Abstract
Background
Family presence is essential in reducing delirium and promoting early recovery of patients in the intensive care unit (ICU). This study was conducted through a questionnaire survey to examine the current visitation policies of ICUs in China and explore flexible visitation options.
Methods
Two versions of independently developed questionnaire, informed by relevant literature, was distributed in two versions: a medical staff questionnaire and a family questionnaire. The survey was administered online and conducted anonymously, with participants completing it after scanning a two-dimensional bar code. Data were collected from January 2020 to June 2020. We accessed the difference between the two groups were compared and the association between factors associated with family satisfaction were assessed.
Results
A total of 1200 hospitals across 30 provinces participated, yielding 16,359 valid responses (13,483 from medical staff and 2876 from family members). Currently, 90.5 % of the ICUs allow once-daily visitation, whereas only 1.2 % permit unrestricted visitation. Family care was allowed in 15.0 % of the ICUs at the end of the patient's life, and 30.3 % allowed flexible visitation for rehabilitation exercises. Among medical staff, 73.9 % of doctors and 58.7 % of nurses supported flexible visitation when rehabilitation exercises are needed. In addition, 73.3 % of family members were willing to help with rehabilitation exercises, and 77.3 % were satisfied with the existing visitation policies.
Conclusions
Most ICUs in mainland of China enforce restrictive visitation policies, most medical staff and family members accept. Moreover, flexible visitation policies for rehabilitation purposes may be increasingly acceptable in the future.
Keywords: Intensive care unit, Medical staff, Policy, Questionnaire, China
Introduction
Visitation is a unique aspect of intensive care unit (ICU) management. ICU visitation policies are typically categorized into restrictive and flexible visitation policies, depending on the specific visitation requirements.[[1], [2], [3]] Flexible visitation allows family members to visit the patient for up to 12 h per day.[4] Current guidelines recommend flexible visitation due to its several benefits, including improved communication, better understanding of the patient's condition, and improved employee satisfaction.[2,3] However, flexible visitation policies can increase nursing difficulties,[5,6] infection complications, and medical disputes.[6] Therefore, restrictive visitation policies are still applied in most ICUs as they help avoid these risks and maintain efficient nursing practices.[[7], [8], [9]]
In China, ICU visitation policies lack uniformity due to the absence of unified regulations, guidelines, or expert opinions. Each ICU sets its own visitation rules. Moreover, no large-scale research has been conducted to evaluate visitation policies in Chinese ICUs, leaving the ideal policies for both healthcare providers and family members unclear.
This study investigates the current situation of ICU visitation policies in mainland of China via an online questionnaire survey, explores the ideal visitation policies from the perspectives of medical staff and patients’ families, and identifies the most suitable visitation policies for Chinese ICUs.
Methods
This multicenter prospective study was conducted from January 2020 to June 2020. The study involved ICU centers across mainland of China, excluding hospitals designated for COVID-19 treatment. During this period, China's COVID-19 preventive and control policies were highly effective, with all patients isolated and treated in designated hospitals. Thus, people's daily lives and work were minimally affected. ICU visitation policies were consistent with those in place before the COVID-19 pandemic. Participating ICU centers posted a two-dimensional bar code at ICU entrances, allowing individuals who scanned the code to voluntarily participate and anonymously complete the online questionnaire. Two separate questionnaires were used: one for medical staff and one for patients’ family members.
Data collection
Variables related to patients’ family members (e.g., age, sex, occupation, and educational level) were collected. Moreover, the family members’ questionnaire included eight multiple-choice questions. Flexible visitation was defined as allowing family members to visit the patient on-demand, including situations where patients required family visits due to special conditions or when family members had specific visitation requests.
Data on medical staff (e.g., age, professional title, years of ICU experience, academic background, and job position) were collected. In addition, medical staff's information about the type of ICU and hospital grade were included. Hospitals in mainland of China are classified into Grade 3 Class A (the highest), Grade 3 Class B, Grade 2 Class A, and Grade 2 Class B categories. The questionnaire for medical staff comprised 12 questions about current ICU visitation policies and 13 questions about their opinions on various visitation scenarios.
The primary outcome assessed the prevailing ICU the current visitation policies in mainland of China. The secondary outcome was the medical staff's and patients’ families’ acceptance of changes in visitation policies.
Statistical analysis
For normality testing, the Shapiro–Wilk test was applied for sample sizes under 5000, and the Kolmogorov–Smirnov test was used for larger samples. Continuous data, if normally distributed, are expressed as mean±standard deviation; non-normally distributed data are expressed as median (interquartile range). Categorical data are expressed as the number of cases (n) and percentage (%). Student's t-test and Wilcoxon rank-sum test were used to compare continuous variables between the two groups according to the data distribution. The chi-squared test was used for comparing categorical data between groups. Moreover, multivariate logistic regression analysis was performed to assess factors associated with family satisfaction. All statistical analyses were performed using R software (version 4.3.1). A two-sided P value of < 0.05 was considered statistically significant.
Results
Baseline data
A total of 1200 hospitals from 30 provinces were invited to participate in the survey (Figure 1). The study gathered 16,359 valid questionnaires: 2876 questionnaires from patients’ family members and 13,483 questionnaires from medical staff.
Figure 1.
Geographical distribution of medical staff respondents in the questionnaire survey across China.
Of the 2876 family members, 1164 were male and 1712 were female (Supplementary Table S1). The distribution of educational levels among the family members was as follows: 723 (25.1 %) had completed technical secondary school, 729 (25.3 %) had attended college, 1243 (43.2 %) held a bachelor's degree, and 181 (6.3 %) had a master's degree.
Of the 13,483 medical staff, 9108 were nurses and 4375 were physicians (Supplementary Table S2). The nursing staff included 936 (6.9 %) practice nurses, 5992 (44.4 %) nurses, 1978 (14.7 %) supervisor nurses, 162 (1.2 %) deputy chief nurses, and 40 (0.3 %) chief nurses. The medical staff included 570 (4.2 %) doctors in training program, 1051 (7.8 %) resident physicians, 1483 (11.0 %) attending physicians, 877 (6.5 %) deputy chief physicians, and 394 (2.9 %) chief physicians.
Current status of ICU visitation policies
Visitation policies vary between different ICUs (Table 1). Regarding daily visits, 428 (3.2 %), 12,201 (90.5 %), 544 (4.0 %), 148 (1.1 %), and 162 (1.2 %) of medical staff voted to none, once, twice, thrice, or unlimited visits, respectively. Regarding additional family visits when a patient's condition changes, 36.3 % of medical staff reported allowing extra visitation, whereas 55.5 % indicated that such additional visits might be allowed. Conversely, 8.2 % of the medical staff stated that such visits were not allowed.
Table 1.
Current status of intensive care unit visiting policies (n = 13,483).
| Variables | n (%) |
|---|---|
| 1. Frequency of visitation (times/day) | |
| 0 | 428 (3.2) |
| 1 | 12,201 (90.5) |
| 2 | 544 (4.0) |
| 3 | 148 (1.1) |
| Unlimited | 162 (1.2) |
| 2. Numbers of families for each time(/time) | |
| 1 | 6223 (46.2) |
| 2 | 5991 (44.4) |
| 3 | 568 (4.2) |
| Unlimited | 701 (5.2) |
| 3. Age requirements for visiting family members | |
| >18 years old | 5858 (43.4) |
| Unlimited | 7625 (56.6) |
| 4. Hand washing is required | |
| No | 1807 (13.4) |
| Yes | 11,676 (86.6) |
| 5. Wearing isolation clothing | |
| No | 734 (5.4) |
| Yes | 12,749 (94.6) |
| 6. Wearing a mask and hat | |
| No | 2508 (18.6) |
| Yes | 10,975 (81.4) |
| 7. Whether family members were allowed to visit when patients condition get worse? | |
| No | 1111 (8.2) |
| Yes | 4891 (36.3) |
| Depends | 7481 (55.5) |
| 8. Whether the family is allowed to be with patient at the end of his or her life? | |
| No | 4442 (32.9) |
| Yes | 2025 (15.0) |
| Depends | 7016 (52.0) |
| 9. Does your ward currently allow flexible family visitation (extended or increased times) for patients who need early rehabilitation exercises? | |
| No | 3466 (25.7) |
| Yes | 4088 (30.3) |
| Depends | 5659 (42.0) |
| No idea | 270 (2.0) |
| 10. Whether to accept the patient's family members at the rescue scene? | |
| No | 10,848 (80.5) |
| Yes | 417 (3.1) |
| Depends | 2218(16.5) |
| 11. Should flexible visitation be added to patients with delirium? | |
| No | 1371 (10.2) |
| Yes | 5049 (37.4) |
| Depends | 6846 (50.8) |
| No idea | 217 (1.6) |
| 12. How to get visitation information? | |
| The pamphlet | 8084 (60.0) |
| Printed notification | 10,278 (76.2) |
| Card | 3737 (27.7) |
| 5158 (38.3) | |
| Web site | 2418 (17.9) |
Regarding the presence of family members at the time of death, 15.0 % of medical staff allowed it, 32.9 % did not, and 52.0 % indicated its possibility. Regarding flexible family visitation for patients undergoing early rehabilitation exercises, 30.3 % of staff agreed, 25.7 % disagreed, 42.0 % stated “It depends,” and 2.0 % had no opinion.
Moreover, 80.5 % of medical staff reported that family visitation was denied during resuscitation in their ICUs. When delirium occurred, 37.4 % of medical staff reported that their ICUs permitted flexible family visitation, 10.2 % stated that visitation was strictly prohibited, and 50.8 % suggested that visitation might be allowed under certain conditions.
Family members’ understanding and points of view on ICU visitation policies
Of the patients’ family members, 95.0 % understood ICU visitation policies (Table 2). Family satisfaction was reported as follows: 643 (22.4 %) were very satisfied, 1580 (54.9 %) were satisfied, and 398 (13.8 %) were dissatisfied.
Table 2.
Family members’ understanding and views on ICU visiting policies (n = 2876).
| Variables | n(%) |
|---|---|
| 1. Do you understand the ICU visiting policy? | |
| No | 145 (5.0) |
| Yes | 2731 (95.0) |
| 2. Do you agree with current visiting policies? | |
| Quite agree | 643 (22.4) |
| Agree | 1580 (54.9) |
| Disagree | 398 (13.8) |
| Strongly disagree | 140 (4.9) |
| No matter | 115 (4.0) |
| 3. How about increasing the number of family visits or extending the time of family visits? | |
| No matter | 353 (12.3) |
| Agree | 1854 (64.5) |
| Disagree | 669 (23.3) |
| 4. Ideal ICU visiting policies | |
| Restricted visiting policies | 2029 (70.5) |
| Flexible visiting policies | 417 (14.5) |
| visit patients at any time | 430 (15.0) |
| 5. How many times do you want to visit each day? | |
| 2 | 2110 (73.4) |
| 3 | 464 (16.1) |
| 4 | 87 (3.0) |
| >4 | 215 (7.5) |
| 6. How many hours do you want visitation? | |
| 1 | 2397 (83.3) |
| 2 | 282 (9.8) |
| 3 | 41 (1.4) |
| 4 | 26 (0.9) |
| >4 | 130 (4.5) |
| 7. How about to be present when doctors checking on patients? | |
| Agree | 1811 (63.0) |
| Disagree | 829 (28.8) |
| No matter | 236 (8.2) |
| 8. How about to participate in the following work: | |
| Feeding | 2102 (73.1) |
| Physical cleaning | 1931 (67.1) |
| Rehabilitation exercise | 2108 (73.3) |
| Psychological comfort | 2444 (85.0) |
| Refuse | 109 (3.8) |
ICU: Intensive care unit.
In addition, 1854 (64.5 %) of the patients’ family members desired increased visitation hours or frequency. In total, 2110 (73.4 %) preferred to visit twice daily, whereas 2397 (83.3 %) wanted to extend the visitation duration to 1 h.
Regarding the presence of family members during examination or treatment, 1811 (63.0 %) patients’ family members found it reasonable, whereas 829 (28.8 %) did not. Regarding involvement in patient care, 2102 (73.1 %) of family members were willing to assist with feeding, 1931 (67.1 %) with cleaning, 2108 (73.3 %) with rehabilitation exercises, and 2444 (85.0 %) with providing psychological support. Conversely, 109 (3.8 %) of family members refused to participate.
Medical staff's views on ICU visitation policies (Table 3)
Table 3.
Medical staff's views on ICU visiting policies.
| Variables | Nurse(n = 9108) | Doctor(n = 4375) | P value |
|---|---|---|---|
| 1. Do you accept family members at the rescue scene? | <0.001 | ||
| No | 7369 (80.9) | 3437 (78.6) | |
| Yes | 275 (3.0) | 187 (4.3) | |
| Depends | 1464 (16.1) | 751 (17.2) | |
| 2. Do you think flexible visiting policies should be carried out for patients who need early rehabilitation exercise? | <0.001 | ||
| No | 1989 (21.8) | 644 (14.7) | |
| Yes | 5348 (58.7) | 3235 (73.9) | |
| No idea | 1771 (19.4) | 496 (11.3) | |
| 3. Do you think flexible family visitation should be carried out for delirium patients? | <0.001 | ||
| No | 2193 (24.1) | 1268 (29.0) | |
| Yes | 2563 (28.1) | 1530 (35.0) | |
| Depends | 4146 (45.5) | 1513 (34.6) | |
| No idea | 206 (2.3) | 64 (1.5) | |
| 4. How about increasing the number of family visits or extending the time of family visits? | <0.001 | ||
| Disagree | 6272 (68.9) | 2594 (59.3) | |
| Agree | 1762 (19.3) | 1418 (32.4) | |
| No matter | 1074 (11.8) | 363 (8.3) | |
| 5. Family visiting policies that you can accept | 0.093 | ||
| Restricted visitation model | 8160 (89.6) | 3877 (88.6) | |
| Flexible visitation model | 948 (10.4) | 498 (11.4) | |
| 6. How many times do you want for patient's family to visit each day when you have to increase times of visitation? | <0.001 | ||
| 2 | 8630 (94.8) | 3997 (91.4) | |
| 3 | 330 (3.6) | 275 (6.3) | |
| 4 | 52 (0.6) | 29 (0.7) | |
| >4 | 96 (1.1) | 74 (1.7) | |
| 7. How about family members to be present when doctors checking on patients? | <0.001 | ||
| Disagree | 3966 (43.5) | 2156 (49.3) | |
| Agree | 2031 (22.3) | 1042 (23.8) | |
| Depends | 3111(34.2) | 1177 (26.9) | |
| 8. How about establishing direct contact with family members | <0.001 | ||
| No | 7292 (80.1) | 2811 (64.3) | |
| Yes | 1816 (19.9) | 1564 (35.7) | |
| 9. If a direct connection is established, which method would you choose? | <0.001 | ||
| 4769 (52.4) | 2259 (51.6) | ||
| 1372 (15.1) | 352 (8.0) | ||
| Telephone | 2967 (32.6) | 1764 (40.3) | |
| 10. Increasing the number of family visits or extending the visiting time of family members may bring about adverse effects | |||
| Increase nursing labor costs | 6650 (73.0) | 3576 (81.7) | <0.001 |
| Increase medical disputes | 6400 (70.3) | 2578 (58.9) | <0.001 |
| Result in space constraints | 6453 (70.8) | 2668 (61.0) | <0.001 |
| Result in family members do not cooperate | 6626 (72.7) | 2486 (56.8) | 0.400 |
| Increased burden on medical staff | 6197 (68.0) | 3009 (68.8) | <0.001 |
| 11. Increasing the number of family visits or extending the visiting time of family members may bring about beneficial effects | |||
| Reduced delirium | 6486 (71.2) | 3489 (79.7) | 0.202 |
| Improved doctor-patient relationship | 4145 (45.5) | 2043 (46.7) | 0.861 |
| Increased doctor-patient trust | 4874 (53.5) | 2349 (53.7) | <0.001 |
| Reduced administration of sedation medication | 4435 (48.7) | 2286 (52.3) | <0.001 |
| Not sure | 2662 (29.2) | 1090 (24.9) | <0.001 |
| 12. Possible benefits about family members to be present when doctors checking on patients? | |||
| Increased trust | 5671 (62.3) | 2470 (56.5) | <0.001 |
| Reduced conflict | 4261 (46.8) | 1691 (38.7) | <0.001 |
| Better understanding of the condition of patient | 7598 (83.4) | 3267 (74.7) | <0.001 |
| More comprehensive ward rounds | 3138 (34.5) | 1149 (26.3) | <0.001 |
| Avoidance of medical error | 2080 (22.8) | 730 (16.7) | <0.001 |
| No benefit | 880 (9.7) | 660 (15.1) | <0.001 |
| Not sure | 1606 (17.6) | 812 (18.6) | <0.001 |
| 13. Possible adverse about family members to be present when doctors checking on patients? | |||
| Reducing trust | 2203 (24.2) | 796 (18.2) | <0.001 |
| Increasing conflict | 4759 (52.3) | 2154 (49.2) | 0.001 |
| Putting doctors under more pressure | 6517 (71.6) | 3112 (71.1) | 0.627 |
| Prolongating the time needed for ward rounds | 6546 (71.9) | 3172 (72.5) | 0.456 |
| Increasing the labor cost | 5886 (64.6) | 2945 (67.3) | 0.002 |
| Increasing the risk of cross-infection | 8107 (89.0) | 3639 (83.2) | <0.001 |
The acceptability of flexible visitation policies among medical staff was evaluated using many hypothetical questions in the medical staff questionnaire. Of the respondents, 7369 (80.9 %) nurses and 3437 (78.6 %) physicians reported rejecting visitation during rescue efforts, with a statistically significant difference between the two groups (P <0.001). In the case of patients requiring early rehabilitation exercises, a significantly higher percentage of medical staff accepted flexible visitation compared to that of nurses (73.9 % vs. 58.7 %, P <0.001).
Nurses were more likely to reject proposals for increased visitation frequency or extended visitation time than physicians (68.9 % vs. 59.3 %, P <0.001). Moreover, 89.6 % of nurses and 88.6 % of physicians accepted restricted visitation. In addition, 94.8 % of nurses and 91.4 % of physicians supported the policy of visiting twice a day. However, 80.1 % of nurses and 64.3 % of physicians opposed establishing direct contact with family members (P <0.001).
Factors affecting patient satisfaction
Multivariate logistic regression analysis was conducted to identify factors affecting satisfaction (Table 4). Five factors were analyzed: age, sex, occupation, academic background, and understanding of ICU visitation policies. The analysis revealed that family satisfaction increased with a better understanding of ICU visitation policies (odds ratio [OR]=2.26, 95 % confidence interval [CI]: 1.57 to 3.23), being male (OR=1.29, 95 % CI: 1.08 to 1.56), and working in healthcare (OR=1.17, 95 % CI: 1.06 to 1.31).
Table 4.
Multivariate logistic regression analysis for influencing factors of patient satisfaction.
| Variables | OR | 95 % CI | P value |
|---|---|---|---|
| Age | 0.93 | 0.8 to 0.98 | 0.006 |
| Sex (male) | 1.29 | 1.08 to 1.56 | 0.006 |
| Occupation | 1.17 | 1.06 to 1.31 | 0.003 |
| Academic | 0.74 | 0.67 to 0.82 | <0.001 |
| understood of ICU visitation | 2.26 | 1.57 to 3.23 | <0.001 |
CI: Confidence interval; ICU: Intensive care unit; OR: Odds ratio.
Discussion
This large-scale clinical study examines ICU visitation policies in China. We found that most ICUs adopted restrictive visitation policies in mainland of China, though flexible visitation was allowed in certain situations. Flexible visitation, as defined in this study, is on-demand visitation, which involves allowing extra visits when necessary for the patient's care. In cases where family presence is considered beneficial, most ICUs permit extra visits or accompaniment, and most medical staff are supportive of such flexible policies. In addition, traditional Chinese practices influence visitation; for instance, it is customary for families to be present during a patient's final moments. However, visitation is prohibited during rescue situations.
Recently, the development of medical humanities has prompted increased research on ICU visitation policies. In Salim et al.’s trial,[10] only 230 questionnaires were distributed, with 221 questionnaires collected from two ICUs (one with open visiting hours and one with restricted visiting hours). Their study, which focused on family satisfaction with the care provided in ICUs, found no significant difference between the two units in satisfaction across five domains between the two ICUs. Conversely, Regis et al.[1] found that flexible visitation policies were associated with better scores for anxiety, depression, and family satisfaction compared with restricted visitation policies. However, they did not survey families about their views on visitation policies. In our study, 77.3 % of family members were satisfied with current visitation policies. Most families were willing to accept restricted visitation policies rather than open visitation policies. However, 64.5 % wanted more frequent or longer visitation. Their ideal visitation policies were twice a day, with each visit lasting 1 h.
Policies for ICU visitation are a controversial topic. A clinical study from Brazil indicated that flexible visitation policies reduced anxiety symptoms among family members and appeared to improve satisfaction[8]. Flexible visitation can be tailored to the cultural background of each ICU. Physicians and nurses may allow visits without disrupting medical activities. Flexible visitation is an efficient, practical, and widely accepted policy. The study showed that 64.5 % of family members desired increased visitation frequency or longer duration of visits. Conversely, 68.9 % of nurses and 59.3 % of physicians disagreed with such changes. Most medical staff permitted visits in cases where patients required early rehabilitation or experienced delirium.
In Chinese ICUs, flexible visitation is largely accepted. However, 80.5 % of ICUs in China restrict visitation during rescue situations. Despite opportunities to modify visitation policies, 78.6 % of physicians and 80.9 % of nurses still opposed visitation during rescue efforts. The advantages and disadvantages of flexible vs. restricted visiting policies vary according to cultural, economic, humanity-related, and historical factors. Many studies have shown that the family presence in the ICU helps reduce anxiety, confusion, agitation, and delirium in patients.[[11], [12], [13]] However, open visitation has also been linked to increased workload, burnout, and occupational violence.[[13], [14], [15]]
Regarding visitation policies, perspectives vary. Family members generally advocate for more frequent and extended visits to better understand the patient's condition and obtain emotional relief. Conversely, medical staff are more concerned with maintaining efficiency and patient safety. We found that 64.5 % of family members desired longer or more frequent visits, whereas only 19.3 % of nurses and 32.4 % of physicians agreed with such changes. Family members wanted to assist with feeding, hygiene, rehabilitation, and psychological comfort. Conversely, most medical staff were concerned that extending visiting hours would lead to increased labor costs, space constraints, and potential conflicts. These findings align with the WELCOME-ICU survey,[14] which suggested that open visiting policies were beneficial for family members but less favorable for patients and staff.
This national study explores the differing views between doctors and nurses regarding ICU visitation policies in China. Doctors were more likely to support additional visitation for patients undergoing rehabilitation or suffering from delirium. Many nurses opposed allowing family members to be present during rescue efforts. Nurses expressed concerns that increasing visitation would lead to increased medical disputes and space constraints. This may be due to the visibility of nursing activities to family members during visitation time.
Visitation policies in ICUs have undergone adaptive changes in response to unique circumstances. During the COVID-19 pandemic, most ICUs worldwide adopted restricted visitation policies.[16,17] A study in Houston found that virtual family ICU visitation, facilitated by telecritical care, was beneficial during the pandemic.[16] Recently, a multicenter study from the United Kingdom investigated communication and virtual visitation in ICUs. The results showed that virtual visiting provided significant benefits, including improvements in patient recovery and staff morale.[18] During the 2022 COVID-19 pandemic, nearly all ICUs in China prohibited visitation. However, mobile video visitation – enabled by WeChat – emerged as a feasible and adaptable model, allowing flexible visitation.
This study recruited ICU centers across the country and excluded hospitals designated for COVID-19 treatment. This study was conducted from January 2020 to June 2020. During this period, China's COVID-19 preventive and control policies were highly effective. All patients with COVID-19 were isolated and treated in designated hospitals. Thus, people's daily lives and work were minimally affected. During this time, ICU visitation policies remained consistent with pre-pandemic practices. The results of this study show the situation of ICU visitation policies in China.
This study has certain limitations. First, patient follow-up was not conducted, and no data was available regarding hospital-associated infections related to various visitation policies. Second, the sample size of family members who participated in the questionnaire was small. Although 1200 hospitals were invited to participate, only 2876 family members responded. Third, the online format of the survey may have excluded family members without Internet access or the time to complete it, potentially causing selection bias. Fourth, the questionnaire did not cover the duration of each visit under the current visitation policies.
Conclusion
Most ICUs in mainland of China adopt restrictive visitation policies, which are accepted by most family members and medical staff. In the future, flexible visitation policies may become more acceptable, particularly when patients need rehabilitation training.
CRediT authorship contribution statement
Yanxia Huang: Writing – review & editing, Writing – original draft, Funding acquisition. Mei Meng: Writing – review & editing, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization. Xiaojun Pan: Software, Formal analysis. Sheng Zhang: Writing – review & editing. Lidi Zhang: Writing – review & editing. Jiao Liu: Writing – review & editing. Dechang Chen: Writing – review & editing.
Acknowledgments
Acknowledgments
None.
Funding
This work was supported by grants from Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine (grant number 2024PY278) and the National Natural Science Foundation of China (grant number 82302477).
Ethics Statement
This research was a questionnaire survey online, statements on consent to participate was not applicable.
Conflict of Interest
Prof. Dechang Chen as Editor-in-Chief and Prof. Jiao Liu as associate editor had no involvement in the peer review of this article and have no access to information regarding its peer review. Prof. Bertrand Guidet took responsibility for the peer-review progress. Prof. Jean-Louis Teboul who is the co-editor-in-chief made the final decision.
Data Availability
The data sets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Managing Editor: Jingling Bao/Zhiyu Wang.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jointm.2024.12.009.
Contributor Information
Jiao Liu, Email: catherine015@163.com.
Dechang Chen, Email: 18918520002@189.cn.
Appendix. Supplementary materials
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data sets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.