Predictors of Return to Work After Stroke in Hungary: A Mixed-Methods Economic and Clinical Data Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Review Comments

The study titled “Predictors of Return To Work After Stroke in Hungary: An Economic and Clinical Data Analysis” examines the clinical and economic predictors influencing return to work (RTW) in patients who have experienced a stroke in Hungary. The study leverages aggregated hospital data from the national Pulvita system, complemented by the expertise of medical professionals experienced in post-stroke care and RTW evaluations. This is a well-designed and important study with relevant clinical and socioeconomic implications. There are minor suggestions listed below:

Minor Comments:

1. Consider discussing potential gender-based correlations between stroke severity and RTW within this dataset.
2. It is recommended to include a graphical representation of the key outcomes from the dataset analysis.
3. Authors are suggested to discuss correlation between any major comorbidities w.r.t stroke severity that could have effected the RTW outcomes in this dataset.

Author Response

Dear Reviewer,

We sincerely thank you for your constructive feedback, which has greatly improved the quality of our manuscript. Below, we provide a point-by-point response:

1. Consider discussing potential gender-based correlations between stroke severity and RTW within this dataset.
2. It is recommended to include a graphical representation of the key outcomes from the dataset analysis.
3. Authors are suggested to discuss the correlation between any major comorbidities w.r.t stroke severity that could have effected the RTW outcomes in this dataset.

Responses:

1. We agree with this important point. However, as clarified, the PulVita dataset does not contain direct RTW outcomes. Instead, we examined rehabilitation intensity as an indirect proxy of recovery potential. We added a new subsection in the Results (Figure 2, Table 5) and expanded the Discussion to highlight gender differences in rehabilitation intensity and their potential implications for RTW, with references to prior literature.
2. We sincerely thank the reviewer for this suggestion. We carefully considered the possibility of adding graphical representations of the dataset. However, the key outcomes are already presented in detailed tabular form (Tables 4–5), which allow readers to directly compare subgroup variations across multiple predictors (age, gender, rehabilitation type, and financing categories). Given the number of categories and the need for precise values, a graphical representation would largely replicate the information already available in the tables and risk oversimplifying the findings. To avoid redundancy, we decided to retain the results in tabular format. Nevertheless, we remain open to providing supplementary figures if it is beneficial for visualization and clarity.
3. Unfortunately, comorbidity information was not available in the PulVita dataset. We acknowledged this explicitly as a limitation in the Discussion. To strengthen the manuscript, we cited relevant international literature showing that comorbidities are strong predictors of delayed recovery and reduced RTW.

We believe these revisions address the reviewer’s concerns while remaining faithful to the structure and limitations of the dataset.

Thank you again for your insightful comments and valuable suggestions.

Kind regards,
Arie Arizandi Kurnianto

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,
Congratulations on your manuscript, but several sections need to be addressed in order to improve its quality.

• Abstract

The abstract mixes results with interpretations and presents somewhat broad conclusions. The background, methods, results, and conclusion could be clarified in short paragraphs.

• Introduction

Although it covers the international and national context, the narrative is repetitive and poorly structured. It could be restructured to clarify the magnitude of the problem (stroke, RTW, social and economic impact), the knowledge gap in the Hungarian context, and the justification for the study and its clear objective.

• Methods

The study is presented as mixed, but the qualitative component lacks a methodological framework. The statistical procedures used with the aggregated data are not clearly described. The process of recoding variables is not sufficiently explained (it is mentioned, but an example or table is missing). Explain how the qualitative data were integrated: was analysis used? How was bias avoided?

• Results

The results are presented correctly, but interpretation is constantly mixed with description of results. The writing could be refined.

• Discussion

Discussion
Provides good contextualisation, but occasionally mixes discussion, results and recommendations despite correctly differentiating between sections. The discussion should detail: main findings, comparison with international and national literature, economic implications and implications for the health system, limitations of the study and implications for future research. With a few improvements, it would be very consistent.

On the other hand, the impact of the findings is overinterpreted, especially in terms of public policy. More caution could be exercised in policy recommendations (avoid extrapolations without direct evidence).

• Conclusion

It could be summarised in 3–4 sentences, reaffirming the clinical and systemic predictors found and mentioning the need for structured RTW programmes.

 

Comments on the Quality of English Language

The English is understandable, but there are grammatical errors, confusing constructions, and an awkward style in multiple sections. A professional linguistic review is recommended, especially in the abstract, introduction, and discussion.

Author Response

Dear Reviewer,

We thank the reviewer for the constructive and detailed feedback. Below we provide a point-by-point response, with details on how we modified the text by highlighting the line with yellow.

1. Abstract

The abstract mixes results with interpretations and presents somewhat broad conclusions. The background, methods, results, and conclusion could be clarified in short paragraphs.

Response:
Thank you for the suggestion. We have fully revised the abstract to clearly separate the background, methods, results, and conclusions into concise segments. Interpretative elements were reduced, and the conclusions were limited to factual statements directly supported by the data.

2. Introduction

Although it covers the international and national context, the narrative is repetitive and poorly structured. It could be restructured to clarify the magnitude of the problem (stroke, RTW, social and economic impact), the knowledge gap in the Hungarian context, and the justification for the study and its clear objective.

Response: 

We agree and have restructured the Introduction to follow a clearer flow that we started to explain the burden of stroke (clinical and economic impact internationally). Then, we highlighted the importance of RTW after stroke and its societal implications. Next, we include the Hungarian context, where it is limited of structured RTW programs and limited economic data. Finally, we highlighted the knowledge gap and study objective. We believe this restructuring improves readability and emphasizes the novelty of our study.

 

3. Methods

The study is presented as mixed, but the qualitative component lacks a methodological framework. The statistical procedures used with the aggregated data are not clearly described. The process of recoding variables is not sufficiently explained (it is mentioned, but an example or table is missing). Explain how the qualitative data were integrated: was analysis used? How was bias avoided?

 

Response: 

We are grateful for the reviewer’s comments. In our revised manuscript, we have made clear the methodological framework used for the qualitative component of the study, namely, that the expert consultations were facilitated using a structured discussion guide focusing on clinical interpretation of rehabilitation outcomes and readiness to return to work (RTW). More detail has been added to the description of the statistical analyses of the aggregated data (descriptive statistics, cross-tabulation, and stratifying based on gender, age group, and type of rehabilitation). In addition to addressing the reviewer’s comment, we added additional explanation on Methods section describing how we recoded the variable “Further Fate of Patient” into disability severity categories using the International Classification of Functioning, Disability and Health (ICF). We also clarified how we integrated qualitative aspects—this was only used to contextualize and interpret quantitative results, and this was not a separate data analysis. We also reduced bias by including a number of clinicians from diverse areas of treatment (neurology, rehabilitation, and occupational health), and triangulation between their comments and the aggregated data.

 

4. Results

The results are presented correctly, but interpretation is constantly mixed with description of results. The writing could be refined.

 

Response: 

 

We thank the reviewer for the suggestion. We made the changes requested, and in the revised version, we have separated the descriptive results (for example, numerical distributions, proportions) from what are interpretive statements. These interpretive statements were moved to the Discussion. The Results section is now strictly reporting the findings from the dataset in tables and figures, allowing for more clarity and ease of understanding.

 

 

5. Discussion

Provides good contextualisation, but occasionally mixes discussion, results and recommendations despite correctly differentiating between sections. The discussion should detail: main findings, comparison with international and national literature, economic implications and implications for the health system, limitations of the study and implications for future research. With a few improvements, it would be very consistent.

On the other hand, the impact of the findings is overinterpreted, especially in terms of public policy. More caution could be exercised in policy recommendations (avoid extrapolations without direct evidence).

Response: 

In the revised Discussion, we begin with a summary of our main findings, which is followed by a more structured comparison with the international evidence on RTW after stroke (including some evidence from Central and Eastern Europe). We included a more robust discussion on the economic aspects, specifically highlighting the potential productivity losses that can result from postponed RTW and some cost comparisons to neighboring countries. The section on the implications of the Hungarian health system has been rewritten, and the policy suggestions are now rewritten with more caution and do not draw on evidence to determine any policy. The limitations were expanded on, and a particular focus was made on the lack of data at the individual level as well as not being able to encapsulate comorbidities. Finally, we highlighted the need and importance for new prospective studies with detailed clinical and economic variables.

 

6. Conclusion

It could be summarised in 3–4 sentences, reaffirming the clinical and systemic predictors found and mentioning the need for structured RTW programmes.

 

Response: 

The Conclusion has been concise based on suggestion. It restates the clinical and economic determinants. It highlights that even though Hungary does not have any formal RTW programs, our results identified where policy could help to enhance better integration. The section finished with a call for structured RTW pathways, and the need to assess the cost-effectiveness of these interventions.

Reviewer 3 Report

Comments and Suggestions for Authors

Return to work (RTW) is a fundamental aspect of recovery after stroke, importantly, for workers of working age. Evidence indicates there is little known about the clinical and systematic predictors of RTW in Hungary. A mixed-method study using aggregated national level administrative data from The Pulvita platform and expert interpretation from the physicians who treat  stroke survivors. In Hungary RTW outcomes were influenced by clinical and system level factors including regionally distributed access to rehabilitation systems and lack of formalized RTW programs. The conducted study findings emphasized the need to provide integrated rehabilitation services, provide coordinated employer activity, and to highlight both legal and policy changes for RTW following stroke

 

1. In Line 2，“Predictors of Return To Work After Stroke in Hungary: An Eco- 2 nomic and Clinical Data Analysis”， It is recommended that the study design, a mixed-methods approach，be explicitly stated in the title.
2. In Line 8, abstract part, please add the 2025 data and specify the study’s sample size.
3. In Line 36-40, “In addition, improvements in acute and thrombolytic care have represented significant improvements with regard to stroke-related mortality, survivors continue to experience residual impairments which restrict quality of life and social engagement. The ability to return to work (RTW) following stroke is an important measure of functional recovery for” Please add the most recent literature.

 

4. ‌In Line 60-66 “This is especially relevant in Central and Eastern Europe, as the mech- anisms and structural supports to re-establish disabled workers may be minimal when compared to Western nations [13]. Hungary represents an interesting context for studying post-stroke RTW outcomes [14]. ……..” Please clarify how Hungary’s rehabilitation policies differ from those of other Central and Eastern European countries, highlight the study’s innovation and unique contribution, and conduct a more thorough literature review.

 

5. In method part, Line 114-116“No personally identifiable information or individual-level clinical data were accessed. Given the aggregate nature of the dataset, ethical approval was not required.” The absence of individual-level data does not justify bypassing ethical principles. Please detail the specific anonymization measures applied to the Pulvita platform. Since the platform’s creation involves personal privacy, how exactly is data de-identified, and was the platform subject to formal ethics review?‌

 

6. In Line 127“For example, the variable "Further Fate of Patient" was recoded using the severity categories of disability according to the International Classification of Functioning, Disability and Health (ICF)[29–31].” Please provide a concrete example of how the ICF classification system was applied.

 

7. In Line 148-150 “In order to provide interpretation of the findings, the study included expert knowledge from clinicians who were directly involved in the stroke rehabilitation process and work capacity evaluations.” Additional details about the expert interviews are needed, including how many experts participated, their professional backgrounds (e.g., neurology, rehabilitation), and how their competence and credentials were assessed for inclusion.

 

8. In Line 366-375, “Applying this to Hungary, the lack of structured RTW pathways may imply missed opportunities for cost containment via reduced sick-leave duration and improved labor participation. The cost for post-stroke care varies significantly depending on factors such as the severity of the stroke, rehabilitation needs, and dependency levels [55].” How do rehabilitation costs in Hungary compare with those in other European countries, both Eastern and Western?

Author Response

We sincerely thank to reviewer for the constructive comments and valuable suggestions that helped us improve the clarity, rigor, and contribution of our manuscript. We have revised the manuscript by highlighting yellow Below, we provide a point-by-point response to each comment:

1. In Line 2，“Predictors of Return To Work After Stroke in Hungary: An Economic and Clinical Data Analysis”， It is recommended that the study design, a mixed-methods approach, be explicitly stated in the title.
   
   Response:
   We appreciate this suggestion. We have revised the title to explicitly indicate the study design:
   “Predictors of Return To Work After Stroke in Hungary: A Mixed-Methods Economic and Clinical Data Analysis.”
   
2. In Line 8, abstract part, please add the 2025 data and specify the study’s sample size.
   
   Response :
   We thank the reviewer for the suggestion. We have clarified the total aggregated sample size analyzed. The abstract now specifies the number of patients represented in the dataset and confirms the period of data provision. However, at the time of analysis, the 2025 dataset was not yet comprehensive and therefore could not provide a reliable basis for inclusion. To maintain consistency and robustness, we used the latest complete dataset (2019–2024). This clarification has been added to the Abstract and Methods sections.
   
   
3. In Line 36-40, “In addition, improvements in acute and thrombolytic care have represented significant improvements with regard to stroke-related mortality, survivors continue to experience residual impairments which restrict quality of life and social engagement. The ability to return to work (RTW) following stroke is an important measure of functional recovery for” Please add the most recent literature.
   
   Response :
   

   We have updated the Introduction with references to recent literature on stroke outcomes, residual disability, and RTW challenges, thereby strengthening the background section.

4. ‌In Line 60-66 “This is especially relevant in Central and Eastern Europe, as the mech- anisms and structural supports to re-establish disabled workers may be minimal when compared to Western nations [13]. Hungary represents an interesting context for studying post-stroke RTW outcomes [14]. ……..” Please clarify how Hungary’s rehabilitation policies differ from those of other Central and Eastern European countries, highlight the study’s innovation and unique contribution, and conduct a more thorough literature review.
   
   Response :
   We revised the Introduction to explain Hungary’s unique rehabilitation landscape: the absence of formal RTW programs compared to some other EU countries, where structured vocational rehabilitation exists. 

5.  In method part, Line 114-116“No personally identifiable information or individual-level clinical data were accessed. Given the aggregate nature of the dataset, ethical approval was not required.” The absence of individual-level data does not justify bypassing ethical principles. Please detail the specific anonymization measures applied to the Pulvita platform. Since the platform’s creation involves personal privacy, how exactly is data de-identified, and was the platform subject to formal ethics review?‌
   
   Response:
   We revised the Methods to clarify that the Pulvita platform contains fully anonymized, aggregated administrative health data with no access to personal identifiers. Data are provided under Hungarian National Health Insurance Fund Management regulations. The platform itself underwent institutional ethics review at the time of establishment. For our study, ethical approval was waived, consistent with Hungarian legislation in accordance with Act CXII of 2011 on the Right of Informational Self-Determination and on Freedom of Information (Hungary).

6. In Line 127“For example, the variable "Further Fate of Patient" was recoded using the severity categories of disability according to the International Classification of Functioning, Disability and Health (ICF)[29–31].” Please provide a concrete example of how the ICF classification system was applied.
   
   Response:
   We have expanded the Methods section with a detailed example.
   
   
7. In Line 148-150 “In order to provide interpretation of the findings, the study included expert knowledge from clinicians who were directly involved in the stroke rehabilitation process and work capacity evaluations.” Additional details about the expert interviews are needed, including how many experts participated, their professional backgrounds (e.g., neurology, rehabilitation), and how their competence and credentials were assessed for inclusion.
   
   Response:
   We have revised the Methods to state that experts (one neurologist, one rehabilitation specialist, and one occupational health physician) contributed contextual insights. 
   
   
8. In Line 366-375, “Applying this to Hungary, the lack of structured RTW pathways may imply missed opportunities for cost containment via reduced sick-leave duration and improved labor participation. The cost for post-stroke care varies significantly depending on factors such as the severity of the stroke, rehabilitation needs, and dependency levels [55].” How do rehabilitation costs in Hungary compare with those in other European countries, both Eastern and Western?
   
   Response:
   We have expanded the Discussion with cost comparison evidence.
   
   "

   Applying this to Hungary, the lack of structured RTW pathways may imply missed opportunities for cost containment via reduced sick-leave duration and improved labor participation. The cost for post-stroke care varies significantly depending on factors such as the severity of the stroke, rehabilitation needs, and dependency levels[66]. Health care expenditure in Hungary was 5.7% of GDP in 2000, which is lower than the average of around 7% in most European countries [67]. This suggests that overall health care funding, including rehabilitation, may be relatively constrained in Hungary. Moreover, in Hungary, cardiac rehabilitation is primarily inpatient, with significant regional disparities in bed availability and utilization [68]. The average length of stay for cardiac rehabilitation increased slightly from 19.2 days in 2014 to 20.2 days in 2017 [68]. Meanwhile, cardiac rehabilitation programs in Europe vary significantly. Western European countries tend to have higher program volumes and more staff compared to other high-income countries [69]."

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The revised manuscript shows clear improvements compared to the previous version. However, there are still important methodological issues.

Introduction

The justification for the mixed approach (economic + clinical) could be clarified further. Simplify long sentences to improve fluency.

Methods

Improvements are evident in variable descriptions and recoding explanations, but details are still insufficient for replication.

Statistical methods are still only described in general terms; the manuscript needs clear specification of tests, models, and handling of missing data.

Results

Presentation is more orderly than in the previous version.  Some interpretation is still mixed into the results section and should be reserved for the discussion.

Figures are clearer, but some captions remain too brief and not fully self-explanatory.

Discussion

Better organized than the previous version, but still tends to overinterpret results.

Implications for policy and practice remain too strong given the observational and proxy-based data used.

Limitations are discussed, but need greater emphasis, especially regarding the absence of direct return-to-work data.

Conclusions

More concise than the earlier version, but still somewhat repetitive of the discussion.

Author Response

Dear Reviewer,

We would like to thank you for your constructive comments on our revised manuscript. Please find below our detailed responses and corresponding revisions.

Introduction

Comment: The justification for the mixed approach (economic + clinical) could be clarified further. Simplify long sentences to improve fluency.

Response: We revised the Introduction to state why a mixed-methods approach was required explicitly. Clinical data provide indicators of recovery, while economic and systemic factors shape reintegration into work. Clinician perspectives were included to provide context for gaps in administrative data. We also shortened long sentences for clarity.

Methods

Comment: Improvements are evident in variable descriptions and recoding explanations, but details are still insufficient for replication.

Statistical methods are still only described in general terms; the manuscript needs clear specification of tests, models, and handling of missing data.

Response: We expanded the “Data Analysis” section to specify the descriptive methods applied: stratification by sex, age, and county; calculation of population-adjusted rates; and recoding rules aligned with ICF. We clarified that no regression models were applied due to aggregated data, and that missing data were reported as-is without imputation. 

Results

Comment: Presentation is more orderly than in the previous version.  Some interpretation is still mixed into the results section and should be reserved for the discussion. Figures are clearer, but some captions remain too brief and not fully self-explanatory.

Response: We revised the Results section to report findings descriptively only. Interpretive phrases were moved to the discussion. We also expanded figure captions to make them fully self-explanatory.

Discussion

Comment: Better organized than the previous version, but still tends to overinterpret results. Implications for policy and practice remain too strong given the observational and proxy-based data used. Limitations are discussed, but need greater emphasis, especially regarding the absence of direct return-to-work data.

Response: We softened policy statements to reflect the observational and proxy-based nature of the findings. For example, sentences implying “strong evidence for policy adoption” were revised to “potential areas for policy consideration pending confirmatory studies.” We also strengthened the Limitations section, explicitly noting the absence of direct RTW data and reliance on proxy measures.

Conclusions

Comment: More concise than the earlier version, but still somewhat repetitive of the discussion.
Response: We condensed the Conclusions to three sentences that started with a summary of the main predictors, then wrote the contribution of our study, and finally, we highlighted implications for future research and policy.

We hope these revisions adequately address your concerns and improve the rigor and clarity of the manuscript.