The Impact of Cardiac Telerehabilitation on Health-Related Quality of Life in Patients Undergoing Percutaneous Coronary Intervention (PCI): A Systematic Review Protocol

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I have attached a file with my comments.

Comments for author File: Comments.pdf

Author Response

Dear reviewers, 

Thank you for taking the time to review our manuscript and for providing such constructive and thoughtful comments. Your feedback has been invaluable in helping us improve the quality and clarity of our work. To address your suggestions, we have prepared a detailed response to all your comments and have incorporated the requested revisions into the manuscript. Specifically, we have collected all the comments in a single file, attached. In this document you will find each comment followed by our corresponding response. We greatly appreciate your constructive input, which has significantly contributed to improving the quality of our manuscript. 

Please do not hesitate to contact us if further clarification is needed.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Strengths of the Manuscript:

1. Timely and Relevant Topic:

   • The focus on telerehabilitation is highly relevant given the increasing reliance on telemedicine, especially after the COVID-19 pandemic. It addresses a significant gap in the literature regarding the efficacy of remote rehabilitation in post-PCI patients.
   • The manuscript highlights the potential benefits of telerehabilitation, such as improved accessibility, reduced healthcare costs, and increased patient adherence, which are critical in managing cardiovascular diseases (CVD).

2. Systematic Approach:

   • The protocol is structured according to PRISMA guidelines, ensuring methodological rigor. The inclusion of a registered protocol on PROSPERO adds transparency and accountability to the review process.
   • The use of the PIO framework to define the research question and search strategy enhances the clarity and focus of the review.

3. Comprehensive Methodology:

   • The planned use of multiple databases (PubMed, Scopus, CINAHL, Cochrane Library) ensures a thorough literature search.
   • The protocol outlines a well-defined strategy for study selection, data extraction, and quality appraisal using the Crowe Critical Appraisal Tool (CCAT). This approach ensures the inclusion of high-quality studies and minimizes bias.

4. Inclusion of Diverse Study Designs:

   • By including randomized controlled trials, cohort studies, and case-control studies, the review aims to capture a broad spectrum of evidence, which can provide a more comprehensive understanding of the impact of telerehabilitation.

Limitations and Areas for Improvement:

1. Lack of Clarity on Inclusion Criteria:

   • The inclusion criteria state that studies published in peer-reviewed journals will be included, but no specific timeline is provided. Clarifying whether there are restrictions on the publication dates (e.g., only studies published in the last 10 years) would help focus the review on the most current evidence.
   • The protocol should clearly state whether non-English studies will be included or excluded. Language bias can affect the comprehensiveness of the review.

2. Potential Selection Bias:

   • Although the use of two independent reviewers is a strength, the manuscript does not specify how disagreements will be resolved if the third reviewer is unavailable. Providing a contingency plan would strengthen the protocol.
   • The exclusion of unpublished studies, conference abstracts, and grey literature may limit the comprehensiveness of the review and introduce publication bias. The authors should consider including these sources or justify their exclusion.

3. Limited Focus on Technological Barriers:

   • The manuscript highlights the benefits of telerehabilitation but does not adequately address the potential barriers, such as digital literacy, access to technology, and socioeconomic disparities. Including these factors in the discussion could enhance the study's relevance.
   • It would be beneficial to include an analysis of patient engagement and adherence rates in telerehabilitation, as these factors significantly impact outcomes but are not well addressed in the protocol.

4. Insufficient Detail on Statistical Analysis:

   • The manuscript lacks details on how the data will be synthesized and analyzed. While a narrative synthesis is mentioned, there is no discussion on whether a meta-analysis will be performed if sufficient data is available. Providing more detail on the planned statistical methods would improve the rigor of the protocol.
   • The authors could consider including a sensitivity analysis to assess the robustness of the findings, especially if a meta-analysis is conducted.

5. Potential Redundancy in Terminology:

   • The use of terms such as "tele-nursing," "telemedicine," "e-health," and "mHealth" is somewhat overlapping. Streamlining these terms or providing clear definitions would improve the manuscript’s clarity.

6. Quality Assessment Tool:

   • While the Crowe Critical Appraisal Tool (CCAT) is a robust instrument, it may not be well-known to some readers. A brief explanation of why this tool was chosen over more commonly used tools (e.g., Cochrane Risk of Bias Tool, ROBINS-I) would strengthen the methodology section.

Specific Recommendations:

1. Enhance the Search Strategy:

   • Provide a sample search string for each database in the appendix to enhance reproducibility.
   • Consider including additional databases like EMBASE and Web of Science to capture more relevant studies.

2. Improve the Data Synthesis Section:

   • Outline specific statistical techniques that will be used for meta-analysis (e.g., random-effects model) if the data allows.
   • Include plans for subgroup analyses, such as differences based on age, gender, or comorbidities, which could influence the outcomes of telerehabilitation.

3. Address Ethical Considerations:

   • The manuscript currently states "not applicable" for ethical approval and informed consent. However, systematic reviews still need to ensure ethical standards, such as the proper handling of patient data from included studies. Consider adding a section addressing data privacy and ethical considerations.

4. Include a Conceptual Framework:

   • Adding a conceptual framework or a flow diagram summarizing the systematic review process (based on PRISMA) would enhance the manuscript's clarity and guide readers through the review process.

5. Discussion and Future Directions:

   • Expand on the potential implications of the findings for clinical practice, especially regarding how telerehabilitation can be integrated into existing healthcare systems.
   • Address potential challenges in implementing telerehabilitation, such as reimbursement issues, regulatory hurdles, and patient preferences.

Conclusion:

The manuscript presents a well-organized and timely review protocol that addresses an important gap in the literature regarding cardiac telerehabilitation. However, some areas require further elaboration to enhance the clarity and robustness of the protocol. Addressing the limitations and suggestions mentioned above would improve the manuscript and increase its potential impact.

Overall Rating:

• Originality: 8/10
• Scientific Rigor: 7/10
• Clarity of Writing: 6/10
• Clinical Relevance: 8/10

Recommendation: Minor revisions are needed before the manuscript is considered for publication.

Author Response

Dear reviewer, 

Thank you for taking the time to review our manuscript and for providing such constructive and thoughtful comments. Your feedback has been invaluable in helping us improve the quality and clarity of our work. To address your suggestions, we have prepared a detailed response to all your comments and have incorporated the requested revisions into the manuscript. Specifically, we have collected all the comments in a single file, attached. In this document you will find each comment followed by our corresponding response. We greatly appreciate your constructive input, which has significantly contributed to improving the quality of our manuscript. 

Please do not hesitate to contact us if further clarification is needed.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Please note spelling error on line 93

Typo in the population column of Table 2 - search strategy. 

Author Response

Dear reviewer, 

Thank you very much for pointing out the errors. We have corrected and highlighted the “Eligibility Criteria” and in Table 2 the 'typographical error.