PONE-D-20-09436

The efficiency in the ordinary hospital bed management in Italy: an in-depth analysis of intensive care unit in the areas affected by COVID-19 before the outbreak

PLOS ONE

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PLOS ONE

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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?

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: Partly

Reviewer #2: Partly

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

Reviewer #1: I Don't Know

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: Yes

Reviewer #2: Yes

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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: No

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: “The efficiency in the ordinary hospital bed management in Italy: an in-depth analysis of intensive care unit in the areas affected by COVID-19 before the outbreak” presents an analysis of bed availability in Italy prior to the epidemic. It concludes that bed supply was adequate and utilized efficiently at this time. Another important question is whether bed supply was adequate to match demand due to the pandemic. Obviously, the demand increased by such large amounts that it was not adequate especially in northern regions. It would be informative for the authors to extend their analysis to address this question. Also, I found the paper confusing and overly detailed in parts. Some specific comments/questions include:

• Provide examples of the calculation of CMI and PI, perhaps in an appendix. Provide a clearer explanation of Figure 2. I assume the numbers within each region represent N of Covid19 pts/N of ICU beds. If so the title could be revised to read, “Percent of routinely available beds occupied by COVID-19 patients by region. Colours indicate ...”

• What is the definition of a specialty (j)? It would be better to do a case-mix adjustment using the diagnosis/DRG of individual patients to provide more sensitivity to differences among regions. Even better would be to add an admission severity of illness score to the diagnosis. If data aren’t available to do this, this limitation in the case-mix adjustment method should be stated.

• Is there any audit or other mechanism to ensure reliability of source data? If not, is there any evidence that there may be differences in diagnostic coding or other data elements among regions?

• Table 1 columns don’t line up with headings. And are the total percentages at the bottom simple or weighted averages?

• On Lines 211-212 it states, “indicators are above the relevant threshold”. The authors should be explicit about the threshold. They should also be consistent. One line 242 they state, “Also in this case, green cells identify efficient regions.” Is this what is meant by “above the relevant threshold”?

• On Line 212 it states “BOR and TOI thresholds are captured in the literature”. What literature are you citing?

• On Line 135 the term “efficacy” is used. I think the authors mean “efficiency” here? If not, “efficacy” should be defined and how it’s measured made explicit.

• Putting “High” and “Low” on Figure 4 and Figure 5 would help the reader know which is the desirable direction.

• There are several grammatical errors, for example the disagreement of the singular nouns and plural verbs in the following:

o 57 highlighted that a reduction in the number of beds have affected many hospitals over the territory.

o 64 was published by Rhodes et al in 2012 [7]. Also in this case the number of beds located in Italy are

o 239 regional hospitals even if this region tend to manage complex cases.

Reviewer #2: The topic is relevant in terms of the present global pandemic situation. However, the aim of this research is not adequate in terms of an international journal perspective.

Data presented using summary statistics is useful, but inclusion of bar charts and graphs whilst comparing the data could be more relevant.

Line 68 ......ending with 'Government has a weak strategic leadership' - Ref required

In general, discussion is too short; there are more points/results to be discussed and more references needs to be included rather than giving vague statements.

Discussion and conclusion could be separated

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Reviewer #1: No

Reviewer #2: Yes: Dr. A Peter

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The efficiency in the ordinary hospital bed management in Italy: an in-depth analysis of intensive care unit in the areas affected by COVID-19 before the outbreak

PONE-D-20-09436R1

Dear Dr. Pecoraro,

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.

The decision depended on the following considerations:

- The authors have substantially clarified the presentation of their paper and the have provided a detailed response to each reviewer/editorial point raised

-  Reviewer 1 proposed a major revison by proposing “ It would be better to do a case-mix adjustment using the diagnosis/DRG of individual patients to provide more sensitivity to differences among regions. Even better would be to add an admission severity of illness score to the diagnosis. If data aren’t available to do this, this limitation in the case-mix adjustment method should be stated.”<o:p></o:p>

The reviewer therefore suggested using DRGs, but if the data were not available, the reviewer suggests to insert this lack as a limit. The reviewer did not make this adjustment binding.

- There are reviewers' comments on the validity of some indicators: “In addition, the measure of performance, bed occupancy rate, can be affected by other factors such as substitutability (e.g. an obstetrics patient can’t be put in infectious disease unit and vice-versa), regional differences in demand patterns (e.g. resort areas have more fluctuation over the year), and the size of a ward.” However, these indicators have not undergone a major revision. <o:p></o:p>

 <o:p></o:p>

-          While agreeing that the case-mix can represent a limitation, the article addresses a health policy problem that is particularly debated in Italy. As a consequence of the Ministerial Decree / 70, an intervention was carried out to reduce the number of beds in hospitals throughout Italy. With the COVID emergency, hospitalizations have increased and the difficulty of hospitals has been attributed to the DM / 70. The article assesses whether this widespread opinion is acceptable.<o:p></o:p>

<o:p></o:p>

 <o:p></o:p>

<o:p></o:p>

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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Kind regards,

Carmen Melatti

Staff Editor

PLOS ONE

on behalf of 

Maria Michela Gianino

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 #1: (No Response) 

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 #1: No

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: Yes

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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 #1: Yes

Reviewer #2: Yes

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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 #1: Yes

Reviewer #2: 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 have substantially clarified the presentation of their paper. However, as I thought might be the case in my previous comments, I believe the case-mix analysis is not sensitive enough to make a valid assessment of a region’s complexity and performance as it is done at too high a level of aggregation: the ward or specialty. There can be considerable differences in case-mix within a ward that can be masked when using ward as a covariate to adjust for measures such as LOS or bed turnover.  For example, a region that has a high rate of referrals from other regions may appear to have low performance as a result of receiving a high proportion of complex cases relative to other regions. This would not be sufficiently captured by using ward as the adjustment variable. A patient admitted to the cardiac ward in region A with a mild heart attack would be equivalent to one admitted to region B with a more severe heart attack exacerbated by comorbidities such as diabetes. As documented in the literature on risk adjustment, to capture these differences among regions would require case-mix analysis at a DRG level at minimum and preferably with severity adjustment as well.

In addition, the measure of performance, bed occupancy rate, can be affected by other factors such as substitutability (e.g. an obstetrics patient can’t be put in infectious disease unit and vice-versa), regional differences in demand patterns (e.g. resort areas have more fluctuation over the year), and the size of a ward. The latter is probably the most important factor that needs to be considered as the larger the ward the smaller the coefficient of variation and thus the higher the occupancy rate it can maintain while still having enough beds to admit urgent patients. Without using ward size (or at least individual hospital size) occupancy rate comparisons can be very misleading.

Finally, there are still a few grammatical or word choice errors:

Line 108 – I believe the authors mean “most up to date” rather than “most outdated”

Line 209 – “institutions” is the correct word, not “institutes”

Line 185 – “reacted to this pandemic period” is stated; however, the data in the next section are from a period prior to the pandemic

Line 195 – “data” is a plural term so the verb should be “are”

Reviewer #2: (No Response)

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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.

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

Reviewer #2: Yes: Dr. A Peter