Stress on caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study.

PURPOSE: Taiwan has implemented an integrated prospective payment program (IPP) for prolonged mechanical ventilation (PMV) patients that consists of four stages of care: intensive care unit (ICU), respiratory care center (RCC), respiratory care ward (RCW), and respiratory home care (RHC). We aimed to investigate the life impact on family caregivers of PMV patients opting for a payment program and compared different care units.
METHOD: A total of 610 questionnaires were recalled. Statistical analyses were conducted by using the chi-square test and multivariate logistic regression model.
RESULTS: The results indicated no associations between caregivers' stress levels and opting for a payment program. Participants in the non-IPP group spent less time with friends and family owing to caregiver responsibilities. The results of the family domain show that the RHC group (OR = 2.54) had worsened family relationships compared with the ICU group; however, there was less psychological stress in the RCC (OR = 0.54) and RCW (OR = 0.16) groups than in the ICU group. In the social domain, RHC interviewees experienced reduced friend and family interactivity (OR = 2.18) and community or religious activities (OR = 2.06) than the ICU group. The RCW group felt that leisure and work time had less effect (OR = 0.37 and 0.41) than the ICU group. Furthermore, RCW interviewees (OR = 0.43) were less influenced by the reduced family income than the ICU group in the economic domain.
CONCLUSIONS: RHC family caregivers had the highest level of stress, whereas family caregivers in the RCW group had the lowest level of stress.

Introduction

Prolonged mechanical ventilation (PMV) is defined as the operation of a mechanical ventilation support system for more than 6 hours per day and exceeding 21 days [1, 2]. The PMV incidence rates per 100 ICU admissions in Europe and the US were found to be 5%-11% [3-6]. Taiwan had a PMV rate per 100 mechanical ventilation patients of 20% [7], while China had a PMV rate of 36% [8], and some PMV patients were found to occupy intensive care unit (ICU) beds. To increase the emergency department turnover rate, control medical expenses, and increase the weaning rate of mechanical ventilation, weaning centers (also called subacute or post-acute care) have been established to rapidly liberate patients from the need for mechanical ventilators in the United States [9, 10], Europe [4, 11], and Taiwan [12-14].

The Taiwan National Health Insurance provides a comprehensive payment system for integrated prospective payment plans for PMV patients called integrated prospective payment program (IPP) who are at least 17 years old. This system has integrated payments with managed care systems since July 2000 [2]. This IPP plan covers four types of care and different payments, including ICU for critical care, respiratory care centers (RCCs) for step-down subacute units, respiratory care ward (RCW) for long-term care facilities, and respiratory home care (RHC) for PMV patients [2]. The regulation of IPP are fee-for-service ICU care (within 21 d), per-diem RCC (for up to 42 d), per capitation RCW, and per-month home ventilation service. The ICU, RCC, and RCW belong to the institutions, and 24 hours medical staff are available. The patients who use ventilators at home have nurses and respiratory therapists visit twice a month and physician visit once two months.

The intervention of the IPP has increased the turnover rate of ICU beds and reduced the length of hospital stay. However, PMV patients in RCC, RCW, and RHC have seen a significant increase in the length of required care [13-15]. Studies that as general home care patients are more familiar with the environment at home, they feel more comfortable, amenable, and experience a better than in-house care group [16]. However, it was also found that most PMV patients were elderly patients [17, 18] with poor life function independence [19] and had a greater care burden which directly affected their family caregivers [20-24].

Caregivers’ fear of caring for PMV patients can cause stress on the physical health, mind, and soul of both the patients and caregivers [25]. Moreover, it can impose financial burdens on families. Studies show low willingness in the main caregivers of PMV patients because of the high pressure that the job puts on them [16, 20, 26]. However, there is a shortage of studies exploring whether the burden of main family caregivers with patients at different unit has been affected by the IPP two decades ago. This study aimed to compare the associations between caregivers’ stress levels and opting for a payment program, and compared with the impaction of life on caregivers of PMV patients in the different units.

Materials and methods

Questionnaire development

We invited 10 PMV subject care experts from each type of institution in northern, central, and southern Taiwan to constitute a panel of experts. The primary family members of the three PMV patients and three nursing staff members from the same RCW formed a focus group to identify the structure and content of the questionnaire items. The content of the questionnaire included (1) the characteristics of respondents, (2) the characteristics of PMV patients, (3) the effect of care for PMV patients on their families, society, and family finances (S1 File); and (4) relevant information on mechanical ventilation.

The questionnaires have three domains (family, social, and economic). They measured aspects related to their lives by a Likert scale (from strongly agree to strongly disagree) to compare the impact of the IPP and different units of primary caregivers of PMV patients on the stress of life. Then we invited five experts to assess the validity of the questionnaire content following the completion of its design. The average content validity index (CVI) was 0.96 (0.73 to 1.00). The reliability of the questionnaire was measured using the Kuder-Richardson Formula 20 (KR-20). After the questionnaire was tested, the KR-20 coefficient of this study was found to be 0.78.

Power of sample size

This was a cross-sectional observational study. According to Mohamad Adam Bujang et al.’s recommendation for observational large-sample studies using logistic regression, the minimum sample size needs to be at least 500 [27]. A sufficient total of 601 valid samples were collected in this study.

Participants

The participants included in this study were at least 20 years of age and served as the main family caregivers of PMV patients from northern, central, and southern Taiwan. According to our definition of the stages of PMV patients, the acute ICU stage was the time in ICU and/or less than 7 days in RCC after transfer from ICU; the subacute stage was ≥30 days of stay in RCC; the chronic stage was ≥30 days of RCW stay; and finally, the RHC was ≥30 days of using a mechanical ventilator at home. The participants were divided into two groups (IPP and none-IPP group) according to whether they had joined IPP.

Participant consent

Because patients are mostly unconscious, interviewers are required to assist in collecting patients’ clinical information, so the research required medical staff, case managers, or respiratory therapists to recruit those who understood the situation of the subjects to agree to do the interview and explain the parameters to the respondents according to the interview instructions (S2 File). This study was approved by the institutional review board of the China Medical University Hospital (IRB No. CMUH102-REC3-105).

Statistical analysis

Chi-square tests were used to compare the characteristics of patients with PMV in terms of subject characteristics, mechanical ventilation status, and the difference between the impact on the main caregivers of patients at different stages. Finally, we combined “strongly agree,” “agree” and “no objection” into one group and “disagree” and “strongly disagree” into another group, and used the logistic regression model to compare the differences in stress levels experienced by the main family caregivers for ICU, RCC, RCW, and RHC patients. Statistical significance was set at p <0.05, and SAS (version 9.4, SAS Institute Inc., Cary, NC, USA) was used for the analysis.

Results

Respondent and patient characteristics

As comprehensive analyses datasets were generated by a previous study [28], including 687 eligible respondents from 64 institutions (6 medical centers, 11 regional hospitals, 23 district hospitals, 15 nursing homes, and 9 home care centers) (S3 File). The study was conducted from November 1, 2013, to April 15, 2014. A total of 601 questionnaires were completed (effective questionnaire response rate 87%) and 50.75% were women, with an average age of 51.88 years. A majority of the responses were provided by children of PMV parents (54.74%). The monthly expense paid by the family for the IPP group was significantly lower than that for the non-IPP group (USD 745 vs. USD 912 respectively) (Table 1). The average age of the PMV patients was 70.76 years. Only 38.77% of patients were in a state of alert consciousness, with 34.78% with near-terminal illnesses. A total of 89.35% of the patients had daily mechanical ventilation of 19–24 hours (Table 2).

Table 1

Demographic characteristics of respondents with and without IPP.

Variables	Total N = 601		Non-IPP: N = 207		IPP: N = 394		p value
	N	%	N	%	N	%
Gender							0.674
Male	296	49.25	99	47.83	197	50.00
Female	305	50.75	108	52.17	197	50.00
Age in years
Mean age (SD)	51.88	(11.84)	53.30	(11.59)	51.13	(11.92)	0.032#
Educational level							0.504
None	13	2.16	7	3.38	6	1.52
≦Grade 9	161	26.79	53	25.60	108	27.41
High school to college	403	67.05	139	67.15	264	67.01
Graduate school	24	3.99	8	3.86	16	4.06
Married							0.636
Yes	480	80.00	170	82.13	310	78.88
Never	90	15.00	28	13.53	62	15.78
Been married	30	5.00	9	4.35	21	5.34
Monthly salary in USD							0.194
<1000	154	25.71	45	21.84	109	27.74
1000~2000	235	39.23	94	45.63	141	35.88
2000~3000	125	20.87	42	20.39	83	21.12
3000~4000	51	8.51	15	7.28	36	9.16
≥4000	34	5.68	10	4.85	24	6.11
Religion							0.746
Yes	502	83.53	171	82.61	331	84.01
No	99	16.47	36	17.39	63	15.99
Relationship with PMV patient							0.423
Parents	41	6.82	8	3.86	33	8.38
Couple	111	18.47	42	20.29	69	17.51
Children	329	54.74	115	55.56	214	54.31
Children-in-law	59	9.82	21	10.14	38	9.64
Brothers and sisters	27	4.49	10	4.83	17	4.31
Grandchildren	17	2.83	7	3.38	10	2.54
Other	17	2.83	4	1.93	13	3.30
Can someone take turns taking care of the patient with you?							0.809
No	194	32.28	65	31.40	129	32.74
Yes	407	67.72	142	68.60	265	67.26
Average monthly expense (USD) Mean (SD)	801.69	(902.27)	912.61	(601.97)	745.3553	(1017.66)	0.014

IPP: integrated prospective payment program.

One US dollar (USD) was 30 New Taiwan dollars (NTD) on Sep. 2013.

# t-test.

Table 2

Demographic characteristics of PMV patients with and without IPP.

Variables	Total N = 601		Non-IPP: N = 207		IPP: N = 394		P value
	N	%	N	%	N	%
Gender							1.000
Male	304	50.58	105	50.72	199	50.51
Female	297	49.42	102	49.28	195	49.49
Age in years
Mean age (SD)	70.76	(17.23)	73.15	(15.99)	69.51	(17.73)	0.014#
Conscious status							0.263
Coma	194	32.28	66	31.88	128	32.49
Unconsciousness	174	28.95	68	32.85	106	26.90
Alert	233	38.77	73	35.27	160	40.61
Cause of respiratory failure							0.003
Chronic lung disease	131	21.80	51	24.64	80	20.30
Central neuropathy	185	30.78	60	28.99	125	31.73
Catastrophic illnesses	209	34.78	83	40.10	126	31.98
Other	76	12.65	13	6.28	63	15.99
Unit							<0.001
ICU	150	24.96	60	28.99	90	22.84
RCC	150	24.96	60	28.99	90	22.84
RCW	150	24.96	60	28.99	90	22.84
RHC	151	25.12	27	13.04	124	31.47
Daily bed-time (hrs.)							0.004 $
0–6	1	0.17	1	0.48	0	0.00
7–12	37	6.16	5	2.42	32	8.12
13–18	26	4.33	6	2.90	20	5.08
19–24	537	89.35	195	94.20	342	86.80
Joint IPP and waive copayment (yes)	494	82.20	143	69.08	351	89.09	<0.001

# t-test

$ Fisher’s exact test; PMV: prolonged mechanical ventilation; IPP: integrated prospective payment program; ICU: intensive care unit; RCC: respiratory care center; RCW: respiratory care ward; RHC; respiratory home care.

Impact of caring for PMV patients on families

Significantly more caregivers in the non-IPP group (p = 0.039), compared with the IPP group, reported reduced time with friends and family. In addition, there were no significant statistical differences in other factors (Table 3).

Table 3

Comparison of the impact of IPP for PMV patients on the life of caregivers.

Variables	All		Non-IPP		IPP		p value
	N	%	N	%	N	%
Total	601	100	207	34.44	394	65.56
[Family domain]
Taking care of the patient worsens the relationship between family members.							0.199
strongly disagree	112	18.64	37	17.87	75	19.04
disagree	227	37.77	81	39.13	146	37.06
no objection	91	15.14	37	17.87	54	13.71
agree	133	22.13	36	17.39	97	24.62
strongly agree	38	6.32	16	7.73	22	5.58
I feel that family life is affected because of caring for the patient							0.195
strongly disagree	47	7.82	14	6.76	33	8.38
disagree	121	20.13	53	25.60	68	17.26
no objection	76	12.65	25	12.08	51	12.94
agree	285	47.42	91	43.96	194	49.24
strongly agree	72	11.98	24	11.59	48	12.18
I experience physical stress because of caring for the patient							0.051
strongly disagree	46	7.65	12	5.80	34	8.63
disagree	132	21.96	59	28.50	73	18.53
no objection	98	16.31	28	13.53	70	17.77
agree	242	40.27	79	38.16	163	41.37
strongly agree	83	13.81	29	14.01	54	13.71
I feel psychologically stressed from caring for the patient							0.651
strongly disagree	27	4.49	9	4.35	18	4.57
disagree	83	13.81	32	15.46	51	12.94
no objection	56	9.32	22	10.63	34	8.63
agree	306	50.92	97	46.86	209	53.05
strongly agree	129	21.46	47	22.71	82	20.81
[Social domain]
I feel that my time for my friends and family has reduced because of caring for the patient							0.039
strongly disagree	36	5.99	12	5.80	24	6.09
disagree	126	20.97	56	27.05	70	17.77
no objection	121	20.13	31	14.98	90	22.84
agree	247	41.10	82	39.61	165	41.88
strongly agree	71	11.81	26	12.56	45	11.42
I feel that the time for community or religious activities has reduced because of caring for the patient							0.170
strongly disagree	37	6.16	13	6.28	24	6.09
disagree	124	20.63	53	25.60	71	18.02
no objection	144	23.96	50	24.15	94	23.86
agree	225	37.44	66	31.88	159	40.36
strongly agree	71	11.81	25	12.08	46	11.68
I feel that leisure time has decreased because of caring for the patient							0.125
strongly disagree	28	4.66	9	4.35	19	4.82
disagree	88	14.64	39	18.84	49	12.44
no objection	95	15.81	38	18.36	57	14.47
agree	286	47.59	88	42.51	198	50.25
strongly agree	104	17.30	33	15.94	71	18.02
My work is affected because of caring for the patient							0.392
strongly disagree	34	5.66	13	6.28	21	5.33
disagree	113	18.8	47	22.71	66	16.75
no objection	118	19.63	41	19.81	77	19.54
agree	213	35.44	66	31.88	147	37.31
strongly agree	123	20.47	40	19.32	83	21.07
It is difficult to find proper social support or assistance to take care of the patient							0.085
strongly disagree	37	6.16	9	4.35	28	7.11
disagree	149	24.79	63	30.43	86	21.83
no objection	132	21.96	40	19.32	92	23.35
agree	206	34.28	65	31.40	141	35.79
strongly agree	77	12.81	30	14.49	47	11.93
[Economic domain]
Reduced family income due to inability to work owing to caregiving responsibilities							0.344
strongly disagree	42	6.99	11	5.31	31	7.87
disagree	110	18.30	46	22.22	64	16.24
no objection	113	18.80	40	19.32	73	18.53
agree	216	35.94	72	34.78	144	36.55
strongly agree	120	19.97	38	18.36	82	20.81
I am under financial pressure because of the cost of caring for the patient							0.446
strongly disagree	21	3.49	7	3.38	14	3.55
disagree	62	10.32	28	13.53	34	8.63
no objection	105	17.47	33	15.94	72	18.27
agree	260	43.26	88	42.51	172	43.65
strongly agree	153	25.46	51	24.64	102	25.89

IPP: integrated prospective payment program; PMV: prolonged mechanical ventilation.

Impact of socioeconomic conditions, caregiver occupation, underlying diseases of the patients on caregiver stress levels and family relationships

We used family income and education level to represent the socioeconomic conditions of caregivers. We then compared the family income and education level of the caregivers of PMV patients at four stages with the psychological pressure and family relationship using Spearman’s rank correlation. In addition, we used the Chi-square test to analyze the patient’s underlying disease, psychological pressure on the caregiver, and family relationships. The results showed that there was no significant difference in the family income of caregivers between psychological stress and family relationships. However, we found that the higher the education level, the lower the adverse effect on the relationship between family members; moreover, this difference was statistically significant (p<0.05) (see Table 4). There was no significant correlation between the underlying disease of PMV patients and the psychological stress on caregivers and family relationships (Table 5).

Table 4

The socioeconomic conditions and occupation of caregiver’s impact on stress level and family relationship.

Variables	Family income of caregiver		Education of caregiver
	correlation coefficient	p-value1	correlation coefficient	p-value1
Family relationship	-0.017	0.677	-0.166	<0.001
Psychologically stressed	0.008	0.850	-0.080	0.050

1Spearman’s rank correlation test.

Table 5

Association of underlying diseases of the patients with stress level and family relationship.

Underline disease	Chronic pulmonary disease		Central neuropathy		Catastrophic illness		Others		P-value1
	n	%	n	%	N	%	n	%
Psychologically stressed										0.515
strongly disagree	4	3.05	9	4.86	9	4.31	5	6.58
disagree	17	12.98	22	11.89	37	17.70	7	9.21
no objection	12	9.16	12	6.49	22	10.53	10	13.16
agree	67	51.15	99	53.51	104	49.76	36	47.37
strongly agree	31	23.66	43	23.24	37	17.70	18	23.68
Total	131	21.80	185	30.78	209	34.78	76	12.65
Family relationship										0.129
strongly disagree	19	14.50	38	20.54	38	18.18	17	22.37
disagree	51	38.93	64	34.59	89	42.58	23	30.26
no objection	19	14.50	22	11.89	39	18.66	11	14.47
agree	32	24.43	50	27.03	34	16.27	17	22.37
strongly agree	10	7.63	11	5.95	9	4.31	8	10.53
Total	131	21.80	185	30.78	209	34.78	76	12.65

Chi-square test.

Regarding the impact on the family caregivers’ life among the ICU, RCC, RCW and RHC groups, results showed that respondents from the RHC group showed more agreement to the item, “Taking care of the patient worsens the relationship between family members” than interviewees in the ICU group (OR = 2.54 (95%CI 1.60–4.05), p<0.001); however, respondents from the RCW group showed less agreement to the item, “I experienced physical stress because caring for the patient” than those in the ICU group (OR = 0.61 (95%CI 0.38–1.00), p = 0.05). For the item, “I feel psychologically stressed from caring for the patient,” respondents from the RCC (OR = 0.54 (95%CI 0.29–0.99), p = 0.048) and RCW (OR = 0.46 (95%CI 0.25–0.85), p = 0.012) groups showed less agreement than those from the ICU group (Fig 1) (S4 File).

Fig 1

Odds of agreement in the life impact of the caregivers of PMV patients at various stages at family domain.

In the social domain, for items such as “I feel that my time for my friends and family has reduced because of caring for the patient” and “I feel that the time for community or religious activities has reduced because of caring for the patient,” caregivers in the RHC group showed more agreement than those in the ICU group (OR = 2.18 (95%CI 1.21–3.92), p = 0.01 and OR = 2.06 (95%CI 1.15–3.68), p = 0.014, respectively). For items such as “I feel that leisure time has decreased because of caring for the patient,” the RCC and RCW groups were in less agreement than those in the ICU group (RCC, OR = 0.47 (95%CI 0.26–0.86), p = 0.014 and RCW, OR = 0.37 (95%CI 0.21–0.67, p<0.001). For the item, “My work is affected because of caring for the patient.” the RCW group was in less agreement than the ICU group (OR = 0.41 (95%CI 0.24–0.69), p<0.001) (Fig 2) (S4 File).

Fig 2

Odds of agreement in the life impact of the caregivers of PMV patients at various stages at social domain.

In the economic domain, the ICU group (OR = 0.43 (95%CI 0.26–0.72), p = 0.001) (Fig 3) (S4 File) had a greater level of agreement with the item “Reduced family income due to inability to work owing to caregiving responsibilities,” than the RCW group.

Fig 3

Odds of agreement in the life impact of the caregivers of PMV patients at various stages at economic domain.

Discussion

The PMV patients and respondents had an average age of 70.76 and 51.88 years respectively. Of the main caregivers, 54.74% were children, and 80% of them were married. In the IPP group, the monthly expenses spent on patients were significantly lower than those of the non-IPP group. The caregivers of home-based patients experienced higher stress levels than caregivers of patients in another stage. The caregivers of ICU patients also experienced high stress levels, but only second to those taking care of home-based patients. Furthermore, it was found that caregivers of RCW patients had significantly lower stress levels than the family caregivers of patients in other situations.

This study demonstrated that the stress levels experienced by caregivers of home-based PMV patients (RHC) were 1.21–2.54 times that of their counterparts who care for ICU patients. According to the results, caregivers of home-based PMV patients had poorer sleep quality [29], higher risks of depression, and poorer health conditions [30, 31]. We also found that although caregivers of home-based patients had higher stress levels than those of RCW patients [29], the difference was not significant. As demonstrated in our study, the stress level of the caregivers of home-based patients was the highest, followed by that of caregivers of ICU, RCC, and RCW patients. Therefore, apart from continued attention paid to the stress of the main caregivers of home-based PMV patients [20, 22, 29, 30, 32, 33], we cannot ignore the stress experienced by caregivers of ICU patients.

The results showed that caregivers of ICU and RHC patients had higher stress levels than those of RCC and RCW patients. This might be caused by uncertainties in emergency medical treatments performed to save the lives of ICU patients [34-37] and the pressure to make life-making decisions on behalf of the patients [38]. These caregivers may have a higher risk of developing depression [39] because their stress levels increase with the severity of the patients’ condition [40]. Although RCC and RCW patients were mechanical ventilator users, they had already experienced the uncertainty of the acute phase. At this point, their family members could support each other in caring for patients using only shared knowledge for methods of care. As the caregivers no longer needed to attend to patients 24 hours a day, the stress they experienced was significantly lower than that experienced by caregivers of home-based patients [29].

Since the main caregivers of home-based PMV patients needed to take care of the patients, they had to give up part of their time with family, their comforts of life, and their opportunities to communicate and build relationships with friends and relatives [41]. Notwithstanding, patients with PMV have a poor prognosis [42]. The considerable expense and physical fatigue can aggravate psychological and physical stress experienced by family members, as well as increase socioeconomic burdens over time [21–23, 31, 34]. As a result, most caregivers of PMV patients choose to work with medical institutions instead of taking total care of patients themselves [29, 43]. The caregivers of RCW patients had significantly lower stress levels than those of patients in other situations, indicating that medical institutions were of great help in relieving caregivers’ stress. Therefore, PMV care centers in medical institutions can help family caregivers get plenty of rest and reduce the stress they experience [34].

The strengths of our study conducted a large number of participants from 64 institutions. However, some limitations were considered. First, the impact of the socioeconomic condition of participants on stress level on family is not clear. Second, we used income and education to represent the socioeconomic condition which might not be a complete evaluation.

Conclusions

Family caregivers of RHC patients had the highest level of stress, followed by their counterparts who care for ICU patients; further, the stress levels of caregivers are not associated with IPP. Higher the education level, the lower the adverse effect on the relationship between family members. Future studies to investigate the relationship between socioeconomic condition and stress level is suggested.

Question about the impact of taking care of prolonged mechanical ventilation patients on life (English and Chinese version).

(DOCX)

Click here for additional data file.

Interviewees manual (English and Chinese version).

(DOCX)

Click here for additional data file.

64 Interviewee’s institutions information.

(DOCX)

Click here for additional data file.

The impact on the family caregivers’ life between the ICU, RCC, RCW and RHC groups.

(DOCX)

Click here for additional data file.

9 Aug 2021

PONE-D-21-24193

Stress of caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study

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2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Furthermore, please provide additional information regarding how participants were recruited for the study, and please ensure that you have provided sufficient detail to allow your work to be replicated.

Moreover,  in your Methods section, please provide a justification for the sample size used in your study, including any relevant power calculations (if applicable).

Finally, please include in your Methods section (or in Supplementary Information files) the participating hospitals/institutions.

3. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified whether consent was written or verbal/oral. If consent was verbal/oral, please specify: 1) whether the ethics committee approved the verbal/oral consent procedure, 2) why written consent could not be obtained, and 3) how verbal/oral consent was recorded. If your study included minors, please state whether you obtained consent from parents or guardians in these cases. If the need for consent was waived by the ethics committee, please include this information.

4. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section

5. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

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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: Yes

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

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 article is interesting one because it has looked issues from different aspects rather than medical only. It would be better if you could find out socioeconomic conditions and occupation of caregivers and underlying diseases of the patients impact on stress level and family relationship.

Page 11, last paragraph, I think it's home-based PMV rather than PMV alone.

Overall, the article is good one. Well done

Reviewer #2: missing tables

can not make the review

Many language errors

Many abbreviation don’t correspond correctly to their phrases

Like “RCW” and “RHC”

“The main purpose of this study is to provide a solution for the

shortage of ICU beds”

That is a confusing sentence as this isn’t the aim of the study!!

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Prof. Shital Adhikari

Reviewer #2: Yes: aljamaan, fadi

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7 Oct 2021

Response to Reviewers’ Comments

PLOS ONE

Ref. No. PONE-D-21-24193

Title: Stress on caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study

Dear Editor and reviewers:

We appreciated your helpful comments to improve the presentation of the paper. We have responded to all advice point by point and revised the manuscript. It is our sincere hope that this revision will enhance readability with strengthened discussions to satisfy the requirements of this prestigious journal.

1. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Response: Thanks for your comments.

We provided the questionnaire in both Chinese and English (Attachment 1) and all of the questions are listed in table 3 on the main document (see page 9-11 on table 3).

2. Furthermore, please provide additional information regarding how participants were recruited for the study, and please ensure that you have provided sufficient detail to allow your work to be replicated.

Response: Thanks for your comments.

The researcher invited medical staff, case managers, or respiratory therapists to recruit those who fit the criteria of the subjects to accept the interview and explained to the respondents according to the interview instructions (Attachment 2). If the interviewee did not agree to accept the questionnaire survey, they could withdraw their consent from this research without any reason, with no negative consequences.

3. Moreover, in the Methods section, please provide a justification for the sample size used in your study, including any relevant power calculations (if applicable).

Response: Thanks for your queries.

Our justification for the sample size is as follows, and was edited in methods section.

This was a cross-sectional observational study. According to Mohamad Adam Bujang et al.'s recommendation for observational large-sample studies using logistic regression, the minimum sample size needs to be at least 500 [25]. A total of 601 valid samples were collected in this study, so there were sufficient samples (See line 103-107 on page 5).

We cited the reference 25 as follows:

Bujang MA, Sa'at N, Sidik T, Joo LC. Sample Size Guidelines for Logistic Regression from Observational Studies with Large Population: Emphasis on the Accuracy Between Statistics and Parameters Based on Real Life Clinical Data. The Malaysian journal of medical sciences: MJMS. 2018;25(4):122-30. Epub 2019/03/28. doi: 10.21315/mjms2018.25.4.12. PubMed PMID: 30914854; PubMed Central PMCID: PMCPMC6422534.

4. Finally, please include in the Methods section (or in Supplementary Information files) of the participating hospitals/institutions.

Response: Thanks for your suggestion.

We have uploaded the list of participating hospitals/institutions in supplementary information file (the Attachment 3) and provides a list of 64 hospital/institution names.

5. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified whether consent was written or verbal/oral. If consent was verbal/oral, please specify: 1) whether the ethics committee approved the verbal/oral consent procedure, 2) why written consent could not be obtained, and 3) how verbal/oral consent was recorded. If your study included minors, please state whether you obtained consent from parents or guardians in these cases. If the need for consent was waived by the ethics committee, please include this information.

Response: Thanks for your queries.

Because patients are mostly unconscious and interviewers are required to assist in collecting patients’ clinical information, the research invites medical staff, case managers, or respiratory therapists to recruit those who understand the situation of the patients to do the interview, and explains to the main caregiver of the family according to the interview instructions (see the Attachment 2).

6. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

Response: Thanks for your suggestion.

This study was supported by grants (grant numbers DOH102-NH-9009; DMR-109-015) from the National Health Insurance Administration and China Medical University Hospital, Taiwan. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript (See line 284-288 on page 19).

7. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

Response: Thank you for your comments.

We have inserted tables in the manuscript.

Reviewer #1

1. The article is interesting one because it has looked issues from different aspects rather than medical only. It would be better if you could find out socioeconomic conditions and occupation of caregivers and underlying diseases of the patients impact on stress level and family relationship.

Response: We used family income and education level to represent the socioeconomic conditions of caregivers, and compared the family income and education level of the caregivers of PMV patients at four stages with the psychological pressure and family relationship with Spearman's rank correlation. In addition, we used the Chi-square test to analyze the patient's underlying disease, psychological pressure of the caregiver, and family relationships. The results showed that there was no significant difference in the family income of caregivers between psychological stress and family relationships, but it was found that the higher the education level, the lower the adverse effect on the relationship between family members, and there was a statistically significant difference (p<0.05) (Table 4). There was no significant correlation between the underlying disease of PMV patients and the psychological stress of caregivers and family relationships (Tables 5). We have revised the text in the manuscript (See table 4-5 on page 14-15.)

2. Page 11, last paragraph, I think it's home-based PMV rather than PMV alone.

Response: Thank you for your comments.

I really want to express home-base, and modified it as follows:

“The results show that caregivers of ICU and home-based PMV patients have higher stress levels than those of RCC and RCW patients.”

Reviewer #2:

1. missing tables can not make the review

Response: Thank you for your comments.

We have inserted tables in the manuscript.

2. Many language errors

Response: Thank you for your comments.

We send the revised file back to the translation agency for revision in English (Attachment 4).

3. Many abbreviation don’t correspond correctly to their phrases Like “RCW” and “RHC”

Response: Thank you for your comments.

We have revised the abbreviations of RCW and RHC in the text to make it the same as the full text. RCW, respiratory care ward; RHC, respiratory home care

4. “The main purpose of this study is to provide a solution for the shortage of ICU beds” That is a confusing sentence as this isn’t the aim of the study!!

Response: Thank you for your comments.

We have deleted this sentence from the introduction.

Submitted filename: renamed_90d68.docx

Click here for additional data file.

20 Oct 2021

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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We look forward to receiving your revised manuscript.

Kind regards,

Robert Jeenchen Chen, MD, MPH

Academic Editor

PLOS 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)

**********

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: Yes

Reviewer #2: No

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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: No

**********

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: No

**********

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: Thank you for taking time to address the comments. I feel, there are a few corrections needed.

Abstract

Page 2, line 42-45, the sentence lacks subject

Page 3, line 58, caregivers home or in-home caregivers?

Introduction

Line 70, Studies…… This sentence is not complete.

Reviewer #2: 1. “Home-based interviewees reported that taking care of

the patient of their family worsens the relationship between family members than the

intensive care unit group interviewees”

What do you mean exactly by this result in the abstract, are you pointing to family member giving care to chronic ventilated patients and the consequences or the respiratory caregiver and the relation to the family ?!

2. In the abstract after that sentence you switch to stress as consequence of this relation to family

You conclude in the abstract that “primary family caregivers of patients with

prolonged mechanical ventilation had the highest level of stress among in-home

caregivers”

I assume those are respiratory therapist handling patients at home as you r inclusion criteria is of healthcare professional only not family members taking care of relative on home ventilator, but in the results you mention nothing about their stress level, only you mention about their relation with family members

3. By the end your abstract isn’t well written and the results aren’t summarized in good way for the reader to perceive the message.

4.Your population isn’t clear or defined especially regarding those involved in RHC (respiratory home care)

5.The objective of your study isn’t clear

“We measured aspects related to their lives using a Likert scale”

6.Where’s the detailed table showing the numbers of respondents in the different subcategories based on the variables you measured , it seems based on table one that all or most of population were from RHC

**********

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.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Dr. Shital Adhikari, DM (Pulmonary, Critical Care and Sleep Medicine)

Reviewer #2: Yes: aljamaan, fadi

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

29 Dec 2021

Response to reviewers’ comments

Reviewer #1:

1. Abstract: Page 2, line 42-45, the sentence lacks subject

Response: Thanks for your queries.

We found no statistically significant difference at p=0.05, so we deleted this sentence in the abstract section.

2. Abstract: Page 3, line 58, caregivers home or in-home caregivers?

Response: Thanks for your comments.

Since what we are visiting is to take care of the family members of PMV patients at home, this should be in-home caregiver. We revise the sentence as “Thus, the government should provide more support systems for in-home caregivers to relieve their life stress.” (Page 3, line 50-51 in revised vision)

3. Introduction: Line 70, Studies…… This sentence is not complete.

Response: Thanks for your comments.

We are grateful for this suggestion and have completed sentences to clarify this point as follows: “Studies show that as patients who stay at home are more familiar with the environment, they feel more comfortable, and experience is better than the in-house care patients. [14].” (Page 5, line 76-78 in revised vision)

Reviewer #2:

1. “Home-based interviewees reported that taking care of the patient of their family worsens the relationship between family members than the intensive care unit group interviewees” What do you mean exactly by this result in the abstract, are you pointing to family member giving care to chronic ventilated patients and the consequences or the respiratory caregiver and the relation to the family?!

Response: Thanks for your queries.

We have revised the result of abstract as follows: “As the results of the life impact presented in the family domain that RHC interviewees (OR=2.54) feel it worsens family relationships than the ICU group; however, there is less psychological stress in RCC (OR=0.54) and RCW (OR=0.16) than ICU group. In the social domain that RHC interviewees feel reducing friend/family interactivity (OR=2.18) and community/religious activities (OR=2.06) than ICU group; however, RCW interviewees fell less effect with leisure time (OR=0.37) and work time (OR=0.41) than ICU group. Furthermore, the economic domain of reducing family income because caregivers cannot work is less influenced in RCW interviewees (OR=0.43) than in ICU groups.” (Page 2, line 39-48 in revise vision)

2. In the abstract after that sentence you switch to stress as consequence of this relation to family You conclude in the abstract that “primary family caregivers of patients with prolonged mechanical ventilation had the highest level of stress among in-home caregivers ”I assume those are respiratory therapist handling patients at home as you r inclusion criteria is of healthcare professional only not family members taking care of relative on home ventilator, but in the results you mention nothing about their stress level, only you mention about their relation with family members

Response: Thanks for your queries.

We have revised the conclusion in abstract as follows: “Stress levels of primary family caregivers of patients with prolonged mechanical ventilation had the highest stress level among in-home caregivers and less in the RCW group. Thus, the government should provide more support systems for in-home caregivers to relieve their life stress.” (Page 2-3, line 66-69 in revised vision)

3. By the end your abstract isn’t well written and the results aren’t summarized in good way for the reader to perceive the message.

Response: Thanks for your comments.

We have major revision in the abstract (Page 2-3 line27-51, in revised vision).

4. Your population isn’t clear or defined especially regarding those involved in RHC (respiratory home care)

Response: Thanks for your comments.

We have revised the introduction as follows:

“The regulations of IPP are fee for service for ICU care (within 21 d), per-diem for RCC (for up to 42 d), per capitation for RCW, and monthly payment for home ventilation service. The ICU, RCC, and RCW belong to the institution care, and 24-hours medical staff is available. The patients who use ventilators at home have nurses’ and respiratory therapists’ visits twice a month and physicians’ visits once two months.” (Page 4 line 69-73, in revised vision)

5. The objective of your study isn’t clear “We measured aspects related to their lives using a Likert scale”

Response: Thanks for your queries.

We have revised the part of questionnaire development in Materials and Methods section as follows:

“The questionnaires have three domains (family, social, and economic aspects) that were measured related to their lives using a Likert scale (from "strongly agree" to "strongly disagree") to evaluate the impact of the IPP and the stress of life on main caregivers of PMV patients at different units.” (Page 6 line 102-105, in revised vision)

6. Where’s the detailed table showing the numbers of respondents in the different subcategories based on the variables you measured, it seems based on table one that all or most of population were from RHC.

Response: Thanks for your queries.

The numbers of respondents in the different subcategories were showed in table 2. A total of 601 interviewees were analyzed, and they consisted of ICU (150), RCC (150), RCW(150), and RHC(151). (Page 9-10, table 2, line 182-185, in revised vision)

Response to the Editor’s comments

1. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response: Thanks for your comments.

We added our supporting information at the end of our manuscript, and please see line 290-296 on page 20. The supporting information is as follows:

S1 File: Question about the impact of taking care of prolonged mechanical ventilation patients on life (English and Chinese version)

S2 File: Interviewees Manual (English and Chinese version)

S3: 64 Interviewee's institutions information

S4: The impact on the family caregivers’ life between the ICU, RCC, RCW and RHC groups

2. We note your Data Availability statement:

"All relevant data are within the table 1-5, the raw data can’t share public due to the data contain personal information. This study was approved by the Institutional Review Board of China Medical University Hospital (IRB No. CMUH102-REC3-105), Taiwan." According to PLOS policy, when specific legal or ethical restrictions prohibit public sharing of a data set, authors must indicate how others may obtain access to the data. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods. Please see this link for more details: https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition If the minimal data set is contained within the raw data, please update your Data Availability statement with a non-author contact who can provide these data upon request. This could be a contact at the Institutional Review Board of China Medical University Hospital, Taiwan, or other such body

Response: Thanks for your comments.

We have added the supporting file (S4 file) for raw data of the figure 1-3. If you have any questions related to the minimal data set, please let us know.

Author’s Statement

1. We are sorry that we found that the first question of the economic domain in figure 3 was misquoted the fifth question of the social domain in Table 3. We have revised it.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

31 Jan 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Robert Jeenchen Chen, MD, MPH

Academic Editor

PLOS 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: All comments have been addressed

**********

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: Yes

Reviewer #2: No

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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: No

**********

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: No

**********

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: Dear Authors

Thank you for addressing the comments. The evidence you have generated about the level of stress of caregivers of patients on prolonged mechanical ventilation (PMV) in different settings will be very useful for planning of care.

Reviewer #2: The paper is still confusing , and mixed up , still you confuse the family caregiver with the respiratory therapist in your abstract and manuscript, to the degree I am not sure the result belong to whom , please revisit your conclusion in the abstract, this is after 2 runs of revision

I cant get the theme from the paper and conclude main outcome or idea

**********

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: Yes: Dr. Shital Adhikari

Reviewer #2: Yes: aljamaan, fadi

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

15 Mar 2022

Response to Reviewer Comments:

1. Reviewer #2: The paper is still confusing, and mixed up, still you confuse the family caregiver with the respiratory therapist in your abstract and manuscript, to the degree I am not sure the result belong to whom, please revisit your conclusion in the abstract, this is after 2 runs of revision. I cant get the theme from the paper and conclude main outcome or idea.

Ans.: We feel very sorry for the confusion. We have revised and marked with red color for revision in the manuscript. Thank you for reminding and providing the opportunity to revise.

Abstract (Revised)

Purpose: Taiwan has implemented an integrated prospective payment program (IPP) for prolonged mechanical ventilation (PMV) patients that consists of four stages of care: intensive care unit (ICU), respiratory care center (RCC), respiratory care ward (RCW), and respiratory home care (RHC). We aimed to investigate the life impact on family caregivers of PMV patients opting for a payment program and compared different care units. Method: A total of 610 questionnaires were recalled. Statistical analyses were conducted by using the chi-square test and multivariate logistic regression model. Results: The results indicated no associations between caregivers’ stress levels and opting for a payment program. Participants in the non-IPP group spent less time with friends and family owing to caregiver responsibilities. The results of the family domain show that the RHC group (OR=2.54) had worsened family relationships compared with the ICU group; however, there was less psychological stress in the RCC (OR=0.54) and RCW (OR=0.16) groups than in the ICU group. In the social domain, RHC interviewees experienced reduced friend and family interactivity (OR=2.18) and community or religious activities (OR=2.06) than the ICU group. The RCW group felt that leisure and work time had less effect (OR=0.37 and 0.41) than the ICU group. Furthermore, RCW interviewees (OR=0.43) were less influenced by the reduced family income than the ICU group in the economic domain. Conclusions: RHC family caregivers had the highest level of stress, whereas family caregivers in the RCW group had the lowest level of stress.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

4 Apr 2022

23 Apr 2022

Response to reviewers’ comments:

PONE-D-21-24193R3

Stress on caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study

Reviewer #1:

The article will be very useful for deciding site of care for patients who need long term ventilatory support. The findings may serve as issues for discussion.

Ans.: Thanks for your comments.

Reviewer #3:

1. Line 66:“The ICU, RCC, and RCW is belonging the institution” –- suggest English consultation “

Ans.: Thanks for your comments.

We are grateful for this suggestion and try to clarify this sentence, which was as follows “The ICU, RCC, and RCW belong to the institutions,” (Page 3, line 67 in revised vision)

2. Line 97:“The questionnaires have three domains (…) was measured aspects related to their lives by a Likert scale(…) to compared with the Impact of the IPP and different unit of main caregiver of PMV patients on the stress of life. ” –- suggest English consultation

Ans.: Thanks for your comments.

We are grateful for this suggestion and try to clarify this sentence, which was as follows “The questionnaires have three domains (family, social, and economic). They measured aspects related to their lives by a Likert scale (from strongly agree to strongly disagree) to compare the impact of the IPP and different units of primary caregivers of PMV patients on the stress of life.” (Page 5, line 97-100 in revised vision)

3. Line 113:“the acute ICU stage was the time or less than 7 days in RCC after transfer from ICU;”→-“the acute ICU stage was the time in ICU and/or less than 7 days in RCC after transfer from ICU;”---???

Ans.: Thanks for your comments.

We are grateful for this suggestion and try to clarify this sentence, which was as follows “the acute ICU stage was the time in ICU and/or less than 7 days in RCC after transfer from ICU” (Page 5, line 113-114 in revised vision).

4. Line 143:“The monthly expense for the IPP group was significantly lower than that for the non-IPP group (USD 745 vs. USD 912 respectively) (Table 1).” --- The definition of “monthly expense” is not clear. Is it the expense paid by the family or by the Taiwan National Health Insurance Program?

Ans.: Thanks for your comments.

We are grateful for this suggestion and try to clarify this sentence, which was as follows “The monthly expense paid by the family for the IPP group was significantly lower than that for the non-IPP group (USD 745 vs. USD 912, respectively) (Table 1).” (Page 7, line 145 in revised vision).

5. Line 144:“the non-IPP group” --- The recruitment of “non-IPP group” was not described in the methodology.

Ans.: Thanks for your comments.

We are grateful for this suggestion and have added sentences to clarify this

point, which were as follows “The participants were divided into two groups (IPP and none-IPP group) according to whether they had joined IPP.” (Page 5, line 117-118 in revised vision).

6. Line 148 Table 1 --- The last line of 1st column“Average monthly expense(SD) (USD) “→“Average monthly expense (USD) Mean (SD)

Ans.: Thanks for your comments. We have changed the description. (Page 8, line 151 the last line of 1st column in revised vision).

7. Line 193, 208, 216 “Odds of agree in the life impact” →“Odds of agreement in the life impact”

Ans.: Thanks for your suggestion. We have changed the description. (Page 15, line 196; Page 16, line 211; Page 16, line 219 in revised vision).

Submitted filename: Response to Reviewers comments.docx

Click here for additional data file.

11 May 2022

Stress on caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study

PONE-D-21-24193R4

Dear Dr. Tsai,

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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Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

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Reviewer #3: Yes

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Reviewer #3: Yes

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Reviewer #1: The article has been interesting showing the stress level when one has to take care of close relatives when being managed with ventilatory support in different conditions. Thank you for addressing all the concerns raised

Reviewer #3: Line 50

“The PMV incidence rates in Europe and the US were found to be 5 %-11 % [3-6]. Taiwan had a PMV rate of 20 %, while China had a PMV rate of 36.1 %,”

---- The background information of incidence rate calculation is not provided. Are these incidence rates based on per 100 ventilated ICU admissions?

Line 138

“As comprehensive analyses datasets were generated by a previous study [26], the

current dataset was generated from 687 eligible respondents from 64 institutions (6

medical centers, 11 regional hospitals, 23 district hospitals, 15 nursing homes, and 9

home care centers) were included in this study (S3 File).”

---- English consultation.

Line 183----Table 5

“Disagree”→ “disagree”

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Reviewer #1: No

Reviewer #3: No

16 May 2022

PONE-D-21-24193R4

Stress on caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study

Dear Dr. Tsai:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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