Electronic data review, client reminders, and expanded clinic hours for improving cervical cancer screening rates after the COVID-19 pandemic shutdowns: A multicomponent quality improvement program

Essential revisions:

Reviewer #1 (Recommendations for the authors):

The structure and flow of the manuscript could be further improved with the addition of flowcharts on the study population and the decision-making process to create a "validated" list of overdue patients.

We have added a flowchart with this information to the Results section. See Figure 2.

The presentation of results and recommendations (lessons learned) is a bit confusing relative to the simplicity of data analysis and results.

We have clarified several aspects based on Reviewer comments which we believe improves the readability of the article.

Reviewer #2 (Recommendations for the authors):

Introduction

Pages 3-4, lines 79-83. The introduction needs more background. Can you please describe how this study fits in the literature concerning cervical cancer screening interventions? Is your study unique in that you used a combination of techniques to increase screening? You mention that the interventions you chose were from the CDC. However, some interventions may work better in certain populations or clinic sites. Why did you choose these interventions, and have they been successful in past studies?

We have added additional reference (Han,et al., page 4, lines 95-101)and based on literature we already mentioned in the manuscript (Oyegbite and Colridge et al., page 19, lines 626-31), we focused on increasing community demand/individual outreach and increasing access by adding clinic sessions. Our focus was also based on what was feasible operationally and financially for our health institution.

Page 4, lines 83-85. Can you please modify the purpose to reflect what kind of study you engaged in e.g., descriptive, RCT, qualitative? It is not clear what outcome you are interested in from your current purpose statement.

This was a descriptive study. We have added this to the introduction (page 3, line 98-101).

Methods

The methods generally need to be edited. While this level of detail is wonderful, some of it is not necessary (e.g., I am not sure the reader needs to know staff were paid overtime).

As the level of detail was not thought to detract from the overall paper by the editors or other reviewers, we chose to leave the description as we feel that these details may be helpful for other clinics planning to implement similar work.

Page 4, lines 99-100. The last statement in the first paragraph. Should this be part of the study purpose?

We did not feel that moving this sentence was necessary.

Page 4-5, lines 90-116. It is not clear to me how many patients ended up in your study, and these 2 paragraphs could be edited for clarity. Is it 1600? 7000? 6126? 6000? 100? (all of these numbers are mentioned). It would be helpful for an explicit statement of how many participants were included in the study.

We have added a flowchart with this information to the Results section. See Figure 2.

I have no idea what kind of data you are collecting by the end of the methods. Your last paragraph should describe this clearly. Is it cervical cancer screening rates at the clinics? We need to know the kind of data you collected and how it was analyzed (i.e., did you use R software? Did you do bivariate analyses or logistic regression analyses?) How did you decide sample size?

We have added a flowchart with this information to the Results section. See Figure 2.

How did you consent participants in the study?

This was a retrospective analysis of a QI intervention. As a QI intervention, consent was not obtained. Retrospective analysis of de-identified data was approved as noted in paper. This has been added to the methods. (page 9, line 238-42)

What cervical cancer screening guidelines did you use to determine eligibility for the study? United States Preventive Services Task Force? What year? What was considered not to be up to date? e.g., 1-month or 1 year overdue?

During the intervention, we used USPSTF 2018 guidelines. (page 4-5, lines 115-8)

Results

I see no description of the sample. Your population should be described (average age, race/ethnicity, etc.).

As this was a QI intervention, complete demographics were not collected. We report age (page 10, line 260). We note the lack of complete demographics in the limitations (page 21-2, lines 676-8).

Your other results should follow what you describe as being measured in the methods which is currently not clear.

We have added a flowchart with this information to the Results section. See figure 2. We have added additional information as requested by reviewers.

The results could benefit from editing extraneous information.

We have not edited as it was not clear which information the Reviewer considered to be extraneous.

Discussion

The discussion should follow the purpose (which isn't clearly described).

The purpose in the introduction (page 3, line 87-90) is mirrored in the discussion (page 16, line 556-8).