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. 2024 Jul 24;19(7):e0306739. doi: 10.1371/journal.pone.0306739

Comparing healthcare systems between the Netherlands and Australia in management for children with acute gastroenteritis

Anouk A H Weghorst 1,*, Lena A Sanci 2, Marjolein Y Berger 1, Harriet Hiscock 3,4, Danielle E M C Jansen 1
Editor: Victor Daniel Miron5
PMCID: PMC11268636  PMID: 39046987

Abstract

Background

Acute gastroenteritis is a highly contagious disease demanding effective public health and clinical care systems for prevention and early intervention to avoid outbreaks and symptom deterioration. The Netherlands and Australia are both top-performing, high-income countries where general practitioners (GPs) act as healthcare gatekeepers. However, there is a lower annual incidence and per-case costs for childhood gastroenteritis in Australia. Understanding the systems and policies in different countries can lead to improvements in processes and care. Therefore, we aimed to compare public health systems and clinical care for children with acute gastroenteritis in both countries.

Methods

A cross-country expert study was conducted for the Netherlands and Australia. Using the Health System Performance Assessment framework and discussions within the research group, two questionnaires (public health and clinical care) were developed. Questionnaires were delivered to local experts in the Netherlands and the state of Victoria, Australia. Data synthesis employed a narrative approach with constant comparison.

Results

In Australia, rotavirus vaccination is implemented in a national program with immunisation requirements and legislation for prevention, which is not the case in the Netherlands. Access to care differs, as Dutch children must visit their regular GP before the hospital, while in Australia, children have multiple options and can go directly to hospital. Funding varies, with the Netherlands providing fully funded healthcare for children, whilst in Australia it depends on which GP (co-payment required or not) and hospital (public or private) they visit. Additionally, the guideline-recommended dosage of the antiemetic ondansetron is lower in the Netherlands.

Conclusions

Healthcare approaches for managing childhood gastroenteritis differ between the Netherlands and Australia. The lower annual incidence and per-case costs for childhood gastroenteritis in Australia cannot solely be explained by the differences in healthcare system functions. Nevertheless, Australia’s robust public health system, characterized by legislation for vaccinations and quarantine, and the Netherland’s well-established clinical care system, featuring fully funded continuity of care and lower ondansetron dosages, offer opportunities for enhancing healthcare in both countries.

Introduction

Acute gastroenteritis is a highly contagious disease that leads to significant morbidity, especially among young children [1]. Although the disease is self-limiting, its associated social and economic burdens are substantial [2,3]. For children with acute gastroenteritis, a good public health and clinical care system is required for prevention and early intervention to avoid outbreaks and symptom deterioration [4]. The Netherlands and Australia are both ranked in the top-performing health systems amongst other high-income countries, and both have general practitioners [GPs] as key components of the healthcare system [5,6]. Despite this, there is a lower annual incidence and per-case costs for childhood gastroenteritis in Australia. Variation in these numbers can be a reflection of care pathways, health system funding, structures or service utilizations.

Differences in the annual incidence of acute gastroenteritis episodes per child under five years are evident between the two countries, with 1.96 episodes per child per year in the Netherlands compared to 1.58 episodes per child per year in Australia [7,8]. The incidence rate of a communicable disease can serve as an indicator of the effectiveness of the public health system, encompassing health promotion, vaccination programs, and infectious disease prevention [9]. Besides the variation in incidence, the costs per episode also vary significantly across these countries. The estimated medical costs per episode for children under five years of age in the Netherlands is €55.68 (AUD$ 81.29) compared to €14.37 (AUD$ 20.98) per episode in Australia in 2016 [7,8]. These costs primarily encompass expenses related to GP visits, referrals, and hospitalizations.

Comparative research in these two countries can contribute to healthcare system strengthening by understanding and acknowledging best practices and learning from these best practices [10]. An overview of the healthcare systems in the Netherlands and Australia for children with acute gastroenteritis is lacking. Therefore, this study aimed to better understand the healthcare system of the Netherlands and Australia for children with acute gastroenteritis, focusing on the public health system and the clinical daily care.

Materials and methods

A cross-country expert study was conducted, among experts from the Netherlands and Australia aiming to compare the public health and clinical daily care for children with acute gastroenteritis. Study methods and findings are reported in accordance with the Consolidated Criteria for Reporting Qualitative Research [11]. Ethical approval was obtained from the Ethics Committee of the University Medical Centre Groningen (METc 2023/134) and University of Melbourne (2023-26907-39606-3). Informed consent was obtained from participating experts.

Health system performance assessment framework

The methods of this study were based on procedures used in a prior report comparing health systems between different countries [12]. Study-designed questionnaires were based on the Health System Performance Assessment (HSPA) for Universal Health Coverage framework [13]. The European Observatory on Health Systems and Policies (hosted by the World Health Organization (WHO) Regional Office for Europe) has established the HSPA framework to be able to understand, describe, and compare the functioning of health systems (Fig 1). This framework provides a foundation for policy makers for evaluating health systems by linking their functions to intermediate objectives and final health system goals. Four health system functions have been created to describe the working of the healthcare system: governance; financing; resource generation; and service delivery (see below). Optimizing these functions can improve the intermediate objectives which will lead to better final health system goals [13].

Fig 1. Health system performance assessment framework–an overview.

Fig 1

Governance is a core health system function, shaping how the other functions are managed and operate. Governance determines the oversight, regulation and policies to effectively address the needs of the country. Financing is vital for sustaining the healthcare system by providing the necessary monetary resources for care implementation. Resource generation is essential for equipping the healthcare system with essential input, including human resource; infrastructure and medical equipment; and pharmaceuticals and other consumables. Service delivery involves the actual provision of medical care, treatment and support to meet the health needs of the individuals. It is a function influenced by the performance of governance, financing and resource generation. It has direct impact on the intermediate objectives, such as access, quality and safety of care.

Questionnaire

Based on the HSPA framework and discussions within the research group, we developed two questionnaires. One questionnaire focussed on the functioning of the public health system for children with gastroenteritis. The other questionnaire addressed clinical daily care for treating children with gastroenteritis (S1 File). Public health includes the effective outbreak management and prevention of this highly contagious disease. Clinical daily care encompasses the healthcare pathway from the initial onset of gastroenteritis until fully recovered. The questionnaires were piloted among experts and were adjusted if needed. For the experts in the Netherlands, the questionnaires were translated into Dutch.

Data collection

To collect up-to-date and country-specific information, questionnaires were delivered online to local experts in the Netherlands and the state of Victoria, for the Australian context, in April and May 2023. As these questionnaires aimed to understand the accepted guidelines and regulatory parameters for public health and clinical care system responses only, we considered two experts per category, per country as an adequate sample size. Opinions on the healthcare system were not requested. Public health questionnaires were provided to experts specializing in the public health of infectious diseases. The clinical care questionnaires were distributed among general practitioners, paediatricians and guideline developers. Input from their organizational group or team was welcome.

Data synthesis

A narrative approach was employed to synthesize the data obtained from the questionnaires, including data from guidelines and other relevant sources provided by the experts. Through the synthesis, a constant comparison was made between data from the Netherlands and Australia. Unless specified, the description of the system for Victoria is the same for all of Australia.

Results

Participants

In the Netherlands, two physicians from the National Institute for Public Health and the Environment answered the public health questionnaire. In Australia, an infectious disease physician and a manager responsible for communicable disease prevention and control, both working for the government of Victoria, provided information for the public health questionnaire. The clinical care questionnaire in the Netherlands was completed by a GP, a staff member from the Dutch College of GPs, and a pharmacist. Responses pertaining to clinical care practices in Australia were obtained from a GP specializing in child health and a paediatrician. The experts, on average, had over 15 years of experience in their professional field. Table 1 gives a summary of the main differences per country.

Table 1. Main differences per country.

The Netherlands Australia
Governance • No legislation aimed at prevention
• Rotavirus in the Immunisation Program since 1st of January 2024
• GP registration is obligatory, not allowed to register with more than one GP
• No Jab No Pay, No Jab No Play legislation1
• Rotavirus in the Immunisation Program since 2007
• GP registration is not obligatory
Financing • Fully funded care for children under 18 years • Funding depends on the choice of GP (co-payment required or not) and hospital (public or private)
Resource generation • Ondansetron2 in syrup (0.1 mg/kg) • Ondansetron2 in wafer (8-15kg 2mg, 15-30kg 4mg, >30kg 6-8mg)
Service delivery • GP care always first
• Direct visits to emergency department are discouraged
• Multiple options for seeking first care
• Direct visits to emergency department are part of organization of daily care

1No Jab No Pay: To access family assistance payments, immunisation is required. No Jab No Play: To attend childcare, immunisation is required. 2 an antiemetic medication.

Governance

Table 2 gives a comprehensive overview of the government and legislations applicable for children with acute gastroenteritis for both the Netherlands and Australia.

Table 2. Government and legislations.

Netherlands Australia
Ministry of Health, Welfare and Sport (VWS) Government department responsible for public health, welfare, and sports policy. Department of Health Government department responsible for the administration and oversight of healthcare, public health and related services.
Health and Youth Care Inspectorate (IGJ) Governmental agency responsible for monitoring and regulating healthcare and youth care. Safer Care Victoria Governmental agency responsible for driving improvements in the quality and safety of healthcare services.
Dutch Medical Treatment Contracts Act (WGBO) Legislation that governs the relationship between healthcare professionals and patients. Health Services Act Legislation that governs various aspects of healthcare services and facilities.
Healthcare Professionals Act (Wet BIG) Legislation that regulates the practice of healthcare professionals. Health Practitioner Regulation National Law Act Legislation that governs the registration, regulation, and professional conduct of healthcare professionals.
Healthcare Insurance Act (Zvw) Legislation that governs the mandatory health insurance system. Health Insurance Act (Australia) Legislation that establishes the legal framework for the country’s public health insurance system known as Medicare.
General Data Protection Regulation Data protections and privacy regulation implemented by the European Union. Privacy and Data Protection Act Legislation that governs the protection of personal information, including health-related data.
Medicines Act Legislation that regulates the production, distribution, sale, and use of medicinal products. Pharmacy Regulation Act Legislation that regulates the practice of pharmacy.
Public Health Act (Wpg) Legislation that governs the public health policy and public health interventions. Public Health and Wellbeing Act Legislation that establishes the framework for public health and wellbeing measures.

Public health

Outbreak management is achieved through the implementation of a systematic approach aimed at rapidly gaining insight into the outbreak. Both countries adopt a multisectoral approach to outbreak management. Acute gastroenteritis is a highly contagious disease with rotavirus being the most common cause [2,14]. In the Netherlands, the inclusion of the rotavirus vaccine in the National Immunisation Program is planned for 2024, and participation in the program is voluntary. There is no legislation specifically aimed at prevention. In Australia, children are required to stay at home for 48 hours in an outbreak setting. The rotavirus vaccine has been included in the National Immunisation Program in Australia since 1st July 2007. To encourage the number of children fully immunised in line with the National Immunisation Program, the Australian Government initiated two policies. To access family assistance payments, children must meet immunisation requirements under the No Jab No Pay scheme. Children attending childcare in Australia are required to meet the National Immunisation Program under the No Jab No Play legislation 2016, unless there is a medical exception.

Clinical care

The Netherlands follows a system where patients must be registered with a GP practice to access their services and are not allowed to register with more than one GP. This ensures access to a GP when needed, allows for after-hours primary care, and facilitates the continuity of healthcare and monitoring of health status. In Australia, patients are not required to register with a regular GP and have the flexibility to book appointments with their preferred GP, sometimes even consulting multiple GPs on a single day.

Financing

The financing of the Dutch healthcare system is based on social health insurance and managed competition. Dutch citizens are required to obtain health insurance that covers a standard basic benefits package. Insurance premiums are determined by individual insurers. In Australia, the healthcare system is financed through Medicare which is the government-funded healthcare system in Australia. Medicare is accessible to all Australian citizens. Citizens can choose to purchase extra private health insurance to access additional healthcare services (largely hospital care) not covered by Medicare.

Public health

Both countries fully cover the expenses associated with rotavirus vaccinations through their Public Health Services.

Clinical care

The funding system for GPs in the Netherlands involves a combination of fee-for-service and capitation-based reimbursement, along with some additional payments for specific services. The fee is based on the type of service and is subject to negotiation between healthcare providers and health insurers. The capitation fee is determined based on factors like the patient’s age, gender, and health status. Fees are adjusted annually to account for inflation and changes in the practice’s patient demographics. The Netherlands has a mandatory health insurance system, and individuals are required to have basic health insurance coverage. Dutch children under 18 years are automatically covered by their caregivers’ insurance and clinical care for children with acute gastroenteritis is fully funded through government contribution from taxes, meaning no out-of-pocket costs for patients. This includes prescription of medication (eg. The anti-emetic ondansetron). Over-the-counter medications (eg. oral rehydration solution, paracetamol) are paid for by caregivers. Hospital care for children with acute gastroenteritis in the Netherlands is also fully covered.

In Australia, the payment structure for GPs is primarily based on a fee-for-service model. GPs charge a fee for each service provided to patients. Patients typically pay the GP directly and then claim a rebate from Medicare. Medicare does not remunerate the GP but it reimburses the patient for services provided. However, the remuneration has not been adjusted for inflation and rising costs for a decade which has been associated with increased co-payments (ie., out-of-pocket costs) for patients. Some GPs offer ‘bulk-billing’, a term which means they do not charge the patient a co-payment; Medicare covers the full consultation cost, and patients authorise Medicare to pay the GP directly on their behalf.

The costs of primary care for caregivers of Australian children with acute gastroenteritis depends on the choice of GP (co-payment or not). Medication for childhood gastroenteritis prescribed in general practice is typically issued as a private prescription, and the caregivers are responsible for the costs. For hospital care, it depends on whether caregivers choose public or private hospitals. Care provided in public emergency departments and public hospitals is fully covered by state and federal governments. Medication prescribed in the public hospital is included in the hospital visit. For private hospital care, state and federal governments cover 75% of the hospital and medical fees. The remaining fees are billed to the caregivers, and depending on their private health insurance, certain fees might be covered.

Resource generation

Health workforce

Organizations and professionals involved in the public health workforce of infectious gastroenteritis outbreaks in children in both countries include: the institution where the outbreak occurred (i.e., schools and child day-care centres), public health services (infectious disease control doctors and nurses, infection prevention experts, youth health care doctors), laboratories (medical microbiology doctors), GPs, and paediatricians. In both countries, management of acute gastroenteritis, particularly dehydration in children, is covered in medical school and training for GPs and paediatricians.

Infrastructure and medical equipment

For public health, both countries offer stool testing to identify the infectious agent causing the gastroenteritis outbreak. For clinical care, the availability of medical equipment for the management of childhood gastroenteritis in primary care is minimal in both countries. Primary care is not typically set up to monitor vital signs in an ongoing way or give fluids other than orally. Emergency departments and paediatricians in-hospital in both countries have access to a wide range of additional diagnostics, including point-of-care blood testing.

Pharmaceuticals and other consumables

For public health, both countries offer access to the rotavirus vaccine. However, in the Netherlands the rotavirus vaccine is not included in the National Immunisation Program whereas in Australia it is included. For clinical care in both countries, over-the-counter measures (i.e., paracetamol, ibuprofen/naproxen, oral rehydration solutions) are available through pharmacies, drugstores or supermarkets. Prescribed ondansetron, an antiemetic, is available through pharmacies in syrup (Netherlands) or wafer form (Australia).

Service delivery

Public health

For the prevention of rotavirus gastroenteritis, in Australia it is recommended to receive the first vaccine dose by 14 weeks of age followed by a second dose by 24 weeks of age.

Both countries have established national guidelines for the public health response to managing infectious gastroenteritis outbreaks in children which outline a step-by-step plan [15,16]: surveillance and detection; reporting to Public Health Service; investigation and epidemiological analysis; control measures; communication and education strategies; and follow-up and evaluation.

Clinical care

In both countries, access to clinical daily care for children with acute gastroenteritis is initiated by caregivers. During working hours, the first point of contact is typically the GP. In the Netherlands, the care for children with acute gastroenteritis emphasizes initial contact with the regular GP during working hours This GP has knowledge of the child’s medical history. The GP can provide guidance or make referrals to emergency care if necessary. After working hours, caregivers can access unscheduled care through GP out-of-hours facilities operated by larger cooperatives of GPs. At the out-of-hours facilities, locum GPs are available for (telephone) consultations. Every citizen has access to this after-hours care. The Dutch healthcare system discourages direct and unscheduled visits to the emergency department without a GP referral, highlighting a preference for a more formalized route through primary care. In Australia, while 80% of patients are said to have a regular GP [17], caregivers have multiple avenues for seeking care, including booking an appointment with any GP, contacting a telephone nurse for basic advice, scheduling virtual emergency department consultations through telehealth services, or visiting the emergency department to see a clinician. After working hours, access to GP services may be limited and clinical care can be provided by locum GPs or through the options mentioned earlier. The Australian system acknowledges the various ways in which unscheduled care may be accessed, providing caregivers with options beyond the GP visit, especially after working hours.

Guidelines for GPs and paediatricians are available online in both countries [1821]. These guidelines cover acute gastroenteritis background, assessment and management.

In both countries, the primary recommendation for the clinical care of children with acute gastroenteritis is to prioritize rehydration as the initial treatment approach, primarily through oral rehydration solutions. The use of antibiotics and anti-diarrheal medications are not recommended for the treatment of children with acute viral gastroenteritis in both countries. As of December 2022, the Netherlands introduced a recommendation for a single dose of oral ondansetron syrup (0.1 mg/kg), an antiemetic medicine, for primary care management of gastroenteritis, whereas it previously was only advised in secondary care provided by paediatricians. In Australia, ondansetron is recommended in a higher weight base dose (8–15 kg 2mg; 15-30kg 4mg; >30kg 6-8mg) in the form of a wafer. After triage in emergency departments, there is early access to oral rehydration and ondansetron. Hospital management by a paediatrician is in both countries based on the severity of dehydration (mild, moderate or severe). For children with mild to moderate dehydration enteral rehydration is preferred. Intravenous dehydration is recommended for severely dehydrated children or children who cannot tolerate enteral rehydration [20,21].

Both countries offer online information for caregivers of children with acute gastroenteritis encompassing information about aetiology, symptoms, treatment advice, when to seek medical assistance, and preventive measures [22,23]. In the Dutch resource, written information is supported with a video. Australian guidelines recommend that children should not refrain from eating for more than 24 hours, while Dutch guidelines state that a few days without or with reduced food intake does not significantly affect the child.

Discussion

A comparative synthesis of healthcare systems of two top-performing, high-income countries, the Netherlands and Australia, with the focus on public health and clinical daily care for children with acute gastroenteritis was performed. We wanted to reflect on the differences in incidence and costs between two countries with high standard healthcare. We recognize that these differences are caused by multiple factors in almost all levels of care. One should be aware of this complexity. Based on our results each country can reflect on the differences and evaluate whether adaptation would be feasible and effective in their own setting.

Public health

While the Netherlands and Australia have similar goals and step-by-step outbreak management plans aiming to promptly address outbreaks, they diverge in their strategies regarding vaccination and legislation for disease prevention. Rotavirus is the most common cause of severe gastroenteritis in young children and is a primary pathogen among hospitalized children with gastroenteritis [2,14]. In Australia, the introduction of a free rotavirus vaccine into the National Immunisation Program in 2007 resulted in a significant reduction in rotavirus-positive tests [24]. Moreover, the hospital admission rate showed a 62% reduction after the free rotavirus vaccine was implemented in Australia [25]. With the implementation of the ‘No Jab No Pay’ and ‘No Jab No Play’ legislations, an increase in full vaccination coverage among children in Australia was seen [26]. In contrast, the Netherlands does not yet include the rotavirus vaccine in its National Immunisation Program and lacks legislation restricting non-vaccinated children. It is plausible to hypothesize that effective immunisation and improved adherence to the immunisation program in Australia, results in less severe rotavirus cases, potentially leading to fewer hospital admissions and reduced healthcare costs. One might assume that similar legislation for immunisation will have the same flow-on benefits in the Netherlands, but the question of whether this type of legislation would be tolerated by Dutch society needs exploring.

Clinical care

In both countries, the primary goal in managing childhood gastroenteritis is rehydration. Oral rehydration solutions are recommended, while antibiotics and anti-diarrheal medications are discouraged, aligning with international guidelines [27]. In the Netherlands, the recommended single dose of oral ondansetron is 0.1 mg/kg, while Australia advises a higher single dosage regimen [8-15kg 2mg; 15-30kg 4mg; >30kg 6-8mg] [19,28] consistent with previous research [29,30]. The lower dosage strategy in the Netherlands is based on a more recent randomized controlled trial that found [cost-]effectiveness at a lower dosage [31,32]. Furthermore, another study has revealed that children with acute gastroenteritis who received higher doses of ondansetron did not experience a greater reduction in vomiting, nor did they require less intravenous rehydration or hospitalizations compared to children who received lower doses [33]. As there seems no added benefit for higher single doses of oral ondansetron and emphasizing the importance of minimizing the risk of side effects, it could be advisable for Australia to consider adopting a lower single dose of ondansetron in their clinical guidelines.

Continuity of care

Effective management of childhood gastroenteritis requires safety netting advice, including dehydration and alarm symptom recognition, along with guidance on help-seeking [34]. The quality of safety netting relies on the GP-patient relationship, and a lack of care continuity hampers its provision [34,35]. Research also highlights the benefits of maintaining continuity of care in general practice and accessing the preferred GP can reduce emergency admissions [36]. Additionally, gatekeeping practices are associated with reduced healthcare utilization and the likelihood of fewer hospitalizations [37]. In the Netherlands, the predominant pathway for children with gastroenteritis involves initially consulting their familiar, fully funded GP before entering the hospital. However, gastroenteritis ranks among the top five diagnoses for children seeking out-of-hours primary care centers in the Netherlands, where multiple GPs work in shifts to provide care outside regular working hours [38]. In Australia, although it is reported that 80% of the patients have a regular GP [17], this is not obligatory and parents have diverse care-seeking options. Whilst our study cannot directly quantify the impacts of continuity of care in prevention or management of childhood gastroenteritis, based on previous research, both countries should be aware of optimizing care continuity, focusing on the establishing GP-patient relationships, as this could affect the actual care delivery for children with gastroenteritis.

Strengths and limitations

Strengths of this study were that we used the HSPA framework established by the WHO, which gave us a full understanding of the health system functioning in both countries and we placed emphasis on the public health as well as clinical daily care. Moreover, the research team responsible for the formulation and evaluation of the questionnaire comprised researchers from both participating countries, thereby enriching the depth of knowledge and expertise applied in the study. Nonetheless, a limitation of this study could be that we only surveyed two experts per category per country. We decided this was an adequate sample size as we aimed to understand the National published guidelines and regulatory parameters and opinions were not requested. We selected experts who possessed considerable experience (on average >15 years) in the field of public health or clinical care and input of their organization was welcome. Lastly, it is worth noting that we used Victoria for the Australian context. However, the measures described here are national and not varying by state in Australia. In addition, the primary care system and National Immunisation program funding and policies are run by the Commonwealth and do not vary in application by jurisdiction.

Conclusions

Healthcare approaches for organizing and providing healthcare for children with acute gastroenteritis varies between the Netherlands and Australia. The lower annual incidence and per-case costs for childhood gastroenteritis in Australia cannot solely be explained by the differences in healthcare system functions. Nevertheless, Australia’s robust public health system, characterized by legislation for vaccination and quarantine, and the Netherland’s well-established clinical care system, featuring fully funded continuity of care and lower ondansetron dosages, offer opportunities for enhancing healthcare in both countries.

Supporting information

S1 File. Questionnaires.

(DOCX)

pone.0306739.s001.docx (19.4KB, docx)
S2 File. Inclusivity in gloval research questionnaire.

(DOCX)

pone.0306739.s002.docx (66.3KB, docx)

Acknowledgments

We would like to thank Dheepa Rajan and Katja Rohrer for their guidance on the Health System Performance Assessment Framework. Our sincere thanks go to all the experts who participated in this research, generously contributing their time and expertise.

Abbreviations

GP

general practitioner

HSPA

Health System Performance Assessment

WHO

World Health Organization

Data Availability

All relevant data are within the paper and/or its Supporting Information files.

Funding Statement

This research was supported by the Koninklijke Nederlandse Akademie van Wetenschappen (KNAW) Ter Meulen Grant/Royal Netherlands Academy of Arts and Sciences (KNAW)Medical Sciences Fund, Royal Netherlands Academy of Arts & Sciences (KNAWWF/1085/TMB424). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

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Decision Letter 0

Victor Daniel Miron

15 Feb 2024

PONE-D-23-40570Comparing healthcare systems between the Netherlands and Australia in management for children with acute gastroenteritisPLOS ONE

Dear Dr. Weghorst,

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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Reviewer #1: Partly

Reviewer #2: Partly

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Reviewer #1: N/A

Reviewer #2: N/A

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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**********

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Reviewer #1: Dear Dr Weghorst,

This is an interesting and unique manuscript. In the data collection is there a reference that one can use to justify the sample size that your team selected?

I find it odd that a significant section of the unscheduled healthcare system has been omitted in this analysis namely the emergency department (ED) . When one studies the structures involved in healthcare one of the more sizeable elements is the unscheduled care delivered in an ED. In fact, many would view in certain jurisdictions i.e Australia that the role played by the ED is significant as parents/patients often attend directly to the ED without referral from primary care. Most ED attendances result in a discharge home after an episode of ED / ED guideline directed care ( in some countries for every 7 children with AGE; 6 go home 1 is admitted under a paediatrician). The care delivered on this setting is not just by paediatricians but more likely to be by emergency medicine consultants and staff. I'm aware this may not be the same in the Netherlands as a Paediatric emergency medicine specific training scheme does not exist in that country ( it does in Australia). This omission is obvious once stated but seems to be skirted around by the manuscript. It is a weakness of the manuscript and should be openly declared.

In page 13 we learn that that for children to attend an ED directly is not customary but this needs greater quantification . What %-age are direct attendances in both jurisdictions ? I suspect there will be another difference here that needs to be mentioned.

Is there a reference or a reasoning behind the statement that what happens in Victoria is representative of all Australia?

I see no mention of public health resources aimed directly at families at home. I suspect that would fall under resource generation.

Congratulation on this piece of work. I believe it is unique and additive to the literature. Please consider the critique and incorporate it as you see is reasonable in the next version. I look forward to your responses

Reviewer #2: Thank you for the opportunity to review this interesting paper, which applies a WHO policy analysis framework to compare the health systems of two countries with respect to managing and preventing gastroenteritis in children.

There are two main considerations that I would recommend be addressed to strengthen the manuscript.

Firstly, it would help the reader to make it clearer the rationale for undertaking this comparative analysis and what the authors aim to understand by doing so. The authors state that they want to understand and acknowledge best practices, but how do we know what a best practice is? In the abstract, it is not until the conclusion that the reader learns what the main differences in outcomes are between the two counties. This gives the rationale for the study and why the how the different functions (governance, financing etc) of the health system operate in each setting that may be relevant and illuminating for policy.

Secondly with respect to the methodology, the framework used worked well to break down the components of each health system to facilitate comparison. However, it would help the reader to be more explicit in how it was applied for this specific problem of gastroenteritis in children. Two participants for each major health system component (public health and clinical services) for each county seems a very small sample. Is there literature to support that this is sufficient?

Greater clarity on what the authors are hoping to explain and how the results address this would improve the manuscript.

Some additional comments.

Line 58 It would help to directly refer to what you mean by ‘functions’, as not all readers may be familiar with the WHO HSPA. What the authors mean by service delivery as defined in the methods needs clarification.

Public health is qualified as outbreak management several times, but its seems that broader public health functions are considered (outbreak management AND disease control through immunisation). Could the authors please clarify how they are defining this?

Re table 1, could you summarise the key differences between the policy and regulatory settings that may explain the problem you are interested in (presumably why Australia has lower incidence and lower cost)? Some of the sections in the results seemed to switch between ideas, particularly the one on clinical care under financing. Review of this would improve readability.

Re registration with a single provider, how does this ensure access when needed as well as after-hours care? Further explanation for audiences that are unfamiliar with the Dutch system would be helpful.

Re financing in Australia and PHI. My understanding it that PHI covers care provided as a private hospital patient (in a public or private hospital) as well as dental, psychological and allied health care but not medical services or medicines.

The authors mention outbreak management as a key public health function of both systems. Is this funded differently?

The authors may like to consider using standard terminology for describing the funding arrangements for clinical services (eg fee for services, capitation etc) as this might be more readily understood by international audiences. Re funding in Australia, Medicare does not remunerate the GP, it reimburses the patient for services provided. This has not been adjusted for 10 + years resulting in increased co-payments and out of pocket costs for the patient.

Why does differences in use of Ondansetron matter for your research question? Re the PBS, this does not cover paracetamol or Oral rehydration solutions (or ondansetron generally) except for very specific populations or conditions (ie. palliative care for ondansetron).

Under resource generation: It would be helpful if the authors could explain how the public health response to outbreaks differs (if it does) between the countries; this may also account for differences in incidence.

Line 216 what do the authors mean by medical equipment? Are there many differences between community vs hospital based pathology services (that are relevant to childhood GE)?

A summary table of the key differences, with emphasis on those that are expected to contribute to lower incidence and costs, would be very helpful to the reader.

Sections of the results are repeated in the discussion, and possibly some of what is in the discussion would be better placed in the results and should be reviewed. The relevance of ondansetron use to the study aim needs further explanation. The logic of the argument in the section on continuity of care was unclear to me. While continuity is a good thing for a multitude of reasons, how had your study shown that continuity of care contributed to managing and preventing GE in childhood?

**********

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Reviewer #1: Yes: Michael Barrett

Reviewer #2: No

**********

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PLoS One. 2024 Jul 24;19(7):e0306739. doi: 10.1371/journal.pone.0306739.r002

Author response to Decision Letter 0


7 Apr 2024

We would like to thank the editor for the opportunity to submit a revised version of our manuscript (PONE-D-23-40570). We thank the reviewers for the constructive comments and suggestions to improve our manuscript. The detailed response to each of their comments is provided in this document. We hope our revisions will meet the expectations put forward by the reviewers. The page and line numbers we refer to correspond to the ‘track changes’ document.

Reviewer 1:

1. This is an interesting and unique manuscript. In the data collection is there a reference that one can use to justify the sample size that your team selected?

Thank you for your comment. The methods of this study were based on a previous performed advisory report comparing public health systems between Denmark, England, Italy, Latvia, the Netherlands, Australia, British Colombia (Canada) and Singapore. In that report, to collect up-to-date and country-specific information, two national experts in public health were approached for each country to gather information regarding the building block model. We replicated this approach.

We therefore added ‘The methods of this study were based on a previous performed advisory report comparing health systems between different countries (Ref 12 (added))’ (Page 6, line 93-94).

Moreover, we were not interested in opinions about the healthcare systems, but collected actual objective data. We selected experts with experience on average >15 years and encouraged them to ask for input of their organization if they couldn’t answer a question input of their organization was welcome. With two experts per category per country we received the information we needed about the healthcare systems.

2. I find it odd that a significant section of the unscheduled healthcare system has been omitted in this analysis namely the emergency department (ED). When one studies the structures involved in healthcare one of the more sizeable elements is the unscheduled care delivered in an ED. In fact, many would view in certain jurisdictions i.e. Australia that the role played by the ED is significant as parents/patients often attend directly to the ED without referral from primary care. Most ED attendances result in a discharge home after an episode of ED / ED guideline directed care ( in some countries for every 7 children with AGE; 6 go home 1 is admitted under a paediatrician). The care delivered on this setting is not just by paediatricians but more likely to be by emergency medicine consultants and staff. I’m aware this may not be the same in the Netherlands as a Paediatric emergency medicine specific training scheme does not exist in that country ( it does in Australia). This omission is obvious once stated but seems to be skirted around by the manuscript. It is a weakness of the manuscript and should be openly declared.

Thank you for the comment. We agree with the reviewer that the unscheduled care was not highlighted enough and we therefore changed the original section to

‘In the Netherlands, the care for children with acute gastroenteritis emphasizes initial contact with the regular GP during working hours. This GP has knowledge of the child’s medical history. The GP can provide guidance or make referrals to emergency care if necessary. After working hours, caregivers can access unscheduled care through GP out-of-hours facilities operated by larger cooperatives of GPs. At the out-of-hours facilities, locum GPs are after working hours available for (telephone) consultations. Every citizen can access this after-hours care. The Dutch healthcare system discourages direct and unscheduled visits to the emergency department without a GP referral, highlighting a preference for a more formalized route through primary care. In Australia, while 80% of patients are said to have a regular GP (15), caregivers have multiple avenues for seeking care, including booking an appointment with any GP, contacting a telephone nurse for basic advice, scheduling virtual emergency department consultations through telehealth services, or visiting the emergency department to see a clinician. After working hours, access to GP services may be limited and clinical care can be provided by locum GPs or through the options mentioned earlier. The Australian system acknowledges the various ways in which unscheduled care may be accessed, providing caregivers with options beyond the traditional GP visit, especially after working hours.’ (now on pages 14 and 15) (in bold the most important differences)

To also include the unscheduled care.

3. In page 13 we learn that that for children to attend an ED directly is not customary but this needs greater quantification . What %-age are direct attendances in both jurisdictions ? I suspect there will be another difference here that needs to be mentioned.

We reformulated the sentence as per above and now state that the Dutch system discourages direct ED attendance. In this manuscript we do not provide exact numbers as that was not the purpose of our research.

4. Is there a reference or a reasoning behind the statement that what happens in Victoria is representative of all Australia?

At first, we wanted to compare the state of Victoria with the Netherlands because of practical reasons. We wanted to have the clinical experts from the same state. After further research, we found that the same public health and clinical care management broadly applies to all the states of Australia. This is because there is the same approach to funding (i.e. predominantly state government for EDs and federal government for primary care) across Australia. We therefore took Australia as a whole.

5. I see no mention of public health resources aimed directly at families at home. I suspect that would fall under resource generation.

Thank you for the comment. Access to public health resources for families dealing with children with acute gastroenteritis is facilitated by the health authorities. On page 16 we stated the information parents can find at home. We also stated differences between the Australian and Dutch guidelines for parents at home (Australian guidelines recommend that children should not refrain from eating for more than 24 hours, while Dutch guidelines state that a few days without or with reduced food intake does not significantly affect the child.).

Moreover, on page 14 we stated what pharmaceuticals and other consumables are available over-the-counter.

Congratulation on this piece of work. I believe it is unique and additive to the literature. Please consider the critique and incorporate it as you see is reasonable in the next version. I look forward to your responses.

Thank you very much!

Reviewer 2:

Thank you for the opportunity to review this interesting paper, which applies a WHO policy analysis framework to compare the health systems of two countries with respect to managing and preventing gastroenteritis in children.

There are two main considerations that I would recommend be addressed to strengthen the manuscript.

1. Firstly, it would help the reader to make it clearer the rationale for undertaking this comparative analysis and what the authors aim to understand by doing so. The authors state that they want to understand and acknowledge best practices, but how do we know what a best practice is? In the abstract, it is not until the conclusion that the reader learns what the main differences in outcomes are between the two counties. This gives the rationale for the study and why the how the different functions (governance, financing etc) of the health system operate in each setting that may be relevant and illuminating for policy.

Thank you for the comment. We have now tried to make the rationale for undertaking this analysis clearer by adding the sentences in the Abstract (Page 2, line 25-28)

‘However, there is a lower annual incidence and per-case costs for childhood gastroenteritis in Australia. Understanding the systems and policies in different countries can lead to improvements in processes and care. Therefore, in this study we aimed to compare public health and clinical care for children with acute gastroenteritis in both countries.’

and in the Introduction (Page 4, line 61-64 and line 77-80):

‘…there is a lower annual incidence and per-case costs for childhood gastroenteritis in Australia. Variation in these numbers can be a reflection of care pathways, health system funding, structures or service utilizations.’ ……. ‘An overview of the healthcare systems in the Netherlands and Australia for children with acute gastroenteritis is lacking. Therefore, this study aimed to better understand the healthcare system of the Netherlands and Australia for children with acute gastroenteritis, focusing on the public health system and the clinical daily care.’

2. Secondly with respect to the methodology, the framework used worked well to break down the components of each health system to facilitate comparison. However, it would help the reader to be more explicit in how it was applied for this specific problem of gastroenteritis in children. Two participants for each major health system component (public health and clinical services) for each county seems a very small sample. Is there literature to support that this is sufficient?

Thank you for the comment. In the first question of the first reviewer, we answer this question.

Greater clarity on what the authors are hoping to explain and how the results address this would improve the manuscript.

Some additional comments:

3. Line 58 It would help to directly refer to what you mean by ‘functions’, as not all readers may be familiar with the WHO HSPA. What the authors mean by service delivery as defined in the methods needs clarification.

We changed the sentence (see question 1 reviewer 2) and ‘functions’ is no longer in that sentence. We use the word ‘functions’ on page 6 line 100, 101, 103. Functions of the healthcare systems is an overarching term covering the governance, financing, resource generation, and service delivery. We hope that by adding the figure directly under the text, it will make it clear what the meaning of functions is.

To clarify what service delivery means, we added the sentence:

‘Service delivery involves the actual provision of medical care, treatment and support to meet the health needs of the individuals.’ (Page 7, line 112-113).

4. Public health is qualified as outbreak management several times, but its seems that broader public health functions are considered (outbreak management AND disease control through immunisation). Could the authors please clarify how they are defining this?

We agree that the public health is broader than outbreak management, as we also mention the immunizations and legislations. We therefore removed ‘(outbreak management)’ if it was stated after public health. (Page 6, line 86; Page 7, line 132; Page 18, line 320; Page 20, line 386)

5. Re table 1, could you summarise the key differences between the policy and regulatory settings that may explain the problem you are interested in (presumably why Australia has lower incidence and lower cost)? Some of the sections in the results seemed to switch between ideas, particularly the one on clinical care under financing. Review of this would improve readability.

Thank you for your comment. We agree that some sections in the results switched between the Netherlands and Australia and reformulated it to first mentioning the Dutch healthcare system, followed by the Australian.

We also added the table below to give a comprehensive overview of the main differences per country. (Page 9, Line 154)

Table 1. Main differences per country

The Netherlands Australia

Governance • No legislations aimed at prevention

• Rotavirus in the Immunization Program since 1st of January 2024

• GP registration is obligatory, not allowed to register with more than one GP • No Jab No Pay, No Jab No Play legislations

• Rotavirus in the Immunization Program since 2007

• GP registration is not obligatory

Financing • Fully funded care for children under 18 years • Funding depends on the choice of GP (bulk-billing or not) and hospital (public or private)

Resource generation • Ondansetron in syrup (0.1 mg/kg) • Ondansetron in wafer ((8-15kg 2mg, 15-30kg 4mg, >30kg 6-8mg)

Service delivery • GP care always first

• Direct visits to emergency department are discouraged • Multiple options for seeking first care

• Direct visits to emergency department are part of organization of daily care

6. Re registration with a single provider, how does this ensure access when needed as well as after-hours care? Further explanation for audiences that are unfamiliar with the Dutch system would be helpful.

Thank you for the comment. We reformulated the sentence to ‘at the out-of-hours facilities, locum GPs are after working hours available for (telephone) consultations. Every citizen has access to this after-hours care.’ (Page 15 line 275-276).

7. Re financing in Australia and PHI. My understanding is that PHI covers care provided as a private hospital patient (in a public or private hospital) as well as dental, psychological and allied health care but not medical services or medicines.

We mention the public health insurance in Australia on Page 11, line 188 (Citizens can choose to purchase extra private health insurance to access additional healthcare services (largely hospital care) and benefits not covered by Medicare.) It depends on the type of public health insurance how much is financed. As for the medication prescribed in general practice, they are typically issued as a private prescription and the caregivers are responsible for the costs (page 13, line 223). For the rotavirus vaccinations these are covered through the Public health services.

8. The authors mention outbreak management as a key public health function of both systems. Is this funded differently?

Yes, both systems cover outbreak management via public health funds. However, we have now left out the outbreak management (question 4, reviewer 2) as we agree that public health is broader than outbreak management alone.

9. The authors may like to consider using standard terminology for describing the funding arrangements for clinical services (eg fee for services, capitation etc) as this might be more readily understood by international audiences. Re funding in Australia, Medicare does not remunerate the GP, it reimburses the patient for services provided. This has not been adjusted for 10 + years resulting in increased co-payments and out of pocket costs for the patient.

Thank you for the suggestion. We adjusted the sentences for financing clinical care in The Netherlands to ‘The funding system for GPs involves a combination of fee-for-service and capitation-based reimbursement, along with some additional payments for specific services. The fee is based on the type of service and is subject to negotiation between healthcare providers and health insurers. The capitation fee is determined based on factors like the patient’s age, gender, and health status. Fees are adjusted annually to account for inflation and changes in the practice’s patient demographics. The Netherlands has a mandatory health insurance system, and individuals are required to have basic health insurance coverage. (Page 12, line 194-202).

We have reformulated the sentences around Medicare as per your suggestions above:

‘In Australia, the payment structure for GPs is primarily based on a fee-for-service model. GPs charge a fee for each service provided to patients. Patients typically pay the GP directly and then claim a rebate from Medicare. Medicare does not remunerate the GP but it reimburses the patient for services provided. However, the remuneration has not been adjusted for over ten years for inflation and rising costs, often leading GPs to charge higher fees, resulting in increased co-payments and out-of-pocket costs for patients. Some GPs offer ‘bulk-billing’, where Medicare covers the full consultation cost, and GPs bill Medicare directly instead of patients.’ (Page 12, line 209-216)

10. Why does differences in use of Ondansetron matter for your research question? Re the PBS, this does not cover paracetamol or Oral rehydration solutions (or ondansetron generally) except for ve

Attachment

Submitted filename: Response to Reviewers.docx

pone.0306739.s003.docx (30.9KB, docx)

Decision Letter 1

Victor Daniel Miron

28 May 2024

PONE-D-23-40570R1Comparing healthcare systems between the Netherlands and Australia in management for children with acute gastroenteritisPLOS ONE

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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: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: N/A

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

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Reviewer #1: All my suggestions have been adequately addressed. The final manuscript reads well and my congratulations to the submitting authors.

Reviewer #2: The edits made by the authors has substantially improved the paper, and I commend the authors in their efforts. The aim of the paper and how this analysis sets out to address this is much clearer.

Some final minor points for attention.

I note the authors have mentioned rotavirus vaccination and specific therapies (eg ondansetron) without reference as to why these are relevant to childhood gastroenteritis. For unfamiliar readers, I would suggest briefly noting why it is relevant at first mention (this is described much later in the paper) or give a very brief overview of current best public health and clinical care practice for the prevention and management of childhood gastroenteritis in the introduction.

Table 1 is terrific and really helps with orienting the reader as to what is coming in the results. This needs a footnote to explain the ‘no jab, no pay’ policy.

The sentence ‘The methods of this study were based on a previous performed advisory report comparing health’ needs review for grammatical correctness. Also, with respect to this could the authors please briefly explain why this method was appropriate to this study aim, and a brief overview of what was involved.

In the methods and under study limitations, assuming no differences across jurisdictions is unreasonable; each will have differing policies, funding arrangements, delivery of services – albeit quite likely minor. This should be amended in the paper.

Re the sentence “Citizens can choose to purchase extra private health insurance to access additional healthcare services (largely hospital care) and benefits not covered by Medicare.” The reference to ‘and benefits’ is vague and adds little. I suggest deleting this.

I would suggest delete “, often leading GPs to charge higher fees’ from the following sentence for clarity, and ‘amend resulting in’ to ‘and has been associated with’ to avoid inferring causality.

“However, the remuneration has not been adjusted for over ten years for inflation and rising costs, often leading GPs to charge higher fees, resulting in increased co-payments and out-of-pocket costs for patients. Some GPs offer ‘bulk-billing’, where Medicare covers the full consultation cost, and GPs bill Medicare directly instead of patients.”

In addition, GP’s accept payment directly from Medicare on behalf of the patient, rather than billing Medicare directly. The text should be amended to reflect this.

Bulk-billing at first mention (whether the table or text) needs explanation for international audiences. So too in the abstract or use a different term more widely understood (eg. Without a co-payment).

In the sentence “Medication prescribed in general practice is typically issued as a private prescription, and the caregivers are responsible for the costs.” This needs to be qualified that this is medications for childhood gastroenteritis not medicines in general.

Re the sentence “For clinical care, the availability of medical equipment for the management of childhood gastroenteritis in primary care is minimal in both countries.” This still needs justification/clarification. Diagnostics and treatments are available in primary care for GE, but unlike in hospital settings, requires attending a second service provider. In addition, while point of care testing (presumably for electrolyte disturbances?) is generally not available in primary care, these are available in some remote/very remote primary care settings in Australia.

With respect to R1 Q3: I agree providing figures would help elucidate the point by giving a quantum reference for comparison (both for within each country as well between the countries).

In the sentence “The Australian system acknowledges the various ways in which unscheduled care may be accessed, providing caregivers with options beyond the traditional GP visit,” what is meant by ‘traditional’ is unclear. Please revise.

The paper should have general review for typographic and grammatical errors.

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Reviewer #1: Yes: Michael Barrett

Reviewer #2: No

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PLoS One. 2024 Jul 24;19(7):e0306739. doi: 10.1371/journal.pone.0306739.r004

Author response to Decision Letter 1


13 Jun 2024

Response to Reviewers 2.0

We would like to thank the editor for the opportunity to submit a revised version of our manuscript (PONE-D-23-40570). We thank the reviewers for the constructive comments and suggestions to improve our manuscript. The detailed response to each of their comments is provided in this document. We hope our revisions will meet the expectations put forward by the reviewers. The page and line numbers we refer to correspond to the ‘track changes’ document.

Reviewer #1: All my suggestions have been adequately addressed. The final manuscript reads well and my congratulations to the submitting authors.

Thank you very much.

Reviewer #2: The edits made by the authors has substantially improved the paper, and I commend the authors in their efforts. The aim of the paper and how this analysis sets out to address this is much clearer.

Some final minor points for attention.

1. I note the authors have mentioned rotavirus vaccination and specific therapies (eg ondansetron) without reference as to why these are relevant to childhood gastroenteritis. For unfamiliar readers, I would suggest briefly noting why it is relevant at first mention (this is described much later in the paper) or give a very brief overview of current best public health and clinical care practice for the prevention and management of childhood gastroenteritis in the introduction.

Thank you for the comment. We added the sentence: ‘Acute gastroenteritis is a highly contagious disease with rotavirus being the most common cause (2, 23)’ (Page 10, line 162).

We added the word ‘an antiemetic medicine’ after ondansetron to give clarity (Page 16, line 303).

In addition, we added it being an anti-emetic in the abstract.

2. Table 1 is terrific and really helps with orienting the reader as to what is coming in the results. This needs a footnote to explain the ‘no jab, no pay’ policy.

Thank you for the compliment. We have added in the footnote of the table the following: ‘1No Jab No Pay: to access family assistance payments, immunisation is required. No Jab No Play: to attend childcare, immunisation is required.’ (Page 9, Table 1). In addition, because of the above comment, we added a footnote about ondansetron too.

3. The sentence ‘The methods of this study were based on a previous performed advisory report comparing health’ needs review for grammatical correctness. Also, with respect to this could the authors please briefly explain why this method was appropriate to this study aim, and a brief overview of what was involved.

We have amended the sentence thus: The methods of this study were based on those used in a prior report comparing health systems between different countries (12).

4. In the methods and under study limitations, assuming no differences across jurisdictions is unreasonable; each will have differing policies, funding arrangements, delivery of services – albeit quite likely minor. This should be amended in the paper.

Everything that is stated in the manuscript is applicable for each jurisdiction. We added ‘The primary care system and National immunisation program funding and policies are run by the Commonwealth and do not vary in application by jurisdiction.’ To the limitations (Page 21, line 401-403)

5. Re the sentence “Citizens can choose to purchase extra private health insurance to access additional healthcare services (largely hospital care) and benefits not covered by Medicare.” The reference to ‘and benefits’ is vague and adds little. I suggest deleting this.

We deleted the ‘and benefits’ (Page 11, line 189).

6. I would suggest delete “, often leading GPs to charge higher fees’ from the following sentence for clarity, and ‘amend resulting in’ to ‘and has been associated with’ to avoid inferring causality.

We deleted the ‘often leading GPs to charge higher fee’ (Page 12, line 213, 214) and reformulated ‘resulting in’ to ‘has been associated with’ (page 12, line 214).

7. “However, the remuneration has not been adjusted for over ten years for inflation and rising costs, often leading GPs to charge higher fees, resulting in increased co-payments and out-of-pocket costs for patients. Some GPs offer ‘bulk-billing’, where Medicare covers the full consultation cost, and GPs bill Medicare directly instead of patients.”

In addition, GP’s accept payment directly from Medicare on behalf of the patient, rather than billing Medicare directly. The text should be amended to reflect this.

Thank you, the sentence has been amended thus:

Some GPs offer ‘bulk-billing’, a term which means they do not charge the patient a co-payment, rather Medicare covers the full consultation cost and patients authorise Medicare to pay the GP directly on their behalf.

8. Bulk-billing at first mention (whether the table or text) needs explanation for international audiences. So too in the abstract or use a different term more widely understood (eg. Without a co-payment).

We agree with the reviewer that it is difficult to explain bulk-billing as early as the abstract so have altered it to co-payment but we describe later in the manuscript the concept of bulk-billing as per the sentence above.

9. In the sentence “Medication prescribed in general practice is typically issued as a private prescription, and the caregivers are responsible for the costs.” This needs to be qualified that this is medications for childhood gastroenteritis not medicines in general.

We added ‘for childhood gastroenteritis’ in the sentence (Page 13, line 223).

10. Re the sentence “For clinical care, the availability of medical equipment for the management of childhood gastroenteritis in primary care is minimal in both countries.” This still needs justification/clarification. Diagnostics and treatments are available in primary care for GE, but unlike in hospital settings, requires attending a second service provider. In addition, while point of care testing (presumably for electrolyte disturbances?) is generally not available in primary care, these are available in some remote/very remote primary care settings in Australia.

We added ‘Primary care is not typically set up to monitor vital signs in an ongoing way or give fluids other than orally’ (Page 14, line 251-252)

11. With respect to R1 Q3: I agree providing figures would help elucidate the point by giving a quantum reference for comparison (both for within each country as well between the countries).

As reviewer 1 is very happy with the revised manuscript we are not sure what reviewer 2 wishes us to change here and we are happy we satisfied the comments made by reviewer 1.

12. In the sentence “The Australian system acknowledges the various ways in which unscheduled care may be accessed, providing caregivers with options beyond the traditional GP visit,” what is meant by ‘traditional’ is unclear. Please revise.

We have removed the word ‘traditional’.

13. The paper should have general review for typographic and grammatical errors.

We regret typographic and grammatical errors. We re-read the manuscript and corrected were appropriate. We would like to notice that we have two native speakers as co-author who checked the manuscript.

Attachment

Submitted filename: Response to Reviewers 2.0 .docx

pone.0306739.s004.docx (19.9KB, docx)

Decision Letter 2

Victor Daniel Miron

24 Jun 2024

Comparing healthcare systems between the Netherlands and Australia in management for children with acute gastroenteritis

PONE-D-23-40570R2

Dear Dr. Weghorst,

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,

Victor Daniel Miron

Academic Editor

PLOS ONE

Acceptance letter

Victor Daniel Miron

15 Jul 2024

PONE-D-23-40570R2

PLOS ONE

Dear Dr. Weghorst,

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on behalf of

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Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Questionnaires.

    (DOCX)

    pone.0306739.s001.docx (19.4KB, docx)
    S2 File. Inclusivity in gloval research questionnaire.

    (DOCX)

    pone.0306739.s002.docx (66.3KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0306739.s003.docx (30.9KB, docx)
    Attachment

    Submitted filename: Response to Reviewers 2.0 .docx

    pone.0306739.s004.docx (19.9KB, docx)

    Data Availability Statement

    All relevant data are within the paper and/or its Supporting Information files.


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