-->PONE-D-25-26319-->-->Incidence and direct medical costs of child injuries in Lebanon (2012-2016): Evidence from closed insurance claims analysis-->-->PLOS One

Dear Dr. Al-Hajj,

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Two reviewers and the academic editor assessed the manuscript. The research question is very relevant and addressed with the appropriate methodology. However the data collection timeline extends back ten years as noted by one of the reviewers. The authors are requested to clarify this issue and provide a rationale supporting the inclusion of older data. They are also asked to provide a point-by-point response to reviewers.

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Reviewers' comments:

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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 #1: Yes

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: No

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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.-->

Reviewer #1: No

Reviewer #2: Yes

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

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Reviewer #1: Yes

Reviewer #2: No

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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: Abstract

1). A clear definition of a paediatric patient should be articulated, as a paediatric patient is an individual who is a minor, typically defined as being under 15 years of age (and in some jurisdictions, under 18 or 21 years of age).

2). The results would benefit from categorisation into specific age groups: neonates (birth to 28 days), infants (29 days to under 2 years), children (2 to under 12 years), and adolescents (12 to 18 or 21 years, depending on the authors' definition).

3). Cost presentation would also be enhanced by categorizing the data, rather than currently providing a total for all claims, while specific types of injuries are presented as proportions.

4). The conclusion requires revision; for instance, the results do not provide any information regarding interventions related to pediatric safety and security or indirect costs.

Introduction

5). A clear definition of a pediatric patient should be articulated.

6). Authors have cited many articles; for example, on page 3, last paragraph [9, 10, 11, 12, 13, ...], there is a lack of summarized information on what the articles explored and their link to pediatric injury in EMR.

7). Content in some of the paragraphs keep on repeating, from page 3 last paragraph, page 4 first paragraph and the last paragraph.

8). The introduction misses out on the country context regarding existing policies, as well as the safety and security of children aged below 18 years.

9). The context of health financing is not clearly articulated, encompassing aspects such as user fees, health insurance, and funding from development partners. Does health insurance cover all the medical costs or patients have to pay some co-payments, for health commodities and admission?

10). Furthermore, the service delivery context requires clarification. Given that some of the results have been presented in relation to various departments, it is necessary to explicitly delineate the service delivery mechanisms.

Methods

11). First paragraph time frame shown is not clear ...... " De-identified, injury- related, closed insurance claims were obtained from four leading Third Party Administrative (TPA) companies for children (<18 years) with International Classification of Diseases (ICD-10) codes corresponding to Injury, poisoning and certain other consequences of external causes (S00-T88) between the period of 01 January 2012 through 31 December 2016 on September 15, 2018...."

Ethics declaration

12). The tern "Ethics declatarion" needs to be corrected.

13). Revise the ethics to align with journal requirement

Methods

14). The section lacks information on

i). Currency conversion USD/LBP (Report the dates of the estimated resource quantities and unit costs, plus the currency and year of conversion).

ii). Clear description of characteristics of the study population (such as age range, demographics, or clinical characteristics)

iii). Setting and location - Provide relevant contextual information that may influence findings.

iv). State the perspective(s) adopted by the study and why chosen

v). Describe how costs were valued, adjusted etc.

vi). Describe any methods for analysing or statistically transforming data, any extrapolation methods etc.

vii). The insurance claim contains various levels of service delivery, which vary in terms of charges/reimbursements; aggregation of these levels could be misleading.

viii). Describe any methods used for estimating how the results of the study vary for subgroups.

ix). Clear stating the cost comparison being presented in the results section (male vs female, facility level [such as Primary Healthcare, Advanced Specialized Care, Super Specialized Care, etc], health facility departments etc)

15). Data analysis

i). How were patterns assessed and presented in the results section? Also pediatric visits needs clarity in the methods section, for the 2nd or 3rd visits were these linked to the single case of injury or multiple cases of injury?

ii). Explain the reason behind decision to present the findings by gender and not by any other categorization (age, health facility level etc)

iii). A log-transformed generalized liner model was used to analyze costs of adult injury, does this mean claim data was filtered to reflect 12 to 18 or 21 years or all the pediatric patient?

iV) A p-value of 0.05 was considered statistically significant. This should be amended to a p-value of less than 0.05 was considered statistically significant.

v). Use of mean and median: was the claim data normally distributed?

Results

16). Amend Table 1: where proportion of the Co-NSSF is presented and merge the cells Yes/Yes or No/No

17). Table 1: A presentation of the top 5 injuries and least 5 can be done and the rest of type of injuries can be presented as supplementary tables

18). Presentation of the costs can also be in terms of service delivery type

19). The table should be properly formatted for easy follow-up.

20). Table 2. Child Injury incidence, unit cost, and overall. Use of child, pediatric patient needs to be consistent as the analysis did not categorize pediatric into age groups [(birth to 28 days), infants (29 days to under 2 years), children (2 to under 12 years), and adolescents (12 to 18 or 21 years]

21). Supplementary Tables should be clearly numbered and referenced

22). Use of mean and median: for example page 24 last sentence ..... "Inpatient injury costs varied by age as well as diagnosis with median costs for orthopedic treatments for extremity fractures or dislocations being 3x – 7x cost of other injuries treated (S2 Table)"..... The methods section did not clarify a comparison will be made between orthopedic care to other injuries care provided in Lebanon.

Discussion and conclusion

23). Discussion and conclusion should be strengthened

24). Conclusion should be revised

Acknowledgement

25). Be revised as, data are own by an institution, authors might have received financial resources to undertake the work (not directly to fund the study), technical support etc

Reviewer #2: The data is nearly ten years old on a subject of trauma. Trauma related findings and information shared have no new information. In fact cost is mixed up with injuries in a unimpressive style. Data is taken from insurance companies thus even injury pattern and its impact on the children and families can not be determined. There is unnecessary verbosity in the introduction. References are irrationally used. There are eight references in the discussion section put together in an unintelligent style like 30, 31,32,33 and 35, 36, 37, 38, 39, 40. It appears that authors are not keen interest in comparing with the reported literature. There are huge limitations already identified by the authors too.

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Reviewer #1: Yes: August Kuwawenaruwa

Reviewer #2: Yes: JAMSHED AKHTAR

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<p>Incidence and direct medical costs of child injuries in Lebanon (2012-2016): Evidence from closed insurance claims analysis

PONE-D-25-26319R1

Dear Dr. Al-Hajj,

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.

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Kind regards,

Mabel Aoun, MD, MPH

Academic 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 #2: All comments have been addressed

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-->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 #2: Yes

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

Reviewer #2: I Don't Know

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-->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 #2: No

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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: Yes

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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: Thank you for responding and clarifying number of issues highlighted during initial review. Though I still data has several limitations in context of injury pattern over a decade as well as cost of the treatment incurred. In context of last few years because political instability, internal migration, and several other factors, the present data fall short of providing true picture and may not be in line with ground realities. However, it did provided a template on which future studies may be conducted.

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-->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.

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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: Yes: Jamshed Akhtar

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