as well. Response: We have modified the Results of the Abstract to include the following lines: Results: A total of 6040 newborns with complete six-week follow-up were enrolled, of whom 50.6% were male and 64% of mothers delivered via caesarean section. Thirty-three (0.55%) infants died within the six-week follow-up period and 241 (3.99%) were readmitted. Line 53: Access to healthcare is not “easy” for all patients and families in high-income settings. There are many documented disparities that make accessing care more challenging for certain populations. As such, please remove “easily”. Response: We have appropriately removed “where care is easily accessed.” As this study really relies on which candidate variables were collected to assess the relationship between readmission and post-discharge mortality, I request that the authors include more of a description of the rationale for the candidate variable selection in the Methods. Response: We have included the following line within our Methods section: “These variables were selected using a modified Delphi process based on clinical and contextual knowledge to identify candidate predictors for post-discharge mortality or readmission.” Fig 3: please avoid increase/decrease as there is no relationship between the variables included and time in this figure. Greater and lower would be more appropriate. Response: Increase/decrease have appropriately been changed to Greater/lower. Reviewer #1 This is helpful, well written manuscript that make a clear and decisive point. The question address is important, the methods used are appropriate and the interpretation is accurate to the results. I have read the manuscript in depth and do not believe the authors need to make any changes. Response: Thank you for your careful review of our manuscript. We appreciate the recognition of the significance of our questions, and the confirmation of the relevance and rigor in our work. We are grateful for the positive review and that the manuscript meets expectations. Reviewer #2 Check these out: Rees CA, Kisenge R, Godfrey E, Ideh RC, Kamara J, Coleman-Nekar YJ, Samma A, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP. Derivation and Internal Validation of a Novel Risk Assessment Tool to Identify Infants and Young Children at Risk for Post-Discharge Mortality in Dar es Salaam, Tanzania and Monrovia, Liberia. J Pediatr. 2024 Oct;273:114147. doi: 10.1016/j.jpeds.2024.114147. Epub 2024 Jun 13. PMID: 38878962; PMCID: PMC11415288. Rees CA, Kisenge R, Godfrey E, Ideh RC, Kamara J, Coleman-Nekar YJ, Samma A, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP. Derivation and Internal Validation of a Novel Risk Assessment Tool to Identify Infants and Young Children at Risk for Post-Discharge Mortality in Dar es Salaam, Tanzania and Monrovia, Liberia. J Pediatr. 2024 Oct;273 :114147. doi: 10.1016/j.jpeds.2024.114147. Epub 2024 Jun 13. PMID: 38878962; PMCID: PMC11415288. Kisenge RR, Godfrey E, Ideh RC, Kamara J, Coleman-Nekar YJ, Samma A, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP, Rees CA. Development and Internal Validation of a Risk Assessment Tool to Identify Neonates at Risk for 60-Day Hospital Readmission in Dar es Salaam, Tanzania, and Monrovia, Liberia. Am J Trop Med Hyg. 2025 Apr 1;112(6):1378-1384. doi: 10.4269/ajtmh.24-0648. PMID: 40168977; PMCID: PMC12139531. The discussion is shallow. there are many issues which have been breifly discussed, but not elaborated in detail. The travel time for example, may need more clarity. The reason for admission may also have various categories. The maternal mortaality as a predictor of young infant mortaloty may also be considered. Response: Thank you for your careful review of our manuscript. We are grateful for the provided links, as they provide useful information within the same context of post-discharge outcomes among infants in LMICs. We add these to our list of references, and cite them as follows: “Our study shows that many predictors have conflicting directions and magnitudes of association while others reflect a consistent association in the same direction with the two outcomes when using a composite outcome of newborn post-discharge readmission and mortality. This is further evidenced by differences in pathways to readmission and post-discharge mortality as found in previous studies (25-27).” For travel time, have expanded our discussion around this point to clarify its diverging role in reducing neonatal readmission whilst increasing mortality: “These observations are not unique to our study in that increased travel times or distance to healthcare facilities and sociocultural barriers linked to gender (29–32) hinder care seeking, while resources or support from other family members facilitate care seeking and access (33–35). Together with our results, these highlight the downstream effects that barriers to care and readmission can have on neonatal mortality.” We agree that the cause of readmission and mortality may play a role, however we were not able to include them in our analysis, and listed this as a limitation in the original text: “Causes of death or readmission were not accounted for, though these may bear some relevance to the interpretation of our results.” Further, we now also acknowledge that while 6-week readmission or mortality are likely to be pregnancy or infection related, reasons for readmissions are likely to be more heterogenous and have included the following text; “Within the short 6-week follow up period after birth, we anticipate most adverse outcomes in infants would be linked to pregnancy and infection related risk. Regardless, reasons for readmissions in particular are likely to be heterogenous in terms of cause and severity of illness and would provide useful insight regarding the care-seeking behavior of our cohort.” Finally, we agree that maternal mortality is likely a strong indicator of newborn mortality, however we only observed two in-hospital cases of mothers who died giving birth, and a single maternal death following discharge so it is not likely we would detect any meaningful associations. Hence, we did not make any edits with regards to this point. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #2: No Response: We have appropriately created a new data repository on Borealis that adheres to the PLOS Data policy and PLOS One’s requirements: https://borealisdata.ca/dataset.xhtml?persistentId=doi:10.5683/SP3/QP5WYE However, due to the sensitive nature of our data, and it being not fully de-identified, we choose not to allow unregulated access. Our updated Data Availability statement is as follows: “Study materials (dataset, data dictionary, and metadata) are publicly available through the Pediatric Sepsis Data CoLaboratory’s (Sepsis CoLab) Dataverse: https://doi.org/10.5683/SP3/QP5WYE . Due to the sensitive nature of clinical data and the potential risk for re-identification of research participants, the de-identified dataset is available through moderated access. Access to this data will be granted on a case-by-case basis following approval from the authors and the Data Governance Committees.” Reviewer #3 This was an appropriately described analysis of composite outcome analysis in newborns in Uganda, recognizing the importance and potential utility of risk differentiation in clinical care in LMIC settings as well as the unique barriers to care. This manuscript was well written, easy to follow, with an appropriately described analysis. As a reviewer with limited knowledge of prediction modeling, I was able to follow along easily and appreciated the authors' clear writing and definitions. I also appreciated the authors recognizing the limitations of their data for interpretation and agree with the need to understanding the complex and multifaceted nature of barriers to readmission and mortality in the Ugandan (and other LMIC) context(s). Response: Thank you for your careful review of our manuscript. We are grateful that the relevance of our work on composite outcomes to clinical care in LMIC settings was recognized. It is also encouraging to learn that the results and writing are clear to an audience without detailed knowledge of statistical modeling, and that the text supports understanding across a broad interdisciplinary target audience including clinicians. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0332787.r002
15 Jan 2026 Decision Letter - Chris Rees, Editor Assessing the validity of post-discharge readmission and mortality as a composite outcome among newborns in Uganda PONE-D-25-46967R1 Dear Dr. Ghosh, 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, Chris A Rees, MD, MPH Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0332787.r003
Formally Accepted
Acceptance Letter - Chris Rees, Editor PONE-D-25-46967R1 PLOS One Dear Dr. Ghosh, 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 Chris A Rees Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0332787.r004

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