-->PONE-D-26-12536-->-->10-Year Utilization and End-of-Life Trajectories in Long-Term Care Hospitals of South Korea-->-->PLOS One

Dear Dr. Shin,

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 02 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:-->

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We look forward to receiving your revised manuscript.

Kind regards,

Kuo-Cherh Huang

Academic Editor

PLOS One

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3. Thank you for stating in your Funding Statement:

“This work was supported by the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI, https://www.khidi.or.kr), funded by the Ministry of Health & Welfare, Republic of Korea (Grant No. RS-2024-00441486 awarded to SS). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

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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.

Additional Editor Comments:

Dear Dr. Shin,

We appreciate you submission to PLOS One. I have now received three reviewers’ reports for your manuscript. Reviewer 2 provided pretty thorough expertly remarks and suggestions regarding your work. Reviewer 3 offered comments and recommendations for Table 1, additionally. Please respond to each remark of all three reviewers carefully and completely. Please explain where you feel you cannot quite agree with reviewers’ suggestions. Thank you.

Kuo-Cherh Huang

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?

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: No

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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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: Yes

Reviewer #2: No

Reviewer #3: No

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-->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

Reviewer #2: Yes

Reviewer #3: 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: Congratulations. It is an excellent article. The methods sextion is complete and it can be replicate in other context.

The discussion is complete and compare the findings. Limitation are highlighted. Some references have more than 10 years, but they are useful for the article.

Only I suggest add the source in tables and figures.

Reviewer #2: Dear Authors,

I've reviewed your manuscript "10-Year Utilization and End-of-Life Trajectories in Long-Term Care Hospitals of South Korea" (PONE-D-26-12536). Detailed comments are attached.

This is an important topic and you have excellent data. But there are some serious concerns that need to be addressed before its release can be recommended.

Respectfully,

Reviewer

Reviewer #3: This manuscript is based on the analysis of the National Health Insurance Service claims data for the period 2014 to 2023. The manuscript is well written, and the results are clearly presented. I have a few minor comments.

Three groups were constructed based on all inpatients, new admissions and deaths. As these groups were not really followed up on, it is not appropriate to call them cohorts. Suggest not using the term 'cohort' when referring to these groups.

In Table 1, how were the compound annual growth rates calculated? It appears that these have been calculated using only the numbers for the first and last years. It is more appropriate to use all available data. This could be done by calculating the slope of the linear regression.

The following part of the abstract (in the results section) could be misleading - "... and exhibited high sociodemographic vulnerability, characterised by a predominance of females, ...". The predominance of females reflects the sex ratio in this age group. Based on this observation, we cannot say females are more vulnerable than males.

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-->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: Yes: Nicolas Padilla-Raygoza

Reviewer #2: No

Reviewer #3: Yes: Arunasalam Pathmeswaran

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[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.]

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

Attachments

Attachment

Submitted filename: PONE-D-26-12536.docx

-->PONE-D-26-12536R1-->-->Utilization and end-of-life trajectories in long-term care hospitals of South Korea-->-->PLOS One

Dear Dr. Shin,

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 Aug 06 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 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Kuo-Cherh Huang

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.

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. Shin,

Thank you for submitting your revised manuscript to PLoS ONE. Although the revised manuscript is much improved, the need for some revisions remains. Reviewer 2 had kindly provided several nice points to help polish your work; for example, “Methodologically, the one-year washout period limitation and the missing time-gap data due to expired access are underplayed, these affect the validity of the ‘near-death’ interpretation more than acknowledged.” Please respond to each comment of Reviewer 2 carefully and thoroughly. Please explain where you feel you cannot completely agree with the reviewer’s suggestions. Thank you.

Kuo-Cherh Huang

Academic Editor

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

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: (No Response)

Reviewer #3: 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: Partly

Reviewer #3: (No Response)

**********

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

Reviewer #2: Yes

Reviewer #3: (No Response)

**********

-->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: Yes

Reviewer #3: (No Response)

**********

-->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

Reviewer #3: (No Response)

**********

-->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: -The authors have made a reasonable effort to address most of my previous concerns. However, several important issues remain.

-The title is still too vague and does not reflect the main finding that LTCHs function as end-of-life settings.

-The abstract needs key percentages and more concrete policy recommendations.

-The introduction would benefit from moving the admission-mortality paradox observation earlier to frame the study's importance.

-Methodologically, the one-year washout period limitation and the missing time-gap data due to expired access are underplayed, these affect the validity of the "near-death" interpretation more than acknowledged.

-The results on heterogeneity in length of stay and cost skew are interesting but not adequately explored; the paper does not examine what distinguishes short-stay from long-stay patients.

-The discussion overstates the "social safety net" narrative and could more openly acknowledge that the diagnostic shift finding aligns with existing literature. The conclusion remains somewhat strong given the limitations. A more balanced tone and clearer statement about what is truly novel would strengthen the manuscript. Please see the attachment for detailed comments.

Reviewer #3: (No Response)

**********

-->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 #2: No

Reviewer #3: Yes: Arunasalam Pathmeswaran

**********

[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.

-->

Long-term care hospitals as end-of-life care settings in South Korea: A nationwide analysis of utilization patterns and clinical trajectories

PONE-D-26-12536R2

Dear Dr. Shin,

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,

Kuo-Cherh Huang

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: