Initial hurdle: the desk rejection stage

The review journey typically begins with an editorial screening, commonly referred to as the desk review. At this stage, editors determine whether a manuscript aligns with the journal’s thematic focus, meets minimum quality standards, and offers adequate novelty. A decision to reject at this point, though discouraging for authors, prevents unnecessary burden on peer reviewers and can expedite overall journal operations. ^{Reference Williams1}

However, this stage can itself become a source of delay. Editors are often inundated with submissions and must balance this workload with other responsibilities. Ambiguous cases, where the decision is not immediately clear-cut, may require internal consultations or multiple rounds of scrutiny, further extending response times. The establishment of transparent screening criteria and more streamlined editorial workflows may reduce delays at this phase. ^{Reference Williams1}

Reviewer identification: the primary Bottleneck

Once a manuscript passes the editorial filter, the most significant impediment often emerges identifying willing and qualified reviewers. While it may appear routine, this step is highly resource-intensive. Editors must locate experts with appropriate subject matter expertise, absence of conflicts of interest, and sufficient availability—a confluence that is increasingly rare. ^{Reference Ho2,Reference Lipworth3}

In niche disciplines, the scarcity of available reviewers is even more pronounced. Even when suitable candidates are identified, many decline due to workload saturation—balancing teaching, administrative duties, grant writing, and their own scholarly endeavours. This necessitates a cycle of invitations, follow-ups, and replacements, contributing substantially to delays. ^{Reference Lovrenčić4–Reference Smith7}

Geographic and seasonal constraints further compound the problem. Reviewer availability fluctuates during academic breaks, holidays, and peak submission seasons, resulting in asynchronous communications and deferred responses.

Delays after reviewer assignment: a multifactorial challenge

Strategies for enhancing efficiency

While some delays may be unavoidable, several targeted strategies can mitigate their frequency and impact.

Author’s view-point

Authors frequently perceive the review process as excessively prolonged, attributing this to reviewers’ preoccupation with minutiae, compelling authors to conform to their subjective perspectives, thereby stifling original thought, coercing authors into superfluous revisions, and often identifying non-existent flaws (Figure 1). ^{Reference Bradley11–Reference Bacchetti13}

At our institution, several low-cost initiatives have improved peer review engagement and efficiency. New faculty undergo structured orientation on peer review expectations, timelines, and ethical standards. A co-reviewing model pairs junior reviewers with experienced faculty, fostering mentorship while maintaining review quality. In addition, reviewer contributions are formally acknowledged during annual academic evaluations, which has measurably increased participation. These context-sensitive strategies may serve as scalable models for journals in similar academic and resource-limited settings.

Enhancing peer review: strengthening standards and efficiency

One of the key challenges in peer review is maintaining high standards while ensuring efficiency and fairness. In regions such as South Asia, there is an urgent need to strengthen medical journals through improved editorial processes and a more robust peer review system. ^{Reference Shankar14} The quality of peer review is not solely dependent on identifying flaws but on providing constructive feedback that fosters scholarly development. A poorly structured or excessively harsh review can discourage researchers and delay the dissemination of valuable findings. ^{Reference Drubin15} Effective peer review requires training and structured guidelines to help reviewers deliver comprehensive yet efficient evaluations. ^{Reference Benos, Kirk and Hall16} In addition, initiatives such as expanding reviewer pools and providing recognition for reviewers’ efforts, as seen in few journals, can significantly improve participation and review timelines ^{Reference Cornelius17,Reference Winck, Fonseca, Azevedo and Wedzicha18} Implementing best practices in academic publishing, including clear reviewer expectations and mentorship programmes for early-career researchers, can raise overall standards and expedite the review process. ^{Reference Jiwa, Oberoi and Oberoi19} Moreover, journal editors play a crucial role in fostering a positive peer review culture. By ensuring that submissions are handled with transparency and efficiency, they can create a system that balances rigorous evaluation with timely decision-making, ultimately benefiting the broader research community. ^{Reference Fischer20}

These observations are consistent with perspectives highlighted by professionals in the publication industry, who have similarly outlined the multifaceted nature of peer review delays and proposed parallel solutions to address them. ²¹

In highly specialised domains such as paediatric cardiology, neurosurgical oncology, and rare genetic syndromes, the availability of qualified reviewers is particularly constrained. Establishing field-specific reviewer networks—formalised pools of experts curated by academic societies, professional bodies, or journal consortia—can streamline reviewer identification and assignment. These networks promote reviewer accountability, distribute workload equitably, and encourage inter-institutional collaboration. For instance, the creation of paediatric cardiology peer review panels within regional or global societies could ensure timely and expert-driven evaluations, especially in journals where such submissions form a niche proportion of total manuscripts. Such systems have already shown promise in other fields, such as oncology and transplant medicine, where collaborative reviewer databases have been adopted by some consortia-based journals to maintain quality while reducing turnaround time. ^{Reference Gasparyan and Kitas22–Reference Rosengaard, Andersen, Rosenberg and Fonnes24}

Recent advances in artificial intelligence have led to the development of editorial platforms that leverage natural language processing and machine learning algorithms to enhance reviewer selection. These systems analyse manuscript content (title, abstract, keywords, and full text) and automatically match them with suitable reviewers by mining databases such as PubMed, ORCID, and institutional repositories. Artificial intelligence tools such as Reviewer Finder, Paper Matcher, and Meta-Reviewer have shown improved reviewer matching accuracy, reduced editorial burden, and decreased time to decision, particularly in high-throughput journals. ^{Reference Shah and Acharya25–Reference Ferguson, Marcus and Oransky27}

Moreover, artificial intelligence models can incorporate conflict-of-interest data, historical reviewer responsiveness, and topic relevance to refine suggestions. Although these technologies are still evolving, early evidence indicates that their integration into editorial workflows may lead to measurable improvements in both efficiency and transparency of peer review. ^{Reference Taylor, Dagan, Youngberg, Kaufman and Radding28,Reference Kankanhalli29}

Regional considerations and structural improvements

In developing regions, such as South Asia, peer review systems face unique infrastructural and resource challenges. Many medical journals in these areas operate with limited editorial staff and inadequate technological support, underscoring the need for reform. ^{Reference Shankar14} Quality peer review is not merely about identifying flaws, but about providing developmental, constructive criticism (Figure 2 (a) and (b)). ^{Reference Drubin15,Reference Benos, Kirk and Hall16}

Training programmes for reviewers, especially early-career researchers, along with editorial mentorship, can raise the quality and timeliness of manuscript evaluation ^{Reference Cornelius17–Reference Jiwa, Oberoi and Oberoi19} Editorial leadership, when committed to transparency and prompt processing, can foster a culture of accountability and continuous improvement. ^{Reference Fischer20}

Reviewer unavailability and delayed report submission are common issues; studies indicate that over 70% of manuscripts face delays due to late reviewer responses, typically extending peer-review times beyond three weeks. ^{Reference Cornelius17}

Systematic reviews of biomedical journals show substantial variability in submission-to-publication durations, ranging widely from approximately 70 to over 550 days, emphasising the broader inefficiencies in editorial workflows. ^{Reference Andersen, Fonnes and Rosenberg30}

Emerging solutions include diversifying reviewer networks and adopting structured reviewer pools, which help reduce dependence on a limited group of frequently solicited reviewers, thereby improving the speed and efficiency of peer-review assignments. ^{Reference Checco, Bracciale and Loreti31,Reference Zhao and Zhang32} In addition, structured reviewer recognition programmes and formal training initiatives have been proposed to enhance responsiveness and review quality, although specific regional implementations and their outcomes require further documented evaluations. ^{Reference Malički and Mehmani33}

Peer review delays can have particularly significant consequences in fields such as paediatric cardiology, where timely dissemination of research is critical for informing clinical guidelines, device innovation, and therapeutic strategies for vulnerable populations. In rapidly evolving areas like CHD management, prolonged publication timelines may delay the adoption of life-saving interventions. Moreover, early-career cardiologists—especially in resource-constrained settings—often depend on timely publications for securing fellowships, academic appointments, and research funding. Extended review cycles can therefore impede both patient-centred innovation and professional development, underscoring the need for more responsive and field-aware peer review mechanisms in paediatric cardiology. ^{Reference Zhao and Zhang32–Reference Kusumoto, Bittl and Creager34}