Dear Dr. EL Moudden,

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 Jan 25 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 rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Kenji Fujiwara, MD, PhD, FACS

Academic Editor

PLOS One

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. 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.

3. In the online submission form, you indicated that the datasets used during the current study are derived from the Virginia Health Information (VHI) Patient Level Database and the Readmissions and Transfers Supplemental Data Set (RATs), which are licensed inpatient hospital discharge data files containing all submitted, processed, and verified discharges in the Commonwealth of Virginia. The data were accessed through the M. Foscue Brock Institute for Community and Global Health at Macon & Joan Brock Virginia Health Sciences at Old Dominion University and the Research and Infrastructure Service Enterprise at Macon & Joan Brock Virginia Health Sciences at Old Dominion University. The data are not publicly available due to VHI licensing agreements and privacy restrictions but may be available from the corresponding author upon reasonable request and subject to approval by VHI and the M. Foscue Brock Institute for Community and Global Health at Macon & Joan Brock Virginia Health Sciences at Old Dominion University. Additional information about the data extraction methodology and the process used in this project to link the Patient Level Database to the RATs can be provided by contacting Dr. Ismail El Moudden at elmoudi@odu.edu. Researchers interested in accessing similar data should contact VHI directly to complete the appropriate license agreement and pay applicable fees. The data are held under the terms stipulated by the VHI licensing agreement, which prohibits public sharing of the data to protect patient confidentiality and comply with legal restrictions. Information about obtaining VHI data can be found at www.vhi.org/pld

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.

4. Thank you for stating the following financial disclosure:

This research was generously funded by the Hampton Roads Biomedical Research Consortium (HRBRC)- Project Number 958830-005, 2023.

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.

5. 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.

6. 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.

7.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 :

Dear Dr. Moudden.

The article was reviewed by two reviewers, both recommending minor revisions. I agree with their comments.

Best regards,

Kenji Fujiwara

Academic editor

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: 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: No

**********

Reviewer #1: Terminology / Language

Replace strong causal phrases like “catastrophic failures” with neutral wording (“critical intervention points”).

Reframe “accelerated progression” to “earlier onset of complications observed in this cohort.”

Adjust phrasing around the “readmission paradox” to emphasize association rather than causation.

Population Clarification

State explicitly that >98% of the cohort were African American, with very limited Hispanic representation.

Consider softening the title and abstract (“racial and ethnic minorities”) to avoid overstating generalizability.

Consistency & Style

Ensure all p-values are in roman font (not italic).

Standardize use of abbreviations (DCC, DMCC, DWO) throughout text, tables, and figures.

Verify that percentages in text match those in tables (e.g., female proportions, SNF discharge rates).

Formatting

Streamline overlapping sections (e.g., cost driver rankings in Tables 2 & 3, forest plot description) to avoid redundancy.

Remove duplicated keywords (“administrative data” appears more than once).

Shorten overly long sentences in the Discussion for clarity.

References

Double-check that all in-text citations (Rubin, Dungan, Jiang, Alrashed, etc.) appear in the reference list.

Ensure reference formatting follows PLOS ONE guidelines (numbered, consistent punctuation, journal abbreviations).

Figures & Tables

Confirm all figure legends define abbreviations (DWO, DCC, DMCC, SNF).

Verify confidence intervals (CIs) are consistently formatted (95% CI, not “95% C.I.” or other variations).

Reviewer #2: This study provides a comprehensive analysis of diabetes hospitalization costs among African American and Hispanic populations in Southeastern Virginia, using rich data to identify sociodemographic, clinical, and administrative predictors of hospitalization costs. The manuscript demonstrates both theoretical and practical relevance. Below are some issues to consider:

1. For the sensitivity analysis, please provide information on how many discharges and how many patients in each of the three discharge categories were excluded.

2. In Table 1, please add a row showing n (%) for the number of patients and the percentages for each discharge category.

3. Please explain how cases in which patients had both Medicare and Medicaid coverage were handled when examining insurance type as a predictor of hospitalization costs.

4. Lines 353–366 are the same as lines 375–387, and lines 262–267 are the same as lines 285–290.

5. In the discussion section, starting at line 440, the authors discuss an interaction between age and diabetes severity. However, based on the multivariable models (Table 4), I do not think we can conclude that such an interaction exists. For the DCC and DWO categories, the association between age and hospitalization costs appears nearly the same, with a 2% decrease in cost for every additional year of age. To properly examine the effect of the interaction between age and disease severity on hospitalization costs, a different model is needed—one that includes age, disease severity, and their interaction term as independent variables.

6. Since Tables 2, 3, 4, and S1 all report percent changes, the format should be consistent—either include the “%” sign in all tables or omit it in all tables.

**********

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: Frank H Annie

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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Differential Impact of Admission Type and Clinical Complexity on Diabetes Hospitalization Costs Among African American and Hispanic Patients in Southeastern Virginia

PONE-D-25-46961R1

Dear Dr. EL Moudden,

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,

Kenji Fujiwara, MD, PhD, FACS

Academic Editor

PLOS One

Additional Editor Comments (optional):

Dear Dr. Moudden.

Thank you for revising your manuscript. All reviewers, as well as I, agree that it is suitable for acceptance.

Yours sincerely,

Kenji Fujiwara

Academic Editor

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

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

Reviewer #2: (No Response)

**********

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

Reviewer #2: (No Response)

**********

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

The PLOS Data policy

Reviewer #2: (No Response)

**********

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

Reviewer #2: (No Response)

**********

Reviewer #2: (No Response)

**********

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 #2: No

**********