Do family physicians with focused practice or Care of the Elderly training practice differently than others? A population-based, propensity score-matched cohort study

Rebecca H. Correia; David Kirkwood; Aaron Jones; Henry Yu-Hin Siu; Meredith Vanstone; Steve Slade; Andrew P. Costa

doi:10.1371/journal.pone.0347828

Peer Review History

Original SubmissionJuly 9, 2025
27 Nov 2025 Decision Letter - Masaki Mogi, Editor -->PONE-D-25-34776-->-->Do family physicians with focused practice or Care of the Elderly training practice differently than others? A population-based, propensity score-matched cohort study-->-->PLOS ONE Dear Dr. Correia, 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. ============================== This paper contains interesting content and is highly regarded. However, the reviewers have suggested several points that require revision. Please read them carefully and address them appopriately. ============================== Please submit your revised manuscript by Jan 11 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. Please include the following items when submitting your revised manuscript:--> 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, Masaki Mogi 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. In the online submission form, you indicated that [The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.]. 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. 3. 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 (if provided): [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions -->Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes ******** -->2. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes ****** -->3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes ****** -->4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes ****** -->5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: This population-based, propensity score–matched cohort study examined whether FPs in Ontario with a COE Certificate of Added Competence or an elderly-focused practice deliver different clinical care compared to those without such specialization. Among 232 COE/focused FPs and 928 matched controls, significant differences were observed in only three of eleven practice indicators: dementia-related testing and higher prescribing of potentially inappropriate medications and antipsychotics (higher in COE group). Overall, clinical practice patterns were largely similar, suggesting structural constraints or limited sensitivity of administrative measures to detect nuanced differences in geriatric competence This is a well-designed and methodologically sound population-based cohort study that explores an important and timely question in primary care geriatrics. The analysis is robust, and the findings are clearly presented. However, the minimal observed differences between groups highlight the challenges of evaluating the impact of specialized geriatric training using administrative indicators alone. Clarifying the study’s primary aim, refining exposure definitions, and strengthening the interpretation toward educational and policy implications would further enhance the manuscript’s clarity and relevance. Overall, this study makes a valuable and policy-relevant contribution to the field of geriatric primary care. 1. The study addresses an important question regarding whether additional geriatric training or focused practice changes primary care behavior. However, the manuscript should more clearly define its primary aim — whether it evaluates clinical performance differences or educational/policy impact. Please state this explicitly in the Introduction and Discussion. 2. The grouping of physicians with COE certification and those with focused practice into a single exposure group may obscure distinct effects. These two categories represent different professional profiles. Provide subgroup or sensitivity analyses distinguishing COE-only, focused-only, and dual-trained physicians. 3. The key finding of limited practice differences requires deeper interpretation. It may suggest that system-level constraints limit the impact of additional training. Discuss how these results inform future design of the CAC/COE programs, remuneration models, and integration of geriatric expertise in primary care. 4. While process indicators are informative, they may not fully capture clinical quality. The discussion would benefit from linking findings to potential downstream outcomes (e.g., hospitalization, medication-related harm, patient function). Add a short paragraph connecting measured processes to meaningful patient outcomes. ****** -->6. PLOS authors have the option to publish the peer review history of their article (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 ******** [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. https://doi.org/10.1371/journal.pone.0347828.r001
Revision 1
20 Jan 2026 Author Response Response to Reviewers Do Family physicians with focused practice or care of the elderly training practice differently than others? A population-based, propensity score-matched cohort study PONE-D-25-34776 Review Comments to the Author This population-based, propensity score–matched cohort study examined whether FPs in Ontario with a COE Certificate of Added Competence or an elderly-focused practice deliver different clinical care compared to those without such specialization. Among 232 COE/focused FPs and 928 matched controls, significant differences were observed in only three of eleven practice indicators: dementia-related testing and higher prescribing of potentially inappropriate medications and antipsychotics (higher in COE group). Overall, clinical practice patterns were largely similar, suggesting structural constraints or limited sensitivity of administrative measures to detect nuanced differences in geriatric competence This is a well-designed and methodologically sound population-based cohort study that explores an important and timely question in primary care geriatrics. The analysis is robust, and the findings are clearly presented. However, the minimal observed differences between groups highlight the challenges of evaluating the impact of specialized geriatric training using administrative indicators alone. Clarifying the study’s primary aim, refining exposure definitions, and strengthening the interpretation toward educational and policy implications would further enhance the manuscript’s clarity and relevance. Overall, this study makes a valuable and policy-relevant contribution to the field of geriatric primary care. Thank you for this comprehensive summary of our study and for your encouraging comments to strengthen this work. In response to the four areas of improvement you indicated, we have revised our manuscript accordingly. 1. The study addresses an important question regarding whether additional geriatric training or focused practice changes primary care behavior. However, the manuscript should more clearly define its primary aim — whether it evaluates clinical performance differences or educational/policy impact. Please state this explicitly in the Introduction and Discussion. We appreciate the opportunity to clarify our main study objective. This study examines clinical practice differences between family physicians (FPs) on the basis of additional geriatric training and/or focused practice compared to other FPs without this training or area of focus. Our findings have implications for both Care of the Elderly (COE) training and focused practice based on the clinical practice differences observed. Based on your feedback, we have clarified this aim in our Introduction and Discussion. Lines 69-72: In this study, we aimed to compare the clinical practice of FPs with/without focused practice or additional training to care for older adults on the consensus-based practice measures. We hypothesized that elderly-focused practice and enhanced geriatric training would contribute to variations in clinical activities. Lines 259-260: We observed limited to no differences in clinical practice measures between FPs with focused practice and certification in COE compared to FPs without additional training or focused practice. 2. The grouping of physicians with COE certification and those with focused practice into a single exposure group may obscure distinct effects. These two categories represent different professional profiles. Provide subgroup or sensitivity analyses distinguishing COE-only, focused-only, and dual-trained physicians. Thank you for this suggestion. We originally chose not delineate findings across the three physician sub-groups (CAC-only, focused-only, both COE and focused) due to concerns about how these findings describe small groups of physicians (ranging from 27-72 FPs). However, as a sensitivity analysis in response to your comment, we added comparisons of the performance measures across these three groups in S5 Appendix. Ultimately, we did not identify clear patterns across the three sub-groups. For example, the CAC-only and both COE and focused groups approximate each other for some indicators, whereas the focused-only relates to the mean estimate for the “no evidence of focused practice or certification” group. However, observations such as these do not apply to all indicators within particular categories (e.g., medical conditions, appropriate prescribing, driving issues, cognitive impairment). Therefore, in our Results, we only commented on how the difference in significance for four indicators changed across the sub-groups. Lines 144-146: In a sensitivity analysis, we compared practice differences between FPs with evidence of elderly-focused practice versus additional training. Lines 180-182: In contrast to the main findings, we identified significant differences between the elderly-focused FP sub-groups on the basis of managing medical conditions (Indicators 1 to 4) and reporting potential driving issues (Indicator 11) (S5 Appendix). 3. The key finding of limited practice differences requires deeper interpretation. It may suggest that system-level constraints limit the impact of additional training. Discuss how these results inform future design of the CAC/COE programs, remuneration models, and integration of geriatric expertise in primary care. Thanks for your comment. We agree that the nominal differences observed between FP groups may reflect that despite having additional training or a greater focus/capacity to care for older adults, these FPs are limited by system-level factors. As said: Lines 183-187: The lack of differences for most performance measures may suggest that FPs who pursue focused practices or CACs in COE function like other FPs whose medical practice comprises a comparable number of older adults and levels of LTC activity. Similarities in clinical practice between the groups may reflect that additional performance is difficult to accomplish in the constraints of practice that limit comprehensive care and follow-up. We have since expanded on these implications in our interpretation: Lines 227-228: Despite this growing and urgent need, COE CAC holders acknowledge limited incentives to establish focused practices,18,19,56 which may be a factor limiting the potential impact of their added training. Lines 238-242: Beyond CAC training and focused practice, other practice considerations related to how FPs organize or are supported in their practice could be shaping care delivery and, in turn, performance on the assessed indicators. For example, preventative care incentives or team-based care models may result in similarities from targeted incentives and shared clinical responsibilities, irrespective of additional training or focused practice. Lines 252-257: These insights point to the need to better align COE training with real-world practice environments, strengthen remuneration structures that support geriatric-focused care, and enhance the integration of geriatric expertise within primary care teams. Education programs alone cannot supersede structural barriers. Ensuring the sustainability and longevity of COE CACs and focused practice will require coordinated reforms in training, compensation, and primary care organization. 4. While process indicators are informative, they may not fully capture clinical quality. The discussion would benefit from linking findings to potential downstream outcomes (e.g., hospitalization, medication-related harm, patient function). Add a short paragraph connecting measured processes to meaningful patient outcomes. The process indicators examined in this work were established in a consensus study conducted previously by our team. That study used the Donabedian Structure-Process-Outcome model to conceptualize the interrelationships of broader factors, physician activities, and impacts for older adult patients. We discuss our focus on processes in the following excerpt: Lines 102-108: The Donabedian model – the dominant health services paradigm to assess, evaluate, and improve quality – conceptualizes the interrelationships of structures and processes affecting outcomes.36 Process measures include interactions between patients and health care providers for clinical practice activities or service provision. Per Donabedian’s model, we can identify and quantify FP practice activities that serve as process factors.37 While these factors are relevant to quality measurement, they do not by themselves constitute complete measures of quality. We focused on processes because they directly relate to FP activities, whereas structures and outcomes are broader and reflect multiple factors (e.g., policies, resources, contributions of other health professionals). Therefore, we cannot connect the measured processes to meaningful outcomes, but we have added a reflection on this in our Limitations: Lines 267-278: Although the process indicators used in this study reflect meaningful aspects of FP practice in caring for older adults, they do not fully capture the downstream impacts of care, such as health service utilization or changes in patient function. As a result, our findings cannot directly link observed changes in practice activities to patient outcomes, highlighting the need for future research that examines whether differences in FP processes relate to measurable improvements in clinical outcomes for older adults. Also, as stated in our Conclusion, examining outcomes could be a future study building on this work: Lines 280-281: Future work can examine the impacts of practice differences on variations in quality of care as measured by patient outcomes. Attachments Attachment Submitted filename: Response to Reviewers_Dec 15 2025.docx https://doi.org/10.1371/journal.pone.0347828.r002
10 May 2026 Decision Letter - Marianne Clemence, Editor Do family physicians with focused practice or Care of the Elderly training practice differently than others? A population-based, propensity score-matched cohort study PONE-D-25-34776R1 Dear Dr. Correia, 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, Marianne Clemence Staff Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions -->Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.--> Reviewer #1: All comments have been addressed ******** -->2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes ****** -->3. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: 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.--> Reviewer #1: Yes ****** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes ****** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: The authors well responded to the reviewer's comments. Current manuscript meets the quality for the publication in PLOS One. ****** -->7. PLOS authors have the option to publish the peer review history of their article (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 ******** https://doi.org/10.1371/journal.pone.0347828.r003
Formally Accepted
Acceptance Letter - Marianne Clemence, Editor PONE-D-25-34776R1 PLOS One Dear Dr. Correia, 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 Marianne Clemence Staff Editor PLOS One https://doi.org/10.1371/journal.pone.0347828.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .