Telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic: A scoping review protocol.

INTRODUCTION: Outpatient care for children and adolescents with chronic conditions needs to be continuous and programmed, encompassing comprehensive care, with periodically scheduled consultations, exams, and procedures, to promote quality of life and reduce mortality. In the context of the new coronavirus pandemic, however, outpatient care for children and adolescents with chronic conditions, in person, was hampered in favor of social isolation, a necessary sanitary measure to reduce and prevent the spread of Coronavirus Disease 2019. In response to this need, studies suggest telehealth in pediatrics as a fertile and expanding field especially in times of pandemics. Here, we aimed to map the evidence related to telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic, to identify which strategies were implemented and their impacts on the continuity of care.
METHODS: A scoping review protocol is reported and guided by the Scoping Reviews Manual of the Joanna Briggs Institute. The search for evidence will cover the following databases: MEDLINE/PubMed, Cochrane Libary; Embase; Web of Science; Scopus; Cinahl and PsycINFO, plus additional sources, such as The British Library, Google Scholar, and Preprints [medRXiv]. No date or language restrictions will be employed in this scoping review. Two independent researchers will conduct the search strategy, study selection, data charting, and data synthesis.
RESULTS: The findings will be presented through tables, charts, narrative summaries, and assessed based on the type of data charted as well as outcomes. Additionally, the meaning of these findings will be considered as they relate to the guiding question, the characterization and measurement of the impact of different telehealth modalities used in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic, and the implications for practice and further research. DISCUSSION: To the best of our knowledge, this will be the first scoping review to look specifically at the telehealth modalities to be used in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic. We expect that our results will be of interest to practitioners as well as researchers concerned with this particular emerging issue in the pandemic context. Also, the plans for the dissemination of this study comprise peer-reviewed publication and conference presentations. TRIAL REGISTRATION: Open Science Framework Registration: osf.io/5pqgu.

Introduction

Chronic conditions encompass a broad category of health problems with biological, psychological, or cognitive causes [1]. These include transmissible diseases such as HIV/AIDS and tuberculosis; non-communicable diseases such as cardiovascular disease, cancer, chronic respiratory diseases, diabetes; long-term mental disorders, and structural disabilities [2].

The prevalence of chronic conditions in childhood has increased by more than 400% in the last 50 years, favoring the occurrence of comorbidities, a large number of hospitalizations, and a high degree of mortality [3]. A retrospective observational study in a pediatric intensive care unit of a hospital in London found that 46% of hospitalized patients had at least one chronic health condition. Also, these children remained hospitalized longer, increasing the chances of mortality [4]. A prospective, multicenter, observational cohort study conducted in 19 pediatric care units of hospitals in Argentina identified that 48% of hospitalized children had one or more chronic conditions, the most prevalent being cardiovascular diseases (22.24%), neuromuscular diseases (18.75%), and genetic diseases (17.7%) [5].

Children and adolescents with chronic conditions demand high hospital readmission rates, as exemplified in a cohort study in 37 pediatric hospitals in the USA with a sample of 69,294 children. Of the total, 18.8% were readmitted to the service, 89.0% of whom had complex chronic conditions, 52.6% used technological devices, and 2.9% were readmitted more than four times within a year [6].

In this sense, outpatient care for children and adolescents with chronic conditions needs to be continuous and programmed, encompassing comprehensive care, with periodically scheduled consultations, exams, and procedures [1], to promote quality of life and reduce mortality. In the context of the new coronavirus pandemic, however, outpatient care for children and adolescents with chronic conditions, in person, was hampered [7] in favor of social isolation, a necessary sanitary measure to reduce and prevent the spread of Coronavirus Disease 2019 (COVID-19) [8].

Research has shown that COVID-19 can lead to more severe complications in people with chronic conditions [9, 10], which reinforces the recommendations of social isolation for this audience. Thus, it is necessary to reflect on innovative outpatient care models that contribute to the continuity of care and comprehensive health care for patients with chronic conditions.

In response to this need, studies suggest telehealth in pediatrics as a fertile and expanding field, especially in times of a pandemic [11-13]. According to the World Health Organization, telehealth refers to health services at a distance, synchronously or asynchronously, through information and communication technologies. This modality makes it possible to carry out clinical care, diagnoses, treatments, prevention of diseases and injuries, research, and evaluation. Another potential use is in continuing education for health professionals [14].

Telehealth is being used in several countries worldwide [15-21], especially in non-emergency/routine care and in cases where services do not require direct patient-provider interaction such as providing psychological services, mainly in the current scenario of COVID-19 pandemic in order to nullify the barriers imposed by the COVID-19 pandemic. Additionally, telehealth can become a basic need for the general population, health care providers, and patients with COVID-19, mainly when people are in quarantine, enabling patients in real time through contact with health care provider for advice on their health problems.

Telehealth can positively affect the care of children and adolescents with chronic conditions. They need long-term, programmed care, but traveling to the health service can lead to a greater risk of contagion. Therefore, innovative care models are needed, such as care provision using remote methods. Hence, this study aims to map the evidence related to telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic. Another aim is to identify the strategies implemented and their impacts on the continuity of care.

Methods

This study is a scoping review (ScR) type, which aims to map the key concepts of a particular field of research to clarify definitions and conceptual limits. Additional aims are to identify evidence, analyze knowledge gaps and examine how research is conducted in a given field [22], providing a descriptive analysis of the included studies [23].

The methodological framework described by Arksey and O’Malley [22], and further outlined in the Scoping Reviews Manual [24] of the Joanna Briggs Institute (JBI) serves as a guide for this ScR. The five steps of the ScR include (I) identifying the research question; (II) identifying the relevant studies; (III) selecting the studies; (IV) charting the data; and (V) collating, summarizing, and reporting the results; and will be depicted as follows. Additionally, this protocol has been registered within the Open Science Framework (osf.io/5pqgu). This ScR will be reported following the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [25].

Step 1: Identifying the research question

For the construction of the research question, the PCC (Population, Concept, and Context) framework was applied to identify the main concepts and is described in detail as follows:

Population

The target population of this scoping review will be children and adolescents aged 0–19 years with chronic conditions. The World Health Organization (WHO) defines a child as a person under 19 years of age [26].

WHO defines chronic conditions as non-communicable diseases (e.g., diabetes, heart disease, lung diseases, and cancer), persistent communicable diseases (e.g., HIV/AIDS and tuberculosis), long-term mental disorders (e.g., schizophrenia and depression), and ongoing physical impairments or structural problems (e.g., amputations, blindness, and musculoskeletal disorders) [2].

Concept

This scoping review will include studies that address telehealth in child and adolescent care with chronic conditions during the COVID-19 pandemic due to the interruption of face-to-face care in outpatient clinics. For this study, telehealth, according to WHO, refers to the use of information and communication technologies for remote diagnosis and treatment of patients, aiming to promote individual and family health [14].

Context

The context analyzed in this scoping review is outpatient care, which refers to any healthcare consultation, procedure, treatment, or other service that is administered without an overnight stay in a hospital or medical facility. Routine physical examinations with a primary care provider are one common type of outpatient care, but the outpatient market has grown to include services such as: diagnostic imaging like x-rays and MRIs; bloodwork and urine tests; physical therapy; chemotherapy and radiation treatments etc. Additionally, certain surgical procedures like hip and knee replacements, dental surgery, gastric bypass, breast augmentation, and others can even be performed in the outpatient setting. These services are administered in a variety of different outpatient facilities. Some examples include primary care clinics, community health centers, urgent care clinics, ambulatory surgery centers, and even some pharmacies for basic healthcare consultations and immunizations [27]. In this scoping review, we link outpatient care to COVID-19—a disease caused by a new type of beta-coronavirus, capable of causing respiratory, enteric, liver, and neurological conditions [28]. COVID-19 was first identified in a group of patients with pneumonia in December 2019 in Wuhan, China [28], and WHO declared it a pandemic on March 11, 2020 [29].

Thus, after applying the PCC framework [22], the research question raised was: "What are the scientific productions available in the literature on the use of telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic?"

Step 2: Identifying the relevant studies

The search for evidence will cover the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, Cochrane Libary; Excerpta Medica database (Embase); Web of Science; Scopus; Cumulative Index to Nursing and Allied (Cinahl) and Psychology Information (PsycINFO), plus additional sources, such as The British Library (UK), Google Scholar, and Preprints [medRXiv]. For the search strategy, we will include a combination of subject headings, e.g., Medical Subject Headings (MeSH), Emtree, Cinahl headings, Thesaurus, [30, 31]. Additionally, the reference list of all included studies will be reviewed for additional relevant studies. No date or language restrictions will be employed in this scoping review.

To structure the search, as already mentioned, searches were carried out in MEDLINE/PubMed to find the best combination of MeSH terms, synonyms as well as free text words, which will be later adjusted for each electronic database. Following the PCC framework (Population/Concept/Context), a pilot search strategy was established for MEDLINE/PubMed (Table 1):

Table 1

Preliminary pilot search strategy in MEDLINE/PubMed.

MEDLINE/PubMed	Search strategy
	(P)—Population
	#1 ((“Infant” [MeSH Terms] OR “Infants” [Title/Abstract] OR “Child, Preschool” [MeSH Terms] OR “Preschool Child” [Title/Abstract] OR “Children, Preschool” [Title/Abstract] OR “Preschool Children” [Title/Abstract] OR “Child” [MeSH Terms] OR “Children” OR “Adolescent” [MeSH Terms] OR “Adolescents” [Title/Abstract] OR “Adolescence” [Title/Abstract] OR “Teens” [Title/Abstract] OR “Teen” [Title/Abstract] OR “Teenagers” [Title/Abstract] OR “Teenager” [Title/Abstract] OR “Youth” [Title/Abstract] OR “Youths” [Title/Abstract]))
	(C)—Concept
	#2 ((“Telemedicine” [MeSH Terms] OR “Mobile Health” [Title/Abstract] OR “Health, Mobile” [Title/Abstract] OR “mHealth” [Title/Abstract] OR “Telehealth” [Title/Abstract] OR “eHealth” [Title/Abstract] OR “Telehealth” [Title/Abstract] OR “Teleconsultation” [Title/Abstract] OR “Telemonitoring” [Title/Abstract] OR “Telenursing” [Title/Abstract]))
	#3 ((“Chronic Disease” [MeSH Terms] OR “Chronic Diseases” [Title/Abstract] OR “Disease, Chronic” [Title/Abstract] OR “Chronic Illness” [Title/Abstract] OR “Chronic Illnesses [Title/Abstract] OR “Illness, Chronic” [Title/Abstract] OR “Chronic Condition” [Title/Abstract] OR “Chronic Conditions” [Title/Abstract] OR “Condition, Chronic” [Title/Abstract] OR “Chronically Ill” [Title/Abstract]))
	(C)—Context
	#4 (("COVID-19" [MeSH Terms] OR “COVID 19” [Title/Abstract] OR “COVID-19 Virus Disease” [Title/Abstract] OR “2019-nCoV Infection” [Title/Abstract] OR “2019 nCoV Infection” [Title/Abstract] OR “Coronavirus Disease-19” [Title/Abstract] OR “Coronavirus Disease 19” [Title/Abstract] OR “2019 Novel Coronavirus Disease” [Title/Abstract] OR “2019 Novel Coronavirus Infection” [Title/Abstract] OR “2019-nCoV Disease” [Title/Abstract] OR “2019 nCoV Disease” [Title/Abstract] OR “Coronavirus Disease 2019” [Title/Abstract] OR “SARS Coronavirus 2 Infection” [Title/Abstract] OR “SARS-CoV-2 Infection” [Title/Abstract] OR “Infection, SARS-CoV-2” [Title/Abstract] OR “SARS CoV 2 Infection” [Title/Abstract] OR “SARS-CoV-2 Infections” [Title/Abstract] OR “COVID-19 Pandemic” [Title/Abstract] OR “COVID 19 Pandemic” [Title/Abstract] OR “COVID-19 Pandemics” [Title/Abstract] OR “Pandemic, COVID-19” [Title/Abstract] OR “SARS-CoV-2" [MeSH Terms] OR “2019 Novel Coronavirus” [Title/Abstract] OR “Coronavirus, 2019 Novel” [Title/Abstract] OR “Novel Coronavirus, 2019” [Title/Abstract] OR “SARS-CoV-2 Virus” [Title/Abstract] OR “SARS CoV 2 Virus” [Title/Abstract] OR “2019-nCoV” [Title/Abstract] OR “COVID-19 Virus” [Title/Abstract] OR “SARS Coronavirus 2” [Title/Abstract] OR “Coronavirus 2, SARS” [Title/Abstract] OR “Severe Acute Respiratory Syndrome Coronavirus” [Title/Abstract] OR “SARS-CoV-2 variants” [Supplementary Concept] OR “SARS-CoV-2 B.1.1.7 variant” [Title/Abstract]))
	#5 ((“Outpatients” [MeSH Terms] OR “Outpatient” [Title/Abstract] OR “Out-patients” [Title/Abstract] OR “Out patients” [Title/Abstract] OR “Out-patient” [Title/Abstract] OR “Ambulatory Care” [MeSH Terms] OR “Care, Ambulatory” [Title/Abstract] OR “Ambulatory Care Facilities” [Title/Abstract] OR “Outpatient Care” [Title/Abstract] OR “Care, Outpatient” [Title/Abstract] OR “Health Services, Outpatient” [Title/Abstract] OR “Health Service, Outpatient” [Title/Abstract] OR “Outpatient Health Service” [Title/Abstract] OR “Service, Outpatient Health” [Title/Abstract] OR “Outpatient Health Services” [Title/Abstract] OR “Outpatient Services” [Title/Abstract] OR “Outpatient Service” [Title/Abstract] OR “Service, Outpatient” [Title/Abstract] OR “Services, Outpatient” [Title/Abstract] OR “Services, Outpatient Health” [Title/Abstract] OR “Outpatient Clinics, Hospital” [MeSH Terms] OR “Ambulatory Care Facilities, Hospital” [Title/Abstract] OR “Hospital Outpatient Clinics” [Title/Abstract] OR “Clinic, Hospital Outpatient” [Title/Abstract] OR “Clinics, Hospital Outpatient” [Title/Abstract] OR “Hospital Outpatient Clinic” [Title/Abstract] OR “Outpatient Clinic, Hospital” [Title/Abstract]))
	#4: #1 AND #2 AND #3 AND #4 AND #5

Inclusion criteria: all the primary studies, experience reports, dissertations, and theses related to the use of telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic will be included. It is noteworthy that there will be no date or language restriction for the study selection.

Exclusion criteria: studies with adults, even if children and adolescents participate; and studies on acute illnesses that address chronic diseases will be excluded.

Step 3: Selecting the studies

After searching for studies, articles will be downloaded to the Endnote Web™ bibliographic software to store, organize, manage all references and identify duplicates. The studies will then be exported to the Rayyan™ application, which assists in the screening and selection of studies. At this stage, the titles and abstracts will be read to carry out an initial assessment of the evidence. Two independent researchers (LKDSC and LCLJ) will search and screen the records by titles and abstract into the Rayyan™ app. After the initial screening, the same two independent researchers (LKDSC and LCLJ) will assess the full text of studies retrieved for inclusion/exclusion, using the Rayyan™ app. A third reviewer (RAGL) will decide on any disagreements as to the selected studies.

Step 4: Charting the data

Two reviewers/authors (LKDSC and LCLJ) will independently chart the data for each included study based on previously published forms [23, 31–35]. The expected date of completion of this scoping review will be December 2022. Information to be extracted includes a) identification of the study and objectives; b) study design; c) study population and baseline characteristics; d) type of exposure; e) study method; f) recruitment methods; g) times of measurement; h) follow-up; i) outcomes; j) main findings; k) clinical and epidemiological significance; and l) conclusions [23, 31–35].

Results

Step 5: Collating, summarizing, and reporting the results

A flowchart diagram will describe the entire study selection process [23]. For data analysis, a thematic evaluation will be done to describe the mapping and telehealth strategies and modalities used in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic, with a view to reporting which actions were implemented and their impacts on the continuity of care. The systematic assessment of study quality (risk of bias of the included studies) will not be performed, as the intent of this ScR is to provide the mapping and extension of the literature rather than a critical appraisal of the studies like in systematic reviews [23]. Our findings will be presented through tables, charts, narrative summaries, and will be assessed based on the type of data charted and the outcomes. Additionally, the meaning of these findings will be considered as they relate to the guiding question, the characterization and measurement of the impact of different telehealth modalities used in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic, and the implications for practice and further research.

Discussion

The purpose of this ScR is to map the evidence related to telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19. In addition, the purpose is to identify which strategies were implemented and their impacts on the continuity of care. Thus, we will undertake an ScR. We will search across multiple electronic databases, additional sources, and grey literature. The ScR method serves to chart and map results and to establish the directions for future research.

It is noteworthy that there are two aspects in which the study within this protocol differs from others. Firstly, the ScR is more suitable for our study theme than a systematic review. Our research question is quite broad and focuses on mapping the extension of the evidence available. Secondly, we combine qualitative and quantitative methods to report our results, using thematic themes and bibliometric trends to provide efficient guidance and meaningful insights into this field.

The use of new and varied methods to review the evidence and collate and summarize our findings represents the strength of our study. To the best of our knowledge, this will be the first ScR that combines these methods to look specifically at the telehealth modalities used in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic.

We expect that our results will be of interest to practitioners, researchers, and anyone concerned with this particular emerging issue in the pandemic context. In addition, the plans of dissemination of this study comprise peer-reviewed publication and conference presentations.

PRISMA-P 2015 checklist.

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15 Mar 2022

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17 Mar 2022

Response letter to the Editor and reviewers

Ribeirão Preto, SP, Brazil, March 16th , 2022

Coments of Academic Editor, Rizaldy Taslim Pinzon

PONE-D-21-25612

Telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic: a scoping review protocol

PLOS ONE

Dear Dr. Regina Aparecida Garcia Lima

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Response: Dear Dr. Rizaldy Taslim Pinzon,

We would like to thank you for the opportunity to review the manuscript after the reviewers' suggestions and recommendations.

All points were addressed and/or clarified in this new version. In addition, we responded item by item to the questions raised by the reviewers in this letter.

-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.

Response: It is not necessary. Thanks!

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We have carefully reviewed the reference list and we ensure that it is complete and correct. Also, we have no papers retracted cited in this manuscript.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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

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

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

Reviewer #1:

The protocol titled Telehealth in outpatient care for children and adolescents with chronic conditionsduring the COVID-19 pandemic: a scoping review protocol seems to be good study and authors will try to find out ways to follow up chronic cases through telehealth after searching published literatures .

Response: Thank you so much for you positive feedback.

- Hence in introduction I have come comments.

- Line 104: Spell check of highlighted word

Response: Done! Thanks for your careful review.

Line 110-112: Can be omitted

Response: We have omitted the sentence as per suggested. Thanks.

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.

Response: Not applicable

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2 May 2022

7 May 2022

Response to Reviewers

Ribeirão Preto, SP, Brazil, May 5th, 2022

Minor revision

PONE-D-21-25612R1

Telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic: a scoping review protocol

Dear Dr. Regina Aparecida Garcia Lima

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

There are some concern about methodological flaws in your study. Please make the revision based on reviewers suggestion and comments.

Response: Dear Dr. Rizaldy Taslim Pinzon,

Thank you for the opportunity to review the manuscript after the reviewers' suggestions and recommendations.

All points were addressed and/or clarified in this new version. In addition, we responded item by item to the questions raised by the reviewers in this letter.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We have carefully reviewed the reference list and we ensure that it is complete and correct. Also, we have no papers retracted cited in this manuscript.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #2: Yes

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #2: Yes

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #2: No

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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 #2: Yes

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 #2: Yes

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

Reviewer #2:

In the context of the COVID-19 pandemic, this is certainly an interesting project and well targeted. The title is well aligned with the objectives.

Response: Thank you so much for your comments.

However, the methods need an extensive revision. A librarian support is needed in order to render the search strategy more robust.

Response: A librarian was consulted for checking the search strategy. We added in this version the complete strategy revised by the librarian of the Federal University of Espírito Santo, respecting the controlled descriptors (subject indexers in each database) and also combining with the synonyms and keywords in order to make the search strategy broad and robust.

Introduction:

P3 L110 What is clinical weaknesses? Details or more clarifications are needed.

Response: We edited this sentence to make it clearer. “Children and adolescents with chronic conditions demand high hospital readmission rates,……”

P3 L130 -P4 L131-133What this is an added value? Use in what context???

Response: We edited this sentence to make it clearer. “Telehealth is being used in several countries worldwide [15-21], especially in non-emergency/routine care and in cases where services do not require direct patient-provider interaction such as providing psychological services, mainly in the current scenario of COVID-19 pandemic in order to nullify the barriers imposed by the COVID-19 pandemic. Additionally, telehealth can become a basic need for the general population, health care providers, and patients with COVID-19, mainly when people are in quarantine, enabling patients in real time through contact with health care provider for advice on their health problems”.

Methods

P4, L151-155 The reference of Tricco et al 2018 suffices.

Response: OK. Done. Thanks!

P4 L163-4 what is the added value of this classification? In case it is worth, please elaborate.

Response: OK. We removed the classification.

P5 L180-1 the definition of outpatient care is very simplistic and may limit the scope of your findings.

Response: OK. Rewriten.

P5 L194 certainly assumed. So, no need to mention this “using the Boolean terms AND/OR”.

Response: OK. Done.

Table 1 based on the study title and the objectives; some essential key concepts are missing. They are outpatient care and chronic conditions. They are totally ignored.

Response: OK. We have added to the search strategy. Many Thanks!

Table 1 Could authors explain why [All fields] is used. Because it is classical to capture references through titles and abstract. Otherwise, this will lead to incredible volume of « noise ». Please elaborate.

Response: OK. We reworded it with the help of the librarian.

Table 1 Do authors sought a support from librarians? This expertise is essential. #1 AND #2 AND #3 needs AND outpatient…..AND chronic….

Response: OK. We reworded it with the help of the librarian.

The type of design to be included or excluded is not stated.

Response: We have added “study design”. Thanks.

P5 L222 is it a typo «2021».

Response: Sure. Thank you. Edited for “2022”.

P5, L245-6 Please remove this as there is no added value.

Response: Ok. Removed.

P8 L259 In what this is a limitation since you don’t what will be found.

Response: Ok. Removed.

The authors

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31 May 2022

Telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic: a scoping review protocol

PONE-D-21-25612R2

Dear Dr. Lima

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.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Rizaldy Taslim Pinzon

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

2 Jun 2022

PONE-D-21-25612R2

Telehealth in outpatient care for children and adolescents with chronic conditions during the COVID-19 pandemic: a scoping review protocol

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