Physician payment models and cardiac imaging in patients at low cardiovascular risk: A population-based cohort study in Alberta, Canada

Yewande Kofoworola Ogundeji; Amity E. Quinn; Derek S. Chew; Flora Au; Stephen B. Wilton; Matthew T. James; Marcello Tonelli; Braden J. Manns

doi:10.1371/journal.pone.0336399

Peer Review History

Original SubmissionApril 25, 2025
10 Jun 2025 Decision Letter - Jialing Lin, Editor Dear Dr. Manns, 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 Jul 25 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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[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: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: 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: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: This paper is well-written, clearly structured, and addresses an important issue in health services research. While the study provides valuable insights, the following suggestions are intended to further strengthen its quality and enhance its potential for publication. • The study addresses a relevant and timely topic in health services research by examining how physician payment models influence cardiac imaging in low-risk populations. • The use of a large retrospective cohort from administrative health data in Alberta enhances the robustness and generalizability of the findings. • The manuscript is generally well-written, with clear articulation of the research objective, methods, results, and conclusions. • The study design is appropriate for the research question, and the use of multilevel, multivariable logistic regression is methodologically sound. • The classification of patients into low cardiovascular risk is appropriately done using administrative data, although the limitations of such classification should be more clearly acknowledged. • The description of the payment models (fee-for-service vs. salary-based) could benefit from additional context to aid readers unfamiliar with the Canadian healthcare system. • The finding that salary-based physicians, particularly internal medicine specialists, are less likely to order imaging is compelling and aligns with hypotheses regarding financial incentives. • The discussion provides a good synthesis of the results, although more emphasis could be placed on potential policy implications of these findings. • The conclusion is supported by the presented data and underscores the role of physician incentives in potentially unnecessary care. • The authors performed several sensitivity analyses to confirm the robustness of their findings, which is commendable. • The manuscript could improve by including a brief explanation of the ethical approval process, particularly given the use of administrative health data. • Some figures or tables (if available in the full version) may need more detailed legends to stand alone for clarity. • There is no indication of ethical concerns or misconduct related to research design, data analysis, or authorship. Reviewer #2: Good work,the topic is timely and relevant, addressing an underexplored area within health services research. However, the manuscript would benefit from several improvements to maximize its global relevance, contextual clarity, and analytical completeness. The comments below are intended to guide your revision constructively. 1. Title and Keywords 1.1 The title is technically accurate but long and clinical. Consider simplifying it to improve accessibility, e.g., Physician Payment Models and Cardiac Imaging in Low-Risk Patients: A Population-Based Cohort Study in Alberta, Canada. 1.2 The keywords do not sufficiently capture the paper’s scope or uniqueness. Suggested replacements: physician remuneration, cardiac test overuse, primary care incentives, Alberta health system, low-value care. 2. Abstract 2.1 Avoid jargon like “receipt of imaging” — use more universally understood terms. 2.2 The conclusion is too narrowly framed. Consider broadening its relevance to readers unfamiliar with Canadian payment models. 3. Introduction 3.1 The introduction is well-focused on Choosing Wisely and overuse but lacks global context. A comparison of physician payment models across countries (e.g., FFS, capitation, salary) would help orient an international audience. 3.2 The literature cited is mainly Canadian; expanding to include studies from the US, UK, or Australia would strengthen framing. broaden this 3.3 The study objective is clearly stated but could be linked more explicitly to the broader issue of health system design and policy reform. 4. Methods 4.1 The study design is appropriate, but the term “retrospective cohort” may overstate longitudinal rigor. A more precise description would be: “A population-based cohort study using health service data in Alberta, Canada.” 4.2 The assumption of imaging attribution to the nearest outpatient visit should be explained and justified. 4.3 The impact of COVID-19 on test volumes in 2020 is not discussed. A sensitivity analysis excluding 2020 or a clear rationale for inclusion is needed. 4.4 While physician- and patient-level variables are handled well, missing clinical variables (e.g., symptoms) should be flagged more explicitly in Methods, not just in Discussion. 4.5 Ethics approval is mentioned but would benefit from more clarity — include board name, reference number, or waiver status. 5. Results 5.1 Results are presented clearly but are overly text-heavy. Consider including: A forest plot of ORs A STROBE-style flow diagram for cohort construction A bar or line chart showing temporal trends (2012–2020) 5.2 The interpretation of ORs should be supported with absolute risk or test rate examples to enhance real-world understanding. 5.3 No subgroup results by sex, rurality, or age are discussed — such insights could enrich interpretation. 5.4 Specialty comparisons could be disaggregated further for clarity (e.g., GP vs internist vs cardiologist). 5.5 A map or graph showing regional imaging variation would be informative. 6. Discussion 6.1 The discussion is balanced but too narrowly scoped. 6.2 Future research directions are not addressed. Consider suggesting: Multi-jurisdictional comparisons Studies with clinical data to assess appropriate vs inappropriate imaging Implications for payment reform or low-value care monitoring 6.3 The conclusion line is overly technical: “Physician payment models and specialty are strongly associated with receipt of imaging…” Consider rephrasing for global readability, e.g.: “How physicians are paid appears to influence imaging use patterns, even in low-risk patients. This has implications for health systems aiming to reduce low-value care.” 7. Global Relevance and Framing 7.1 The framing leans heavily on Alberta/Canada context. Consider: Generalizing findings into broader health economics or system design language Citing international frameworks (e.g., OECD health data, Choosing Wisely Global) 7.2 While local details are critical, striking a balance between specificity and transferability would increase the paper’s reach and relevance. This manuscript is well-conceived and methodologically sound but would benefit from revisions that strengthen its clarity, expand its global framing, and deepen result interpretability. Addressing the issues outlined above will improve the paper . all the best ****** 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: Mohsin Hassan Alvi Reviewer #2: Yes: Thamburaj Anthuvan ******** [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.0336399.r001
Revision 1
22 Sep 2025 Author Response 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 Thank you. We have done so. 2. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Thank you. It appears that I had multiple records in PLOS but that has been corrected, and my ORCID number now appears. 3. 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. See below 4. In the online submission form, you indicated that we cannot make our dataset available to other researchers due to our contractual arrangements with the provincial health ministry (Alberta Health), who is the data custodian. Researchers may make requests to obtain a similar dataset at https://absporu.ca/research-services/service-application/. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. I corresponded with Dr Lin on this matter on June 24 (response from Ethan Krajewski, Peer Review Operations Specialist, suggesting our response was satisfactory). I will reiterate that here. “There are legal restrictions on sharing our dataset, even fully de-identified data, from our provincial health ministry, who is the formal custodian for the health administrative data that we use for this study. We have been advocating for a change to their policy, which is embedded within the contract through which we access the health data, but have not been successful. Attached, please see a letter from the Alberta government health ministry confirming this legal restriction, and that we would be in breach of the law if we were to make a de-identified dataset available. As an alternative, those interested in conducting similar analyses can make requests to obtain a similar dataset at https://absporu.ca/research-services/service-application/ ." As you note above, we have informed readers of this opportunity. Unfortunately, this policy doesn’t just apply to this one study – it applies to all research conducted by our group using this dataset. Of note, this rationale was recently accepted by PLOSOne within the past year - https://pmc.ncbi.nlm.nih.gov/articles/PMC11156280/ using the same Data Sharing statement. Thank you very much for considering this exemption. 5. Thank you for stating the following financial disclosure: A Canadian Institutes of Health Research Foundation Grant to Manns and a Data Collection Grant from the Clinical Research Fund, University of Calgary to Ogundeji and Manns funded this study 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. Thank you. I can confirm that “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." This has now been added. 6. Please remove all personal information, ensure that the data shared are in accordance with participant consent, and re-upload a fully anonymized data set. Note: spreadsheet columns with personal information must be removed and not hidden as all hidden columns will appear in the published file. Additional guidance on preparing raw data for publication can be found in our Data Policy (https://journals.plos.org/plosone/s/data-availability#loc-human-research-participant-data-and-other-sensitive-data) and in the following article: http://www.bmj.com/content/340/bmj.c181.long. See response above. Unfortunately, we are not able to share our de-identified data. 7. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. See response above. Unfortunately, we are not able to share our de-identified data. [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: Partly 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: 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 Thank you 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 paper is well-written, clearly structured, and addresses an important issue in health services research. While the study provides valuable insights, the following suggestions are intended to further strengthen its quality and enhance its potential for publication. • The study addresses a relevant and timely topic in health services research by examining how physician payment models influence cardiac imaging in low-risk populations. • The use of a large retrospective cohort from administrative health data in Alberta enhances the robustness and generalizability of the findings. • The manuscript is generally well-written, with clear articulation of the research objective, methods, results, and conclusions. • The study design is appropriate for the research question, and the use of multilevel, multivariable logistic regression is methodologically sound. • The classification of patients into low cardiovascular risk is appropriately done using administrative data, although the limitations of such classification should be more clearly acknowledged. • The description of the payment models (fee-for-service vs. salary-based) could benefit from additional context to aid readers unfamiliar with the Canadian healthcare system. • The finding that salary-based physicians, particularly internal medicine specialists, are less likely to order imaging is compelling and aligns with hypotheses regarding financial incentives. • The discussion provides a good synthesis of the results, although more emphasis could be placed on potential policy implications of these findings. • The conclusion is supported by the presented data and underscores the role of physician incentives in potentially unnecessary care. • The authors performed several sensitivity analyses to confirm the robustness of their findings, which is commendable. • The manuscript could improve by including a brief explanation of the ethical approval process, particularly given the use of administrative health data. Thank you. We have provided additional detail. • Some figures or tables (if available in the full version) may need more detailed legends to stand alone for clarity. Thank you. We have modified several of the tables / figures based on reviewers’ comments and added additional detail in the legends • There is no indication of ethical concerns or misconduct related to research design, data analysis, or authorship. Reviewer #2: Good work,the topic is timely and relevant, addressing an underexplored area within health services research. However, the manuscript would benefit from several improvements to maximize its global relevance, contextual clarity, and analytical completeness. The comments below are intended to guide your revision constructively. 1. Title and Keywords 1.1 The title is technically accurate but long and clinical. Consider simplifying it to improve accessibility, e.g., Physician Payment Models and Cardiac Imaging in Low-Risk Patients: A Population-Based Cohort Study in Alberta, Canada. Thank you. We have accepted your suggestion (with one small wording change) 1.2 The keywords do not sufficiently capture the paper’s scope or uniqueness. Suggested replacements: physician remuneration, cardiac test overuse, primary care incentives, Alberta health system, low-value care. Thank you. We have added physician remuneration, cardiac test overuse, low value care. 2. Abstract 2.1 Avoid jargon like “receipt of imaging” — use more universally understood terms. Thank you. This has been changed to cardiac imaging throughout the manuscript. 2.2 The conclusion is too narrowly framed. Consider broadening its relevance to readers unfamiliar with Canadian payment models. Thank you. We have broadened the conclusion, while keeping in mind that many PLOS ONE readers will be international 3. Introduction 3.1 The introduction is well-focused on Choosing Wisely and overuse but lacks global context. A comparison of physician payment models across countries (e.g., FFS, capitation, salary) would help orient an international audience. An additional paragraph has been included in the introduction to include relevant literature across broader health systems context (see pages 3 and 4). 3.2 The literature cited is mainly Canadian; expanding to include studies from the US, UK, or Australia would strengthen framing. broaden this An additional paragraph has been included in the introduction to include relevant literature across broader health system contexts (see pages 3 and 4). We’ve also augmented the evidence cited to include other countries. 3.3 The study objective is clearly stated but could be linked more explicitly to the broader issue of health system design and policy reform. In addition to linking the study to global contexts, we’ve included additional text on the potential influence/impact on physician payment policy reforms 4. Methods 4.1 The study design is appropriate, but the term “retrospective cohort” may overstate longitudinal rigor. A more precise description would be: “A population-based cohort study using health service data in Alberta, Canada.” The title and description have been changed to reflect this. 4.2 The assumption of imaging attribution to the nearest outpatient visit should be explained and justified. Thank you. We are happy to expand, and have added some additional text to the limitation section of the paper. Without clinical data that indicated the ordering physician, we examined the distribution of imaging tests 90 days before patients’ initial visits and up to a year following their initial visits (see figure below). We determined that the majority of tests were ordered during the -30 to +90 day window (Figure). We also spoke to cardiologists about their test ordering practices. Some cardiology specialists routinely ordered testing in advance of their new visits while others ordered them afterwards. Given that there is a short wait time (<30 days) for cardiology imaging studies in Alberta, but often long waits to have a consultation with a specialist, we made the assumption that tests ordered within the 30 days before or 90 days after were related to the clinic visit. We cannot be certain that the tests were ordered by the internist or cardiologist, but it seems unlikely that primary care physicians would change their own imaging ordering practices based on the payment model of the specialist they are referring patients to. So if primary care physicians were ordering many of the tests, we would expect this to dilute the observed association. 4.3 The impact of COVID-19 on test volumes in 2020 is not discussed. A sensitivity analysis excluding 2020 or a clear rationale for inclusion is needed. Our study period did not extend into the period of the pandemic. 4.4 While physician- and patient-level variables are handled well, missing clinical v Attachments Attachment Submitted filename: Response to reviewers PLOS Sept 2.docx https://doi.org/10.1371/journal.pone.0336399.r002
26 Oct 2025 Decision Letter - Jialing Lin, Editor Physician payment models and cardiac imaging in patients at low cardiovascular risk: a population-based cohort study in Alberta, Canada. PONE-D-25-18807R1 Dear Dr. Manns, 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, Jialing Lin Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0336399.r003
Formally Accepted
Acceptance Letter - Jialing Lin, Editor PONE-D-25-18807R1 PLOS ONE Dear Dr. Manns, 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. Jialing Lin Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0336399.r004

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