International Surgery Journal

Shah PP. Int Surg J. 2017 Oct;4(10):3280-3287

http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

Original Research Article DOI: http://dx.doi.org/10.18203/2349-2902.isj20174140

In patient satisfaction survey- how does it help our health care delivery
system (the patient, the health care giver and the organization)?
Priti Prasad Shah*

Department of Surgery, Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India

Received: 22 August 2017

Accepted: 26 August 2017

*Correspondence:
Dr. Priti Prasad Shah,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Patient satisfaction is a mean of measuring the effectiveness of health care delivery. It can suggest
proportion to the problem areas and a reference point to take management decisions. It can serve as a mean of holding
physician accountable. Patient satisfaction data can be used to document health care quality for accrediting
organizations and consumer groups. They can also measure specific initiative or changes in service delivery. They
can increase loyalty of patients by demonstrating you care their perceptions and looking for ways to improve. The
purpose of our study is to carry out evaluation of hospital services by getting a patient satisfaction survey. Main aim
is to identify potential problems in the services.
Methods: A hospital based inpatient satisfaction survey study done on 200 patients. A Predesigned structured
questionnaire was based on relevance of questions to healthcare services on various aspects of inpatient care. The
interviewer based questionnaires were filled after obtaining verbal informed consent from all subjects. 200 valid
responses were analyzed using MS office excel. Data analysis of study is done using the SPSS (Statistical Package
for the Social Science) Version 17 for window.
Results: Results of our study is very positive and suggest that patients were satisfied with the attitude of doctors,
nurses and paramedical staff and it was appreciated. As in D Y Patil Medical College and Hospital most facilities are
free for the patients, so we got better feedback for the facilities and satisfaction for this study. Satisfied patients are
more likely to continue using the health care services and maintain their relationship with specific health care
providers.
Conclusions: Patient satisfaction survey can be a driving force for changes in health care delivery with institutions
and individuals. These initiatives can promote improvement in practice and also respond to patient expressed needs.

Keywords: Health care delivery, Patient satisfaction, Satisfaction survey

INTRODUCTION developing countries is to find ways to make them more

client-oriented. Indifferent treatment of patients,
Health care is changing rapidly. Patients are educated and unofficial payments to providers, lack of patient privacy,
demand that we meet their needs. Patient centered care and inadequate provision of medicines and supplies are
usually improve treatment outcomes and its common, and rarely acknowledged by traditional quality
implementation has become the focus of national and assessment methods.2
local efforts to optimize health care delivery. 1 Patient
satisfaction is one of the pillars of patient centered care. The primary goal of the tertiary care hospital as a highest
A main challenge for health service providers in level of health care provision is to provide best possible

International Surgery Journal | October 2017 | Vol 4 | Issue 10 Page 1

Shah PP. Int Surg J. 2017 Oct;4(10):3280-3287

health care to the patients. In modern era where it is the could impact on the patient’s perception of the care
right of every patient to demand best possible care in provided throughout an inpatient stay.
hospitals, it is the duty of every staff member of the
hospital to deliver optimum efforts to the satisfaction of Factors can be the cleanliness of the environment, the
the patient. Its assessment will give us an opportunity to appearance of the facility, the ease of access to specific
find loopholes in our services and future ratification.3 locations the quality of the interaction with providers, the
clarity of the communication from providers, the outcome
Patient satisfaction is the established yardsticks to from the care provided, the concern expressed from
measure success of the services being provided in the various staff and providers for the patient’s well-being,
health facilities. It is very difficult to measure the the amount of time they had to wait before getting care,
satisfaction and gauze responsiveness of the health the cost of the visit, the quality of the food, and on and
systems as not only the clinical but also the non-clinical on. Over the years there have been various definitions of
outcomes of care influence the patient satisfaction.4 patient satisfaction. Susie Linder-Pelz, in her review of
the patient satisfaction literature, offers the following
The long-term survival of any hospital depends on loyal definition: patient satisfaction is “Positive evaluations of
patients who come back or recommend the hospital to distinct dimensions of the health care.” 8 Human
others. Satisfied patients are more likely to continue satisfaction is a complex concept which is related to a
using the health care services, maintaining the number of factors including lifestyle, past experiences,
relationship with specific healthcare providers and future expectations and the value of both individual and
complying with the care regimen.5 society.

The data gathered through patient satisfaction study For any health care organization to be successful
reflects care delivered by staff and physicians and can customer’s perception is a simple but important strategy
serve as a tool in decision-making. Patient satisfaction to assess and improve their performance. But very few
surveys can serve as tools for learning; they can give studies are being carried out in India for measuring
proportion to problem areas and can be a reference point inpatient satisfaction with hospital services as a routine
for making management decisions. They can also be used process. The purpose of present study is to carry out
to assess and measure specific initiatives or changes in patient satisfaction Survey to evaluate hospital services
service delivery. They can identify those operations and by getting feedback from indoor patients conducted at in
procedures that require better explanation to patients. surgical in-patient department in our tertiary care hospital
And most importantly, they can increase loyalty of with the aim to study patient care provided in the
patient by demonstrating you care about their perceptions hospital, by medical, nursing and supportive staff, the
and are looking for ways to improve.6 availability of necessary services and amenities in the
hospital and to identify areas of improvement.
There are a lot of challenges small facilities, in particular,
may face with conducting patient satisfaction surveys. METHODS
These may be: tight budgets, lack of commitment, lack of
in-house expertise to plan and manage task, lack of This was a hospital based cross sectional study was
resources for existing staff, with small sample size, carried out in Padmashree Dr D. Y. Patil Medical College
designing a statistically valid sampling process, obtaining Hospital and Research Centre, Pimpri Pune, which is a
acceptable response rates and reliable data, proper tertiary care hospital. The study was conducted from
analyzing and reporting survey data, translating findings August 15 - January 2016 among patients admitted in
into information no institutional incentives for wards of General Surgery, with a minimum hospital stay
performance improvement, and selecting a survey of 24 hours preferably who have completed the indoor
instrument that will produce valid and reliable results.7 stay and are going to be discharged within next 24 hrs.
Most patients are satisfied with their service experience 200 inpatients were considered among patients admitted
generally, they may not be uniformly satisfied with all in wards of General Surgery.
aspects of the care they receive. There lies the challenge
to management – for how much service is enough to elicit All the patients (n=200) discharged during the study
high satisfaction and keep them coming back.8 period were included in the study. On the day of the
discharge, after taking informed consent the patients were
A patient’s experience within a hospital environment is interviewed. A pre- designed pre- validated “Indoor
based on numerous encounters with a wide variety of Patient Feedback Form” was filled up. The questionnaire
individuals and locations parking lot, followed by was translated into local language. Based on relevance of
physically accessing the facility, the admissions process, questions to healthcare services in Patiala our final
encounters with physicians, nurses, lab personnel, and questionnaire included questions on various aspects of
other service providers and their respective physical care including questions regarding demographic profile,
locations, including patient rooms and the care they admission services, perception regarding quality of
receive while in their room There are many factors that laboratory services, Doctors services, Nursing,
paramedical staff services and availability of basic
amenities/services of the ward. The interviewer based month. This weaker section is largely dependent on the
questionnaires were filled after obtaining verbal informed tertiary care hospital and these needy people do not have
consent from all subjects. large expectations from the hospital besides their medical
treatment and provision of basic amenities during the stay
Data collection and processing at hospital (Table 1).
Duly oriented to the survey process, questionnaires to the Table 1: Socio - demographic profile.
sample patients were explained in local language. All
respondents were assured the confidentiality of their
responses. All respondents were encouraged to express
their opinion freely and fairly. Precautions were also
taken to obtained unbiased result.

Stastical analysis

At the end of the survey, 200 valid responses were

analyzed using MS office excel. Data analysis done using
the SPSS (Statistical Package for the Soal Science)
Version 17 for window. The demographic profile,
admission services, perception regarding quality of
laboratory services, Doctors services, Nursing,
paramedical staff services and availability of basic
amenities/services were calculated with number and
percentage.

RESULTS

The Socio- demographic profile in the study shows the

importance of the hospital because majority of the
respondent i.e. 55% were in the age group of 20 - 60
years which is economically productive age group for the
families belonging to underserved, needy section of the
society. Among them 52% were illiterate, 39% were
primary and only 9% were having education beyond
matriculation. 34.5% were unskilled workers; 24.5%
were unemployed and 19% were housewives. 79%
belonged to families having income lesser than Rs.5000/
No of Percentage
Parameters
patient (n=200)
Patient 141 70.5
Respondent Attendant 59 29.5
<20 58 29
21 - 40 56 28
Age (years) 41 - 60 54 27
>60 32 16
Gender Male 100 50
Female 100 50
Duration of <2 14 7
stay / 2-5 78 39
admission
(days) >5 108 54
Illiterate 104 52
Primary 78 39
Education Matriculation 9 4.5
Sen. Secondary 4 2
Graduate 5 2.5
Skilled 39 19.5
Unskilled 69 34.5
Occupation Unemployed 49 24.5
Housewife 38 19
Student 5 2.5
<2000 95 47.5
Family 2000 - 5000 63 31.5
income / 5000 - 10000 35 17.5
month (Rs)
>10000 7 3.5

Table 2: Services available at admission.

Parameters No. of patient Percentage (n=200)

Emergency 21 10.5
Mode of admission through Outdoor 179 89.5
Average 26 13
Helpfulness of the person at registration desk Satisfactory 78 39
Good 96 48
Available 165 82.5
Availability of wheel chair/ stretcher Not available 35 17.5
Ward attendant/ Support staff for assistance at Available 193 96.5
entrance Not available 7 3.5
Approachable 184 92
Ward location Difficult to approach 16 8
Adequate and helpful 187 93.5
Sign boards Inadequate 13 6.5
Immediate 59 29.5
Time taken
treatment between Admission and Initiation of
(min) <10 101 50.5
10 - 30 40 20
The perception regarding services at the time of The perception regarding quality of professional service
admission, 10.5% were admitted through emergency and by doctors, 93.5% doctors devoted time at the time of
rest 89.5% through outdoor. Most of them were satisfied admission, 96% and 97% doctors described the disease
in this aspect helpfulness of person at registration desk status and lab reports of patient/respondent, 95% of
(87%), availability of wheel chair/stretcher (82.5%), ward respondents satisfied the efficiency of the doctors of the
attendant/ support staff for assistance at entrance hospital handling of illness of patients and 8.5 % are
(96.5%), ward location (92%) and sign board (93.5%) unsatisfied with the no. of visits of senior
and the time lapse between admission and initiation of doctors/consultants (Table 3).
treatment which was 10 - 30 minutes in 20% cases and no
cases found more than 30 minutes (Table 2).

Table 3: Perception regarding quality of professional service by doctors.

Parameters No. of patient Percentage (n=200)

Time devoted by the Dr at Adequate 187 93.5
the time of admission Inadequate 13 6.5
Description of disease status Adequate/satisfactory 192 96
by Doctor Inadequate/unsatisfactory 8 4
Good/ Pleasant 178 89
General
Doctor communication of Satisfactory 18 9
Unsatisfactory 4 2
Perception of Efficiency of Satisfactory 190 95
Doctors in handling illness of
patients Unsatisfactory 10 5
Doctors discussed Lab Satisfactory 194 97
investigation with Patient Unsatisfactory 6 3
No. of visits of senior Satisfactory 183 91.5
doctors/ consultants Unsatisfactory 17 8.5

Table 4: Perception of quality of laboratory services.

Parameters No of patient Percentage (n=200)

Have you been told about the location / room no./ Yes 182 91
department where investigations were advised No 18 9
Easily approachable /
186 93
locatable
Location of labs for investigations
Difficult to locate/
14 7
approach
<10 170 85
10 - 30 24 12
Time to reach lab/ department for investigations >30 6 3

Yes 189 94.5

No 9 4.5
Availability of lab technician Not responded 2 1

Satisfactory 181 90.5

Approach/ behaviour of lab technician Unsatisfactory 19 9.5
Available on schedule
Availability of investigations results 184 92
time
Delayed 16 8

The perception of quality of laboratories services, patients. But the problem lies with the difficulty to locate
Availability of lab technician was found to be 94.5% and the labs and time taken to reach the labs for investigations
90.5% were satisfied with their approach towards which was less than 10 min in 85% of the cases, 10-30
min in 12% of cases and more than 30 minutes in 3% of locating the labs. 92% investigations result available on
the cases with 7% admitting that they had a problem in schedule time (Table 4).

Table 5: Perception regarding quality of service by nursing and paramedical staff.

Parameters No. of patient Percentage (n=200)

Adequate 192 96
Availability of nursing staff in the wards Inadequate 8 4
Good / pleasant 172 86
Communication/ behaviour of nursing staff towards Satisfactory 22 11
patient Not responded 6 3
Yes 192 96
Dispensing/ providing prescribed medications in
timely manner No, has to be asked 5 2.5
Not responded 3 1.5
Adequate 186 193
Availability of para medical staff to the Pts Inadequate 14 7
Approach of other paramedical staff towards Satisfactory 195 97.5
patients/ attendants Unsatisfactory 5 2.5
Quality of health care / support provided by para Satisfactory 196 98
medical staff Unsatisfactory 4 2

Table 6: Perception regarding availability of basic amenities/services.

Parameters No of patient Percentage (n=200)

Available 187 93.5
Availability / provision of medicines by Very few 9 4.5
hospital Not responded 4 2
Available 184 92
Availability
admission of oxygen cylinders during Very few 6 3
Not responded 10 5
Availability of drinking water in the Available 195 97.5
premises Unavailable 5 2.5
Availability of toilet / handwashing facility Yes 193 196.5
in the wards No 7 3.5
Yes 172 86
Toilets well maintained / cleaned by staff No 26 13
Not responded 2 1
Satisfactory 191 95.5
Cleanliness in the wards Unsatisfactory 9 4.5
Adequate 183 91.5
Availability of fans / lights in wards Inadequate 17 8.5
Available on scheduled time 183 91.5
Availability/ regular change of bed sheets Delayed 16 8
Available but not usable/ unclean 1 0.5
Good 155 77.5
Convenience of parking Satisfactory 39 19.5
Unsatisfactory 6 3
Yes 191 95.5
Meals available / provided in the ward No 9 4.5
Satisfactory 181 94.76
If yes, quality of food provided (n=191) Unsatisfactory 10 5.24
Availability of retiring / waiting room for Available 173 86.5
relatives/ attendants Unavailable 27 13.5

The perception of quality of service by nursing and nurses in ward. 96% patients were provided medication
paramedical staff, 96% of the patient stated the adequate in timely manner by nurses and communication /
behaviour of the nurses as good /pleasant and satisfactory In perception regarding quality of health care in study
in 86% and 11% of the cases respectively but 3% conducted by Singh S et al 26% patients are unsatisfied
respondents not responded. 97.5% and 98% patients with the no. of visits of senior doctors/consultants. 94%
approach to other paramedical staff and quality of health stated the time devoted by the doctor on them as
care/ support provided by paramedical staff was
adequate.11 91 % of the respondents perceived the
satisfactory (Table 5).
efficiency of the doctors of the hospital in managing the
condition of the patient as satisfactory. Doctors described
The perception of the availability of basic amenities and the disease status and lab reports to the patient/
services, 93.5% of the patients stated availability of respondent in 87% and 84% cases respectively.
medicine, only 2% patients were not responded; 2.5%
patients reported unavailability of drinking water; 3.5% In Kulkarni et al, study the level of satisfaction among
reported unavailability of toilets / hand washing facility patients was found to be better with behaviour of doctors
in the wards. 13% and 4.5% were dissatisfied by the
(87.76%).13
cleanliness in the toilets and wards respectively. 8.5%
stated inadequacy of fans / lights in the wards. Only
Sharma R et al, in their study concludes that the overall
91.5% of the patients were satisfied with the timely
satisfaction regarding the doctor-patient professional and
change of bed sheets. Around 3% of the respondents were
behavioural communication was more than 80 per cent at
dissatisfied with the convenience of parking. 95.5% of
almost all the levels of health care facilities.14 In total, 55
the patients were provided meals, of which only 5.24%
per cent of respondents opined that doctors have shown
patients were not satisfied (Table 6).
little interest to listen to their problem. Ahsan N et al,
assessed that 80% patients satisfied with attitude of
DISCUSSION
doctors.12
There is an increasing need to improve the quality of care
Singh S et al, in their study observed that availability of
in health. The patients’ satisfaction is its key determinant.
lab technician was found to be 98% and 89% were
In this study, we assessed patients’ opinions concerning
their demographic profile, admission services and satisfied with their approach towards patients. 11 But the
perception regarding quality of laboratory services, problem lies with the difficulty to locate the labs and time
doctor’s services, nursing, paramedical staff services and taken to reach the labs for investigations which was 10-
availability of basic amenities/services provided to them. 30 minutes in 71% of cases and more than 30 minutes in
7% of the cases with 27% admitting that they had a
problem in locating the labs.
Patient satisfaction is as important as other clinical health
measures in measuring the effectiveness of health care
Sharma R et al, also concludes that more than 70 percent
delivery. The current competitive environment has forced
satisfaction level was observed with staff of
health care organizations to focus on patient satisfaction
and so as to know their strengths and weaknesses to laboratories.14
compete effectively.10
Singh S et al, observed that 98% of the patients stated the
As our sociodemographic profile (Table 1) similar no. of the nurses as adequate. 11 83% patients affirmed
finding was observed in study conducted by Sumeet that they were provided medication in timely manner by
Singh et al, that majority i.e. 77% patients in the age the nurses and rated communication / behaviour of the
group of 20 - 60 years which is economically productive nurses as good /pleasant and satisfactory in 23% and 59%
of the cases respectively, but 18 % of respondents
age group.11 44 % were illiterate and only 14% were
having education beyond matriculation. 36% were described their behaviour as harsh/ rude/ avoiding. 84%
respondents reported availability of investigation results
unskilled workers, 10% were unemployed and 28% were
housewives. 67% belonged to families having income on scheduled time.
lesser than Rs.5000/ month.
Ahsan N et al, observed that 66% patients were satisfied
Perception regarding admission servicesin study with the attitude of nurses.12
conducted by Singh S et al 72% patients were admitted
through emergency and rest through outdoor.11 Most of Singh S et al, observed that 56% of the patients stated
them were satisfied in this aspect but still the areas unavailability of medicine; 21% patients reported
needing attention are the sign boards showing direction unavailability of drinking water; 43% reported
and the time lapse between admission and initiation of unavailability of toilets / hand washing facility in the
treatment which was more than 30 minutes in 13% cases. wards. 62% and 40% were dissatisfied by the cleanliness
in the toilets and wards respectively. 11 34% stated
Naveed Ahsan et al, study level of patient’s satisfaction inadequacy of fans / lights in the wards. Only 20% of the
during admission was 52.7% and it took 73 minutes to patients were satisfied with the timely change of bed
complete admission process.12 sheets. Around 63% of the respondents were dissatisfied
with the convenience of parking.
In Kulkarni et al, study dissatisfaction was found to be direction to quality enhancement measures in areas that
more with cleanliness in toilets (56.01%) as compared to require focused interventions. It helps patient for revisit
the other hospital areas which was also statistically highly and suggest other people. It helps health care provider for
significant.13 their self-boost and /or improvement. It also helps
organization for market stake and accreditation.
Sharma R et al, also conclude that more than 80.0 per
cent were satisfied with basic amenities, which is far Recommendations
better as compared to studied hospital.14
Continuous supervision of patient satisfaction levels
Ahsan N et al, observed that more patients were satisfied should be done to deduce methods to improve admission
with cleanliness of ward but condition of washroom was services and perception regarding quality of laboratory
highly criticized.12 services, Doctors services, nursing, paramedical staff
services and availability of basic amenities/services and
Imam et al, study very few patients reported any degree measures should be taken to reduce and eliminate any
of dissatisfaction with the cleanliness of the wards or the source of dissatisfaction.
washrooms.15 Our study suggests that it is below
satisfaction level because 80.5% surgical patients claimed Funding: No funding sources
that the cleanliness of the bathrooms was poor. Conflict of interest: None declared
Ethical approval: The study was approved by the
Basic amenities and services at the hospital has a much institutional ethics committee
scope of improvement in terms of availability of
medicine, drinking water, toilets / hand washing facility REFERENCES
in the wards, cleanliness in the toilets and wards, fans /
lights in the wards, bed sheets. Many were dissatisfied 1. Borglum K. Practice Mgmt.com, Patient
with the convenience of parking. Satisfaction Surveys - A Look in the Mirror, 2002.
Available at http://www.practicemgmt.com.
Limitations of this present study was only a baseline 2. Walpert B. ACP-ASIM Observer, Patient
study with a sample, which was carried out for evaluating Satisfaction Surveys - How to do them right, 2000.
hospital services like admission services and perception Available at http://www.acpoline.org/journals/.
regarding quality of laboratory services, Doctors services, 3. Alcorn S. Medical Group Management Association,
nursing, paramedical staff services and availability of Marketing Guidepost. Case study: “Mission is
basic amenities/services. A continuous ongoing process Possible” program boosts patient satisfaction scores.
of evaluating the services at the time of discharge is MGMA. 1998;9(4).
required for getting definitive results. We believe the 4. Choong P. Medical Group Management
outcome of services obtained from the present study can Association, Ensuring patient satisfaction in medical
serve as baseline against which to compare the results groups. MGM J. 2000;47(2).
from future surveys. 5. Moore JD. Medical Group Management
Association, ACMPE Paper, An Analysis of Patient
CONCLUSION Satisfaction and Compliance with Nurse
Recommendations form an After Hours Call Center;
This study shows assessing satisfaction of patients is 2000.
simple, easy and cost-effective way for evaluation of 6. Elaine Y, Gail CD, Richard R. the measurement of
hospital services and has helped finding that indoor patient satisfaction. J Nurse Care Quality.
patients admitted were more satisfied with behavior of 2002;16(4):23-9.
doctors but some problem lies with the availability of 7. Bjertnaes OA, Sjetne IS, Iversen HH. Overall
basic amenities more regarding cleanliness in the toilets patient satisfaction with hospitals: effects of patient-
and the wards. Majority of the patients were satisfied reported experiences and fulfilment of expectations.
with the attitude of doctors, nurses and paramedical staff BMJ Qual Saf. 2012;21(1):39-46.
and it was appreciated. As in D Y Patil Medical College 8. Jenkinson C, Coulter A, Bruster S, Richards N,
and Hospital most facilities are free for the patients, so Chandola T. Patients' experience and satisfaction
we got better feedback for the facilities and satisfaction with Health Care: Results of a questionnaire study
for this study. of specific aspects of care. Quality Safety Health
Care. 2003;11:335-9 .
Considerable research confirms that patient satisfaction 9. Linder-Pelz S. Toward a theory of patients'
surveys are indicators of healthcare outcomes, including satisfaction. Social Sci Med. 1982;16:577-82.
compliance with medical advice, likelihood to 10. Tonio S, Joerg K, Joachim K. Determinants of
recommend, and return visits for care although all patient satisfaction: a study among 39 hospitals in
patient-derived information is subjective. The survey an in-patient setting in Germany. Int J Quality
offers valuable inputs on patient expectations and Health Care. 2011;23(5):503-9.
evaluation of hospital care and services. It provides
11. Singh S, Kaur P, Rochwani R. Patient satisfaction hospital, PGIMER, Chandigarh, India", Leadership
levels in a tertiary care medical college hospital in in Health Services. 2011;24(1):64-73.
Punjab, North India IJRDH Int J Res Dev Health. 15. Imam ZS, Syed SK, Ali AS, Ali US, Fatima K, Gill
2013;1(4):172-82. M, et al. Patients’ satisfaction and opinions of their
12. Ahsan N, Chawala JA, Farooq U, Rasool A, Ahmad experiences during admission in a tertiary care
A. Assessment of patients’ satisfaction in medical hospital in Pakistan: a cross sectional study. BMC
and surgical wards in a tertiary care hospital - a Health Serv Res. 2007;7:161.
cross sectional study. JAMC. 2012;24(3-4).
13. Kulkarni MV, Dasgupta S, Deoke AR, Nayse. Study
of satisfaction of patients admitted in a Tertiary
Care Hospital in Nagpur. National J Comm Med. Cite this article as: Shah PP. In patient satisfaction
2011;2(1):37-9. survey- how does it help our health care delivery
14. Sharma R, Sharma M, Sharma RK. The patient system (the patient, the health care giver and the
satisfaction study in a multispecialty tertiary level organization)? Int Surg J 2017;4:3280-7.