Quality of referral system and associated factors among referred clients referred to dessie comprehensive specialized hospital, Northeast, Ethiopia

Biruk Abera; Toyib Yasin; Hiwot Gizaw; Yonas Fissha Adem

doi:10.1371/journal.pone.0337715

Peer Review History

Original SubmissionJune 19, 2024
23 Oct 2024 Decision Letter - Trhas Berhe, Editor PLOS ONE Dear Dr. Adem, 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. ============================== Thank you for your submission. Could you please ensure that your manuscript follows the STROBE checklist for cross-sectional studies and adheres to the PLOS ONE guidelines for figures and tables? Additionally, we kindly ask that you provide more details on how reliability and validity were ensured in your study. Best regards ============================== Please submit your revised manuscript by Dec 07 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . 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Please upload a copy of Supporting Information Figure/Table/etc. Supporting Information which you refer to in your text on page 41 in PDF submission.-->?> [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: Partly Reviewer #2: Yes ******** 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: Dear author(s), thank you for your manuscript. Overall, this is a clear, concise, and well-written manuscript on an important topic that is often under-researched. The introduction is relevant. Sufficient information about the importance of the research topic is presented for readers to follow the present study rationale and procedures. Although the article is well written but clarification of a few details should be provided. Specific comments follow: 1. What was the reason for choosing the study method? As the study uses a cross-sectional design, Can this method establish cause and effect relationships between variables? 2. What was the reason for choosing only one hospital? The study only includes patients referred to one hospital. This geographic limitation means the findings may not apply to other hospitals with different patient demographics or healthcare infrastructures. 3. The article predominantly uses descriptive statistics to report results (e.g., frequencies and percentages), but lacks deeper inferential statistical analyses to explore more complex relationships between variables. This restricts the depth of insight that can be gained from the data. 4. While some operational definitions are provided, others like “good” and “poor” referral quality are based on arbitrary cutoffs (75%), without a robust explanation of why these thresholds were chosen. This raises questions about the validity and reliability of the quality assessments. 5. Since data collection was done in a healthcare facility, patients might have provided more favorable responses due to social desirability bias, particularly in reporting their satisfaction. This bias could skew the findings, but the authors do not discuss how they managed or mitigated this issue. 6. The article mentions that verbal informed consent was obtained, but it does not explain why written consent was not sought or how verbal consent was documented, raising concerns about ethical rigor. Additionally, it does not address any potential risks to participants or how these were mitigated. 7. Given the global trend towards electronic referral systems, the absence of any discussion on the potential role of digital solutions (e.g., e-referrals, telemedicine) in improving referral quality is a missed opportunity, especially in regions with infrastructure development plans like Ethiopia. Reviewer #2: The main text mentions Table 7, but the table does not actually exist. Please recheck the arrangement and ensure that all referenced tables are correctly accounted for. The resolution of the figures should be improved. Please resubmit new, clearer figures to ensure better publication quality. Conclusion subtitle has a unexpected dot (line 412) ****** 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. 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Revision 1
6 Dec 2024 Author Response Date: 01 /11/2024 Trhas Tadesse Berhe PLOS ONE Dear… D.r Trhas Tadesse Berhe Thank you for giving us the opportunity to submit a revised draft of our manuscript titled “Quality of Referral System and Associated Factors Among Referred Clients Referred to Dessie Comprehensive Specialized Hospital, Northeast, Ethiopia” to the PLOS ONE. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on our manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. We have highlighted the changes within the manuscript. Please let us know if you still have any questions or concerns about the manuscript. We will be happy to address them, now in a timely manner. Sincerely, Yonas Fissha Adem Reviewer 1 Reviewer #1: Dear author(s), thank you for your manuscript. Overall, this is a clear, concise, and well-written manuscript on an important topic that is often under-researched. The introduction is relevant. Sufficient information about the importance of the research topic is presented for readers to follow the present study rationale and procedures. Although the article is well written but clarification of a few details should be provided. Response: dear reviewer, thank you very much for your motivational comment. Specific comments follow: 1. What was the reason for choosing the study method? As the study uses a cross-sectional design, Can this method establishes cause and effect relationships between variables? Response: dear reviewer, thank you for your valuable feedback. a cross-sectional design doesn’t show cause and effect relationships between variables because it is collected data at a single point in a time. But before now there is not studies conduct in Ethiopian especially in the study areas so it better to know first prevalence of good quality of referral system. So, to achieved this purpose cross-sectional study was preferred to conduct. 2. What was the reason for choosing only one hospital? The study only includes patients referred to one hospital. This geographic limitation means the findings may not apply to other hospitals with different patient demographics or healthcare infrastructures. Response: dear reviewer, thank you for spotting this. We are choosing this hospital because it’s the only Comprehensive Specialized Hospital in wollo, which currently provides services for 10 million people in the South Wollo, North Wollo, Waghimra, and Oromia specialized zones. 3. The article predominantly uses descriptive statistics to report results (e.g., frequencies and percentages), but lacks deeper inferential statistical analyses to explore more complex relationships between variables. This restricts the depth of insight that can be gained from the data. Response: Thank you for your thoughtful concern of our study. But this study was done both descriptive and analytical study. Descriptive study consists frequencies and percentages in this study. Analytical study consists comparison between dependent and independent variables using bivariable and multivariable binary logistic regression analysis in this study. So we consider this study have deeper inferential statistical analyses. 4. While some operational definitions are provided, others like “good” and “poor” referral quality are based on arbitrary cutoffs (75%), without a robust explanation of why these thresholds were chosen. This raises questions about the validity and reliability of the quality assessments. Response: Thank you for your detailed comments. We are using “good” and “poor” referral quality system based on reference from previous studies. It isn’t arbitrary cutoffs. We have already putted a reference. 5. Since data collection was done in a healthcare facility, patients might have provided more favorable responses due to social desirability bias, particularly in reporting their satisfaction. This bias could skew the findings, but the authors do not discuss how they managed or mitigated this issue. Response: Thank you so much for your careful check. But we have deployed four BSc. Nurses data collector and two BSc Nurses supervisor from other health facilities to reduce social desirability bias. The data collector informed the study participants that they came from other health facilities and its objective of the studies. 6. The article mentions that verbal informed consent was obtained, but it does not explain why written consent was not sought or how verbal consent was documented, raising concerns about ethical rigor. Additionally, it does not address any potential risks to participants or how these were mitigated. Response: Thank you for your valuable input. Verbal consent is appropriate for routine procedures that don't pose a significant risk to the patient and no need of written informed consent because we didn’t do any invasive procedures here rather we simply collected data from respondents. But we have incorporated the issue about mitigate potential risks to participants. 7. Given the global trend towards electronic referral systems, the absence of any discussion on the potential role of digital solutions (e.g., e-referrals, telemedicine) in improving referral quality is a missed opportunity, especially in regions with infrastructure development plans like Ethiopia. Response: Thank you for raising this important point. We have incorporated the issue you raised in the introduction part of the revised manuscript according to your comment. Reviewer #2: The main text mentions Table 7, but the table does not actually exist. Please recheck the arrangement and ensure that all referenced tables are correctly accounted for. The resolution of the figures should be improved. Please resubmit new, clearer figures to ensure better publication quality. Response: We would like to thank the dear reviewer for your frank comment. We reviewed and made adjustments in the revised manuscript. Conclusion subtitle has a unexpected dot (line 412) Response: We appreciate your valuable suggestion. We have made corrected in the revised manuscript as per your expectations. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0337715.r002
15 Apr 2025 Decision Letter - Trhas Berhe, Editor Dear Dr. Yonas Fissha Adem, 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 ensure that the reviewers' comments are fully addressed, particularly those related to the sampling procedure, the clarity and coherence of the discussion section, and the alignment of the conclusion with the study findings. Additionally, we recommend that the manuscript be thoroughly proofread by a professional language editor prior to submission to improve overall clarity and academic tone Please submit your revised manuscript by May 30 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 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, Trhas Tadesse Berhe, PhD Academic Editor PLOS ONE [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 #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #3: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: I Don't Know Reviewer #3: I Don't Know ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #3: Yes ****** Reviewer #1: (No Response) Reviewer #3: Thank you for the opportunity to review this manuscript. It is a worthwhile study of an interesting subject, however there are a number of things that should be addressed before it is published. The first 2 sentences of the abstract are not relevant to the study and should be deleted. The components assessed to determine the overall quality, input quality and process quality of the referral are not provided until the Tables in the body of the results. It would be helpful to have some examples in the Abstract and Methods eg Process Quality measured whether the important patient demographic and clinical information was included in the referral, Outcome quality was based on the patient’s impression of their referral etc. It is not clear what “focal person” means. Does it mean ‘contact person’? The presence or absence of a “focal person” is mentioned in the introduction and discussion, but not in the methods or results so it is not clear how this was measured or what was found. Either the methods and results should be included, or the concept removed from the introduction and discussion. The recruitment strategy and numbers do not seem realistic and require clarification. The methods state that every 4th patient of an expected 2000 patients per month was approached and interviewed. It is inconceivable that there were no protocol violations during this process. What happened if patients presented overnight, if multiple patients presented at once, if patients were too confused or unwell or not available to respond to questions, if the research staff were sick? The actual recruitment strategy should be explained. If it is a convenience sample of ~1/4 of patients presenting to the hospital, that should be stated. Reference 16 reports that in Tigray, 82% of patients were self-referred. Dessie Comprehensive Specialized Hospital presumably treats similar numbers of self-referred patients. Are the 2000 patients per month only the ‘referred’ patients, (ie does the hospital see 10000 patients per month, of whom 20% are referred) or is this all the patients, and what proportion were referred? How did the research staff distinguish between self-referred patients and those transferred from other hospitals on foot or by public taxi, some of whom are likely to have lost their referral papers? Inclusion or exclusion of patients with missing papers could significantly change the results. Patient satisfaction is reported as 44.6% overall, but the individual questions suggest a much higher level of satisfaction. How was the 44.6% overall satisfaction derived? Similarly, the overall quality of the referral system is reported as 62.5%, but in the data tables 94.7% of the referrals were good, and 87.3% of the feedback was good. Can this please be clarified? Similarly, the conclusions that’ generally clients had poor referral quality’ are not supported by the data, which shows that most referrals were good quality. The paper would benefit from editing to improve the academic English. ****** 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 #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.] 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.0337715.r003
Revision 2
4 Jul 2025 Author Response Date: 01 /06/2025 Trhas Tadesse Berhe PLOS ONE Dear… D.r Trhas Tadesse Berhe Thank you for giving us the opportunity to submit a revised draft of our manuscript titled “Quality of Referral System and Associated Factors Among Referred Clients Referred to Dessie Comprehensive Specialized Hospital, Northeast, Ethiopia” to the PLOS ONE. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on our manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. We have highlighted the changes within the manuscript. Please let us know if you still have any questions or concerns about the manuscript. We will be happy to address them, now in a timely manner. Sincerely, Yonas Fissha Adem Point by Point Response to - Editor Point by Point Response to – Reviewer Reviewer #3: Thank you for the opportunity to review this manuscript. It is a worthwhile study of an interesting subject; however there are a number of things that should be addressed before it is published. The first 2 sentences of the abstract are not relevant to the study and should be deleted. Response: We appreciate your thoughtful observation regarding this issue. We've made changes to this section based on your comments. The components assessed to determine the overall quality, input quality and process quality of the referral are not provided until the Tables in the body of the results. It would be helpful to have some examples in the Abstract and Methods eg Process Quality measured whether the important patient demographic and clinical information was included in the referral, Outcome quality was based on the patient’s impression of their referral etc. Response: Thank you for your suggestion, dear. However, in this study, the components of the quality referral system (structure, process, and outcome) have already been mentioned in the operational definition section of the methods. We can explain their meanings in the abstract, but to keep it short and precise; we haven’t mentioned them in the abstract. It is not clear what “focal person” means. Does it mean ‘contact person’? The presence or absence of a “focal person” is mentioned in the introduction and discussion, but not in the methods or results so it is not clear how this was measured or what was found. Either the methods and results should be included, or the concept removed from the introduction and discussion. Response: We appreciate your thoughtful observation regarding this issue. But, We've already incorporated about “focal person” in the Method part “operational definition” and in result part “Structural (input) part of the referral system”. "Focal person" typically refers to an individual designated to oversee and coordinate activities related to a specific program, initiative, or area of focus within the hospital. The recruitment strategy and numbers do not seem realistic and require clarification. The methods state that every 4th patient of an expected 2000 patients per month was approached and interviewed. It is inconceivable that there were no protocol violations during this process. What happened if patients presented overnight, if multiple patients presented at once, if patients were too confused or unwell or not available to respond to questions, if the research staff were sick? The actual recruitment strategy should be explained. If it is a convenience sample of ~1/4 of patients presenting to the hospital, that should be stated. Response: Thank you for your suggestion, dear. However, this study's recruitment strategy was systematic random sampling, selecting every 4th patient out of an expected 2,007 patients monthly. Multiple patients cannot be presented at once because their charts are organized based on their assigned order. Therefore, every 4th patient was selected; patients can come during the night, but patient chart was given based on the order so no problem for random patient selection, but the data collection was conducted in day. If a patient was confused or unable to communicate, the next random sample was taken. No research staffs were sick during our study, but if any staff member had fallen ill, other data collectors would have been deployed. Reference 16 reports that in Tigray, 82% of patients were self-referred. Dessie Comprehensive Specialized Hospital presumably treats similar numbers of self-referred patients. Are the 2000 patients per month only the ‘referred’ patients, (ie does the hospital see 10000 patients per month, of whom 20% are referred) or is this all the patients, and what proportion were referred? How did the research staff distinguish between self-referred patients and those transferred from other hospitals on foot or by public taxi, some of whom are likely to have lost their referral papers? Inclusion or exclusion of patients with missing papers could significantly change the results. Response: Thank you for your suggestion dear, but this study is aimed to assess the quality of referral system but not about magnitude of self-referred patients. Every patient should bring referral paper so if it’s lost it should be rewrite again to get treatment from Hospital since its referral hospital. But in our stud, no patients loss the referral paper. So no need of putting this idea in the inclusion and exclusion criteria. Patient satisfaction is reported as 44.6% overall, but the individual questions suggest a much higher level of satisfaction. How was the 44.6% overall satisfaction derived? Similarly, the overall quality of the referral system is reported as 62.5%, but in the data tables 94.7% of the referrals were good, and 87.3% of the feedback was good. Can this please be clarified? Similarly, the conclusions that’ generally clients had poor referral quality’ are not supported by the data, which shows that most referrals were good quality. Response: Thank you for your suggestions. In this stud, the overall patient satisfaction with the referral system of health facilities to Dessie Comprehensive Specialized Hospital was found to be 44.6%, this result was found by calculating the average value of each 8 measuring variables of patient satisfaction for each individual then patients who scored above the half(50%) was considered satisfied. Even when you see each individual variables value, it’s not highest and it was classified into five. In addition to this the overall quality of referral system was computed by three components of quality. So even if the structural and process parts of the referral system have highest score which was 90.3% and 94.7% respectively. But the outcome (patient satisfaction) was poor which score 44.6%. So the overall quality of referral was calculated by computing the above three referral system so final we have got 62.5% of the patients scored 75 % and above. The paper would benefit from editing to improve the academic English. Response: Thank you for your suggestions. We will improve the whole document based on your comments. Attachments Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0337715.r004
10 Jul 2025 Decision Letter - Trhas Berhe, Editor 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. Thank you for your response. However, the explanation regarding the feasibility of systematic sampling and the absence of any protocol violations appears unrealistic. Please revise your response and the Methods section to acknowledge potential real-world challenges (e.g., patient unavailability, staff absence, night-time arrivals), and explain how such issues were handled or mitigated. Transparency about possible limitations is important for methodological rigor. -the reviewer’s request was not fully addressed. While the components of quality (structure, process, and outcome) are defined in the operational definitions, the reviewer specifically asked for brief examples to be included in the Abstract and Methods sections for clarity. Please revise the Abstract to include a short example for each component, and add a concise explanation in the Methods section to improve reader understanding -While the term “focal person” is defined in the operational definitions and mentioned in the results, it would benefit readers if it were clearly introduced and defined upon first use in the Introduction. Please revise the manuscript to define the term earlier in the narrative to improve clarity and flow. -the reviewer’s concern was not fully addressed. While we understand the focus was not on self-referral, the issue raised relates to potential sample bias due to possible exclusion of patients who may have lost referral papers. Please clarify how such cases were handled and revise the inclusion criteria and limitations sections to reflect this, ensuring transparency in your methodology. -The explanation regarding the overall satisfaction score and referral quality remains unclear. There appears to be a misalignment between the findings and the conclusion, particularly as structure and process scores were high, yet the conclusion states that clients experienced “poor referral quality.” Please provide a clearer explanation of how the overall quality score was calculated, especially how satisfaction was incorporated. Also, revise the conclusion to more accurately reflect the mixed findings for example, acknowledging high structural and process performance alongside lower patient satisfaction. -Thank you for acknowledging the need to improve the language quality of the manuscript. However, your response does not indicate whether a thorough language revision has been carried out. To ensure clarity and academic quality, please revise the manuscript with support from a native English speaker or a professional language editor, and submit a track-changed version highlighting the edits made. Please submit your revised manuscript by Aug 24 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 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, Trhas Tadesse Berhe, PhD Academic Editor PLOS ONE Journal Requirements: 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. [Note: HTML markup is below. Please do not edit.] [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.0337715.r005
Revision 3
2 Sep 2025 Author Response Date: 20 /08/2025 Trhas Tadesse Berhe PLOS ONE Dear… D.r Trhas Tadesse Berhe Thank you for giving us the opportunity to submit a revised draft of our manuscript titled “Quality of Referral System and Associated Factors Among Referred Clients Referred to Dessie Comprehensive Specialized Hospital, Northeast, Ethiopia” to the PLOS ONE. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on our manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. We have highlighted the changes within the manuscript. Please let us know if you still have any questions or concerns about the manuscript. We will be happy to address them, now in a timely manner. Sincerely, Yonas Fissha Adem Point by Point Response to - Editor Point by Point Response to – Reviewer Thank you for your response. However, the explanation regarding the feasibility of systematic sampling and the absence of any protocol violations appears unrealistic. Please revise your response and the Methods section to acknowledge potential real-world challenges (e.g., patient unavailability, staff absence, night-time arrivals), and explain how such issues were handled or mitigated. Transparency about possible limitations is important for methodological rigor. Response: Response: We appreciate your thoughtful observation regarding this issue. We've made changes to this section based on your comments. -the reviewer’s request was not fully addressed. While the components of quality (structure, process, and outcome) are defined in the operational definitions, the reviewer specifically asked for brief examples to be included in the Abstract and Methods sections for clarity.Please revise the Abstract to include a short example for each component, and add a concise explanation in the Methods section to improve reader understanding Response: Thank you for your suggestions. We've made incorporated to the Abstract and Methods section based on your comments. -While the term “focal person” is defined in the operational definitions and mentioned in the results, it would benefit readers if it were clearly introduced and defined upon first use in the Introduction. Please revise the manuscript to define the term earlier in the narrative to improve clarity and flow. Response: Thank you for your suggestions. We have defined the raised issue in the introduction part. -the reviewer’s concern was not fully addressed. While we understand the focus was not on self-referral, the issue raised relates to potential sample bias due to possible exclusion of patients who may have lost referral papers. Please clarify how such cases were handled and revise the inclusion criteria and limitations sections to reflect this, ensuring transparency in your methodology. Response: Thank you for your suggestions. But in our study, no patients loss the referral paper. We want to ask a great apologize for making a mistake here and we have replaced loss the referral paper with unable to communicate in the exclusion criteria. -The explanation regarding the overall satisfaction score and referral quality remains unclear. There appears to be a misalignment between the findings and the conclusion, particularly as structure and process scores were high, yet the conclusion states that clients experienced “poor referral quality.” Please provide a clearer explanation of how the overall quality score was calculated, especially how satisfaction was incorporated. Also, revise the conclusion to more accurately reflect the mixed findings for example, acknowledging high structural and process performance alongside lower patient satisfaction. Response: Thank you for your suggestions. The perceived misalignment arises because the overall quality of the referral system was calculated by considering three components of quality measures: input, process, and outcome. While the structural (input) and process aspects scored highly, the outcome component, specifically patient satisfaction, was considerably lower, which pulled down the overall quality score. • Structural (Input) Quality: The overall structural input quality of the referral system was 90.3%. This indicates a high availability of essential components like a referral focal person, registry book, standard referral paper, and transport. • Process Quality: The overall quality related to the referral and feedback papers was also high. ◦ The overall quality of the referral paper was good in 94.7% of participants. ◦ The score of components of feedback sent was good in quality in 87.3% of study subjects, and the overall quality of the referral feedback was good in 87.7% of participants. ◦ The overall process quality was good in 88.3% of study participants. • Outcome (Patient Satisfaction): This is where a significant difference is observed. The overall patient satisfaction with the referral system at Dessie Comprehensive Specialized Hospital was only 44.6% (95% CI: 40.00%–49.20%). For example, only 68.3% of referred patients agreed that health professionals explained the referral in a way they could understand, and 62.5% agreed that professionals included them in deciding the reason for the referral. • Overall Referral Quality: When all three components (input, process, and outcome) were considered, the overall quality of the referral system was computed to be 62.5% (95% CI 57.6%-66.8%), meaning 37.5% was considered poor in quality. • The conclusion part has accordingly modified -Thank you for acknowledging the need to improve the language quality of the manuscript. However, your response does not indicate whether a thorough language revision has been carried out. To ensure clarity and academic quality, please revise the manuscript with support from a native English speaker or a professional language editor, and submit a track-changed version highlighting the edits made. Response: Thank you for your suggestions. We have improved as much as possible. But we didn’t highlight the change because many grammatical and spelling correction might presented. Attachments Attachment Submitted filename: Response to Reviewers 3.docx https://doi.org/10.1371/journal.pone.0337715.r006
22 Sep 2025 Decision Letter - Trhas Berhe, Editor Dear Dr. Adem, 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. ============================== I appreciate the efforts you have made in addressing the reviewer’s comments. However, after careful review, it is evident that several key concerns raised by the reviewers have not been fully resolved. To move your manuscript forward in the review process, we kindly ask you to provide further revisions as outlined below: Systematic Sampling & Real-World Challenges While your revision briefly mentions night-time arrivals and uncommunicative patients, the explanation remains limited. Kindly expand the Methods section to explicitly acknowledge common real-world challenges (e.g., patient unavailability, staff absence, timing of arrivals) and describe how these were handled in practice. Examples of Quality Components (Abstract and Methods) In the Methods section, you have outlined structure, process, and outcome components. However, the Abstract still does not include short illustrative examples (e.g., structure = referral forms/focal person, process = referral and feedback papers, outcome = patient satisfaction). Kidly revise the Abstract accordingly for clarity. Sample Bias Referral Papers The reviewer raised concerns about potential bias if patients lost referral papers. Your current response simply replaces this with “unable to communicate” in the exclusion criteria. Please clarify whether any such cases occurred, how they were handled, and acknowledge this as a possible limitation if applicable. Language Revision Although you mention improving the manuscript, there is no evidence that a full language revision was carried out. Given the number of grammatical and stylistic issues still present, we strongly recommend that the manuscript be thoroughly revised by a native English speaker or a professional editor before resubmission. I encourage you to carefully revise your manuscript in light of these points. Once the above issues are addressed, we will be happy to proceed with the next stage of review. ============================== Please submit your revised manuscript by Nov 06 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. 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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, Trhas Tadesse Berhe, PhD Academic Editor PLOS ONE Journal Requirements: 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. [Note: HTML markup is below. Please do not edit.] 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.0337715.r007
Revision 4
2 Oct 2025 Author Response Date: 01 /10/2025 Trhas Tadesse Berhe PLOS ONE Dear… D.r Trhas Tadesse Berhe Thank you for giving us the opportunity to submit a revised draft of our manuscript titled “Quality of Referral System and Associated Factors Among Referred Clients Referred to Dessie Comprehensive Specialized Hospital, Northeast, Ethiopia” to the PLOS ONE. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on our manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. We have highlighted the changes within the manuscript. Please let us know if you still have any questions or concerns about the manuscript. We will be happy to address them, now in a timely manner. Sincerely, Yonas Fissha Adem Point by Point Response to - Editor Point by Point Response to – Reviewer Systematic Sampling & Real-World Challenges while your revision briefly mentions night-time arrivals and uncommunicative patients, the explanation remains limited. Kindly expand the Methods section to explicitly acknowledge common real-world challenges (e.g., patient unavailability, staff absence, timing of arrivals) and describe how these were handled in practice. Response: We appreciate your thoughtful observation regarding this issue. We've made changes to this section based on your comments in the sampling procedures and technique. Examples of Quality Components (Abstract and Methods) In the Methods section, you have outlined structure, process, and outcome components. However, the Abstract still does not include short illustrative examples (e.g., structure = referral forms/focal person, process = referral and feedback papers, outcome = patient satisfaction). Kindly revise the Abstract accordingly for clarity. Response: Thank you for your suggestions. We've made incorporated this issue in the Abstract section previously but we have put it short and precisely again based on your comments. Sample Bias Referral Papers The reviewer raised concerns about potential bias if patients lost referral papers. Your current response simply replaces this with “unable to communicate” in the exclusion criteria. Please clarify whether any such cases occurred, how they were handled, and acknowledge this as a possible limitation if applicable. Response: Thank you for your suggestions. But in our study, no patient’s lost the referral paper in reality. But we have incorporated this issue in the sampling procedures and technique part based on your comments. If we have got patient lost referral paper the next random sample were taken. Language Revision Although you mention improving the manuscript, there is no evidence that a full language revision was carried out. Given the number of grammatical and stylistic issues still present, we strongly recommend that the manuscript be thoroughly revised by a native English speaker or a professional editor before resubmission. Response: Thank you for your suggestions. We have improved as much as we can. But we didn’t highlight the change because many grammatical and spelling corrections might presented. Attachments Attachment Submitted filename: Response to Reviewers 4.docx https://doi.org/10.1371/journal.pone.0337715.r008
13 Nov 2025 Decision Letter - Trhas Berhe, Editor Quality of Referral System and Associated Factors Among Referred Clients Referred to Dessie Comprehensive Specialized Hospital, Northeast, Ethiopia PONE-D-24-24344R4 Dear Dr. Yonas Fissha Adem, 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, Trhas Tadesse Berhe, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0337715.r009
Formally Accepted
Acceptance Letter - Trhas Berhe, Editor PONE-D-24-24344R4 PLOS ONE Dear Dr. Adem, 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. Trhas Tadesse Berhe Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0337715.r010

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