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 Table of Contents  
STUDY PROTOCOL
Year : 2016  |  Volume : 1  |  Issue : 4  |  Page : 166-175

Shared decision making between Chinese medical staff members and patients with coronary heart disease: study protocol for a multicenter, large sample, cross-sectional, open-label, clinical survey


1 Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
2 Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
3 Beijing Anzhen Hospital, Capital Medical University, Beijing, China
4 China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
5 The Third People's Hospital of Dalian, Dalian, Liaoning Province, China
6 Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
7 Value Institute, New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York, NY, USA
8 Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN; Division of Endocrinology, Mayo Clinic, Rochester, MN, USA

Date of Web Publication30-Dec-2016

Correspondence Address:
Rong-chong Huang
Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-5658.196985

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  Abstract 

Background: Shared decision making is an emerging approach through which physicians and patients can reach health care decisions based on mutual agreement. Scientific physician-patient shared decision making can facilitate selection of optimized treatments, improvement in curative effects, postoperative prognosis, and short-term and long-term rehabilitation in patients with coronary heart disease. However, there have been no studies on Chinese physicians' and patients' attitude to shared decision making.
Methods/Design: This is a multicenter, large sample, cross-sectional, open-label, clinical survey. Participants are 1,000 Chinese patients with coronary heart disease and 200 medical staff members of both sexes over 18 years old. The primary survey index is the satisfaction of medical staff members and coronary heart disease patients with shared decision making. The secondary survey indices include staff and patient satisfaction with a clinical decision-making aid, patients' awareness of disease risk and curative benefits, and physician-patient trust.
Discussion: This study is the first to investigate the attitude of Chinese medical staff members and coronary heart disease patients to clinical shared decision making and to examine the feasibility of using this approach. This study provides an evidence-based foundation for investigating the problems and solutions of clinical shared decision making and strengthening the adherence to statin medication in patients with coronary heart disease.
Trial registration: This study protocol was registered at Chinese Clinical Trial Registry (registration number: ChiCTR-OCS-14004646).
Ethics: This study protocol has been approved by Ethics Committee, The First Affiliated Hospital of Dalian Medical University (approval number: LCKY2014-14) and will be performed in strict accordance with the Declaration of Helsinki, formulated by the World Medical Association.
Informed consent: Signed informed consent will be obtained from each included subject.

Keywords: cross-sectional survey; coronary heart disease patients; medical staff; China; clinical shared decision making; drug compliance


How to cite this article:
Huang Rc, Ma Sm, Song Xt, Yang P, Liang B, Sun M, Xu Jy, Li Q, Teng Xf, Zhang Df, Liu Y, Li B, Yan Y, Li Z, Boehmer KR, Ting HH, Montori VM. Shared decision making between Chinese medical staff members and patients with coronary heart disease: study protocol for a multicenter, large sample, cross-sectional, open-label, clinical survey. Clin Trials Degener Dis 2016;1:166-75

How to cite this URL:
Huang Rc, Ma Sm, Song Xt, Yang P, Liang B, Sun M, Xu Jy, Li Q, Teng Xf, Zhang Df, Liu Y, Li B, Yan Y, Li Z, Boehmer KR, Ting HH, Montori VM. Shared decision making between Chinese medical staff members and patients with coronary heart disease: study protocol for a multicenter, large sample, cross-sectional, open-label, clinical survey. Clin Trials Degener Dis [serial online] 2016 [cited 2018 Dec 12];1:166-75. Available from: http://www.clinicaltdd.com/text.asp?2016/1/4/166/196985


  Introduction Top


History and current related studies

Recent evidence indicates that the incidence of cardiovascular disease has been gradually increasing and that there are now 230 million cardiovascular patients in China. Population aging has led to a particularly rapid increase in the incidence of coronary heart disease (CHD), a degenerative disease of cardiovascular function. The number of patients with CHD receiving only interventional therapy increases by over 30% every year, and CHD is therefore a major health problem for people in China (Liu et al., 2009).

Current treatments for CHD include lifestyle improvement, drug treatment, interventional therapy, and surgical treatment. Optimal medication outcomes are the control of angina and the reduction of the CHD fatality rate. However, withdrawal of dual antiplatelet agents, statins, receptor blockers, and other drugs 1 year after surgery can increase cardiac events in 30-40% of CHD patients receiving percutaneous coronary intervention in China (Li et al., 2015). Li et al. (2015) have reported that long-term preventive drug treatment is used less often in patients with stable CHD than in patients with other types of CHD. In China, dual antiplatelet drugs and statins are more often withdrawn in higher-risk cases of CHD; for example, patients with heart failure, diabetes mellitus, stroke, and renal inadequacy (Liu et al., 2009). Current areas of concern are how to increase medication adherence in patients with CHD, improve clinical presentation, decrease the incidence of cardiac events and the rate of rehospitalization, and reduce medical costs.

In most cases, physicians make treatment decisions based on their own experience and then inform patients of the decisions. This approach is necessary at particular times and under certain circumstances, for example, in emergency situations. However, this approach cannot solve all clinical problems.

Shared decision making refers to the process by which physicians and patients together reach the most suitable medical decision for the patient's condition, based on mutual agreement. It provides opportunities for patients to develop clinical decision making (Huang et al., 2015). Shared decision making is characterized by participation from both physicians and patients, which allows for information communication between them. This leads to the achievement and implementation of diagnoses and treatment consensus and contributes to implementation of long-term therapeutic regimens for chronic disease. The 2015 American College of Cardiology/American Heart Association (ACC/AHA) Focused Update of Secondary Prevention Lipid Performance Measures was based on a patient-centered approach and emphasizes a shared decision-making strategy. Previous lipid performance measures guidelines emphasized the prescription of medication and the 2015 ACC/AHA guideline focuses on offered medication. In the previous guideline, prescribed medication is completely under the physician's control and can be implemented without any patient participation. Future performance measures will better promote patient-centered medication (including shared decision making), which are also the important features in the 2013 ACC/AHA guideline and in a study by Martin et al. The study of Martin et al. defined physician- and patient-initiated discussion, shared decision making and auxiliary decisions, used the ACC/AHA atherosclerotic cardiovascular disease risk assessment equation (as a primary prevention implementation tool), and provided important details regarding potential barriers to the implementation of shared decision making. The key features of shared decision making are the discussion implemented by physicians and patients regarding reduction in potential risk for atherosclerotic cardiovascular disease, adverse reactions, drug interactions, and patient willingness. Shared decision making can increase participation of patients in treatment, potentially increasing adherence to guideline-recommended care and improving patient-centered outcomes. The 2015 ACC/AHA guideline suggested that physicians should not base medication prescription only on simple evidence-based guidelines or convince patients that their prescribed medication is appropriate; rather they should choose an optimal treatment strategy after in-depth discussions with the patient. Stacey et al. (2014) have demonstrated that the number of patients who participated in shared decision making and chose invasive treatment decreased 20% than those who do not participate in shared decision making. In addition, patients' trust in physicians increases after shared decision making (Entwistle, 2004; Peek et al., 2013).

A meta-analysis of 55 randomized controlled studies performed between 1985 and 2010 showed that, compared with patients who did not participate in shared decision making, those who participated in this process better understood the disease condition, were less concerned about the diagnosis and treatment scheme, adhered more to the treatment scheme, and were more satisfied with treatment outcomes; in addition, the treatment cost less and there were fewer medical disputes (Wei and Zhang, 2012).

Main objectives

This study will examine shared decision making for patients with CHD and will investigate patient adherence to statins and the attitude of Chinese medical staff members and patients toward shared decision making.

Distinguishing features from related studies

Traditional clinical decision-making models include paternalistic (patients play a passive role), professional-as-agent (the physician makes the decision and then communicates it to the patient; the patient agrees to the treatment decision, making the physician the sole decision maker), and informed decision making (the physician incorporates the idea of information sharing with the patient, who makes the decision themselves at the end). In shared decision making, the physician and the patient are a team. The physician first informs the patient of the treatment choices that the patient can make and the possible benefits and risks inherent in each selection; then, both the physician and the patient participate in the decision-making process and agree to the treatment decision (Frosch and Kaplan, 1999; Shepperd et al., 1999; Salzburg Global Seminar, 2011). However, there is no investigational study on shared decision making attitude or preference in Chinese medical staff members and patients with CHD. Chinese medical staff members know little about shared decision making. With the support of academician Jun-bo Ge in Shanghai, China, and Professor Yong Huo in Beijing, China, and with the guidance of Dr. Victor M. Montori, Mayo Clinic Knowledge and Evaluation Research Unit, USA, and Ms. Henry H. Ting, New York Presbyterian Hospital, USA, our team (including China-Japan Union Hospital of Jilin University, Shengjing Hospital of China Medical University, Beijing Anzhen Hospital, Capital Medical University, and The Third People's Hospital of Dalian, China) led by Rong-chong Huang, The First Affiliated Hospital of Dalian Medical University, China, will perform a series of studies on shared decision making between Chinese medical staff members and patients with CHD and statin choice in China.


  Methods/Design Top


Study design

A multicenter, large sample, cross-sectional, open-label, clinical survey.

Study setting

The First Affiliated Hospital of Dalian Medical University, China-Japan Union Hospital of Jilin University, Shengjing Hospital of China Medical University, Beijing Anzhen Hospital, Capital Medical University, China

Study procedures

A cohort of 1,000 eligible patients with chronic stable CHD and 200 eligible Chinese medical staff members will be surveyed.

Physician team training: physicians scheduled to participate in the survey should be cardiology specialists and have more than 1 year's work experience in the independent management of cardiology patients. Prior to the research, physicians will be trained to understand the objective model and basic procedure of shared decision making and learn how to use a decision aid and an online assessment tool for Statin Choice. The training will be performed by Dr. Victor M. Montori and Ms. Kasey R. Boehmer, Dr. Henry H. Ting and Dr. Rong-chong Huang.

Online selection of statins ([Figure 1]) and standardized clinical shared decision making: Dr. Rong-chong Huang will construct the online assessment tool for statin selection and record the video about the standardized shared decision making in advance. The survey questionnaire used for patients with CHD will be provided by Kasey R. Boehmer ([Figure 2]).
Figure 1: Shared decision making on statin choice.
Note: (A) Paper version; (B) online version


Click here to view
Figure 2: Questionnaire measuring Chinese patients' preferences in shared decision making on statin choice

Click here to view


The cohort of 1,000 patients will first complete a questionnaire survey and then watch a standardized video about shared decision making. Patients will experience sufficient physician-patient communication to allow them to thoroughly understand the process and significance of the shared decision making. Then, patients will complete the same questionnaire again and their attitude change will be examined. Patients with CHD will be informed about statin use, including adverse effects on hepatic function, myolysis, risks and benefits, as well as the most important risks and benefits for them.

All patients will undergo a clinic visit and telephone follow-up evaluations 12 months after the shared decision making. The category, dose, and duration of statins used will be recorded. Patients who take statins for over 80% of the follow-up duration will be considered highly adherent, those who take statins for less than 40% of the follow-up duration as low adherent, and those who take statins for an intermediate period as moderately adherent. The incidence of cardiac adverse events (death, myocardial infarction, heart failure, revascularization, stroke) occurring during the follow-up period (i.e., 12 months) will be recorded. In addition, adverse drug reactions (muscle damage and damage to hepatic and renal functions) will be monitored.

A total of 200 Chinese medical staff members from The First Affiliated Hospital of Dalian Medical University and Beijing Anzhen Hospital, Capital Medical University, China, will first complete the questionnaire survey and then watch the video of the standardized shared decision making and statin choice decision aid. This is to allow Chinese medical staff members to become thoroughly familiar with the process and importance of shared decision making. Then, the attitude change of Chinese medical staff members will be examined. The survey questionnaire used for Chinese medical staff members will be provided by Kasey R. Boehmer ([Figure 3]). The flow chart of the survey protocol is shown in [Figure 4].
Figure 3: Questionnaire measuring Chinese physicians' preferences in shared decision making on statin choice

Click here to view
Figure 4: Flow chart of survey protocol

Click here to view


Study participants

A cohort of 1,000 Chinese patients with chronic stable CHD and 200 medical staff members will be included from The First Affiliated Hospital of Dalian Medical University, China-Japan Union Hospital of Jilin University, Shengjing Hospital of China Medical University, Beijing Anzhen Hospital, Capital Medical University, and The Third People's Hospital of Dalian, China.

Inclusion criteria

Patients of either sex with all of the following conditions will be considered for study inclusion:

  • Patients with stable angina (Chinese Society of Cardiology, 2007a)
  • Patients aged >18 years
  • Patients who volunteer for participation in this survey and who provide informed consent


Medical staff members with all of the following conditions will be considered for study inclusion:

  • Medical students who have participated in clinical practice for over 1 year
  • Physicians, nurses, and assistants who have worked in cardiology departments and related fields for over 1 year
  • Staff who volunteer for participation in this survey and who provide informed consent


Exclusion criteria

Patients with one or more of the following will be excluded:

  • Acute coronary syndrome, including acute ST-segment elevation myocardial infarction (Chinese Society of Cardiology, 2010), non-ST-segment elevation myocardial infarction, and unstable angina (Chinese Society of Cardiology, 2007b)
  • Conditions complicated by acute heart failure, severe renal inadequacy (eGFR < 30 mL/min/1.73 m 2 ) or severe hepatic function impairment (aspartate aminotransferase or alanine transaminase three times higher than the upper limit of the normal value)
  • Conditions complicated by malignant tumors, immune system diseases, severe malnutrition, or other diseases
  • Inability to complete the survey because of cognitive impairment, or severe hearing or visual impairment
  • Refusal to undergo reexamination


Medical staff members with one or more of the following will be excluded:

  • Medical students who have participated in clinical practice for no more than 1 year
  • Physicians, nurses, and assistants who have worked in cardiology departments and related fields for no more than 1 year


Sample size

A cohort of 1,000 Chinese patients with CHD and 200 medical staff members will be scheduled to participate in the survey between May 1, 2014, and April 30, 2015.

Baseline evaluation

After providing informed consent, baseline data of patients with CHD and medical staff members will be evaluated.

For patients with CHD, the following factors will be evaluated: age, sex, education level, marital status, income, CHD risk factors, medical history, drug history, basic physical examination results (including body mass index and waist circumference), blood biochemical examination results (hepatic function, renal function, blood lipid profiles, fasting blood glucose, glycosylated hemoglobin, routine blood and urine tests, high-sensitivity C-reactive protein, creatine kinase, creatine kinase isoenzymes, cardiac troponin I, and brain natriuretic peptide), and glomerular filtration rate.

For medical staff, the following factors will be evaluated: age, sex, education level, medical-related work time, and specific job positions.

The baseline characteristics that will be evaluated for all patients with CHD and medical staff members included in this survey are shown in [Table 1].
Table 1: Baseline characteristics of patients with
coronary heart disease (CHD) and medical staff
members


Click here to view


Recruitment

Potential patients in the clinics were informed about the survey by the attending physician. Those interested in participating in the survey contacted the project manager through telephone, email, and Webchat. Patient recruitment was also conducted through a recruitment advertisement on posters and bulletin boards in the hospitals or local communities or in the media (reporters, newspapers).

Eligible medical staff members were recruited by advertising on posters and hospital bulletin boards or hospital websites.

Survey contents and methods

Survey contents

[Figure 2] shows the questionnaire measuring patient knowledge and preferences regarding the information-sharing model, satisfaction with the clinical shared decision-making aid, recognition of risks and benefits, and physician-patient trust.

[Figure 3] shows the questionnaire measuring medical staff member's knowledge and preferences regarding the information-sharing model, satisfaction with the clinical shared decision-making aid, and satisfaction with the use of the clinical shared decision making aid.

Survey methods

The trained physicians were responsible for administering the survey to patients and medical staff members ([Figure 2], [Figure 3]). After learning about the shared decision making process and the clinical statin choice decision aid, the survey was performed again and the survey completion time was recorded.

Videos were made about standardized informed decision making (patient makes the decision by themselves at the end), professional-as-agent (physician is the sole decision maker), and the shared decision-making models (both patient and physician involved in the decision making). The shared decision-making model was normalized, and patients were involved in the shared decision making process based on the statin choice decision aid (Weymiller et al.., 2007).

Before seeing the video about the medical decision-making model, the patients and medical staff members participating were surveyed and their basic information, previous history, personal history, family history, medical history, and routine physical examination history were recorded.

After seeing the video of the standardized shared decision making and statin choice decision aid ([Figure 2]), the same survey was performed again with the same groups of patients and medical staff members.

Survey indices

Primary survey indices


  • The primary survey index will be Chinese medical staff members' and CHD patients' satisfaction with clinical decision making; the degree of satisfaction was self-rated from 1 to 5 (as shown in [Figure 3]), which is from completely to little. The average degree of satisfaction was included in the final analysis.


Secondary survey indices

  • Chinese medical staff members' and CHD patients' satisfaction with the information-sharing model and clinical decision-making aid.
  • Chinese CHD patients' awareness of disease risks and curative benefits.
  • Chinese CHD patients' understanding of physician-patient trust.


Trust and satisfaction rating criteria were consistent and were calculated using the questionnaire scores.

Data management

According to trial design type and requirement, a table was developed to record survey data. The recorded data were input into an electronic database by trained professional staff members using a double-data entry strategy.

The database was locked by the project manager and was not altered. All information relating to this survey was retained by The First Affiliated Hospital of Dalian Medical University, China.

The electronic data were fully disclosed to a professional statistician for statistical analysis.

Anonymized trial data will be published at http://www.figshare.com.

Statistical analysis

All recorded data were statistically analyzed using SPSS 17.0 software (SPSS Inc., Chicago, USA). Measurement data were expressed as the mean ± SD. To test for differences between groups, analysis of vairiance was used for data that were normally distributed and showed homogeneity of variance and the Kruskal-Wallis test was used for data that were not normally distributed. The count data were expressed as an absolute value or a percentage and analyzed using the chi-square test, Fisher's exact test, or the Kruskal-Wallis test. A level of P < 0.05 was considered statistically significant.


  Survey Status Top


(1) Data collection and statistical analysis have been completed at the time of submission.

(2) We have been invited to present the survey-related results at the 3 rd International Society for Evidence-Based Health Care Conference 2014 and the 25 th Great Wall International Congress of Cardiology. The latest results have been reported at the 2015 Sydney ISDM-ISEHC Conference.

(3) The survey protocol has been approved by the ethics committee of The First Affiliated Hospital of Dalian Medical University, China (approval number: LCKY2014-14).

(4) This study considered the following rights and interests of Chinese medical staff members and patients with CHD:

  • The ethics committee and informed consent are the main organizations and measures to protect the rights and interests of the participants.
  • The questionnaire should be agreed and approval signed before implementation of the survey. Any amendments during the survey should be approved by the ethics committee before implementation.
  • Each participant should voluntarily participate in this study, should have the right to withdraw from this study at any time without discrimination or retaliation, and his/her medical treatment and rights/interests should not be affected. Each participant should be informed that his/her personal information relating to this study would not be disclosed to any non-authorized persons.
  • Each participant should be informed of the nature and objective of this survey as well as the rights and obligations of the participant as stated in the Declaration of Helsinki. In addition, each participant should be informed that the study would not alter the scheduled therapeutic protocol and medical staff member's health care-related behaviors. These procedures will allow participants sufficient time to consider whether or not they wish to participate in this study and to provide written, informed consent.



  Discussion Top


Significance of this study

In recent years, there have been frequent medical disputes between physicians and patients; this has become an increasing area of interest in the medical field at home and abroad. There is a need to strengthen medical management and physician-patient communication. In addition, there has been increased attention on the effects of the medical decision-making model on the treatment process and patient satisfaction with treatments and treatment outcomes. The use of the shared decision making model (to alter the current clinical decision-making model and increase patient participation) would help to increase patient adherence and patient satisfaction, which can influence medical outcomes.

Strengths and limitations of this study

This study is the first to use a multicenter, large sample, cross-sectional, open-label, clinical survey. In this study, we will include 1,000 Chinese patients with CHD and 200 medical staff members and survey several indices, including participants' understanding and satisfaction of the clinical shared decision making model and their understanding of CHD medication.

In-depth studies should be performed to investigate statin choice for the treatment of CHD using the online decision-making aid provided by Mayo Clinic, USA. Follow-up of Chinese CHD patients is also needed to understand their attitudes to the clinical shared decision-making model, drug adherence, clinical decision making, and clinical outcomes.

Evidence for contribution to future studies

Our study will investigate Chinese medical staff members' and CHD patients' understanding of and attitude to clinical shared decision making, their knowledge and satisfaction with a clinical shared decision making aid, patients' knowledge of CHD medication, and patient satisfaction with the clinical decision making model. These outcomes help to reveal the attitudes of Chinese medical staff members and CHD patients and the feasibility of the use of a clinical shared decision-making aid. The findings may also help to identify the barriers and solutions to the promotion of shared decision making, which can increase patient drug adherence.[16]

 
  References Top

1.
Chinese Society of Cardiology (2007a) Guidelines for diagnosis and treatment of chronic stable angina. Zhonghua Xinxueguan Bing Zazhi 35:195-206.  Back to cited text no. 1
    
2.
Chinese Society of Cardiology (2007b) Guidelines for diagnosis and treatment of unstable angina and non-ST-segment elevation myocardial infarction. Zhonghua Xinxueguan Bing Zazhi 35:295-331.  Back to cited text no. 2
    
3.
Chinese Society of Cardiology (2010) Guidelines for diagnosis and treatment of acute ST-segment elevation myocardial infarction. Zhonghua Xinxueguan Bing Zazhi 38:675-697.  Back to cited text no. 3
    
4.
Entwistle V (2004) Trust and shared decision-making: an emerging research agenda. Health Expect 7:271-273.  Back to cited text no. 4
    
5.
Frosch DL, Kaplan RM (1999) Shared decision making in clinical medicine: past research and future directions. Am J Prev Med 17:285-294.  Back to cited text no. 5
    
6.
Huang R, Gionfriddo MR, Zhang L, Leppin AL, Ting HH, Montori VM (2015) Shared decision-making in the People′s Republic of China: current status and future directions. Patient Prefer Adherence 9:1129-1141.  Back to cited text no. 6
    
7.
Li ST, Xu JY, Huang RC (2015) Effect of statin adherence on the prognosis of primary and secondary prevention of coronary heart disease: a meta analysis. Zhongguo Xuehuan Zazhi (z1):144.   Back to cited text no. 7
    
8.
Liu JT, Du X, Ma CS, Zhang P, Wu XS (2014) The influence factors of clinical decision making in patients with cardiovascular disease. Zhongguo Yiyao 9:293-297.  Back to cited text no. 8
    
9.
Liu Q, Zhao D, Liu J, Wang W, Liu J, Chinese Coronary Heart Disease Secondary Prevention Bridgework Research Group (2009) Current clinical practice patterns and outcome for acute coronary syndromes in China: results of BRIG project. Zhonghua Xinxueguan Bing Zazhi 37:213-217.  Back to cited text no. 9
    
10.
Peek ME, Gorawara-Bhat R, Quinn MT, Odoms-Young A, Wilson SC, Chin MH (2013) Patient trust in physicians and shared decision-making among African-Americans with diabetes. Health Commun 28:616-623.  Back to cited text no. 10
    
11.
Salzburg Global Seminar (2011) Salzburg statement on shared decision making. BMJ 342:d1745.  Back to cited text no. 11
    
12.
Shepperd S, Charnock D, Gann B (1999) Helping patients access high quality health information. BMJ 319:764-766.  Back to cited text no. 12
    
13.
Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JH (2014) Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev:CD001431.  Back to cited text no. 13
    
14.
Trevena L, Barratt A (2003) Integrated decision making: definitions for a new discipline. Patient Educ Couns 50:265-268.  Back to cited text no. 14
    
15.
Wei JH, Zhang RL (2012) Management of My Health. Jiankang Bao. 3rd January: page 005.  Back to cited text no. 15
    
16.
Weymiller AJ, Montori VM, Jones LA, Gafni A, Guyatt GH, Bryant SC, Christianson TJ, Mullan RJ, Smith SA (2007) Helping patients with type 2 diabetes mellitus make treatment decisions: statin choice randomized trial. Arch Intern Med 167:1076-1082.  Back to cited text no. 16
    

Declaration of patient consent
The authors certified that they had obtained all appropriate patient consent forms. In the form the patient(s) had given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understood that their names and initials would not be published and due efforts would be made to conceal their identity, but anonymity could not be guaranteed.
Conflicts of interest
None declared.
Author contributions
Study design: RCH, XTS, VMM and HHT; data collection and management: SMM, XFT, YL, DFZ, QL, JYX, PY, BL, BL, YY, ZL, and MS; questionnaire design: KRB; paper writing: RCH. All authors read and agreed the final version of this paper for publication.
Plagiarism check
This paper was screened twice using CrossCheck to verify originality before publication.
Peer review
This paper was double-blinded and stringently reviewed by international expert reviewers.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]


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[Pubmed] | [DOI]



 

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