Dear Dr. Scott,

• In spite of the major concerns that have ben raised, the authors have been granted a second chance to improve the manuscript. please address all the points that have been raised

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.. 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.. 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.. 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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We look forward to receiving your revised manuscript.

Kind regards,

Tarek Samy Abdelaziz, MD,FRCP

Academic Editor

PLOS ONE

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Additional Editor Comments:

The reviewers have raised major concerns about data accuracy and comparison to between virtual ward and acute wards

It has been decided that the authors will be granted a second chance to improve the manuscript provided that the authors will address those major concerns

Reviewers' comments:

Comments to the Author

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

Reviewer #1: Partly

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

Reviewer #1: N/A

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

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

Reviewer #1: Yes

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Reviewer #1: The authors conduct a retrospective analysis of physiological parameters for patients managed on a virtual ward network. The authors conduct a retrospective analysis of physiological parameters for patients managed on a virtual ward network. The authors conduct a retrospective analysis of physiological parameters for patients managed on a virtual ward network. The authors conduct a retrospective analysis of physiological parameters for patients managed on a virtual ward network.

There are a number of areas of major concerns which need to be considered.

The first area is the definition and description of the hospital level interventions delivered on this virtual ward network. This is missing and it is essential for interpretation of the manuscript. Was their point of care ultrasound delivered diagnostics, point of care blood monitoring, intravenous therapies etc.. Delivering physiological monitoring in isolation is insufficient to meet this criteria.

Further why have OPAT services been included? OPAT services has been in existence since the last 1990s and should not be regarded as meeting the criteria for virtual ward admission unless further interventions are also being delivered in the service.

The second area that needs consideration is the equivalence in the paper given to clinical acuity and physiological stability (as measured by NEWS2). It does not appear that any other markers of clinical acuity are examined in the paper and by themselves physiological parameters are not a good measure of clinical acuity.

The third area is the NEWS2 data itself:-

1. Only 57% of patients have a NEWS2 score that can be calculated. This is an almost insurmountable issue and the conclusions made in the paper should be stated with significantly less confidence in the context of this missing data.

2. How did the authors derive their implausible physiological parameters to be excluded? How many of these were there? This raises concerns about the accuracy of the device used. How many patients had a respiratory rate of >50 for example. Further, when do the authors think people may have a temperature >43?

3. "Clinical acuity" cannot be compared to acute hospital care when 12% of initial observations were taken >48 hours after "admission" to the virtual ward.

The fourth area is comparison to hospital care:-

1. Over 80% of the patients have undergone a period of acute inpatient care, assessment and treatment prior to discharge to a "virtual ward". Therefore, this is an entirely different cohort to those analyzed during SAMBA. Their clinical acuity will have been assessed as less than those requiring inpatient care by a senior clinician.

2. The prediction in this cohort is thus predominantly not "admission" to hospital but actually a marker of "readmission". This should be the metric in this study.

3. The conclusion that the clinical acuity of those admitted to virtual wards is similar to those admitted on the acute medical take is thus deeply flawed.

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Reviewer #1: No

**********

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Dear Dr. Scott,

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 Mar 19 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.. 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.. 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.. 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 . 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 . 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 . 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,

Tarek Samy Abdelaziz, MD,FRCP

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.

Additional Editor Comments:

Please carefully address the reviewers comments especially regarding missing data

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

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

Reviewer #2: (No Response)

Reviewer #3: No

**********

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

Reviewer #2: Yes

Reviewer #3: No

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

Reviewer #3: No

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #2: Rather than putting the median and IQR by demographics in the supplementary material the authors could have actually shown the distributions through histograms. That would have been more informative.

I have concerns about the large amount of missing data. The authors' response indicates that data at the beginning was unavailable because the full digitization had not been completed. If this is the case, I'm curious why then the study period was not adjusted to have only the time of full digitization? The authors are sort of mixing the study because they have patients that they describe for all variables and then some for only some variables. I do not quite feel the response to the reviewer's comment is satisfactory on that.

Reviewer #3: Thank you for letting me have the chance to see this work relating to an important aspect of care.

I have four major issues with the paper:

1.Missing data

The levels of missing data are, as described by Reviewer 1, almost insurmountable in terms of reliability of the findings. This is not least as there are clear imbalances in the degree of missingness, for example 23% of the youngest patients are excluded rising to 60% of the oldest patients, who are not only the largest age group but surely the group to most likely experience the outcomes of interest.

The authors give at least two explanations for this. They state that as a new service more data were missing at the earlier stages of the service but there is no clear evidence of any improvement over time in Figure 1 that suggest limiting the scope to a more recent period would improve the reliability of the analysis.

In the discussion its stated that the kit is not universally distributed and in fact the elderly (and likely more frail) are less likely to get it. The flip side of this then is surely that those at highest risk of the outcome were systematically excluded from this dataset and therefore this dataset is more representative of the lower risk patients than the entire virtual ward population as a whole.

At the least the paper needs to make the degree of missingness in all groups explicit in a table and beef up the discussion of the implications of this.

2.Only counting first admission

The rationale for, and implications of, using only the first virtual ward admission where there was more than one is not made clear and appears to create a number of important gaps in the data which aren’t mentioned, quantified, or addressed.

For example in this dataset, no patient can have both outcomes, they cannot both be re(admitted) to hospital and die as an outcome of their first virtual ward admission.

In reality of course a patient could have both, i.e. they get (re)admitted and die in hospital, but here only the readmission counts.

Another scenario which appears to be overlooked is where a virtual ward admission leads to a hospital (re)admission which leads to another virtual ward admission. The authors wording implies that this second virtual ward admission is not in the dataset and so any readmission or death at the end of that is not counted.

Whilst counting these deaths would be addressing a subtly different question (akin to the outcomes of a spell of care) it’s hard to see why that wouldn’t be a more important question than one which essentially ignores anything that happens after the first virtual ward admission.

As it is the analysis takes a person based approach, nobody can appear in the dataset more than once. And to facilitate that they use only the first virtual ward admission. It is not clear why the analysis of virtual ward admission outcomes could not be on an virtual ward admission basis, i.e. individuals could appear more than once.

Or with perhaps a stronger rationale than the first admission, to be based on the final virtual ward admission within a continuous spell, mirroring the approach used for hospital episodes within a spell. At least this would tell you the ultimate outcome of the spell of care, rather than just of part of it.

If the paper remains focused on the first virtual ward admission then it needs to quantify somewhere the outcomes for the omitted ward admissions, principally the final virtual ward admission. This would then enable the reader to understand if the first admission approach was suitable or not.

3.Composite outcome measure

The composite outcome measure of (re)admission or mortality (on the virtual ward) is problematic as clearly the implications to the two aspects are markedly different.

This exact combination of mortality or hospital admission is criticised in a BMJ paper on the deficiencies in composite outcome measures where the components are “not of similar importance” (doi: https://doi.org/10.1136/bmj.c3920).

This is further compounded by the decision to count only the first virtual ward admission as discussed above. Death, the most important outcome to the patient, is certain to be undercounted in the sense of final outcome at the end of the connected spell of care.

Whilst the stated number of deaths is small, this is certain to be an underestimate and it would be better to treat the two outcomes separately, having first identified the final outcome of the spell.

At the very least the paper should tabulate somewhere the number of outcomes by the demographic groups to give some sense of the risk and therefore help assess the impacts of the inherent biases in the dataset.

Ideally it would establish and focus on the final outcome of the “spell” of care.

4.Unadjusted analysis

I don’t really understand why just univariate analysis has been used.

It would seem that a multivariable approach would be more informative and may indicate important patterns not visible at the moment, for example perhaps the score is predictive in certain groups (perhaps those with less missing data) and not in others.

At the very least there needs to be a clear rationale stated as to why the current univariate analytical approach is the best approach to assessing predictiveness and give reassurance that there are no subgroup effects that have been overlooked.

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #2: No

Reviewer #3: No

**********

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

Dear Dr. Scott,

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 May 13 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.. 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.. 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.. 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 . 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 . 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 . 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....

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We look forward to receiving your revised manuscript.

Kind regards,

Tarek Samy Abdelaziz, MD,FRCP

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 #2: All comments have been addressed

Reviewer #3: (No Response)

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

Reviewer #3: No

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #2: (No Response)

Reviewer #3: Thank you for your consideration of my comments and for the resulting changes you have made which make it generally much easier to read and interpret.

My only final comment is that you can see now in the new supplemental table 3 a gradient for hospital readmission risk by First NEWS2 score (NEWS2 0 = 5.2%, then 6.4%, 7.7%, 8.3% up to NEWS2 7+ = 12.7%), which surprisingly you don't mention in the actual paper and seems at face value to to run contrary to your claim that "...prediction of readmission to hospital using NEWS2 in this setting was poor".

Plugging those numbers into a quick Chi square confirms your finding that its not statistically significant but it does to me seem to warrant a mention. If your study was twice the size then the Chi square would be highly significant (and clinically meaningfully so as the risk in the 7+ group is 2.5 times that of the risk the 0 group).

It does seem to me that your paper would benefit from being a bit clearer about this as a weakness (there is evidence of a trend but the sample size is relatively small) rather than just saying its prediction ability was poor.

**********

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Reviewer #3: No

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Clinical acuity and National Early Warning Scores (NEWS2) of remotely monitored patients on virtual wards: a retrospective cohort study

PONE-D-25-43041R3

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