Title: Can the CANKADO Online Application Improve Quality of Life Monitoring via the
Endometriosis Health Profile-30 in Endometriosis Patients? A Randomized Cohort Study on
Acceptance, Usability, and Correlations with Demographics and Media Usage
Version: 1 Date: 07 Mar 2025
Reviewer's report:
The manuscript presents a relevant and timely investigation into the electronic assessment
of health-related quality of life in patients with endometriosis using the CANKADO online
application. The study is well-structured, with a clear research question and methodology. The
findings are significant in the context of digital health and patient-reported outcomes.  However,
there are several areas where the manuscript could be improved to enhance clarity:
• The randomization process should be described in greater detail, especially how blinding was
maintained when patients selected envelopes.
• The inclusion and exclusion criteria should be explicitly justified in relation to the study’s
objectives. For instance, the rationale for requiring German language proficiency should be
stated explicitly.
• The evaluation metrics for usability (e.g., “handling of the digital questionnaire” and its
subscales) should be explained with greater detail to ensure replicability.
• While the manuscript includes extensive statistical analysis, some key results require clearer
interpretation. For example, the reported significance of completion time differences (T0 vs. T3)
should be explained in the context of user adaptation over time.
• The response rate for the evaluation forms should be critically discussed, particularly at later
time points where attrition may have influenced results.
• The discussion should further integrate the study’s findings with prior research. For instance,
how do these usability findings compare with similar studies in digital health for chronic
gynecological conditions?
• The issue of technical difficulties encountered during the study should be discussed more
thoroughly, with potential solutions for future implementation.
• The implications for clinical practice should be more clearly stated, particularly regarding how
ePRO could be feasibly implemented in routine gynecological care.
• Additionally, the discussion should consider the broader implications of digitalization in
healthcare. While online resources and digital tools are beneficial in an increasingly digital
world, they can also pose challenges. For example, misinformation spread via social media
about various gynecological and non-gynecological conditions may influence patient decisions
and treatment adherence (PMID: 39118465 ; PMID: 38201027 ; PMID: 39729920). This aspect
should be acknowledged, emphasizing the need for reliable and evidence-based online platforms
to counteract misinformation and ensure that digital health interventions effectively support
clinical care.
• The single-center study design is mentioned as limitation , but the potential for selection bias
should be acknowledged.
• The study only included conservatively treated patients; the potential generalizability to
surgically treated patients should be discussed.
• The study’s reliance on self-reported IT skills may introduce bias, as individuals with lower
confidence in their digital literacy may underreport their difficulties.
• Data privacy concerns were noted as a counter-reason for ePRO adoption. More detail should
be provided regarding how patient data security was ensured, which is critical for acceptance
of digital health interventions.