Reviewer's report
Title:Access to Primary Care is Associated with Better Autoimmune Hepatitis
Outcomes in an Urban County Hospital
Version:2Date:17 March 2015
Reviewer: Cynthia Levy
Reviewer's report:
This is a nice study evaluating the importance of having access to (and following
through with recommendations from) primary care services.
The authors reviewed all patients with new diagnosis of AIH and who were
managed at a single county hospital. Of the initially identified 150 patients, only
83 were included. Most patients were of Hispanic origin (84%). The spectrum of
clinical presentation was consistent with that described in the literature, with 39%
having cirrhosis at presentation.
Patients were evaluated according to presence or absence of previous follow-up
with established primary care MD for at least 6 months. 57 (68.7%) did not have
access to PCP prior to diagnosis of AIH. These patients were more likely to have
cirrhosis at presentation, with higher MELDs, more clinical decompensation, and
get lost to follow-up after discharge from the hospital. Also, patients without PCP
were less likely to receive treatment. More importantly, patients without prior PCP
had worse long term survival free of liver transplantation.
Major comments:
1- Please clarify the definition of remission in the study. According to AASLD
guideline, disappearance of symptoms and normalization of
transaminases/bilirubin/globulin levels are required for remission.
2- When evaluating outcomes, authors should try to classify patients according to
known endpoints in AIH: remission, relapse, treatment failure, drug toxicity.
3- The text says that 81 patients were treated (page 7, line 152), but table 1
states 67 patients were treated. Which is it?
4- Please provide median duration of follow-up for the study.
5- Please provide number of patients at risk for each time point in the Kaplan
Meier curves
6- Table 1 is titled “baseline characteristics” but it includes data at presentation,
during treatment and at follow-up. I suggest separating the information
accordingly. For better understanding of the study population, please present the
data as done for table 2, with separate columns for patients with and without
primary care access. Since you are comparing outcomes (treatment, response,
relapse), statistical analyses can be done here.
7- Table 2 discusses “follow-up”, but includes data at baseline – cirrhosis, other
autoimmune diseases and labs/ MELD. Again, the authors can re-do the tables
for demographics, clinical presentation, treatment and outcomes, always
comparing the 2 groups.
8- Even though the sample size is small, as acknowledged by the authors, you
should still show us the numbers for those with and without primary care access.
This can be done in table 1.
Minor comments:
1- Ascites is misspelled in table 1
2- Did the authors really mean encephalitis in table 1? Or was it hepatic
encephalopathy? – please review
3- Abbreviation 2/2 in table 1 is not acceptable
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests.
Reviewer's report
Title:Access to Primary Care is Associated with Better Autoimmune Hepatitis
Outcomes in an Urban County Hospital
Version:2Date:17 March 2015
Reviewer: Cynthia Levy
Reviewer's report:
This is a nice study evaluating the importance of having access to (and following
through with recommendations from) primary care services.
The authors reviewed all patients with new diagnosis of AIH and who were
managed at a single county hospital. Of the initially identified 150 patients, only
83 were included. Most patients were of Hispanic origin (84%). The spectrum of
clinical presentation was consistent with that described in the literature, with 39%
having cirrhosis at presentation.
Patients were evaluated according to presence or absence of previous follow-up
with established primary care MD for at least 6 months. 57 (68.7%) did not have
access to PCP prior to diagnosis of AIH. These patients were more likely to have
cirrhosis at presentation, with higher MELDs, more clinical decompensation, and
get lost to follow-up after discharge from the hospital. Also, patients without PCP
were less likely to receive treatment. More importantly, patients without prior PCP
had worse long term survival free of liver transplantation.
Major comments:
1- Please clarify the definition of remission in the study. According to AASLD
guideline, disappearance of symptoms and normalization of
transaminases/bilirubin/globulin levels are required for remission.
2- When evaluating outcomes, authors should try to classify patients according to
known endpoints in AIH: remission, relapse, treatment failure, drug toxicity.
3- The text says that 81 patients were treated (page 7, line 152), but table 1
states 67 patients were treated. Which is it?
4- Please provide median duration of follow-up for the study.
5- Please provide number of patients at risk for each time point in the Kaplan
Meier curves
6- Table 1 is titled “baseline characteristics” but it includes data at presentation,
during treatment and at follow-up. I suggest separating the information
accordingly. For better understanding of the study population, please present the
data as done for table 2, with separate columns for patients with and without
primary care access. Since you are comparing outcomes (treatment, response,
relapse), statistical analyses can be done here.
7- Table 2 discusses “follow-up”, but includes data at baseline – cirrhosis, other
autoimmune diseases and labs/ MELD. Again, the authors can re-do the tables
for demographics, clinical presentation, treatment and outcomes, always
comparing the 2 groups.
8- Even though the sample size is small, as acknowledged by the authors, you
should still show us the numbers for those with and without primary care access.
This can be done in table 1.
Minor comments:
1- Ascites is misspelled in table 1
2- Did the authors really mean encephalitis in table 1? Or was it hepatic
encephalopathy? – please review
3- Abbreviation 2/2 in table 1 is not acceptable
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests.
Please review this paper.
user
Reviewer's report
Title:Access to Primary Care is Associated with Better Autoimmune Hepatitis
Outcomes in an Urban County Hospital
Version:2Date:17 March 2015
Reviewer: Cynthia Levy
Reviewer's report:
This is a nice study evaluating the importance of having access to (and following
through with recommendations from) primary care services.
The authors reviewed all patients with new diagnosis of AIH and who were
managed at a single county hospital. Of the initially identified 150 patients, only
83 were included. Most patients were of Hispanic origin (84%). The spectrum of
clinical presentation was consistent with that described in the literature, with 39%
having cirrhosis at presentation.
Patients were evaluated according to presence or absence of previous follow-up
with established primary care MD for at least 6 months. 57 (68.7%) did not have
access to PCP prior to diagnosis of AIH. These patients were more likely to have
cirrhosis at presentation, with higher MELDs, more clinical decompensation, and
get lost to follow-up after discharge from the hospital. Also, patients without PCP
were less likely to receive treatment. More importantly, patients without prior PCP
had worse long term survival free of liver transplantation.
Major comments:
1- Please clarify the definition of remission in the study. According to AASLD
guideline, disappearance of symptoms and normalization of
transaminases/bilirubin/globulin levels are required for remission.
2- When evaluating outcomes, authors should try to classify patients according to
known endpoints in AIH: remission, relapse, treatment failure, drug toxicity.
3- The text says that 81 patients were treated (page 7, line 152), but table 1
states 67 patients were treated. Which is it?
4- Please provide median duration of follow-up for the study.
5- Please provide number of patients at risk for each time point in the Kaplan
Meier curves
6- Table 1 is titled “baseline characteristics” but it includes data at presentation,
during treatment and at follow-up. I suggest separating the information
accordingly. For better understanding of the study population, please present the
data as done for table 2, with separate columns for patients with and without
primary care access. Since you are comparing outcomes (treatment, response,
relapse), statistical analyses can be done here.
7- Table 2 discusses “follow-up”, but includes data at baseline – cirrhosis, other
autoimmune diseases and labs/ MELD. Again, the authors can re-do the tables
for demographics, clinical presentation, treatment and outcomes, always
comparing the 2 groups.
8- Even though the sample size is small, as acknowledged by the authors, you
should still show us the numbers for those with and without primary care access.
This can be done in table 1.
Minor comments:
1- Ascites is misspelled in table 1
2- Did the authors really mean encephalitis in table 1? Or was it hepatic
encephalopathy? – please review
3- Abbreviation 2/2 in table 1 is not acceptable
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests.
assistant