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. 2023 Dec 21;18(12):e0291686. doi: 10.1371/journal.pone.0291686

Burden and predictors of heart failure treatment outcomes in Ethiopia: A systematic review and meta-analysis protocol

Firomsa Bekele 1,*, Lalise Tafese 2, Bayisa Garbessa 3, Shimalis Tadasa 4, Ginenus Fekadu 1,5
Editor: Tariq Jamal Siddiqi6
PMCID: PMC10735021  PMID: 38127971

Abstract

Background

Heart failure is an important global health problem which is associated with high mortality. Uncontrolled heart failure leads to hospitalization and reduction in quality of life. Therefore, the study aimed to assess the treatment outcome such as improved, death, hospitalization, and self-discharges without improvement and associated factors in heart failure patients admitted to south western Ethiopian hospitals.

Methods

We will use databases such as PubMed, Science Direct, HINARI, Scopus and Google Scholar. The final systematic review and meta-analysis will contain papers that fulfill the eligible criteria. A systematic data extraction check list will be used to extract the data, and STATA version 14 will be used for the analysis. Heterogeneity is evaluated using the I2 tests and the Cochrane Q test statistic. To examine publication bias, a funnel plot, Egger’s weighted regression, and Begg’s test are utilized. The sensitivity analysis and subgroup analysis will be done for studies having heterogeneity. The Joanna Briggs institute meta-analysis of statistics assessment and review instrument (JBI- MAStARI) will be used for quality assessment.

Discussion

This protocol is expected to provide adequate evidence on the burden of poor heart failure treatment outcome that includes self-discharge, developing complication and finally leads to death in acute and chronic heart failure patients in Ethiopia. Furthermore, to enrich our estimation, we also intended to assess the associated factors of poor treatment outcome. Therefore, our review will call for government and non-government interventions in reducing the mortality associated with heart failure.

Introduction

Heart failure (HF) is a complex clinical syndrome characterized by the reduced ability of the heart to pump and/or fill with blood. It can also be defined as an inadequate cardiac output to meet metabolic demands [1]. The complex clinical syndrome of HF is associated with a wide spectrum of left ventricular functional abnormalities that is manifested as dyspnea, fatigue, poor exercise tolerance, and fluid retention [2, 3].

Globally, the magnitude of heart failure is 64.34 million [4]. HF is a well-recognized public health problem representing a significant burden for patients and healthcare systems in developed countries [5]. It is a major public health issue, with a prevalence of 6.5 million in the United States (U.S) [6]. The prevalence of HF in the U.S is projected to increase by 46% between 2012 and 2030 (3). HF is a growing problem in Africa, particularly in sub-Saharan Africa [7]. A study conducted in Ethiopia indicated that HF is one of the most common cardiovascular diseases which counted 23.9% [8].

In Ethiopia, different heart failure treatment outcomes such as improved, death, hospitalization, and self-discharge without improvement were reported. High in-hospital mortality (17.2%) was observed among acute heart failure patients admitted to a Tikur Anbessa Specialized Hospital, Addis Ababa [9], Debre Markos Comprehensive Specialized Hospital (12.7%) [10], and University of Gondar Comprehensive Specialized Hospital(10.6%) [11]. In Jimma Medical Center, a total of 51 (21.1%) patients were hospitalized, and 58 (24.0%) of patients had worsened clinical states [12]. The limitation of the previous study was the single setting of the study that cannot be generalized to other settings. The various reports of heart failure mortality and hospitalization necessitate the systematic review and meta-analysis study across Ethiopia.

The good self-care practices among heart failure a patient is viewed as the cornerstone of heart failure (HF) therapy and entails essential practices that have been shown to improve HF clinical outcomes. These include appropriate adherence to prescribed medication, sodium diet restriction, physical activity, reducing liquid intake, and weight reduction [13]. Besides to non-pharmacological management of heart failure, Angiotensin-converting enzyme inhibitors, beta-blockers, and mineralocorticoid receptor antagonists are medications that can be used to treat heart failure (HF) and reduce mortality and hospitalization [12, 14].

Coordinated discharge planning and the establishment of a properly structured follow-up treatment are two strategies that have been created to lower mortality and morbidity during the sensitive post-discharge period [15]. However, HF hospitalizations and readmissions are frequent, and residual mortality is still high in developed nations [5, 16–18]. Within the first 30 days of discharge, 20% of HF patients were readmitted to the hospital [15]. Heart failure treatment outcomes that includes improved, death, hospitalization, and self-discharge without improvement were poor, according to several studies conducted in Ethiopia [9, 12, 19].

It has been shown the presence of co-morbidity, drug therapy problem, smoking cigarette are the risk factors that are associated with poor treatment outcomes such as death, hospitalization, and self-discharges without improvement [9, 20, 21]. Despite a variable reports of magnitude and predictors of heart failure treatment outcomes (improved, death, hospitalization, and self-discharge without improvement) in Ethiopia, there was no systematic review and meta-analysis conducted and the purpose of this paper is to develop a protocol to summarize the recent findings on factors related to poor treatment outcome such as death, hospitalization, and self-discharges without improvement in order to provide an appropriate intervention.

The study will identify the predictors of mortality among heart failure patients. The finding will help in optimizing patient’s heart failure therapy by providing a recommendation for hospital administrators and health care organization to implement Clinical Pharmacy services in health care policy of Ethiopia. The Clinical Pharmacy services will also reduce the treatment burden, hospitalization and untoward effects of heart failure medications.

The study will assist policy makers in improving the evidence for planning various types of interventions in the specific context of decreasing mortality from heart failure. Besides, it will help the government in developing the standard treatment guidelines and evaluating the effect of their program on heart failure patients. The review will help in the clinical practice by providing appropriate treatments and addressing factors associated with poor heart failure outcome such as death, hospitalization, and self-discharges without improvement. Finally, our study will be used as a benchmark for future researchers conducting the interventional studies to reduce heart failure hospitalization and mortality.

Study objectives

General objectives

The aim of this systematic review and meta-analysis is to estimate the pooled magnitude of heart failure treatment outcome and associated factors

Specific objectives

To assess the burden of heart failure treatment outcome in Ethiopia.

To assess the risk factors of heart failure treatment outcome in Ethiopia.

Research questions

General questions

This protocol aims to answering the questions: what is the burden of heart failure treatment outcome in Ethiopia, as well as what determines the poor treatment outcome?

Specific questions

What is the burden of poor heart failure treatment outcome in Ethiopia?

What are the associated factors of heart failure treatment outcome?

Materials and methods

Study design

The protocol of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-P) checklist will be used to undertake this systematic review and meta-analysis [22]. The Review protocol was registered on PROSPERO CRD 42023437397. The PRISMA flow diagram will be used [Fig 1].

Fig 1. Flow chart of the systematic research and study selection process.

Fig 1

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Quality assessment and risk of bias

The Joanna Briggs institute meta-analysis of statistics assessment and review instrument (JBI- MAStARI) will be used for quality assessment [23]. The criteria used for assessing the quality of included studies are as follows; are the criteria for inclusion in the sample clearly defined?, are the study subjects and the setting described in detail?, is the exposure measured in a valid and reliable way?, are objective, standard criteria used for measurement of the condition?, are confounding factors identified?, are strategies to deal with confounding factors stated?, are the outcomes measured in a valid and reliable way?, and is appropriate statistical analysis used?.

Two authors will assess the risk of bias among the studies. The disagreement between the authors will be solved by discussion. The type of bias will be identified for all studies

Outcome measurement

There are two main outcomes. The primary outcome of interest is the prevalence of poor heart failure treatment outcome, which will be estimated as the total number of patients having poor treatment outcome divided by the total number of heart failure patients multiplied by 100. The second outcome is identifying factors associated with poor treatment outcome, which are determined using the odds ratio (OR) and calculated based on binary outcomes from the included primary studies. Independent variables that have association with the primary outcome (heart failure treatment outcome) will be included in the meta-analysis in order to identify the association between heart failure treatment outcome and independent variables that includes socio-demographic and clinical characteristics. The pooled finding of the meta-analysis will be identified to predict the final pooled association. This will be done on Microsoft excel heet as listing as authors name, factors associated with heart failure treatment outcome, odds ratio, lower class limit, upper class limit, log of lower class limit, log of upper class limit, log of odds ratio and selog of odds ratio.

Operational definitions

Treatment outcome. The achievement of a specified end result like improvement and/or mortality [9].

Poor outcome. Hospital mortality secondary to congestive heart failure (CHF), self-discharges, and presents with complications [9].

Good outcome. Patients that was improved at discharge [9].

Eligibility criteria

The findings published related to magnitude and predictors of heart failure treatment outcome in Ethiopia having all primary outcome and full texts available will be included. The articles with unknown primary outcomes, systematic reviews and meta-analysis studies, not peer reviewed and commentary to editors will not be eligible. The review will use the CoCoPop (condition, Context, and Population) framework to assess the eligibility of the studies.

The study Population (POP) is the adult heart failure patients greater than 18 years having a co-morbidity of renal insufficiency, stroke, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and anemia. The Condition (CO) is heart failure treatment outcome that includes improved, death, hospitalization, and self-discharge without improvement, and the context (CO) studies conducted in Ethiopia.

Searching strategy

The time period used to conduct search of the literature review will be on September 21, 2024. The primary searching data bases will includes PubMed, HINARI, Science direct, Scopus and Google scholar. The primary data on magnitude and associated factors of heart failure treatment outcome will be retrieved. The search term will include the MESH terms, Boolean operators, free text, key words and gray literature searches. The MESH term for the database is ((heart failure treatment outcome) OR (prevalence)) mortality OR (associated factors) AND (Ethiopia).

Data collection process, items and extraction

Two authors namely FB and LT will be involved in collecting different literatures. Reference management software (endnote version X7.2) will be used to combine search results from databases and to remove duplicate articles. Data will be extracted by three data extractors (ST, GF and BG) using a standardized data extraction checklist on Microsoft excel. For the first outcome (magnitude), the data extraction checklist includes author name, year of publication, region, study design, sample size and number of participants with the outcome. For the second outcome (associated factors), data will be extracted in a format of two by two tables, and then the log OR for each factor will be calculated based on the findings of the original studies. Discrepancies between two independent reviewers will be resolved by involving a third reviewer (FB) after discussion for possible consensus. LT and GF will oversee the overall process of data extraction and synthesis.

Ethical approval and consent to participate

No ethical approval will be needed because data from previous published studies in which informed consent was obtained by primary investigators will be retrieved and analyzed. No human subject participants will be involved. The participant recruitment dates and/or date on which medical records were accessed were mentioned by previous studies.

Data analysis and synthesis

Data will be exported to STATA V. 14 to calculate the pooled effect size with 95% CIs. To check heterogeneity among the studies, the Cochran Q test (chi-squared statistic) and I2 statistic on forest plots will be computed. Cochran’s Q statistical heterogeneity test will be considered statistically significant at P ≤ 0.05. I2 statistics range from 0 to 100% and I2 statistic values of 0, 25, 50, and 75% are considered as no, low, moderate, and high degrees of heterogeneity, respectively. The subgroup analysis and sensitivity analysis will be done if the heterogeneity is reported. A random effect model was used if heterogeneity is present and whereas a fixed effect model is used if the study variation is not occurred. A funnel plot will be used to assess publication bias. Asymmetry of the funnel plot is an indicator of publication bias. Besides, Egger’s weighted regression and Begg’s test will be used to check publication bias. Statistical significance of publication bias will be declared at a P-value of less than 0.05.

Discussion

Heart failure, which affects around 26 million people globally and is linked to high mortality, is a significant global health issue. The industrialized world provides the majority of the information on heart failure patient outcomes, while underdeveloped nations like Ethiopia provide significantly less data. Based on the little information available, low- and middle-income countries’ (LMIC) heart failure patient mortality may be higher than in high-income nations. As a result, both cardiac variables such as decreased ejection fraction, prolonged hospital stay, advanced stage of heart failure, higher class of heart failure and non-cardiac variables that includes being an elder, being a male, the presence of medication related problem, drinking alcohol and the presence of co-morbidity continued to cause significant geographical variations in heart failure patient mortality. The infrastructure, quality, and accessibility of healthcare as well as environmental and genetic factors may all contribute to regional disparities in mortality.

According to the authors’ knowledge, there hasn’t been a review published yet on determining how Ethiopian patients with heart failure are being treated thus far. The study will aim to identify the burden and predictors of poor heart failure outcomes that includes mortality, self-discharge without improvement of the disease in poor resource settings. The finding will update the evidence based decisions among heart failure patients in Ethiopia.

Both published and unpublished research will be considered in the investigation in order to better understand the pooled prevalence of heart failure treatment result and its associated factors. Hence, the systematic reviews and meta-analysis study is needed to summarize the outcome of heart failure in Ethiopia. Furthermore, to enrich our estimation, we will also intended to assess the prevalence of poor treatment outcome that includes self-discharge, developing complication and finally leads to death in acute and chronic heart failure patients. Besides, we aim to assess the predictors of poor treatment outcome to early tackle the worsening situations. Therefore, our review will call for government and non-government interventions in reducing the mortality associated with heart failure. The study will assist policy makers in improving the evidence for planning various types of interventions in the specific context of decreasing mortality from heart failure. Besides, it will help the government in developing the standard treatment guidelines and evaluating the effect of their program on heart failure patients. The review will help in the clinical practice by providing appropriate treatments and addressing factors associated with poor heart failure outcome such as mortality. Finally, our study will be used as a benchmark for future researchers conducting the interventional studies to reduce heart failure hospitalization and mortality.

Undoubtedly, the result of our review will be disseminated to the stakeholders through research conferences, and workshops. Furthermore, the finding will be published in highly ranked journals. Including studies published only in the English language, which might impose bias on the outcome, and the lack of free access to some databases like EMBASE is the limitation of the study. Therefore, the finding of the study should carefully generalize to outsides of the study area.

Conclusion

The finding of our review will provide the insight for the burden of heart failure in poor resource country. The result might provide a baseline for developing the interventions and evaluating the program to combat burden of the disease. It will also help identify risk factors of mortality secondary to heart failure. Finally it will provide a clue on the importance of clinical pharmacist in monitoring drug therapy of heart failure patients and designing standard treatment guidelines for hospitalized heart failure patients.

Supporting information

S1 Checklist. PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist.

(DOC)

Click here for additional data file. (80.5KB, doc)

Abbreviations

OR

Odds Ratio

CHF

Congestive Heart failure

CI

Confidence Interval

LMIC

low- and middle-income countries

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-analyses

Data Availability

The data are only available upon request. The data would be guarded carefully by our third party data for the only purpose of this scientific study. Participants were not signed consent for data publicly. For all these reasons and following the indications of the research review committee of College of Health Sciences, Mettu University, the authors must not upload the dataset to a stable, public repository. Interested, qualified researchers can access the data by requesting our third party, Mattu University (mattuniversity@meu.edu.et).

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Tariq Jamal Siddiqi

22 Aug 2023

PONE-D-23-18181Burden and predictors of heart failure treatment outcomes in Ethiopia: A systematic review and meta-analysis protocolPLOS ONE

Dear Dr. Bekele,

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.

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Reviewer #1: Yes

Reviewer #2: Yes

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

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Reviewer #1: Thank you for submitting your article for consideration to Plos One. The meta-analysis protocol is well-written and detailed. Some minor additions will help strengthen the protocol.

1) It would be beneficial to provide details on how secondary outcomes will be handled, or why they might not be applicable to this study.

2) While the discussion is detailed and well-thought-out, it may be helpful to give more emphasis on the impact of this study on policy-making, clinical practice, and future research in Ethiopia.

Reviewer #2: In their study protocol on “Burden and predictors of heart failure treatment outcome in Ethiopia: A systematic review and meta-analysis protocol,” the authors present a crucial investigation that addresses a significant global health issue. Heart Failure affects millions worldwide, and optimizing treatment outcomes in this population is of paramount importance for their overall well-being and healthcare management in Ethiopia. However, to further enhance the impact and robustness of this study protocol the authors should consider addressing the following points.

1. Pages 8-9, Introduction Section: The introduction efficiently presents the topic of the study. However, the authors should consider providing a comprehensive review of the existing literature to further enhance the introduction. For instance, the authors could include more specific details from relevant studies in Ethiopia related to heart failure outcomes and address the strengths and weaknesses of previous research. By doing so, the authors can better set the context for their study and emphasize its significance.

2. Pages 8-9, Introduction Section: The authors could also further explain the potential impact of the study on patient care and healthcare interventions in Ethiopia by explaining how the findings may improve clinical practice and policies. This will strengthen the study's credibility and create a sense of importance and urgency in addressing heart failure treatment outcomes.

3. Pages 8-9, Introduction Section: The term “treatment outcome” has been used throughout the introduction, but it would be helpful if the authors could further elaborate on this and explain in the introduction section what treatment outcome entails in the context of heart failure in Ethiopia. This will help improve the clarity and understanding of the reader.

4. Pages 9-11, Methodology Section: The authors have provided a very well-structured and comprehensive methodology. However, they should consider clarifying and providing more specific details about the Condition (CO) and Population (POP) of the study. For example, they could specify the age ranges and comorbidities of the population and explain the type and severity of heart failure treatment outcomes considered. This will help enhance the robustness and reliability of the study.

5. Pages 9-11, Methodology Section: While the methodology mentions using The Joanna Briggs Institute meta-analysis of statistics assessment and review instrument (JBIMAStARI) for quality assessment. It would be helpful if the authors could provide a brief explanation of the key elements assessed in (JBIMAStARI), as doing so will improve the reliability and transparency of the study.

6. Page 12, Discussion Section: The discussion effectively mentions the potential geographical variation in heart failure patient mortality due to cardiac and non-cardiac variables. However, to further strengthen the discussion the authors should consider providing specific examples or explanations of these variables. This will help improve the readers’ understanding.

7. Page 12, Discussion Section: While the authors acknowledge the absence of published reviews on Ethiopian patients with heart failure, the discussion could be improved by highlighting the unique nature of this study's objectives and its potential to guide evidence-based interventions. This will help underscore the significance and relevance of the research in advancing heart failure management and care in Ethiopian patients.

8. Page 12, Discussion Section: This section briefly mentions language bias and lack of access to some databases as limitations. To improve the study protocol, it would be helpful to elaborate on the potential implications of these limitations on the generalizability of the study's findings. By doing so the authors can bolster the overall rigor and reliability of the study.

9. Page 12, Discussion Section: Please consider revising the phrase “including studies published only in English language that might impose bias on the outcome and lack of free assess of some database like EMBASE.” To “including studies published only in the English language, which might impose bias on the outcome, and the lack of free access to some databases like EMBASE.” This will help improve the clarity and readability of the text.

**********

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Reviewer #1: Yes: Mahammed Z Khan suheb

Reviewer #2: No

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PLoS One. 2023 Dec 21;18(12):e0291686. doi: 10.1371/journal.pone.0291686.r002

Author response to Decision Letter 0

29 Aug 2023

Tariq Jamal Siddiqi

Academic Editor of PLOS ONE

Dear Editor of the manuscript PONE-D-23-18181 entitled “Burden and predictors of heart failure treatment outcomes in Ethiopia: A systematic review and meta-analysis protocol" submitted to PLOS ONE. Thanks for your time and consideration in editing and reviewing the manuscript. We have carefully read your comments and corrected inline of your comments and suggestions. All comments raised were edited and incorporated in the revised manuscript. Here are the responses and elaborations for the comments from the reviewers!

REVIEWERS COMMENT

Reviewer 1:

Reviewer comment: It would be beneficial to provide details on how secondary outcomes will be handled, or why they might not be applicable to this study.

Author response: We have mentioned the secondary outcomes and clearly stated the procedures to handle it in revised manuscript under Outcome measurement section of revised manuscript

Reviewer comment: While the discussion is detailed and well-thought-out, it may be helpful to give more emphasis on the impact of this study on policy-making, clinical practice, and future research in Ethiopia.

Author response: The impact of the study was discussed in revised manuscript

Reviewer 2:

Reviewer comment: Pages 8-9, Introduction Section: The introduction efficiently presents the topic of the study. However, the authors should consider providing a comprehensive review of the existing literature to further enhance the introduction. For instance, the authors could include more specific details from relevant studies in Ethiopia related to heart failure outcomes and address the strengths and weaknesses of previous research. By doing so, the authors can better set the context for their study and emphasize its significance.

Author response: We have included additional the important literatures related to heart failure outcomes under introduction section of revised manuscript. The strengths and weaknesses of previous research were mentioned.

Reviewer comment: Pages 8-9, Introduction Section: The authors could also further explain the potential impact of the study on patient care and healthcare interventions in Ethiopia by explaining how the findings may improve clinical practice and policies. This will strengthen the study's credibility and create a sense of importance and urgency in addressing heart failure treatment outcomes.

Author response: The significance/impact of the study was described in revised manuscript

Reviewer comment: Pages 8-9, Introduction Section: The term “treatment outcome” has been used throughout the introduction, but it would be helpful if the authors could further elaborate on this and explain in the introduction section what treatment outcome entails in the context of heart failure in Ethiopia. This will help improve the clarity and understanding of the reader.

Author response: We have elaborated it in revised manuscript as heart failure treatment outcomes includes improved, death, hospitalization, and self-discharge without improvement

Reviewer comment: Pages 9-11, Methodology Section: The authors have provided a very well-structured and comprehensive methodology. However, they should consider clarifying and providing more specific details about the Condition (CO) and Population (POP) of the study. For example, they could specify the age ranges and comorbidities of the population and explain the type and severity of heart failure treatment outcomes considered. This will help enhance the robustness and reliability of the study.

Author response: We have provided more details of Condition and Population in revised manuscript

Reviewer comment: Pages 9-11, Methodology Section: While the methodology mentions using The Joanna Briggs Institute meta-analysis of statistics assessment and review instrument (JBIMAStARI) for quality assessment. It would be helpful if the authors could provide a brief explanation of the key elements assessed in (JBIMAStARI), as doing so will improve the reliability and transparency of the study.

Author response: The key elements of JBIMAStARI was described under the Quality assessment and risk of bias section of revised manuscript.

Reviewer comment: Page 12, Discussion Section: The discussion effectively mentions the potential geographical variation in heart failure patient mortality due to cardiac and non-cardiac variables. However, to further strengthen the discussion the authors should consider providing specific examples or explanations of these variables. This will help improve the readers’ understanding.

Author response: We have mentions the specific examples of cardiac and non-cardiac variables in revised manuscript as the cardiac variables includes decreased ejection fraction, prolonged hospital stay, advanced stage of heart failure, higher class of heart failure and non-cardiac variables includes being an elder, being a male, the presence of medication related problem, drinking alcohol and the presence of co-morbidity.

Reviewer comment: Page 12, Discussion Section: While the authors acknowledge the absence of published reviews on Ethiopian patients with heart failure, the discussion could be improved by highlighting the unique nature of this study's objectives and its potential to guide evidence-based interventions. This will help underscore the significance and relevance of the research in advancing heart failure management and care in Ethiopian patients.

Author response: We have added the study objectives and impact of the study on health care interventions in the revised manuscript.

Reviewer comment: Page 12, Discussion Section: This section briefly mentions language bias and lack of access to some databases as limitations. To improve the study protocol, it would be helpful to elaborate on the potential implications of these limitations on the generalizability of the study's findings. By doing so the authors can bolster the overall rigor and reliability of the study.

Author response: We have added the potential implications of limitations on the generalizability of the study's findings in revised manuscript

Reviewer comment: Page 12, Discussion Section: Please consider revising the phrase “including studies published only in English language that might impose bias on the outcome and lack of free assess of some database like EMBASE.” To “including studies published only in the English language, which might impose bias on the outcome, and the lack of free access to some databases like EMBASE.” This will help improve the clarity and readability of the text.

Author response: We have edited as per your comment

Thanks for your time and consideration,

Regards!

Attachment

Submitted filename: CHF Protocol RESPONSE.docx

Click here for additional data file. (29.5KB, docx)

Decision Letter 1

Tariq Jamal Siddiqi

4 Sep 2023

Burden and predictors of heart failure treatment outcomes in Ethiopia: A systematic review and meta-analysis protocol

PONE-D-23-18181R1

Dear Dr. Bekele,

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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Kind regards,

Tariq Jamal Siddiqi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Tariq Jamal Siddiqi

13 Dec 2023

PONE-D-23-18181R1

PLOS ONE

Dear Dr. Bekele Negera,

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on behalf of

Dr. Tariq Jamal Siddiqi

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist.

    (DOC)

    Click here for additional data file. (80.5KB, doc)
    Attachment

    Submitted filename: CHF Protocol RESPONSE.docx

    Click here for additional data file. (29.5KB, docx)

    Data Availability Statement

    The data are only available upon request. The data would be guarded carefully by our third party data for the only purpose of this scientific study. Participants were not signed consent for data publicly. For all these reasons and following the indications of the research review committee of College of Health Sciences, Mettu University, the authors must not upload the dataset to a stable, public repository. Interested, qualified researchers can access the data by requesting our third party, Mattu University (mattuniversity@meu.edu.et).

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