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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 1  |  Issue : 2  |  Page : 115-123

Balanced Scorecard method: The success factor in achieving medical tourism objectives in hospitals


Department of Health care Management, Science and Research Branch, Islamic Azad University, Fars, Iran

Date of Web Publication4-Mar-2014

Correspondence Address:
Zohreh Seidmoradi
Department of Health care Management, Science and Research Branch, Islamic Azad University, Fars
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-9019.128129

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  Abstract 

Introduction: In the medical tourism industry, which is considered to be one of the branches of health tourism, understanding the component of medical tourism in healthcare centers and their evaluation in this area, especially with multilateral and multi-dimensional tools such as balanced scorecard (BSC) can be a solution for growth and improvement of performance in the health centers, care quality, and economic growth of the country. This research has been conducted aiming to create a BSC in order to determine factors which affect medical tourism in healthcare centers. Review method: Thisresearch isdescriptive in nature, conducted in 2012-2013 in an application form. The statistical population consists of clients, hospital managers, and university faculty members involved in strategic planning, managers of medical tourism and executive managers of Isfahan University of Medical Sciences. Since Delphi technique has been used in data collection, only 15-20 people were selected as sample models. In the present study the sampling method based on purpose was used. The research tool comprised a check list, which was given to the sample models and collected after its finalization. In order to ensure the results of the Delphi method and analyze the data obtained from the opinions of the decision-making group, operations research techniques (group decision-making method) has been used. Results: BSC method includes four perspectives, customer, learning and growth, internal processes and financial. The customer perspective includes two main measures customer loyalty and customer needs; the internal processes perspective includes four main measures, space and equipment, health indicators, excellence and referral system; the learning and growth perspectives includes three main measures, human resources, information and corporate culture; and the financial perspective includes two main sub measures, profit and service costs. Conclusion: The BSC method proposes four perspectives- customer, internal processes, learning and growth, and financial-in order to review an organization such as a hospital. Measures obtained in this way have significant universality to them, so that in comparison with other similar methods more measures will be reviewed and studiedin order to determine factors affecting health tourism.

Keywords: Balanced Scorecard, evaluation, medical tourism


How to cite this article:
Hessam S, Vahdat S, Seidmoradi Z. Balanced Scorecard method: The success factor in achieving medical tourism objectives in hospitals. Int J Health Syst Disaster Manage 2013;1:115-23

How to cite this URL:
Hessam S, Vahdat S, Seidmoradi Z. Balanced Scorecard method: The success factor in achieving medical tourism objectives in hospitals. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2022 Jan 25];1:115-23. Available from: https://www.ijhsdm.org/text.asp?2013/1/2/115/128129


  Introduction Top


Globalization of health services in the past decade in the form of new organizations for healthcare, and increased health care services abroad in the form of relocation of staff and consumers of electronic instruments and services, medicines, etc., has been manifested; therefore, discussion on export and trade in this section compared to the agricultural and industrial section is very young and little attention has been given to it. [1] Any undertaken trip with the intention of improving one's health (or someone in the family) is termed as health tourism. [2] Health tourism is divided into three categories: Wellness tourism, medical wellness tourism, and medical tourism. [3] Medical tourism includes travelling to another country to obtain medical services, dentistry, and surgery. [4] There are purposeful reasons which force people to choose international travel for their health: Long waiting lists in developed countries, the development of internet services and the rise of communication companies acting asmiddlemen between international patients and a network of hospitals, making it easier for patients to obtain information and prices, and finally, advanced technologies, which have been created to offer new healthcare services. [5]

The potential advantages of medical tourism has been proposed by supporters of this industry, including the fact that using medical tourism as a progressive strategy of economy in the country of destination (a place where medical tourists spend more dollars than other tourists) will bring about an increase in income and help in development of its GDP. The supporters are of the opinion that medical tourism will prevent "Brain-drain" from a country, and the specialists will prefer to stay rather than migrate. This industry may also help in job creation (medical or otherwise), improve infrastructure, technology and training in order to attract more tourists. [6] All these factors have made medical tourism industry to grow in Asia.

Research shows that Iran faces many challenges in the fields of primary infrastructure and treatment, efficient government support, having a regular medical tourism development program, inter-sectorial cooperation and coordination at macro and operational level, having centers to provide healthcare services within international standards, and promotion and integrated marketing. Finally, if Iran wishes to profit from the medical tourism industry, then it has to undertake measures to resolve these challenges. [7]

The hospitals and health care centers, which offer medical tourism services, need to be evaluated and analyzed accurately to make sure that they continue to operate with maximum efficiency and effectiveness. The method of evaluation and the implementation of its results are of great importance. The lack of evaluation not only brings about a rise in medical costs, but also will initiate a decrease in service quality and tourist attraction. On the other hand, providing of the same will not only ensure health, but also total efficiency of healthcare institutes with appropriate prices. Growth and development of any country or system is based on its self-evaluation in order to achieve its objectives trough rational concepts and proper tools. Managers and the lawmakers in such systems need detailed, correct and timely information for policy making and planning. The healthcare system of a country is powerful only if it can, with the help of other sectors, reach its objectives by national development programs. [8]

From among various methods which have been used until now to evaluate and lead the mentioned organizations, the Balanced Scorecard (BSC) model, with the objective to implement strategies in action, is the only method which shows the impact of the total function of the organization's subsets in the functioning of the organization. [9] BSC method is a system of evaluation and integrated performance measurement which was presented by David Norton and Robert Kaplan (1996). In this method of performance evaluation we do not rely on financial measures only, rather, we evaluate the performance from three different perspectives: Customer, internal processes, and learning and growth. The balanced scorecard method is introduced not only as a strong tool for evaluation of performance but also as a tool for achieving strategies by the management community. [10] The objectives of the performance are concise and yet accurate statements which explain the specific measures important for the success of the strategy. The measures of the performance are the tools used for ensuring the achievement of objectives and moving toward a successful performance of the strategy. The total objectives and measures of performance are the perspectives which make up the BSC method. [11]

With regards to the importance of attracting and providing health and other needs of medical tourists, many of the service providers in this field need to adopt a multi-dimensional performance evaluation system in order to achieve their objectives; and since BSC method has a similar approach, therefore, this research seeks to determine the influencing factors on medical tourism, through this method.


  Review Method Top


This research is descriptive in nature, conducted in 2012-13 in an application form. The statistical population consists of clients, hospital managers, and university faculty members involved in strategic planning, managers of medical tourism and executive managers of Isfahan Medical University (N = 100). Since Delphi method has been used in data collection, only 15-20 people were selected as sample models (n = 20). [12] In this study sampling method based on purpose has been used which does not use random sampling. [13]

The Delphi technique has been used to gather the views of hospital administrators, professors, process owners, and customers. To achieve this purpose, a designed check list has been used for primary data collection. The research tool comprisesa check list, which is given to the sample models and collected after its finalization.

Stages of tool construction

Formation of the Delphi team

In this stage, based on the conducted studies and the opinion of the experts, 20 people were chosen for the Delphi team. Based on this, necessary arrangements were made with the Isfahan University of Medical Sciences. With regards to the diversity among team members, criterions such as educational qualification, work experience and management experience were used to determine the managers in the team, and in this way five senior directors from the Isfahan University of Medical Sciences were chosen. The criterion for the selection of process owners was their educational qualification and work experience, thus, four of the hospital staff were chosen for this section. From among the customers seven people were chosen, as well as four university professors/lecturers based on the number of their articles and research conducted on medical tourism.

Making primary form for data collection (measures):

In order to reach an overall view, the desired measures were extracted from the references and then with regards to the dimensions of similar projects and the opinion of the experts the forms for data collection were adjusted. These forms were distributed among the team members and the necessary explanations on the research, its objectives and how the forms should be completed in the Delphi manner were given. Separate forms were set for each of the four perspectives in the balanced scorecard method. Since it was necessary to evaluate the totality of medical tourism as a whole, therefore all the team members gave their opinion on all 4 perspectives and no separate expert teams were formed for them.

Collection and review of forms (1 st round of Delphi method)

After the completion of the forms by the members of the team and their collection after a period of one week, the information in these forms were summed up and a list of points and warning indicators provided by the members was made and conveyed to other members of the team. Also, ambiguous points and differences in opinion were also pointed out to the members. Rankings ofthe member's opinions, based on the "Berda" group decision making, were converted into points and the results were made available to the members.

In the Berda method, the desired indicators in the balanced scorecard method in the "evaluation options" were considered and three general indicators, i.e., "efficiency", "effectiveness" and "stakeholder satisfaction" were chosen as decision making indicators.

The weight of the three indicators wasconsidered as 0.2, 0.5 and 0.3, respectively; every member of the group formed his own score tables and then various stages of the Berda technique were performed.

The re-distribution of the forms among the members of the group (2 nd round of Delphi method)

At this stage the results obtained from the 1 st round of Delphi method and the Berda group decision making was conveyed to the members and then after a period of 1 week its results were collected. As in the previous stage, the Berda method was used to rank member opinion. In calculating the percentage of agreements-with regards to the fact that the criterion for selecting the indicators in the Delphi method is "important" and "very important"- it was determined that more than 83% of the members agree on the proposed measures and therefore the Delphi method was discontinuedat this stage.

In order to ensure the result of the Delphi method and analyzing the data obtained from the decision making group, operations research technique (group decision-making method) was used.


  Results Top


In this research four perspectives, customer, internal processes, learning and growth, and financial, 11 main measures and 62 sub-measures were identified as components needed in hospitals to attract medical tourists. The main research findings in the form of four BSC is provided as follows:

Customer perspective

This perspective has been developed to maintain and increase customers (medical tourists), and is comprised two main measures of customer loyalty and customer needs. The customer loyalty measure includes four sub-measures, and customer needs measure includes nine sub-measures [Table 1].
Table 1: Customer perspective, its measures and sub-measures

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With regards to the obtained results through the opinion of the experts, the highest weigh was given to appropriate information resources about hospital services, i.e., 2.5, because this is the most important factor in attracting patients, especially foreign patients who obtain the required information about the services provided in the country. In second place is the "The number of foreign patients attracted in the year", followed by the number of translators fluent in foreign languages (English, Arabic, Turkish), access to legal authorities in case of problems, the number of foreign insurance companies in contract with the hospital, and easy communication services (internet, telephone) with a score of 2. These are important components of communicating with medical tourists.

Cause and effect relationship between the measures and sub-measures of the customer

This has been shown in the casualty network chart [Figure 1]. In this network the blue color shows: The primary relationship between the measures (for example A14 is derived from A1 and is its subset), the red color shows: The correlation between subsidiary measures in a primary measure (for example A28 causes the formation of A23 means, meaningthat the presence of a VIP room will provide the necessary conditions for the medical tourists to conduct religious and cultural ceremonies), green color shows: The relationship between subsidiary measures in a strategic objective (for example A24 causes the formation of A13, meaning that the presence of appropriate information services about the hospital increases the number of foreign patients) and orange (light brown) shows: The relationship between the subsidiary measures of the strategic objectives (for example C22 causes the formation of B24, meaning that registration of information in English will create an appropriate database for the foreign tourist).
Figure 1: Casualty network (strategic chart) patients dimension

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Internal process perspective

This perspective has been developed to improve internal processes in order to raise the quality of services and create distinction between the services; it includes four primary measures, space and equipment, health indicators, excellence, andreferral system. The physical space and equipment measure includes seven sub-measures, health indicator measure includes eight sub-measures, excellence includes seven sub-measures and referral system includes four sub-measures [Table 2].
Table 2: Internal process perspective, its measures and sub-measures

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With regards to the obtained results through the opinion of the experts, the highest weigh was given to the number of ISO certificates, 3.75, because, to have international credibility is one of the important components to gaina patient's trust in the services provided in an organization especially healthcare centers. This credibility is provided in the form of ISO certificates or evaluations by the health ministry to a hospital, but in the near future a new accreditation system will be granted to these organizations which would determine their credibility. This measure is followed by "Legal permits (presentable to international tribunals)" with a weigh of 3.5. This measure is important because with permits such as doctor or nurse responsibility insurance against foreign patients will protect the medical staff against possible accidents; this will bring about a sense of relief for both patient and medical staff in knowing that their rights are preserved. Standard hospital equipment, system of clinical governance, and other independent admission systems (in person, by telephone, or internet) are measures with high ratings (3).

Causality network dimension of internal processes

Has been shown as follows [Figure 2]; for example: Tele-medicine (medical services from a distance) (B16) has brought about the situation whereby the patient may follow-up his services even after discharge (B42), or the high percentage of hospital infections (B28) has caused readmission of the patients (B23).
Figure 2: Casualty network (strategic chart) internal process

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Learning and growth perspective

This perspective with the strategic objective of promoting efficiency and motivated energy includes three primary measures of human resources, information, and culture. Human resources include five sub-measures, information four sub-measures and culture includes seven sub-measures [Table 3].
Table 3: Learning and growth perspective, its measures and sub-measures

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With regards to the obtained results through the opinion of the experts, the highest weigh was given to the number of specialist doctors, 2, followed by "the number of medical and administrative violations per year" and "Presence of an evaluation system for the staff" with a weigh of 1. The minimum number of violations and the presence of an accurate system for evaluation will bring about an improvement in service quality by the personnel.

Causality network ofLearning and growth

As shown in the [Figure 3], the presence of an appropriate evaluation system for the personnel (C15) will decrease the number of administrative and medical violations in a year (C15) (red color) or increase in the total education and training hours while in service (C22) will form a specialist and experienced staff in the hospital (C12) which will in itself attract medical tourists (green color).
Figure 3: Casualty network (strategic chart) learning and growth dimension

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Financial perspective

This perspective with the strategic objective of promoting growth and profitability includes two primary measures of profit and total service finished costs. Profit includes threesub-measures and total service finished costs include four sub-measures [Table 4].
Table 4: Financial dimension, its measures and sub-measures

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With regards to the obtained results through the opinion of the experts, the highest weigh in this dimension was given to "registration system for monthly incomes, dividing into type of income", with a weigh of 6.5, followed by "registration system for monthly expenditure, dividing into type of expenditure" with 5.5. By using these two components we will always have accurate and transparent information on income and expenditure, the monthly analysis of which will enable the correct use of the resources. The management as well, stands to benefit from this information; knowledge of income sources will help to strengthen their cash flow, and also knowledge of expenditure will provide information as to where they can be utilized. The customer likewise, will be faced with clear information which will help him consciously choose the right services.

Causality network of financial dimension

As shown in the [Figure 4], in the financial dimension, for example the system for monthly deductions (D13) helps tremendously in recording monthly expenditure and dividing the type of expenditure (D12) (red color), or calculation of the total service costs (D22) will cause the registration of monthly income divided into the type of income (D11) (green color).
Figure 4: Casualty network (strategic chart) financial dimension

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  Discussion Top


The city of Isfahan, with its pleasant climate and four-seasoned nature, is rich in historical, religious natural and cultural tourist attractions and has modern equipped health care centers with specialist human resources; these centers are renowned worldwide, especially among the neighboring countries, and with an appropriate environment for Islamic countries, Isfahan holds a suitable position.

In this research, from the customer viewpoint and primary measure of customer loyalty, the most important factor is "the number of attracted foreign patients". This point indicates that the patient, as the main trust indicator, contributes to the health organizations, their past, and also other patient's viewpoint. In their research, Sadr Momtaz and Agharahimi have indicated the importance of the number of attracted foreign patients by a center, and their presentation to higher authorities such as the Ministry of Health. [13] In the primary measure for customer needs, the main factor includes: The existence of appropriate information sources for better knowledge of hospital services. These results are similar to those obtained by Kazemi [4] and Sadr Momtaz. [14] Other important factors in this measure include the presence of translators and legal authorities, local and foreign insurance companies in contract with the hospital and the ability to contact friends and family. Porter et al. in their research, find that it is necessary to create a special insurance system and access to legal authorities for the medical tourism of Philippine. [15]

Nagarajan finds that the non-existence of financial council's support for the applicants of health tourism is one of the main factors for the failure of medical tourism. [16] From the perspective of internal processes and the primary measure for space and equipment, the main factor is considered to be a standard building and equipment. Delgoshayi et al., in a similar research, have placed importance on the physical infrastructure of the hospitals asonethe main factors effecting medical tourism industry. [7]

Hengleng considers the absence of standard institutions and infrastructure for providing and improving the service quality as a hurdle for the expansion of medical tourism. [17] In the health indicators, death and medical errors are of great importance. In his research, Shalbafian while enumerating the solutions for the expansion of Iranian medical tourism stresses on the fact that the health ministry should supervise over the functioning of healthcare centers. He also indicates that accreditation of hospitals is one of the important solutions to medical tourism of Iran. [18]

The presence of legal permits is an important factor affecting the measure of excellence. Gonzales et al., propose the revival and strengthening of the legal framework for the purpose of ensuring the protection of the consumer; quality care is another important factor in medical tourism. [19] The number of obtained ISO certificates, and the presence of continuous improvement systems and EFQM, is some of the factors in the excellence in this research. Benzel in his research states that high quality of health services and accreditation of these services and facilities are looked upon with doubt and skepticism by the patients, and unless the hospital shows enough evidence of improvement in services it will remain as one of the main hurdles of medical tourism. [20] These results match those obtained by Thailand's Center for Comprehensive Study on Health Tourism. [21]

From the perspective of learning and growth, and in the primary measure for human resources, the main factor is considered to be the specialist doctors. In all the studies conducted on this subject, including those by Delgoshayi, Kazemi and Jabari, [4],[7],[22] the doctors and their expertise is considered to be the most important factor.

None of the studies reviewed by the researchers of this article have directly touched the subject of electronic systems for registration of data. The authors of this article are of the opinion that the presence of electronic systems in registration of data and consequently the HIS systems is one of the prerequisites for medical tourism, especially in developing countries. The measures for corporate culture and the staff loyalty factor in the same measure can be an important indicator for the evaluation of hospitals who wish to accept foreign patients. Studies conducted in Thailand and Jordan show similar results. [23]

The results of this research based on balanced scorecard, indicate that in the primary measure for profit, systems for the registration of income and expenditure and their division into type of income and expenditure, is one of the most important factors in health tourism. Total service costs, which will be calculated using such systems, will lead to transparency of the services rendered by the hospitals. This will provide an opportunity for the patient to compare and decide. All the local and foreign studies, reviewed in this research, stress on the importance of total service costs and determining the real tariffs.


  Conclusions Top


The BSC method proposes four perspectives-customer, internal processes, learning and growth, and financial-to review an organization such as a hospital. In each of these viewpoints a strategic objective is defined and then based on those objectives the primary and subsidiary measures are determined. Measures obtained in this manner have significant universality to them, so that in comparison with other similar methods more measures will be reviewed and studied in order to determine factors affecting health tourism. Iran and especially Isfahan, despite having all the potentials in the field of health tourism, does not stand in its rightful place and is in need of a purposeful and comprehensive planning, determined objectives, development of effective strategies and effective measures, and all-round supervision.

 
  References Top

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2.Anzia I, Aidalina M, Nirmalini R, Inggit MCH, Ajeng TE. Health Tourism In Malaysia: The Strength And Weakness. Journal of Community Health 2009; 15: 7-15.  Back to cited text no. 2
    
3.Travers R, Thelen S, Helmy E, Nabil N, Elmasri AW. Medical Tourism Development Strategy. [Final Report Num. PS_401] Cairo, Egypt: Federation of Egyptian Industries: 2008.  Back to cited text no. 3
    
4.Kazemi Z. Study of the effective factor for attracting medical tourism in Iran [dissertation]. Netherland: Lulea,University of Technology; 2007  Back to cited text no. 4
    
5.Suthin K, Assenov I, Tirasatayapitak A. Medical Tourism: Can supply keep up with the demand. APac-CHRIE and Asia PacificTourism Association Joint Conference 2007, Beijing, China.  Back to cited text no. 5
    
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8.Salemi A, Vatankhah S. A Study on Evaluation System of Hospitals Affiliated to Iran University of Medical Sciences Using Balance Score Cards, Tehran, Iran. Journal of health administration 2010;12:49-58. [Persian].  Back to cited text no. 8
    
9.Asadi M, Mirghafoori H, Sadeqhi Arani Z, Khosravanian H. Qualitative Performance Evaluation of Hospitals Using DEA, Balanced Scorecard and Servqual; A Case Study of General Hospitals of Yazd. Journal of Shaheed Sadoughi University of Medical Sciences 2011;18:559-569. [Persian].  Back to cited text no. 9
    
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12.Salsali M, Prvizi S, Adib Hajbagheri M. Qualitative research methods. Tehran, Iran: Boshra publications; 2008. [Persian].  Back to cited text no. 12
    
13.Danai fard H, Alvani S, Azar A, Quantitative research methodology in management: A comprehensive approach. Tehran, Iran: Publisher Saffar; 2008. [Persian].  Back to cited text no. 13
    
14.Sadr Momtaz N, Agharahimi Z. Medical Tourism Industry in Iran: Strategies for Development. Health Inf Manage 2011;7:516-24. [In Persian].  Back to cited text no. 14
    
15.Porter EM, Vera MD, Huang B, Khan O, Qin Z, Tan A. Medical tourism in the Philippines. [updated 2008 Jan 16; cited 2012 Jul 20] Available from: http://www.rxpinoy.com.  Back to cited text no. 15
    
16.Nagarajan GS. Medical tourism in India: Strategy for its development. Banglore: Crisil young leader series 2004;10:13-6  Back to cited text no. 16
    
17.Heng Leng C. Medical tourism in Malaysia: International movement of health care consumers and the co modification of health care. Asia Research Institute of National University of Singapore; Working paper; 2007.  Back to cited text no. 17
    
18.Shalbafian A. Effective factors for developing health tourism [dissertation]. Tehran: Allame Tabatabaei University; 2006. [Persian]  Back to cited text no. 18
    
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22.Jabbari A, Agharahimi Z, Seidmoradi Z, Ferdosi M. Potentials of Cosmetic Surgery Tourism in Isfahan: A Qualitative Study. Health management and economics research center, School of Management and Medical Information, Isfahan university of medical Sciences, Isfahan, Iran; 2009. [Persian].  Back to cited text no. 22
    
23.Harahsheh S. Curative tourism in Jordan and its potential development [Thesis] Bournemouth: Bournemouth.  Back to cited text no. 23
    


    Figures

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

  [Table 1], [Table 2], [Table 3], [Table 4]


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[Pubmed] | [DOI]



 

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