Dear Dr. Ndwandwe,

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.

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Davide Costa

Academic Editor

PLOS ONE

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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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

The PLOS Data policy

Reviewer #1: No

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1:  Review for Preferences for community-based asynchronous-review eye clinics in the UK: a discrete choice experiment among patients, healthcare professionals, and the public.

The abstract presents clear picture of what readers should expect with the whole work and shows consistency throughout the write-up while also filling a research gap in patient care in eye clinics.

The research appears to be well thought-out with rigorous design demonstrated, consistent referencing and supplementary materials provided.

Sentences are precise and easy to understand despite presenting complex scenarios. The results were clearly presented and shows analytical rigour with the discussion section well-presented and highlighting related studies.

Two review points to consider:

First, perhaps for non-expert readers, the paper could benefit from a few lines in the introductory section that provides more details of cases where asynchronous-review eye clinics have been successful in other countries if there are no sufficient evidence from the UK.

Second review point is with regards to this statement “All respondents were asked to respond from a patient’s perspective, so that the same language could be used for all, to make the results comparable across respondent types and simplify distribution of the survey link”. While asking all respondents to respond from a patient’s perspective as stated above is justified by the authors in the statement, it is difficult to be certain that respondents that do not fall into the patient category can make choices as patient respondents would since they may not have the experiences in terms of treatment and appointment needs as patients would. Also, even if non-patient respondents responded from patients’ perspective, it could imply that the preferences of non-patient respondents themselves were not really captured for comparisons with the responses of patients. Thus, querying why there was a need to involve non-patient respondents or whether the opinions of non-patient respondents were actually captured by the survey.

Reviewer #2: 1.This research explores alternative treatment options for patients with eye diseases with the involvement of technicians. While this research is promising, it must be cautious because there are many types of eye diseases ranging from mild to severe, and not all can be treated by technicians. The questions in this study are not about general eye treatments, nor are they differentiated or grouped by type of disease. If the eye disease groups were differentiated, the service options would be different.

2.The respondents were divided into three groups: patients, healthcare professionals, and the public. The last two groups could not indicate whether or not they had ever experienced eye pain (this question was not included in the questionnaire). Respondents who have experienced eye pain may differ from those who have not in their choice of services.

3.The concept of willingness to pay is examined in relation to willingness to wait and willingness to travel. Is there data on how respondents' occupations relate to time expenditure? Those with time-consuming jobs tend to choose short-distance services.

4.If no information is available from the previous point, it can be included as a limitation of this research

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Reviewer #1: No

Reviewer #2: No

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Preferences for community-based asynchronous-review eye clinics in the UK: a discrete choice experiment among patients, healthcare professionals, and the public

PLOS One

Dear Dr. Ndwandwe,

Please submit your revised manuscript by Mar 26 2026 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 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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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.

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,

Ilse Bloom

Staff Editor

PLOS One

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2. 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:

The manuscript has been evaluated by five reviewers, and their comments are available below.

Could you please carefully revise the manuscript to address all comments raised?

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Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: No

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

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #1: The authors have addressed all my comments in the first review and have made changes in the article to reflect them.

Reviewer #2: (No Response)

Reviewer #3: 2. Methods Clarification:

>Line 175-176: Please clarify the eligibility criteria used in Section 1 to screen respondents.

>Consistency Checks: You note the absence of consistency/dominance checks as a limitation. Consider briefly discussing in the methods or limitations why this common DCE practice was omitted (e.g., due to cognitive burden concerns from your design work).

3. Results Presentation:

>Figure 1 & Legend: The legend for Figure 1 (lines 278-282) describes results for a different topic ("acceptable mode of appointment") which seems misplaced. The legend should describe the attribute ranking figure itself. The text currently in the legend appears to belong in the Supplementary Materials or a different part of the results (e.g., around Supplementary Part 6).

>Tables 4 & 5: The estimates for Patients in Tables 4 and 5 have very wide confidence intervals (e.g., WTT: -305 (-628, 18) minutes). This should be briefly acknowledged in the text as indicating less precise estimates within this subgroup, potentially due to heterogeneity or sample size.

4. Discussion Refinement:

>Limitations - Socioeconomic Representativeness: The point about homeownership rates is well-taken. Consider also commenting briefly on the overrepresentation of highly educated respondents (60% with a degree) and its potential impact on the generalizability of preferences.

>Interpretation of WTW: The discussion on lines 357-370 about patients "willing to wait... longer to see a clinician" is insightful. To avoid misinterpretation, you could explicitly state that from a service design perspective, the primary utility of the finding is in quantifying the reduction in delay needed to make technician-led models acceptable, not in endorsing longer delays.

5. Language and Copyediting:

>Please perform a thorough proofread to correct the typographical errors, awkward line breaks, and minor grammatical issues noted above and throughout the text. Ensure consistency in table formatting.

Reviewer #4: The exploration of alternative service delivery models in the interest of public health is commendable, especially given the premise that delayed care can equate to denied care. The study is well-designed to assess the trade-offs patients are willing to make, such as balancing travel time against waiting periods for appointments. It is particularly insightful in evaluating patient preferences in the context of technician-led clinics, remote result communication, and reduced appointment delays. Understanding these preferences is crucial for shaping more efficient and accessible healthcare services.

However, there are notable limitations regarding the sample composition. A significant proportion of respondents—approximately 79% of patients and 65% of the general public—were above 55 years of age. This age distribution likely influenced the findings on willingness to wait and to travel, as older individuals may have different preferences and constraints compared to younger populations. Furthermore, the majority of participants were from outside London, where access to healthcare facilities and public transport may differ from larger cities. This could explain the greater acceptance of local technician-led models. If the sample had included a broader age range and more participants from metropolitan areas with robust public transport infrastructure, the acceptance of non-clinician-led care might have yielded different results. Future studies should consider a more heterogeneous sample to enhance the generalisability of the findings. In public health service delivery there is no one shoe that fits all as shown in literature so what works in once place and population group

Recommendation:

Since the study clearly indicated that clinician driven care was the preferred option and sample was skewed more geraitric, it would be good to conclude saying that technician led care of service delivery could be considered as a door step/ close to home care model in remote locations for geriatic population as part of NHS service. And considering that same day results was also a preferred option, this could be coupled with AI or telehealth or MHealth platforms. for expert opinion on the spot.

Reviewer #5: In “Preferences for community-based asynchronous-review eye clinics in the UK: a discrete choice experiment among patients, healthcare professionals, and the public,” Siyabonga Ndwandwe et al. examine the trade-offs that eye-care users are willing to make between care setting and time costs when accessing care for stable eye conditions. The study demonstrates that decentralizing chronic eye-care monitoring from hospitals to community-based settings can help reduce pressure on hospital clinics, among other benefits highlighted in the paper. A particular strength is the stratification of respondents by their interaction with eye-care and healthcare services, which allows the authors to focus on individuals with actual eye-care needs who are most likely to use community-based services.

The authors present a clear research question and apply a robust methodology aligned with their aims. The results are clearly reported and thoughtfully discussed. Overall, the manuscript is well written and makes for an engaging and informative read.

Specific comments

1. The severity of patients' eye conditions likely influences the urgency of their eye care needs and thus their willingness to wait for care or travel to receive it. The authors collected information on the frequency of eye follow-up visits and the receipt of regular intraocular injections. Could the authors clarify how these factors were incorporated into the analysis?

As mentioned in lines 243–244, were similar tests conducted within patient subgroups stratified by frequency of eye care use?

2. The discussion section is brief and does not address all the presented results. A focused discussion of the implications of the subgroup analyses (lines 326–332) would provide valuable insight and strengthen the paper.

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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: Yes: Md Mahmudul Hasan

Reviewer #4: No

Reviewer #5: No

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Dear Dr. Ndwandwe,

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 Aug 09 2026 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 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Taiwo Opeyemi Aremu, MD, MPH, PhD

Academic Editor

PLOS One

Journal Requirements:

1. 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.

2. 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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #3: No

Reviewer #4: Yes

Reviewer #5: (No Response)

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

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

Reviewer #1: (No Response)

Reviewer #3: Major Strengths

>Unique contribution: This is the first DCE to explicitly test preference for a technician-led asynchonous-review model of ophthalmology care, filling in a critical knowledge gap for implementation science of workforce-efficient clinical models.

>Sound methodology: The D-optimal design, forced-choice, and choice between dominance checks (justified for reasons of cognitive load) are thoughtful choices.

>Relevant clinical insights: The core finding that respondents would accept technician-led care if appointment wait times were cut by 3-6 months (or time travelling to the appointment by 1-2.5 hours) offers useful insights for service planners.

Major Concerns to Address

1. Generalisability

>The authors note some substantial demographic bias (79% homeowners vs. national average of 62.5%; 60% college degree vs. national average of 33%), but this should be emphasised in the abstract and conclusions. These factors are known to affect preferences for health-care services and may affect generalizability to socioeconomically more diverse communities. The authors should consider:

>Including a statement of limitations in the abstract

>Including more detail on how these may impact the WTW/WTT estimates (e.g., higher education is associated with stronger preferences for more contact with health care providers?

2. Inconsistent patient vs. public perspective

>All respondents (including HCPs and the public) were asked to answer "from a patient's perspective". This approach is problematic for the following reasons:

>HCPs may find it challenging to put aside their own beliefs and thoughts, creating a response bias

>The members of the public without chronic eye disease lack the experience needed to develop preferences

>These are two different groups (subgroup analyses) but still asked to take on a patient perspective

Suggestion: This should be explained and defended, or the authors should report it as a weakness. Perhaps the use of independent models (patient vs. reference) could be justified, rather than having them all think in a certain way.

3. Unrealistic WTT estimates range beyond attributes

The authors acknowledge the estimated WTTs (e.g., 305 minutes for patients who would accept technician+post vs. reference) are larger than the largest travel times presented in the DCE (90+ minutes). They refer to other data, but this implies extrapolations. The authors should:

>Clearly report these estimates are extrapolations and should be used carefully

>Explore the possibility of a non-linear utility function in modelling travel time values

>Include the proportion of respondents who had WTT values higher than the highest attribute level

4. Handling of missing data and completion rate

The authors say "rates of missing data were very low" but this is not quantified. An average of 14.5 minutes (SD 26.3) to complete had a long tail, with some taking a long time. The authors should:

>Include the survey completion rate (percentage of the survey started completed)

>Report the number of people who initiated but did not complete the survey

>Disclose rates of missing data for key variables

5. Composite attribute interpretability

The composite attribute ("who the patient sees") and ("how the results are given") is justified but causes interpretational problems. The bundle "clinician + same-day results" is different to the other bundles (technician + phone or technician + post) in two ways. This means the WTW estimates bundle:

>The disutility of technician (not clinician)

>The disutility of phone/post vs. in-person communication

>The disutility of phone/post vs. face-to-face

>The authors note this but consider whether changing the design (e.g., separate attributes with interactions) may have allowed for decomposition of this.

Minor Concerns and Clarifications Needed

6. Table size: Table 3 is long. Move data to the supplement or reduce categories.

7. Interpretation of confidence intervals: For patients WTT estimates (Table 5), 95% CI for technician+post (-628 to 18) includes zero and is very large, corresponding to the non-significant travel time coefficient in S7. This is noted, but should be made clearer that they are statistically unreliable and should not be misinterpreted.

8. Opportunity for more with attitudinal data: Section 4 involved attitudinal data collection but not in the main findings. Could any insights be added from the attitudinal data (e.g. relationship between trust in technicians and preferences).

9. Conflicts of interest: Multiple authors (PJF, SS, PTK, HJ) have multiple industry ties. These are all declared but readers should remain alert to the influence of sponsorship (this is less likely in a DCE).

Questions for Authors

>Did you investigate preference heterogeneity (mixed logit and latent class)? If yes, please provide estimates. If not, explain why on not needed conditional logit.

>How did you check that the composite attribute was understood? Were checks made using the longer descriptions?

>Since 49% of patients used public transport to attend appointments, but only 19% of the public would be willing to do so, does this indicate hypothetical bias in the public's responses from adopting a patient perspective?

>The fact that schedules are delayed implicitly and by implication patients would wait 6 months for appointments (lines 378-380) appears to imply a change in direction of causality for the WTW estimate. Please note that the estimate is the compensation needed for patients to accept care from a technician, not a preference for a longer wait.

Recommendation

Minor Revision - The manuscript is well done and a valuable contribution but needs to address the need for representativeness, for providing care from a patient's perspective, and explain the WTT concerns.

Reviewer #4: The authors have tried to incorporate the comments with the available data. And I have no further comments for them.

Reviewer #5: (No Response)

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Reviewer #1: No

Reviewer #3: Yes: Md Mahmudul Hasan

Reviewer #4: No

Reviewer #5: No

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Preferences for community-based asynchronous-review eye clinics in the UK: a discrete choice experiment among patients, healthcare professionals, and the public

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Reviewer #3: All comments have been addressed

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Reviewer #3: Yes: Md Mahmudul Hasan

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