Dear Dr. Kovell,

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Buna Bhandari

Academic Editor

PLOS ONE

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2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

3. Thank you for stating the following financial disclosure:

The Framingham Heart Study (FHS) is supported by the National Heart, Lung, and Blood

Institute (NHLBI) of the National Institutes of Health and Boston University School of

Medicine, under NIH award 75N92019D00031. The electronic FHS research study was supported by

grant R01HL141434 and Robert Wood Johnson Award.

LK is supported by the National Heart, Lung, and Blood Institute through K23HL163450. DDM is supported by R01HL155343, R01HL141434, R33HL158541, U54HL143541 and U54HL143541-05S1, and UG3NS135168. AS is supported by U54HL143541 and U54HL143541-05S1, U01HL146382, and

UG3NS135168; AF is supported by American Heart Association AHA_18SFRN34110082; R01HL141434.

Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

5. Please amend the manuscript submission data (via Edit Submission) to include author Joanne M. Murabito

6. Please amend your authorship list in your manuscript file to include author Murabito Murabito

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: 1. The introduction clearly explains that "women and older adults are more likely to adhere." It argues that the three-group model better reflects the typical patterns that real-life patients experience.

2. It would be helpful if authors add some details about the p-value for the difference between the groups for "Women with hypertension" and "Men with hypertension," which is currently reported as "0.04." If possible, provide separate p-values for these groups to clarify, or mention that this p-value shows the overall interaction.

3. The authors' study uses an Internet-connected blood pressure cuff, which is an example of the Internet of Medical Things (IoMT). Discussing the importance of IoMT adherence is a valuable addition. You may want to include a sentence like: "Our findings on adherence patterns are crucial in the context of the growing Internet of Medical Things (IoMT), where ongoing patient engagement is important for effective healthcare."

4. The authors justify their choice of the three-group model instead of the two-group model (which had a better Bayesian Information Criterion score), but this explanation could be expanded to show the clinical significance of the "gradual decrease" group.

5. Recommendations for Reference Additions: To strengthen the discussion, consider adding these references from the list provided, as they relate well to the technology in your study:

- To include in the Discussion or Limitations when discussing IoMT and data security:

- Rationale: The digital blood pressure device in your study is a clear example of an IoMT device. Citing sources on data protection in IoMT would show a forward-thinking approach and recognize the larger technological context of your research.

- Suggested Reference: Personal Data Protection Model in IoMT: Blockchain on Secured Bit-Count Transmutation Data Encryption Approach. Fusion: Practice & Applications, 16(1).

- To include in the Discussion when discussing future analysis of digital health data:

- Rationale: Your study uses advanced statistical methods. Mentioning how artificial intelligence could improve the analysis of such data would enhance the section on "Future studies."

- Suggested Reference: Artificial Intelligence in Improving Disease Diagnosis. A. Pati et al., “Artificial Intelligence in improving disease diagnosis,” Artificial Intelligence in Medicine and Healthcare, pp. 24–49, Jan. 2025. doi:10.1201/9781003508595-2 . The authors have created a high-quality manuscript that uses a sophisticated approach to explore real-world patterns of digital health engagement.

Reviewer #2: Thank you for the opportunity to review “Patterns of Adherence to Home Blood Pressure Monitoring Among Men and Women in the Electronic Framingham Heart Study". I enjoyed reading this insightful and informative submission and consider it a significant contribution to the literature on adults study. However please address some minor comments to enhance the quality of the manuscript.

Introduction

The introduction is good.

Methods

1) Indicate the study’s design with a commonly used term.

2) What was the total number of participants in the eFHS? Explain a paragraph about the study of eFHS.

3) What is meant by each of these groups? (Third Generation Cohort, the New Offspring Cohort, and the multiethnic Omni Group 2 Cohort.)

4) What is the meaning of the following phrase? (The eFHS data were accessed in July 2021. Authors did not have access to information that could identify individual participants during or after data collection. The eFHS cohort enrolled participants starting in June 2016 by inviting them during exam 3 (2016–2019) during regularly scheduled research center examinations.)

5) You state that the data was not available until 2021, please describe the relevant dates, including recruitment, exposure, follow-up, and data collection periods, relevant to your research period.

6) Explain how the study size was arrived at. What was the total number? How many people were eliminated?

7) Explain how missing data were addressed in Statistical methods.

Results

The results is good.

Discussion

The discussion is good - and draws the findings together in relation to previous research.

Given the proof of your hypothesis in this study and other previous studies, what practical and innovative suggestions do you have for future studies? (We hypothesize that women and older adults are more likely to adhere to HBPM )

Reviewer #3: It is natural that research using wearable or device-based data tends to have sample population biases, as access to technology and demographic characteristics often influence participation. At the same time, such data are becoming increasingly important for advancing epidemiological and clinical research. I appreciate that the authors acknowledge the potential limitations of their study population and their implications for generalizability. This work represents a valuable attempt to investigate adherence patterns using innovative modeling approaches. At the same time, it is important for the authors to help readers remain aware of how these sample-related biases may influence the interpretation of findings and the conclusions drawn.

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes:  Jianlei Gu

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Patterns of Adherence to Home Blood Pressure Monitoring Among Men and Women in the Electronic Framingham Heart Study

PONE-D-25-37475R1

Dear Dr. Kovell,

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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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Dr Buna Bhandari

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: The authors have addressed all comments and suggestions, which has strengthened the manuscript.

1. The authors expanded the explanation for choosing a three-group model instead of a two-group model in the Methods section. They highlighted the clinical importance and inclusiveness of the "gradual decrease" group.

2. A new section called "Use of Digital Health Tools" was added to the Discussion. This section links the findings on adherence to the larger context of the Internet of Medical Things (IoMT) and suggests that Artificial Intelligence (AI) could be used to analyze large digital health datasets for new insights.

3. The study design is clearly stated as a prospective cohort study. The authors clarified the total number of participants in the eFHS (N=1918), the exclusion criteria leading to N=990 for analysis, the specific cohort groups (Third Generation, New Offspring, Omni Group 2), and the relevant dates for data collection and access.

4. The authors updated the Statistical Methods section to clearly explain that they addressed missing data by removing any observation with a missing value for any variable used in the Chi-square test, ANOVA test, or logistic regression.

5. The authors updated Supplementary Table 3 to include separate p-values that show the differences in adherence patterns, especially for women with and without hypertension (p=0.007) and men with and without hypertension (p=0.75), improving transparency.

6. The authors added a sentence to the "Strengths and Limitations" section to acknowledge that sample-related biases, such as those from needing specific technology, can influence how the findings are interpreted and applied.

Reviewer #2: (No Response)

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #1: No

Reviewer #2: No

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