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Table 1.  
Coding Taxonomy for Comment Classificationa
Coding Taxonomy for Comment Classificationa
Table 2.  
Subgroups Within Interpersonal Theme
Subgroups Within Interpersonal Theme
Table 3.  
Subgroups Within Technical Skills/Knowledge/Preparation Theme
Subgroups Within Technical Skills/Knowledge/Preparation Theme
1.
Berwick  DM.  What ‘patient-centered’ should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-w565.
PubMedArticle
2.
Cromwell  J, Trisolini  MG, Pope  GC, Mitchell  JB, Greenwald  LM, eds. Pay for Performance in Health Care: Methods and Approaches. Research Triangle Park, NC: RTI Press; 2011.
3.
Centers for Medicare & Medicaid Services. Fact Sheet HCAHPS.http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet%202010.pdf. Accessed February 2, 2013.
4.
Centers for Medicare and Medicaid Services. Physician Compare Initiative.http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physician-compare-initiative/index.html. Accessed February 2, 2013.
5.
Boss  EF, Thompson  RE.  Patient experience in outpatient pediatric otolaryngology. Laryngoscope. 2012;122(10):2304-2310.
PubMedArticle
6.
Zopf  D, Joseph  AW, Thorne  MC.  Patient and family satisfaction in a pediatric otolaryngology clinic. Int J Pediatr Otorhinolaryngol. 2012;76(9):1339-1342.
PubMedArticle
7.
Margaritis  E, Katharaki  M, Katharakis  G.  Exceeding parents’ expectations in Ear-Nose-Throat outpatient facilities: the development and analysis of a questionnaire. Eval Program Plann. 2012;35(2):246-255.
PubMedArticle
8.
Drain  M.  Quality improvement in primary care and the importance of patient perceptions. J Ambul Care Manage. 2001;24(2):30-46.
PubMedArticle
9.
Hsieh  HF, Shannon  SE.  Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.
PubMedArticle
10.
O’Connor  EJ, Annison  MH.  Building trust through promises and performance. Can your organization achieve the stellar results and employee loyalty found at Southwest Airlines? Physician Exec. 2002;28(1):68-73.
PubMed
11.
Lagu  T, Goff  SL, Hannon  NS, Shatz  A, Lindenauer  PK.  A mixed-methods analysis of patient reviews of hospital care in England: implications for public reporting of health care quality data in the United States. Jt Comm J Qual Patient Saf. 2013;39(1):7-15.
PubMed
12.
López  A, Detz  A, Ratanawongsa  N, Sarkar  U.  What patients say about their doctors online: a qualitative content analysis. J Gen Intern Med. 2012;27(6):685-692.
PubMedArticle
13.
Murakami  G, Imanaka  Y, Kobuse  H, Lee  J, Goto  E.  Patient perceived priorities between technical skills and interpersonal skills: their influence on correlates of patient satisfaction. J Eval Clin Pract. 2010;16(3):560-568.
PubMed
14.
Boss  EF, Thompson  RE.  Patient satisfaction in otolaryngology: Can academic institutions compete? Laryngoscope. 2012;122(5):1000-1009.
PubMedArticle
15.
Boss  EF, Thompson  RE.  Patient experience in the pediatric otolaryngology clinic: does the teaching setting influence parent satisfaction? Int J Pediatr Otorhinolaryngol. 2013;77:59-64.
PubMedArticle
16.
Holland  MS, Counte  MA, Hinrichs  BG.  Determinants of patient satisfaction with outpatient surgery. Qual Manag Health Care. 1995;4(1):82-90.
PubMedArticle
17.
Worth  T.  Practicing in a world of transparency. Online scores and comments about you can be painful, but they also provide an opportunity for improvement. Med Econ. 2012;89(21):52-58.
PubMed
18.
Born  K, Rizo  C, Seeman  N.  Participatory storytelling online: a complementary model of patient satisfaction. Healthc Q. 2009;12(4):105-110.
PubMed
Original Investigation
May 2014

What Parents Say About Their Child’s SurgeonParent-Reported Experiences With Pediatric Surgical Physicians

Author Affiliations
  • 1Department of Otolaryngology, George Washington University, Washington, DC
  • 2Department of Otolaryngology, Children’s National Medical Center, Washington, DC
  • 3Department of Internal Medicine, Johns Hopkins University, and the Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland
  • 4Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins University, and the Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland
JAMA Otolaryngol Head Neck Surg. 2014;140(5):397-402. doi:10.1001/jamaoto.2014.102
Abstract

Importance  Reviews of patient and caregiver experience with health practitioners are increasingly important to consumers. Understanding physician qualities valued by patients and their families may facilitate more effective care and communication.

Objective  To identify physician qualities and care dimensions valued by parents during their child’s outpatient surgical care encounter.

Design  Mixed-methods analysis of comments from patient-satisfaction surveys.

Setting  Outpatient pediatric otolaryngology and surgical specialty clinics in an urban tertiary care center.

Participants  Parents of children seen in pediatric otolaryngology and surgical specialty clinics who completed the physician section of the patient satisfaction survey.

Main Outcomes and Measures  Free-text comments written in the physician section of the survey.

Results  A total of 195 survey comments from visits to 18 surgical specialty clinics were analyzed; 64 comments (33%) were global in nature, of which 58 (90%) were positive; 25 of 195 comments (13%) discussed recommendation of care. Of the 131 comments (67%) with specific content, 79 (60%) were positive. Major themes were physician interpersonal style (n = 78, 45%), physician technical skills/knowledge/preparation (n = 82, 47%), and systems issues (n = 14, 8%). The most commonly noted interpersonal subthemes were inclusion/interaction with the child (20%) and empathy/concern for the patient’s needs (29%). The most common skills themes related to whether the physician answered questions (16%) or explained treatment (23%). The most common negative subgroup was inadequate explanation of treatment (18%). The majority of comments related to systems were negative (13 of 14, 93%).

Conclusions and Relevance  Parents highly value physician interpersonal style and visit-specific skills (involving the child in discussion; showing empathy/concern for the patient/family; answering questions; explaining treatment). While most comments about surgeons were affirmative, clinical systems were more often negatively perceived. Attention to parent-reported experiences may help physicians improve communication and overall effectiveness of care provided.

Patient and family–centered care has always been revered as an important element of health care quality. Recently, patient centeredness has received critical attention because it is now evaluated as a stand-alone measure of quality separate from its effect on health outcomes. Patient-centered care has been succinctly defined as “the experience of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.”1(pw560) The focus on patient experience of care emphasizes the importance of understanding patients’ opinions of what health care elements need improvement. The onus is on physicians to ensure delivery of patient-centered care in every setting.

Additionally, in the evolving US health system, patient experience is beginning to impact health care financing.2 In 2010, the Patient Protection and Affordable Care Act passed, initiating the utilization of patient experience scores by the Centers for Medicare and Medicaid Services (CMS) to calculate incentive payments for specific compliance programs.3 In the near future, CMS will be adding quality-of-care data and publicly reporting patient experiences and satisfaction related to individual physicians through the Physician Compare website.4 These data will be available for patients to review, so they may make informed choices of physicians and facilities.

Previous studies have evaluated numeric scores as a measure of overall satisfaction and factors influencing satisfaction in pediatric surgical outpatient clinics57; however, qualitative content of parent-perceived experience of care has not been examined. In the present study, we evaluate free-text comments provided by parents on outpatient satisfaction surveys to identify physician qualities and care dimensions valued by parents during their child’s outpatient surgical encounter.

Methods
Data Source

We conducted a mixed-methods analysis using responses to the Medical Practice survey (Press Ganey) to analyze parent comments regarding their experience in pediatric surgical clinics. Patient surveys associated with any pediatric surgical outpatient clinic in a single tertiary pediatric hospital over a 10-month period (January 17, 2012, through October 24, 2012) were included for analysis. Surveys were included only if a free-text response was provided in the “your physician” comments section. Prior to data review, all surveys were fully deidentified, patient and facility names and record numbers removed. The institutional review board approved conduct of this research.

The Press Ganey Medical Practice survey evaluates patient satisfaction with care delivery following a single outpatient clinic encounter. The survey reads on a fifth to sixth grade level. Questions are grouped into 6 service domains: access to care, during your visit, nursing care, your physician, personal issues, and overall assessment.6 Following each group of Likert-rated questions, patients (or caregivers) are provided several lines where they may provide free-text comments related to the specific service domain. Survey psychometrics and factor validation have been previously described.8 Surveys are distributed, tabulated, and benchmarked by Press Ganey. Surveys are administered via mail or e-mail within the week after the patient-physician encounter so as to encourage participation and reduce bias.6 Although response rates could not accurately be calculated for this study owing to clinic heterogeneity, the overall institutional average survey response rate in 2013 was 29%, which is consistent with other large academic institutions.

Analysis

Summative content analysis was applied.9 Two investigators developed a coding taxonomy by which comments were grouped based on the aspect of care specific to each comment (Table 1). First, the tone or intent of the comment was graded as positive, negative, or neutral. The comment was subsequently classified based on specificity as either global (“my doctor is great”) or descriptive (“my doctor is great because he takes time to listen to my concerns”) with respect to either the physician or system (eg, parking, reception). The “recommendation” code encompassed comments that did or did not endorse recommendation of care in the future; this concept has been well associated with consumer loyalty and has been previously associated with practice sustainment or growth.10

Content was then coded based on major themes and subgroups within the themes. Major themes identified were physician interpersonal style, physician technical skills/knowledge/preparation (“visit-specific skills”), and systems. Interpersonal style included comments related to the physician’s interaction with the child, parents, and interpersonal behaviors (kind, thoughtful, helpful, professional, impersonal). Visit-specific skills encompassed bedside manner and technique, knowledge, ability, time spent with patient, and explanation of diagnosis, treatment, and follow-up. Systems comments included those regarding facility and system issues such as scheduling, wait time, and facilities.

The investigators refined the template by independently coding 50 different comments. When an attribute outside of the initial coding template was mentioned, it was integrated into the overall scheme.

After the template was formalized, 3 investigators independently coded all (n = 195) comments. The Fleiss κ interrater reliability was 0.91. When there was disparity between codes, the comment was reanalyzed within the group and recoded based on consensus. The investigators then reviewed all codes and combined them into larger themes based on agreement.

Results

During the period studied, 729 surveys were collected from pediatric surgical clinics. In 195 of these surveys (27%), respondents left comments in the “your physician” section. The intent was to determine and classify the qualities parents most frequently mentioned regarding their experience in pediatric surgical clinics. A total of 137 comments (70%) were positive in intent, 50 were negative, and 8 were neutral. Sixty-four (33%) of all the comments were global. Among the specific comments, major themes identified were communication (n = 78, 45%), physician technical skills (n = 82, 47%), and systems issues (n = 14, 8%).

Global Comments

Fifty-eight (90%) of the global comments were positive in intent. Ten were completely not specific, and 4 referenced systems, while most (n = 44) related to physicians.

Recommendation of Care

Twenty-five comments discussed recommendation of care, most of which (n = 19) included a positive recommendation of care (parent would recommend the physician for others to see). Of these, 5 did not cite a reason for the recommendation (“I will recommend this physician to others”), while 14 did. All of the cited reasons for recommending care were specifically related to the physician. Five of these were globally positive comments (“Dr X is an excellent doctor. We highly recommend him”), while 9 mentioned a specific physician trait (“Dr X was friendly, courteous, and knowledgeable. I would recommend her to anyone”). Seven involved interpersonal style behaviors (“The doctor was very friendly and made us feel safe and secure in his hands. I highly recommend him”), and 8 involved a physician visit-specific skill (“Dr X is an amazing, caring, skilled doctor. I highly recommend her”). “Caring” and “friendly” subgroup codes were the most common interpersonal style themes, while “knowledge” was the most common physician skill associated with a recommendation.

In all of the comments in which there was a negative recommendation, a specific reason was given (“I loved the doctor, however I would not recommend her because it takes 2 hours to be seen in this department”). Four negative recommendation comments were systems related. One negative physician-specific comment related to poor communication with the child.

Specific Comments

Seventy-nine (60%) of the 131 specific comments were positive in intent.

Interpersonal Style

Within the interpersonal theme, 13 subordinate themes were identified: inclusion of the child; exclusion of the child; child made to feel comfortable; child made to feel uncomfortable; physician was kind, nice, or friendly; physician was helpful or accommodating; physician was unhelpful; physician was thoughtful, caring, or listened; physician was not caring; physician was professional; parents did not feel important; physician was impersonal; and physician was confident.

Seventy-eight comments involved interpersonal style (Table 2), 26 of which specifically mentioned communication with the child (“I really appreciated that she spoke to my daughter vs me, the parent”). Most of these comments (21 of 26) were positive.

Fifty-nine comments involved communication with the adult. The most common subgroups were empathy/concern for the patients’ needs (n = 29), kind/friendly physician (n = 16), and professionalism (n = 11).

Technical Skills/Knowledge/Preparation

Visit-specific skills identified in comments were further grouped into 15 categories: physician demonstrated good/poor bedside manner; physician perceived as knowledgeable or having great ability; physician did/did not explain treatment or follow-up; physician did/did not answer questions; physician spent a lot of/too little time with the patient; physician was/was not detailed or prepared; physician involvement in medical education was perceived as positive/negative; physician was rushed; and physician was/was not listening.

Eighty-two comments were identified, with most falling into multiple subgroups resulting 110 technical skill-related comments (Table 3), 71 (65%) of which were positive in intent. The most common positive subgroups were physician knowledge/ability (n = 21); physician answered questions (n = 15); and physician explained treatment and/or follow-up (n = 14). The most common negative subgroups were physician did not explain treatment and/or follow-up (n = 11), physician was rushed (n = 9); and physician spent too little time with the patient (n = 5).

Systems

The systems comments (n = 14) were subgrouped into those related to scheduling, wait time, parking, location, or cleanliness. Most of the systems comments (n = 13) were negative; 11 of these were related to conflicts in appointment scheduling.

Discussion

To our knowledge, this is the first study to review and analyze parent comments about their child’s care physicians in the pediatric surgical outpatient setting. Parents highly value physician interpersonal behaviors such as involving the child in the discussion, demonstrating empathy and concern for the child and family, and visit-specific skills such as thoroughly answering questions and explaining treatment.

Because respect for patient values is an integral aspect of patient and family-centered care, an understanding of the patient voice is essential to improving overall satisfaction. Narrative reviews provide useful and complementary information about the patient experience, especially when combined with quantitative data.11 Patient satisfaction is multidimensional, and adding comment analysis allows us to better understand the qualities driving satisfaction. This understanding provides useful information for determining specific areas for quality improvement.

López and colleagues12 analyzed online comments about primary care physicians and found most reviews to be positive and with common themes related to perception of the physician as listening, empathetic, and friendly. Similarly, in the present study, most of the comments made by parents about the pediatric surgical physicians were positive in nature.

Prior research has shown that patients in a primary care setting prioritize different types of skills than those in a surgical setting.13 The experience in pediatric surgery is a culmination of patient and family experience in the outpatient and perioperative settings, blending both the child and parent experience of care. Thus, overall assessment of satisfaction is influenced by a multitude of factors that cannot be solely represented in a rating scale.

In pediatric care, patient satisfaction is truly a measure of parent experience rather than the child’s experience because parents complete the evaluations and make medical decisions on behalf of or as proxies for their children.7 Previous studies have shown that parents rank physician interpersonal behaviors highly, but the studies do not specify if the interaction is with the child or the adult.13 Thus, pediatric practitioners are faced with the challenge of treating the child while also interacting with and satisfying the parent. Responses in the present study show that parents notice and value physician interaction with their children nearly as much as they comment on their own interactions with the physician. Many comments reflected appreciation of inclusion of the child and ensuring the child’s comfort. While there may be the tendency to focus on discussion with the parents, it is important to include the child as well, since this shapes the overall pediatric surgical care experience and influences satisfaction.

We also found surgeons’ skills, including technical ability, knowledge, and preparation for the health care visit, to be highly valued by parents. It is well known that patient priorities change according to setting and acuity of care. For example, patients seen in primary care clinics have been shown to most value interpersonal skills, while those in surgical clinics have been shown to prioritize technical skills.13 Thus, patient perspectives unique to each setting should be evaluated independently because physician qualities valued highly in the inpatient setting may have less significance or impact in the outpatient environment. This study demonstrates that a comprehensive discussion, including eliciting and answering questions as well as thoroughly explaining treatment, has a large impact on parent’s impression of the experience. By focusing on these content areas during the outpatient visit, surgeons can be more efficient with the limited time allotted to each patient. Parents will not only have the information they need to make informed choices for their child’s care but will also feel that enough time was spent with them because their expectation for information was met.

Several negative comments focused on systems or facility-specific issues. Multiple studies have shown that overall satisfaction is associated with systems issues such as wait times, scheduling, and facility environment; these factors are also cited as reasons why patients would not return to a practice.57,1416 Our data demonstrate that deficits in medical systems can negate positive interactions between the physician and parent, resulting in suboptimal patient care. Most of the negative referral comments were related to systems issues despite parents mentioning positive qualities about the doctor. This finding suggests that these convenience factors are equally or more important to them than their interaction with the physician. Of note, the only systems comments analyzed were those included in the “physician” free-text section. Therefore, it is possible that these comments represented the most negative perceptions of the health system, so much so that parents would comment at every opportunity given within the survey.

Our study has several limitations. First, since the free-text comment sections of the survey are optional, our results are subject to selection bias. Parents may have commented only on the very good and very bad, leaving out neutral comments. Second, each comment was analyzed independently of the survey it belonged to, so we were unable to analyze the correlation between comment tone and overall numeric survey score. We do not have access to nonresponders, and therefore their opinions or experience of care are not represented in this analysis.

Additionally, the small sample size suggests that these data may represent only a small fraction of patients. The 195 comments analyzed represent 27% of all of the surveys collected from pediatric surgical clinics. While the sentiments may not represent the majority of patients, this phenomenon of a minority of reviews representing public opinion is not unlike many common websites on which patients rate and review physicians. On such public sites, only a few comments pertain to each physician, but this information is broadly transparent to all public viewers and may ultimately influence how patients select their physicians. Thus the impact of patient and parent comments is critical even if the comments reflect only a minority of actual patients seen. Moreover, patient comments may be more influential than numeric satisfaction scores in motivating health care physicians to improve the quality of their interactions with patients.17,18

Finally, these data are representative only of patients in an urban tertiary academic center. The patient population as well as the specific systems issues may not be representative of the larger pediatric surgical population.

Conclusions

Patient experience in pediatric surgical care is a complex entity influenced by multiple factors. Interpretation of parent comments provides important insight into the care experience and into areas for quality improvement. By knowing what factors parents value, physicians may improve their interpersonal behaviors and technical skills to improve the overall care experience and patient outcomes. Parents most value physician interaction with their child and feeling that the child is cared for by an empathetic physician. Additionally, they value clear explanations of treatment recommendations and thorough answers to questions related to diagnosis and management. Systems-related factors such as a long wait or difficulty in scheduling can negate positive interactions with the physician and result in poor satisfaction. Further investigations of parent comments can help pediatric clinicians develop family-centered policies and practices.

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Article Information

Corresponding Author: Emily F. Boss, MD, MPH, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, 601 N Caroline St, Sixth Floor, Baltimore, MD 21287 (erudnic2@jhmi.edu).

Submitted for Publication: November 4, 2013; final revision received January 4, 2014; accepted January 24, 2014.

Published Online: March 20, 2014. doi:10.1001/jamaoto.2014.102.

Author Contributions: Dr Boss had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Espinel, Boss.

Acquisition of data: Espinel, Boss.

Analysis and interpretation of data: Espinel, Shah, Beach, Boss.

Drafting of the manuscript: Espinel, Boss.

Critical revision of the manuscript for important intellectual content: Espinel, Shah, Beach, Boss.

Statistical analysis: Espinel, Shah, Boss.

Administrative, technical, and material support: Boss.

Study supervision: Shah, Beach, Boss.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This research was presented at the American Society of Pediatric Otolaryngology Meeting; April 25-28, 2013; Arlington, Virginia.

Additional Contributions: We thank Dr John F. Bridges for his assistance in the preparation of the initial abstract.

References
1.
Berwick  DM.  What ‘patient-centered’ should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-w565.
PubMedArticle
2.
Cromwell  J, Trisolini  MG, Pope  GC, Mitchell  JB, Greenwald  LM, eds. Pay for Performance in Health Care: Methods and Approaches. Research Triangle Park, NC: RTI Press; 2011.
3.
Centers for Medicare & Medicaid Services. Fact Sheet HCAHPS.http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet%202010.pdf. Accessed February 2, 2013.
4.
Centers for Medicare and Medicaid Services. Physician Compare Initiative.http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physician-compare-initiative/index.html. Accessed February 2, 2013.
5.
Boss  EF, Thompson  RE.  Patient experience in outpatient pediatric otolaryngology. Laryngoscope. 2012;122(10):2304-2310.
PubMedArticle
6.
Zopf  D, Joseph  AW, Thorne  MC.  Patient and family satisfaction in a pediatric otolaryngology clinic. Int J Pediatr Otorhinolaryngol. 2012;76(9):1339-1342.
PubMedArticle
7.
Margaritis  E, Katharaki  M, Katharakis  G.  Exceeding parents’ expectations in Ear-Nose-Throat outpatient facilities: the development and analysis of a questionnaire. Eval Program Plann. 2012;35(2):246-255.
PubMedArticle
8.
Drain  M.  Quality improvement in primary care and the importance of patient perceptions. J Ambul Care Manage. 2001;24(2):30-46.
PubMedArticle
9.
Hsieh  HF, Shannon  SE.  Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.
PubMedArticle
10.
O’Connor  EJ, Annison  MH.  Building trust through promises and performance. Can your organization achieve the stellar results and employee loyalty found at Southwest Airlines? Physician Exec. 2002;28(1):68-73.
PubMed
11.
Lagu  T, Goff  SL, Hannon  NS, Shatz  A, Lindenauer  PK.  A mixed-methods analysis of patient reviews of hospital care in England: implications for public reporting of health care quality data in the United States. Jt Comm J Qual Patient Saf. 2013;39(1):7-15.
PubMed
12.
López  A, Detz  A, Ratanawongsa  N, Sarkar  U.  What patients say about their doctors online: a qualitative content analysis. J Gen Intern Med. 2012;27(6):685-692.
PubMedArticle
13.
Murakami  G, Imanaka  Y, Kobuse  H, Lee  J, Goto  E.  Patient perceived priorities between technical skills and interpersonal skills: their influence on correlates of patient satisfaction. J Eval Clin Pract. 2010;16(3):560-568.
PubMed
14.
Boss  EF, Thompson  RE.  Patient satisfaction in otolaryngology: Can academic institutions compete? Laryngoscope. 2012;122(5):1000-1009.
PubMedArticle
15.
Boss  EF, Thompson  RE.  Patient experience in the pediatric otolaryngology clinic: does the teaching setting influence parent satisfaction? Int J Pediatr Otorhinolaryngol. 2013;77:59-64.
PubMedArticle
16.
Holland  MS, Counte  MA, Hinrichs  BG.  Determinants of patient satisfaction with outpatient surgery. Qual Manag Health Care. 1995;4(1):82-90.
PubMedArticle
17.
Worth  T.  Practicing in a world of transparency. Online scores and comments about you can be painful, but they also provide an opportunity for improvement. Med Econ. 2012;89(21):52-58.
PubMed
18.
Born  K, Rizo  C, Seeman  N.  Participatory storytelling online: a complementary model of patient satisfaction. Healthc Q. 2009;12(4):105-110.
PubMed
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