Impact of Educational Chronic Care Model on Diabetic Patients: A Prospective Cohort Study

Lack of knowledge and understanding about diabetes are important barriers to cure. Treatment of diabetes alone without education is not sucient. Nowadays, health education could reach us on mobiles. Aim Our aim is how to make advice-giving becomes a system to treat our patients. The theme of this study is diabetes education. And to know how far the prompt well-structured education could affect the clinical status and the quality of life of a poorly controlled diabetic patients. Methods 702 patients with type 1 diabetes were followed for 2 years (2017, 2018), by condensed friendly education and training sessions. Our activities were mainly through direct individual approach and social media, structured in the form of visits. The study was done in a specialized clinics of diabetes (SDC) in a tertiary university hospital. We evaluated the clinical status, psychological, sociocultural and satisfaction of the patients, pre and post education. We assessed our patients at the beginning of the study, throughout, and at the time of discharge. Quantitative and qualitative data were compared statistically by paired t test and chi-square test at 0.05 level of signicance. 96.7% our what they have The average HbA1C become less than eight in 54% of patients. Patients with HbA1C 8-9%, BP and LDL <3.36 mmol/l, were 46%, 51% and 79% respectively. The average blood pressure for 56% of patients was 132/77. The average LDL level among 71% of was 27% of patients had average discharged HbA1c of Net promotor score of SDC was passives and were 9.5% and 2.8% respectively. P value <0.05 Conclusion


Introduction
To improve the lives of people with diabetes and prevent its complications through innovative care, treatment, patient education, professional training and research. This is a worthy goal to struggle for. Glycemic control and improvement could be achieved by structured education programs and behavioral changes. , Glycemic control can preserve long-term clinical outcomes and prevent or delay the development of macro-and microvascular sequelae of diabetes. , Effective programs are best delivered through face-to-face approach in combination with far-reaching, E-learning approach. They incorporate perceptive restructuring together with better interaction. 3 , , Because of the economic growth, almost all people now are using online social media on their smart phones, relying on them as communication channels. Kingdom of Saudi Arabia (KSA) has the highest rank in the world of smart-phone users, according to the report of the United Nations submitted in the Conference of Trade and Development. Healthcare researchers and providers invest this opportunity to better educate diabetic patients for better disease management. Many studies showed the advantage of using social media campaigns in patient education. , and In China, the glycemic control among diabetic patients is still low, due to poor patient education.
This study assesses the effect of social media in combination with face-to-face group education in improving the clinical status and quality of life, among multi-national type 1 diabetic patients in Saudi Arabia.

Materials And Methods:
2.1. Participants and sample size: From January to December 2017-2018, a total of 702 patients with TIDM, aged from 14 to 60 years were selected as convenient sample from specialized diabetic clinics at the King Saud University Medical City Tertiary Hospital, of 920 beds.

Aim of the study:
Our aim is how to make advice-giving becomes a system to treat our patients. This -two years-prospective cohort study compared the effect of health education through individual approach combined with usage of social media groups, on uncontrolled type 1 diabetes. The same group of patients subjected to pre-intervention evaluation and post-intervention evaluation. We used clinical outcome, quality of life and psychological improvement as variables to measure in the study.

Ethics Committee Approval and Consenting:
We had approval from Research Ethics Committee on this study of the King Saud University Medical City. All patients participated in this study signed an informed consent. The research has been approved by the Clinical research Ethics commission of the Medical College. Crafted informed consents were acquired from all patients prior to the start of this study.

Inclusion and Exclusion Criteria:
Patients with diabetes have been included in the study as follows: doctors diagnosed TIDM according to the guidelines of the World Health Organization (WHO), patients should have a mobile phone, gave consent to receive messages and also had the ability to understand text messages and to engage willingly in this research. Patients have also been excluded whether they have been diagnosed with type II diabetes, speci c diabetes or a history of serious medical conditions such as kidney or liver failure, serious vision problems, mental illnesses or other metabolic diseases.

Number and frequency of sessions:
Our patients were visiting the clinic 3-5 times per week, during the rst six months. Then they have had multiple visits to be followed; three visits per month to the completion of follow up. In each visit, they received the care, had their lab investigations, took their medications, attended the education sessions, and repeated the arrangement of their schedule.

Professional background of educators:
The doctors provided the educational related messages and selected them were board quali ed and specialists in the eld of diabetes research. They trained the nursing staff that sent the educational messages. The trained nurses followed up with patients with diabetes. Nurses had graduated from college or above and served for at least 3 years.

Data Collection Process
A quali ed nurses and physicians in our unit collected the data in hard copies, soft copies on the electronic patient les, structured forms and questionnaires. Basic information on socioeconomic and demographic characteristics such as age, sex, educational achievement level, personal health and lifestyle such as a regular physical activity has been obtained. Data collected; at baseline, 6 months and 12 months, as well as at each visit. We collected data about; physical assessment results, laboratory investigation results and education program outcomes. Data on self-care activities were collected from all patients. Laboratory investigation results such as; fasting blood glucose and 2-hour postprandial glucose, LDL, BP, and glycosylated hemoglobin (HbAlc).

Research Tools:
We used three tools; educational program, measurement tools (physical assessment, and laboratory investigations):

Educational program:
Education is intended to promote responsible decision-making, issue-solving, constructive engagement with the health education group and self-care, as well as to enhance clinical performance, quality of life and tness status. Such goals are achieved by comprehensive health education in a community given by health educators every month for more than 2 years. A total of 702 persons were invited to take part in the program. Reasons for decreasing involvement involved regular travel, job too hard, loss of con dence, and not being able to reach software applications or phone. The data obtained were socio-demographic factors, eating patterns, smoking, physical exercise, foot-body-care, capillary glycaemia self-monitoring, and medication compliance. Together with subsequent morbidity, such as obesity; hypertension; dyslipidemia; ischemic cardiac failure, including "acute myocardial infarction", angina, stroke; and other complications (neuropathy, micro-macrovascular, retinopathy). During the follow-up visits, data were obtained on different variables (HbA1c, total cholesterol, low-density lipoprotein (LDL) cholesterol, systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL) cholesterol, and BMI). The systemic model of health education was focused on the following dimensions: 2.9.1. Image education: Patients were supplied by videos on DM which are focused on audiovisual strategies to raise understanding of the value of diabetes. Picture education will provide patients with more information regarding DM pathophysiology, impermissibility, risks, and diagnosis, while growing awareness about the signi cance of managing risk factors.
Often members of the family would engage in picture education; they were all invited. The intervention was in the form of focus group face-to-face well-structured education sessions, individual approach one-to-one interviews, using education curriculum and well prepared education materials. Also, these were combined with telemedicine apps, WhatsApp groups, mobile services and support groups.
With on-site appointments, patients may obtain basic awareness of the impact of medications on the bloodstream, the diet pattern, alternate medicine choices, insulin self-injection, dosage guidelines, alert indicators of hypoglycemia, and carbohydrate-counting strategies.
Patients subdivided into one face-to-face group discussion and individual approach through personal interviews, through which the nurse began to provide the patient with direct education and training using speci c educational material aside with friendly psychological support and con dence-building talk.
The learning strategy is more pragmatic and focused on the day-to-day interactions of people dealing with an illness compared to earlier treatment approaches that were based on information. They stress the necessity of increasing the dignity and security of clinicians. There should be ongoing training. One must learn to incorporate the information that he accumulates in daily practice.

Distribution of instructional content:
In order to enhance diabetes self-care and to be an involved member in the whole process, our community has created a low-literacy colored brochures. Patients in the program were provided with a paper guide comprising the question-explanation resources on diabetes and care aims.

Therapy in personalized medicinal care:
In a detailed and personally arranged diet plan, the interests, cultural context and conditions of every participant as well as the overall recovery system are addressed. Due to the di culty of the medical and dietary problems with most patients, our staff proposed a simpler scheme named "restricted plate diet" Fig. 9, It comprises of three sections: ½ plate vegetables, ¼ plate staple food (carbohydrate) and ¼ plate lean red meat (protein) and dishes remain variable not the same.

Personal exercise programs:
Exercises involve riding, jogging, running, sur ng, gymnastics, table tennis, and music. Physical activity goals, techniques, rates and intensities must be discussed for patients who are extremely open to the identi cation of challenges and to helping patients pursue alternatives. Patients that show signs of cardiac ischemia should be forwarded for further examination and diagnosis.
2.9.6. Groups and lectures: WhatsApp group and Regular Medical Meetings. Face-to-face seminars were the most common mode of presentation, and there was a monthly frequent educational lectures. The WhatsApp community offers a way of delivering quality health information for patients. If the results are usually below the de ned goal levels, patients will be checked and reported on a daily basis to the WhatsApp Health Care Team or on an occasional visit to cause improvements in treatment if appropriate. The main objectives of the lectures are to offer feedback on the aim of reducing the possibility of complications, to share knowledge and methods for addressing challenges, to recommend approaches for meeting targets, to help track complications and to offer skills training.

Complication evaluation:
The key task of the team is to examine complications (nephropathy, artery disorder, retinopathy, and neuropathy) and discover strategies for patients to exercise safe. The group offered advice on complications monitoring, established recovery schedules, evaluated success in achieving care goals, and helped establish approaches to ful ll recovery targets and prevent complications.

Modi cation of life style:
Lifestyle modi cation consists of weight loss; decreased saturated fat, trans-fat and cholesterol intake; lowered sodium and improved potassium intake; smoking cessation; and enhanced physical activity. Lifestyle modi cation elements include activity guidelines, professional diet guidance and thorough diabetes awareness with the goal of transforming the diabetes treatment model from a patient-focused system to a patient-focused physician. 15 2.9.9. Systemic Healthcare Program: To order to effectively follow this procedure, the individual must engage actively in the implementation of a recovery program, adhere to the values of self-care, make day-to-day "self-care" choices, interact openly and with adequate consistency with the team, and minimize the regular consumption of food. Boost physical exercise, feed less meals a day, blood glucose self-monitoring, increase compliance to medications, and develop insulin therapy skills.

Glycemic control self-monitoring:
Patients were advised to track their blood sugars, report values, and keep a record book for appointments. Most patients do routine blood glucose self-monitoring, report ndings as advised, and review them with the health care staff. Patients should consult with the staff when goals are not met or where di culties or obstacles are found.

Evaluation of therapeutic effect monthly:
Reinforcing care, establishing the target of wellness promotion and problem-solving everyday life are needed; doctors have speci c monitoring goals for patients like HbA1c, LDL/HDL cholesterol, blood pressure, and total cholesterol. Patients need to be motivated to incorporate behavioral therapy into their everyday lives and to engage more fully in the process. Patients can interact with the staff equally and regularly.
Continuous training workshops on self-care, general and speci c nutrition, medications, tness, blood sugar screening, foot care, changes in lifestyle, and tobacco smoking. What about diabetes? How am I going to know if I have diabetes? How is my diabetes going to be treated? What kind of complications are possible? How can I avoid problems with my health? How is my diabetes drug going to help me? Drug name, type of drug, what does it do? Things to look for. Diabetes ABCs, "A" means "A1C," "B" means "blood pressure," "C" means "cholesterol".
Diabetic patients have all provided traditional medical care and diabetes nursing education and will also be driven by telemedicine applications, WhatsApp groups, mobile services and support groups. We were responsible for sending and describing the information related to diabetes to our patients, including blood glucose self-monitoring, a healthy lifestyle, physical exercise, adherence with prescribed medication, low and high blood glucose regulation, and weight control for diabetes patients.

Improvement proposed measures:
A more development program was formulated on the grounds of medication effectiveness, blood pressure, risks and allergic reactions. Repeated nutritional histories and subsequent minor improvements discussed every several weeks to months by the community render it easier to determine how the adjustments already accepted have been adopted, to reinforce the value of nutritional measures, and to enable patients to exercise good food options.
1. Personal follow-up scheme: Effective follow-up will be an important part of the long-term maintenance. The patient follow-up program covered follow-up duration, risk conditions, foot protection, insulin self-injection, early symptoms of hypoglycemia, diabetes-related problems, and hypoglycemia. Such initiatives will regularly enhance behavioral improvement and long-term sustainability.

Measurement tools
All patients underwent physical assessments, which include vitals, anthropometric measures (such as height, weight, BMI) and blood chemical tests (such as glucose levels, glycosylated hemoglobin, LDL, and triglycerides) were carried out by medical professionals using conventional methods.
Patient evaluation was set up; pre and post intervention, through measurement of glycosylated hemoglobin, baseline and discharge glycosylated hemoglobin, Measurement of blood pressure, and LDL. Measurement of patient satisfaction through patient satisfaction survey and evaluation of patients' feelings and self-esteem by; Net promoter score, SDC score, diabetes knowledge score, words from our patients. Patient evaluation was done as primary and secondary end points.

Reinforcement of education
Another problem is the enforcement of the value of regular training sessions. As at the beginning of the process the best results achieved through academic stimulation are seen but usually diminish afterwards. To prevent attrition, a few days before the learning meeting, it may be helpful to inform the patients by their clinicians about the appointment by phone or text message.

Barriers to self-management
There are many obstacles to diabetes education and self-management. A few are human such as empowerment, education, inspiration, problem-solving skills, anxiety, gender, cognitive impairment, certain disorders, etc. and others are linked to the setting and community. Instructors must recognize some obstacles through open and trusting interaction with participants. Single face-to-face meetings can be more effective for this reason than group meetings. However, even when the education program is focused on group sessions, single lessons can be used chronologically. Cultural and linguistic discrepancies of minority groups represent signi cant barriers. It is essential for these group members to use special tools for adapting education.

Outcome indicators
Primary outcome Normal Glycated Hemoglobin (HbA1c) was the primary goal. A Diabetes Control and Complications Trial (DCCT) method were used to measure glycated hemoglobin.

Clinical outcomes:
Body weight: Calibrated electronic scales were used to measure body weight. Of measuring height, a portable sonic machine was used. The value of Body mass index (kg / m2) was determined from measures of height and weight. The Tanita Body Fat Control measured the precision of body fat to ± 0.5%. The correct waist circumference assessment procedure has been used.

Laboratory Results:
A complete lipid pro le has been obtained. Blood pressure was measured using a digital blood pressure monitor by accepted methods. Current guideline studies also provided appropriate levels of blood lipids and blood pressure.

Medication prescribed:
Drugs approved for diabetes treatment were tested every 14 months and compared at baseline with those prescribed. We de ned the increase in medication by launching a new drug, increasing the dose of oral hypoglycemic drugs or use of insulin. However, a decrease of medication was described as a decrease in oral hypoglycemic drug type, quantity or the number of insulin units administered.

Lifestyle
The outcomes of lifestyle were evaluated regularly, 6 months, 12 months and 24 months. To what degree we were effective for encouraging, improving adaptation and strengthening family relationships of our patients. How many occasions have they been through periods of hopelessness and despair after the end of the study? To what extent we made our patient believe in self-e cacy and have a positive outlook on life? To what extent did our patients build a strong favorable doctor-patient interaction? And become more effective in coping with actions and had a better health-related quality of life with a favorable impact on their life. Variables of socialization, particularly skills for problem-solving and self-e cacy. Mental well-being. Identify and encourage personal goals and habits to accomplish self-determined objectives. How to build trust in an interpersonal relationship.

Psychological
We used Net promoter score, SDC score, and patient words through customer satisfaction surveys. Assessment of pre-and post-intervention patients ' self-esteem and psychosocial status. We evaluated the degree to which the educational sessions render our patients feel empowerment, emotional adjustment, and the real quality of life changes. How they adopt new challenges, essential survival skills. The extent to which they become fully consistent with a healthy, great life with social and psychological concerns.

Statistical analysis
The action program and the personal appointment groups were attributed by evaluating the cohort by time interface term from frequent measurement analysis of variability with Greenhouse-Geisser sphericity adjustment, taking the primary outcome of HbA1cas and analyzing others as developing a hypothesis. With Microsoft Windows version 11.0 (SPSS Inc., Chicago, Illinois, United States), Stata version Nine (Stata Corp, Baton rouge, TX, USA) was used. If appropriate, the CONSORT claim was adhered to and as far as possible an attempt to examine was carried out.
Based on the t-test and chi-square test, we analyzed differences among groups. An analysis of the intention to treat, along with all other individuals involved, was carried out. Differences from baseline assessment were evaluated using multiple variability measurement methods to determine the discrepancies between self-care behaviors and HbA1c in the same group, pre and post-intervention. Pearson or Spearman rho correlations have been used to examine the relationships between data. Multiple regressions have been used to identify glycemic control predictors. Table 1 shows the baseline distribution in our patients of the comorbidity characteristics. The ANOVA analysis showed signi cant differences, before, during and after implementation of the program, in terms of Hb1AC, BP and LDL. 702 potentially eligible patients sought enrollment and achievement of enrollment and were referred to a comprehensive model of clinical care. Demographic and socio-cultural characteristics in terms of age, length of T1DM and sex. The speci c health features, compliance to treatment, distribution of morbidity, commitment to diet, and medical risks as seen in Table 1.

Results
The systematic model of health education resulted in favorable variations in HbA1c, LDL cholesterol and SBP (P < 0 05); statistically signi cant differences were observed during the study (Fig. 1, Table 2). The non-adjusted effect of the systematic health education model on parameter changes was higher for LDL, HbA1c, and SBP; this showed signi cant differences during the study (P < 0 05). After an updated study, the HbA1c decreased by 0.67 per cent (P < 0 01) in the systemic model of health education. In comparison, SBP decreased by 10.83 mmHg (P < 0 01) and the amount of DBP, HDL and total cholesterol decreased signi cantly and did not important. (Fig. 2, 3) Table 2 List of potential themes included in a therapeutic patient education for type 1 diabetic patients The BMI did not change substantially during the study and the adjusted effect of the systematic health education model was-0.23 (Table 2). Though, after 2 years of follow-up, the systematic health education model demonstrated e cacy in the percentage of patients targeted for cardiovascular risk factors: LDL cholesterol < 100 mg / dl (P = 0 02), HbA1c < 7% (P < 0 01), BP regulation (< 130/80 mmHg) (P = 0 03), SBP < 130 mmHg (P = 0 03), and global monitoring (metabolic and BP) (P < 0 01). However, it was not important for the parameters DBP < 80 mmHg and BMI < 25 kg / m2 (Table 3). Net promotor score of SDC was 85%, were promotors, passives and detractors were 87.8%, 9.5% and 2.8% respectively. P value < 0.05 (Table 4, Fig. 4)

Discussion
This prospective, study is considered as a strategic integrated project. It was established, as a clinical project including its infrastructure, man power, material, budget, policies and procedures. This project was established for full integrated management of diabetic patients. Our care rendered to the patients has been re ected on their outcomes. Therapy together with health education through social media, what-Sapp groups and focus group discussion together with individual face to face interviews, had a good impact on our patients. It was an effective intervention that had an observed effect on patients' outcomes. We evaluated our patients, pre and post intervention to see the change in some pre-speci ed variables. (Fig. 5, 6) We noticed the change in their clinical statuses, anthropometric measures, laboratory results, psychosocial lives, lifestyles, and quality of lives.
702 patients is a good number to start a prospective study, with zero percent attrition or drop-outs. Indeed, building up of good friendly relationships, trust and rapport with your patients from the beginning, is better than insulin. Health education, patient motivation, self-management knowledge, skills, is useful in improving metabolic control.
This will reduce the patient and family costs in secondary and tertiary management. Moreover, this improvement observed and maintained at 24 months.
There is no longer a need to justify the value of patient education: education is part of a patient-centered humanistic therapeutic approach; it enables patients to be actively involved in their own recovery with the goal of increasing the quality of life and adherence with medication, as well as minimizing possible complications. Thus, our healthcare professionals are therefore educating, advising, preparing, engaging with, inspire and support physicians in disease follow-up which takes long time.
Our study showed a portrayal in cognitive and behavioral therapy and inspirational interviews as a main contributor to clinical patient education, which occurs in an environment of understanding and emotions, correlated with several psycho-educational strategies. This paradigm had an obvious effect on clinical and laboratory outcomes, as well as, the psychological aspect and the quality of life. Many studies have shown that diabetic patients' education is a patient-centered humanitarian strategy that encourages clinicians to be protagonists in their own care, improve their well-being, and reduce the likelihood of possible complications.
( Fig. 7) Group preparation for patient education must start as soon as a training need is de ned through diagnosis. Early diagnosis and education offers time to identify and overcome challenges, creates constructive practice opportunities and promotes the ability to solve and deal with issues and problems. Our aim was to provide the patient (or healthcare provider) with time to perform survival skills and self-management.
Our key nutritional targets were to improve glycemic control, offer appropriate nutrients and calories to satisfy metabolic needs, and establish a follow-up treatment life-plan. Some of the problems that may hinder the accomplishment of these targets in our facilities include: meal time planning and need-based modi cations; in case of surgery laboratory testing, and procedures. When the patients lose their appetite or loss of ability of eating after drug administration or after acute diseases, glycemic control becomes very di cult. Other problems such as; inconsistent consumption of sugar, nutrition that is not addressed in the diet plan, ine cient food distribution arrangement with point of care sugar level monitoring and insulin treatment, lack of principles understanding by doctors, patients and families of the existing values of diabetes health, variability of requirements of insulin among patients, either on enteral or parenteral nutrition, decreased exercise and sedentary life. (Fig. 8) We met maximum glycemic targets for our patients. To achieve optimal glycemic control and glycemic targets thus reducing hypoglycemia, successful insulin therapy needs to be understood and used. Recent studies have highlighted the signi cance of preventing hypoglycemia to minimize risk, but avoiding hyperglycemia is equally as important.
It is advised to develop guidelines, order sets, and glycemic goals by an interdisciplinary group of administrative support. Developing and enforcing hospital-wide protocols and uniform insulin order sets will assist patients in choosing the right insulin protocol while preventing adverse events. The use of a responsive "sliding scale" should be discontinued, and the standard of care should be therapeutic insulin schemes including basal, postprandial and corrective insulin.
Throughout tandem with a patient-centered strategy, the diabetes educator can also promote the production and use of structured insulin order sets and procedures to avoid hypoglycemic episodes, achieve optimal performance, and mitigate harm capacity. The diabetes educator should also promote the development and use of protocols to manage and control hypoglycemia and make recommendations for improvement.
When indicated for all patients with hyperglycemia or at high risk of hyperglycemia, our clinicians followed them through routine check of glycated hemoglobin and daily glucose monitoring. This includes diagnosis of cases with diabetes as well as patients received high-dose corticosteroids, immune suppressants, and intravenous and oral nutrition. After blood transfusions or with a record of uncontrolled glucose levels, the glycated hemoglobin level may not be accurate, or if there are hemoglobinopathies in case of dialysis patients or those receiving chemotherapy. In pediatric, obstetric, and emergency patients, point-of-care ketone screening should be recommended.
With this objective in mind, the diabetes educator may engage in the foregoing educational activities: evaluating the knowledge and skills of patients having diabetes; improving self-management skills; providing training in a variety of contexts, including staff induction, medical areas and big rounds; designing curricula for sharing with other team leaders; using a variety of educational tools; for example; case studies, workshops of self-learning, journal societies, templates of survival skills and ash cards to meet the needs and preferences of all environments and learners.
In our study, every patient had a good experience and take-home message after two years of hard work. After a countless episodes of depression, suicidal attempts, anxiety, upset, loss of hope, loss of self-esteem, loss of self- For present, however, it is important to maintain the education systems while at the same time continuing to investigate the effects of social media in order to identify certain categories of patients who may prosper from this tool. Regular medical interaction may be more relevant to patients and families modifying their insulin protocol, promoting self-management and encouragement. It will also be very bene cial in pre-gestational diabetes, patients with constant subcutaneous insulin infusion and patients with a high risk of developing serious acute complications correlated with other therapies (corticosteroids). In order to know the impact on health care system and leadership performance to patients with chronic disorders, it is also important to identify the implications of education on the interaction of primary and secondary management.
To summarize, using an immersive tele-education system embedded into an intense face-to-face follow-up, produces signi cant changes in metabolic pro le, quality of life, and self-care compared to traditional drug prescribing and reconciliation follow-up. Improving contact services, though, is important to provide effective cost reductions to the healthcare and diabetes community.

Conclusion
As a consequence of all the variables listed above, it can be inferred that the comprehensive health education approach is a valuable tool for the treatment of T1DM, as it leads to a decrease in HbA1c, LDL cholesterol and SBP rates, as well as to that conformity with the regulation criterion, except for DBP and BMI.
Since health education will result in cost reductions and better results, Medicare and other payers would be protected by health education. In order to address this scarcity, DM-care educators will provide comprehensive health education to raise understanding of the seriousness of diabetes, its risk factors, and approaches to avoid diabetes and its complications in at-risk populations. The data used to support the ndings of this study are available from the corresponding author upon request.

Funding
The author declared they did not receive any funds

Con icts of Interest (Competing interests)
The authors declare that they have no con icts of interest.

Authors' Contributions
Crafted a research plan and prepared a report. Checked out the manuscript. Writers contributed to the writing of the text and read and support the nal document.   Dashboard of patients views and opinions