-->PONE-D-25-68026-->-->FOCUS - Finding Optimal Care in Urgent Settings-->-->PLOS One

Dear Dr. Körnmann,

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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The manuscript was assessed by two reviewers and the academic editor. The research question is very relevant given the overcrowded emergency departments worldwide (not only in the Netherlands). However, a major revision of the manuscript is required. Please provide a point-by-point response to reviewers’ comments. The title should follow PLOS ONE requirements and include at the end the design of the study.  The reporting of the methods section needs some improvement. Please clarify in the study design that the study includes two steps, the first assessing patients and the second questioning doctors. Please provide the exact question asked to doctors. Please provide a clear paragraph of major variables collected with definitions especially for the variables included in the tables (what is U0, U1,…etc?).  -->-->==============================

Please submit your revised manuscript by Apr 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.

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We look forward to receiving your revised manuscript.

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Mabel Aoun, MD, MPH

Academic Editor

PLOS One

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6. Thank you for stating the following financial disclosure:

This work was supported by a Science Grant of €7,500 from the Dutch Society of Acute Internal Medicine (Nederlandse Vereniging voor Internisten Acute Geneeskunde, NVIAG). No additional funding was received from public, commercial, or not-for-profit sectors.

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8. Please amend your authorship list in your manuscript file to include author Michelle Noël Körnmann, Elisabeth Margaretha Mols, Harm R. Haak, Jelmer Alsma, Patricia Stassen, Karin Kaasjager, Geert Groeneveld, Marjolein N.T. Kremers.

9. Please amend the manuscript submission data (via Edit Submission) to include author E.M. Mols, M.N. Körnmann, H.R. Haak, J. Alsma, P. Stassen, H.A.H. Kaasjager, G.H. Groeneveld, M.N.T. Kremers.

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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?

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Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: Yes

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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

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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-->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: Many thanks to the authors for investigating possibilities to relieve pressure from Dutch emergency departments (EDs) by assessing the potential for redirection to alternative acute care settings, providing a foundation fo optimizing the delivery of care in the right place at the right time. Nobody will oppose to that. However, reading the manuscript I have the following remarks and concerns:

INTRODUCTION PART

The authors state a decline in ED visits in recent years. Indeed this is known as a temporary postcovid effect. However, since 2000 the growth of ED-visits is reasonable in line with demographic growth. The post-corona dip has now been overtaken and the pre-corona trend restored.

A more plausible explanation may indeed lie in the increasing complexity of patient care needs, driven by an aging population with multiple health problems.

However, when it comes to pressure on acute care and crowded EDs the authors do not mention anything about landscape changes that have taken place over the last 15 years and played an major role in the rising number of overcrowded EDs and ED diversions. A steady growing total number of ED-visits over the years, with 25% less EDs and an enormous reduction of hospital beds behind the remaining EDs overthe last 15 years. The ED landscape has stiffened.

ED crowding is a complex and systemic problem, expressing itself in the ED. The complexity ED-crowding, if mentioned, should be brought out better.

The authors state that: Traditionally, EDs are not designed to provide care to patients with complex needs, due to their primary focus on trauma care and diagnosis-driven pathways. However, a shift in the acute care landscape had occured, with an increasing number of patients presenting to the ED due to detoriation or complications of pre-existing chronic illnesses.'

True, but 25 - 20 years ago. Since then EDs in the Netherlands have developed long ago to areas of a medical facilities is not adequate for certain devoted to the provision of an organized system of emergency medical care that is staffed by Medical Specialist Physicians and/or Emergency Physicians and has the basis resources to resuscitate, diagnose and treat patients with medical emergencies of any kind (illness, trauma and acute mental issues). The authors paint too modest a picture of the highly and broad professionalized current EDs in the Netherlands, suggesting ED-design is a problem to handle certain presentations. This is not substantiated.

Having made these comments, ofcourse it is good to see whether internal medicine problems can be seen outside the ED safely, cost effective and with enough personel (the biggest tightness).

METHODS

Study design: The authors have chosen for a flashmob-study, which comes with distict limitations regarding scope, data, depth and bias. But I can understand the attractiveness of this method.

Study setting: Not in every ED all patients are registered under a specific traditional specialty. The trend in the Netherlands since formal recognition of the specialty Emergency Medicine in January 2024 is towards registration also under emergency physicians names.

Study population: 'The study included all patients > 18 years presenting t the ED for internal medicine etc.' So prospective included, based upon referral. It is known that a significant part of referred patients end up having another problem then initially thought of and needing treatment of another specialism then referred to. In the Netherlands known to be around 20%. I'm curious how the authors dealt with this in their study.

Study outcomes: '3) The proportion of ED visits that could have been redirected elsewhere in the emergency care chain or prevented, as retrospectively assessed by the treating physician.' First, Retrospectively assessed... The matter is that in practice it needs to be assessed prospectively. How does the retrospective assessment relate to ED/acute care practice? Second, by the treating physician only? On what grounds exactly? Can these be shared in the manuscript? How consistent were these assessments? Were these assessments reviewed by another physician? Can the physicians that actually did the assessments during the 24 hours perion be specified? Role? Experience?

RESULTS

Patient chracteristics: How many patients have been asked to participate and how many refused?

Redirecting urgent care: I reiterate my concerns about the methodology used and as a result these Results.

DISCUSSION

'In this prospective, nationwide flashmob study', Is the addition prospective appropriate?

'in nearly 40%, patients could theoretically have been redirected to alternative acute care settings as judged by the treating physician'. Based on the methodology used this is a too strong statement.

The authors spent a lot of attention on ácute on chronic care' for substantiation much of ED presentations could potentially be seen elsewhere in the hospital. But could they also reflect on what has made all this care being directed to the ED in the first place? What has caused, despite good alternatives (out patient clinics, internal wards, acute medical units), that internal medicne patient flow has shifted to the EDs and away from the alternatives in the first place? Were there good reasons for that? How do the alternatives compare to the ED? I think this perspective might be of added value to the manuscript.

Reviewer #2: Overall Assessment

This manuscript presents a nationwide, prospective multicentre flashmob study conducted across 28 Dutch hospitals, evaluating the proportion of internal medicine emergency department (ED) visits related to chronic conditions and the potential for redirection to alternative acute care settings.

The research question is timely and highly relevant in the context of ED crowding, workforce constraints, and the increasing burden of chronic disease. The flashmob methodology—characterised by short-term, simultaneous, prospective data collection across multiple centres—is innovative and appropriate for capturing a real-time snapshot of acute care delivery at the system level.

Major Comments

1. Flashmob Methodology: Appropriateness and Inherent Constraints

The use of a flashmob design is a central methodological feature of this study (Methods section).

This approach is appropriate for descriptive, system-level questions and allows broad national participation with limited resources. However, the snapshot nature of flashmob studies inherently limits:

• Temporal representativeness (single 24-hour window)

• Seasonal variability

• Weekday vs weekend variation

• Causal inference

• Precision of subgroup analyses

While some limitations are acknowledged, the Discussion should more explicitly emphasise that the findings represent exploratory, descriptive estimates rather than definitive national prevalence measures.

Explicitly framing the study as a system-level observational snapshot would strengthen methodological coherence and interpretation.

2. Subjectivity of Key Outcomes (Preventability and Redirection)

A key outcome—whether ED visits were “preventable” or “redirectable”—was determined retrospectively by the treating physician after ED evaluation.

This introduces:

• Hindsight bias

• Optimism bias

• Post-diagnostic reassessment bias

Because physicians had access to full diagnostic information at the time of judgement, these assessments may overestimate theoretical redirection feasibility.

Although acknowledged in the Limitations section, this issue should be more prominently integrated into the interpretation of the main results and conclusion.

3. External Generalisability

The study is conducted within the Dutch healthcare system, characterised by:

• Strong GP gatekeeping

• Structured referral systems

• Developed outpatient acute care infrastructure

These features significantly influence ED utilisation patterns.

The authors should more clearly discuss how these system characteristics may limit generalisability to:

• Open-access ED systems

• Healthcare environments with weaker primary care integration

• Different reimbursement models

Broader policy implications should therefore be framed cautiously and contextually.

Minor Comments

1. Comment on the Title

While “FOCUS – Finding Optimal Care in Urgent Settings” is a memorable study acronym, the current title does not clearly convey the study population, setting, design, or main outcomes. In its present form, it provides limited information about the focus on internal medicine emergency department presentations, chronic disease–related visits, and the assessment of potential redirection to alternative acute care settings. I recommend revising the title to be more descriptive and informative, in line with PLOS ONE’s preference for titles that clearly reflect the content and scope of the study.

2. Abstract and Language

• In the Abstract (p. 10), “EDs are face increasing pressure” should be corrected to “EDs are facing increasing pressure.”

• Ensure consistent use of terminology throughout the manuscript (e.g., “acute on chronic,” “preventable,” “redirectable”).

3. Tables

• Tables 1–3 contain valuable information but are relatively dense. Consider condensing selected organisational details in Table 1 (p. 16) or relocating some elements to Supplementary Material to improve readability.

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Reviewer #1: No

Reviewer #2: No

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-->PONE-D-25-68026R1-->-->Chronic disease related emergency department presentations and potential for redirection to alternative acute care settings (“FOCUS” study): a nationwide flashmob study-->-->PLOS One

Dear Dr. Körnmann,

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 Jul 23 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.

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• 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Vijayaprakash Suppiah, PhD

Academic Editor

PLOS One

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-->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 #2: (No Response)

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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 #2: (No Response)

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

Reviewer #2: (No Response)

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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 #2: (No Response)

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-->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 #2: (No Response)

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-->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 #2: (No Response)

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Reviewer #2: No

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Attachments

Attachment

Submitted filename: PONE-D-25-68026 2nd review.docx

Chronic disease related emergency department presentations and potential for redirection to alternative acute care settings (“FOCUS” study): a nationwide flashmob study

PONE-D-25-68026R2

Dear Dr. Körnmann,

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.

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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,

Vijayaprakash Suppiah, PhD

Academic Editor

PLOS One