Focus Group Discussion as a Tool to Assess Patient-Based Outcomes, Practical Tips for Conducting Focus Group Discussion for Medical Students—Learning With an Example

Abstract

Patient-based outcomes (patient-reported outcomes) of any intervention can change according to factors like age, gender, region, culture, education, and socioeconomic status. Most of the available outcome measuring tools have a surgeon-related bias. Focus group discussion (FGD) is a simple and effective way to assess the outcome of an intervention. In FGD, people from similar backgrounds and experiences discuss a specific topic of interest. Our objective is to discuss the problems of common outcome measuring tools for patient satisfaction and to understand the method of conducting an FGD. We have set our own published article on patient-based outcomes after total knee arthroplasty (TKA) as an example for explaining the method of conducting an FGD. The planning, advantages, disadvantages, practicalities, and problems of conducting an FGD are explained. In conclusion, many of the tools used for assessing patient satisfaction is surgeon-centered. Focus group discussion is simple, cost-effective, requiring a small number of participants, and can be completed in a short period. It is an effective tool for assessing patient-based outcomes in TKA.

Full text

Research Article
Focus Group Discussion as a Tool to Assess
Patient-Based Outcomes, Practical Tips for
Conducting Focus Group Discussion for
Medical Students—Learning With an Example
Balaji Zacharia, MBBS, Dortho, MSortho
1
, Puneeth Katapadi Pai, MBBS, MSortho
2
,
and Manu Paul, MBBS, MSortho
3
Abstract
Patient-based outcomes (patient-reported outcomes) of any intervention can change according to factors like age, gender,
region, culture, education, and socioeconomic status. Most of the available outcome measuring tools have a surgeon-related
bias. Focus group discussion (FGD) is a simple and effective way to assess the outcome of an intervention. In FGD, people from
similar backgrounds and experiences discuss a specific topic of interest. Our objective is to discuss the problems of common
outcome measuring tools for patient satisfaction and to understand the method of conducting an FGD. We have set our own
published article on patient-based outcomes after total knee arthroplasty (TKA) as an example for explaining the method of
conducting an FGD. The planning, advantages, disadvantages, practicalities, and problems of conducting an FGD are explained.
In conclusion, many of the tools used for assessing patient satisfaction is surgeon-centered. Focus group discussion is simple,
cost-effective, requiring a small number of participants, and can be completed in a short period. It is an effective tool for
assessing patient-based outcomes in TKA.
Keywords
patient-reported outcomes, focus group discussion, qualitative research methods, total knee arthroplasty
Introduction
The patient satisfaction assessment is very important in med-
ical practice. It helps to improve medical care and make the
patient happier (1). A patient’s expectation after a procedure
is defined as the anticipation of certain events happening
during or after surgery (2). Patient dissatisfaction can result
either from inappropriate expectations or from a lack of
proper information regarding the outcomes. The surgeon
gives importance to procedural success. They are usually
unaware of patient dissatisfaction. Regional, social, cultural,
and economic factors have a bearing on the outcomes of any
treatment (3).
Surgical outcomes refer to data regarding operation
results, including information about mortality and morbidity,
recovery time, operative numbers, and repeat rates (4). This
is different from the surgeon’s expectations about the out-
come which vary with the type of surgery, the seriousness of
the condition, the age and fitness of the patient, the experi-
ence of the surgeon, and the volume of surgery done. Most of
the tools used to find out the outcomes and measure the
ability of the surgeon to produce statistically significant data
using certain prescribed parameters (5). The surgeon judges
the success of surgery based on the anatomical, radiological,
and functional outcomes. The majority of the tools used for
measuring the outcomes of surgery are based on the fact that
the patient and the clinician have a common viewpoint
about the outcome. This is not always true as the patient and
the doctor have different perceptions about all domains of
outcomes. This is true in subjective quality-of-life domains
1
Department of Orthopedics, Government Medical College, Kozhikode,
Kerala, India
2
Government Medical College, Kozhikode, Kerala, India
3
Department of Surgical Oncology, Regional Cancer Center, Trivandrum,
Kerala, India
Corresponding Author:
Balaji Zacharia, Department of Orthopedics, Government Medical College,
Kozhikode, Kerala, 673008, India.
Email: balaji.zacharia@gmail.com
Journal of Patient Experience
2021, Volume 8: 1-7
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like emotional and social functioning (6). This may be prob-
ably due to the differing priorities of the 2 groups. This
discrepancy between patient and clinician in the validation
of health-related outcomes has guided the development of
many validated patient-related outcome measures like Short
Form 36 (SF 36), Eating disorder Quality of life (ED-QOL),
Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC), Oxford Knee Score, and so on. These
tools allow patients to rate their health and they are the center
of outcome assessment (7).
Total knee replacement (TKR) is a common surgery done
for osteoarthritis (OA) of the knee worldwide. It has a major
effect on the activities of daily living. The geographical,
social, cultural, economic, and many factors of a population
can influence the outcomes of TKR. Expectations after the
knee replacement will differ entirely among different popu-
lations (8). A successful TKR may not be a satisfactory one
for the patient due to differences in factors determining the
outcome measures (Table 1). Many previous studies have
looked into the patient-reported outcomes of TKR (Table 2).
Focus group discussion (FGD) is a qualitative research
method. It can be used for evaluating the outcomes of health
care interventions (9). A focused group discussion is an
effective way to bring people from similar backgrounds and
experiences to discuss a specific topic of interest. This group
is guided by a moderator/leader. The moderator introduces
the topic for discussion and helps the group to participate in a
lively and natural way. The participants should stay on the
topic and not wander (10–12).
There are many advantages to FGD. It can be used to
explore the outcomes that cannot be explained statistically.
Responses in FGD are spoken open-ended, relatively broad,
and qualitative (13). They have more depth and variety.
There can be nonverbal communication and group interac-
tions. They can give an idea closer to what people are think-
ing and feeling. Focus group discussion is a good way to
gather in-depth information about the community’s thoughts
and opinions on a topic (14,15). Focus group discussion can
yield a lot of information about a topic in a relatively short
time. All these pieces of information may not be relevant.
Observations and the opinions we get from FGD have to be
mentioned in their own words. It can cause difficulties dur-
ing translation (16,17). Thematic analysis and constant com-
parison techniques are used for data analysis (18).
Our objective is to discuss FGD as a tool to assess patient
satisfaction. We also want to give some general guidelines
for conducting FGD. This is based on our article published in
the Journal of Medical Devices:Evidence and Research
“Patient-based outcome analysis is important to determine
the success of total knee arthroplasty: the result of a focus
group discussion” (19) (We have taken permission from the
publisher).
Materials and Methods
FiftypatientswereselectedforFGD.Amongthem,
42 patients participated in FGD. The remaining 8 did not
participated. We included persons who had completed 2
years after primary TKR. Six FGD sessions was conducted.
We included participants who were homogeneous in terms
of age, status, class, occupation, and follow-up characteris-
tics. Patients with inflammatory arthritis, secondary OA,
posttraumatic arthritis, old high tibial osteotomy, and revi-
sion TKR were excluded from our study. Since we aimed to
find out the patient-reported outcomes, we used a purposive
sampling method. We collected the patient details from our
hospital records. We selected a moderator who had no rela-
tionship with the patients. The participants were divided into
8 groups, each having 6 members. The allocation was done
by simple randomization. After each FGD, we went through
the discussions and created new domains and subdomains.
Based on this, we prepared new questions for the next ses-
sions. It helped us to discuss a bit deeper into the new
domains (19). Proper planning is needed before the conduct
of FGD (Appendix A).
The group’s composition and the discussion should be
carefully planned to create a nonthreatening environment.
All participants feel free to talk openly and give honest
opinions. There is freedom for the participants to agree or
disagree with each other. We have to support them to come
out with their own opinions. They are free to express their
thoughts and feelings, although their responses are hard or
impossible to record on a scale.
Table 1. A Comparison Between the Factors Affecting the Outcomes in a Successful Total Knee Replacement and Patient Satisfaction After
a Total Knee Replacement.
Successful TKR Patient satisfaction after TKR
Based on implant longevity Based on patient satisfaction
Based on the revision rate Depends on pain relief and functional improvement
The unrevised implant may not function well The patient will be symptomatic even when the implant is proper
A third party interpret the outcome The patient interpret it
Mainly depend on functional and radiological
parameters
A variety of factors like functional status, emotional aspect, and social behavior can
influence the outcomes
An in-person assessment is necessary Can be assessed using electronic and social media also
Less costly Some PRO methods can be costly and some privacy issues
Abbreviation: TKR, total knee replacement.
2Journal of Patient Experience

The demographic data of the participants were collected.
We also checked the knee society score of all the participants
before FGD. The FGD sessions were started with a self-
introduction session. We gave some time for the participants
for getting to know each other. This helped them to alleviate
their fear of open discussion. Then the moderator introduced
himself and his team. The moderator explained the objective
of this discussion and the procedure. Then he initiated the
FGD by putting an open general question. Group members
were free to talk openly. The groups took more time to
respond than individuals. Some group members felt hesitant
to speak openly. Participants were actively encouraged to
express their own opinions and to respond to other members
and questions posed by the leader. The moderator made sure
that the discussions revolved around the topic. The group
members could often stimulate thought for each other which
might not have occurred otherwise. We stopped the sessions
when no fresh domains emerged (20,21).
During our FGD, most of the participants were discussing
the problems they had before the knee arthroplasty and about
Table 2. The List of Few Previous studies to Assess Patient-Reported Outcomes After Total Knee Replacement With the Methods Used
for Assessment and Their Conclusions.
References
Method used
assessment Conclusions
Williams DP, Price AJ, Beard DJ, Hadfield SG, Arden NK,
Murray DW, et al. The effects of age on patient-
reported outcome measures in total knee
replacements. The Bone Joint J. 2013;95-B:38-44.
Oxford knee
score (OKS) and
EuroQoL-5D
(EQ-5D)
The early outcome after TKA by OKS and EQ-5D is
comparable across all age groups. Patients <55 years are
more likely to be dissatisfied with surgery. The OKS and
EQ-5D alone might not accurately reflect the true
outcome in all age-groups
Lange JK, Yang HY, Collins JE, Losina E, Katz JN.
Association between preoperative radiographic
severity of osteoarthritis and patient-reported
outcomes of total knee Replacement. JB JS Open
Access. 2020;5: e19.00073-e19.00073.
WOMAC
and KOOS
TKA offers substantial symptomatic relief and functional
improvement regardless of the radiographic severity of
osteoarthritis.
Wylde V, Blom AW, Whitehouse SL, Taylor AH, Pattison
GT, Bannister GC. Patient-reported outcomes after
total hip and knee arthroplasty. J Arthroplasty.
2009;24:210-16.
OKS TKA patients experience a significantly poorer functional
outcome than THA patients 5 to 8 years
postoperatively.
Collins NJ, Roos EM. Patient-reported outcomes for total
hip and knee arthroplasty. Clin Geriatr Med.
2012;28:367-94.
The osteoarthritis-specific and arthroplasty-specific
measures like HOOS, KOOS, WOMAC, Oxford Hip,
and Knee Scores can more consistently be considered
“good” patient-reported outcomes for THA and TKA.
Bin Sheeha B, Williams A, Johnson DS, Granat M, Jones R.
Patients’ experiences and satisfaction at one year
following primary total knee arthroplasty: A focus-group
discussion. Musculoskeletal Care. 2020;18:434-49.
FGD Patient attitudes, expectations, preoperative education,
communication with the surgeon, and rehabilitation
affect postoperative outcomes.
Kennedy D, Wainwright A, Pereira L, Robarts S, Dickson
P, Christian J, et al. A qualitative study of patient
education needs for hip and knee replacement. BMC
Musculoskelet Disord. 2017;18:413.
FGD A multimodal patient education tailored to individual
preferences and experiences according to age and
gender is important before arthroplasty
Ayyar V, Burnett R, Coutts FJ, van der Linden ML, Mercer
TH (2012). The influence of obesity on patient reported
outcomes following total knee replacement. Arthritis,
2012, 1-6. https://doi.org/10.1155/2012/185208
OKS There is no significant difference in outcomes of TKA in
obese and nonobese patients
Trieu J, Gould DJ, Schilling C, Spelman T, Dowsey MM,
Choong PF. Patient-reported outcomes following total
knee replacement in patients. J Clin Med. 2020;9:3150.
Pain and functional deterioration start during the second
decade after TKA
Ayers DC, Li W, Oatis C, Rosal MC, Franklin PD. Patient-
reported outcomes after total knee replacement vary
on the basis of preoperative coexisting disease in the
lumbar spine and other nonoperatively treated joints. J
Bone Joint Surg Am. 2013;95:1833-37.
WOMAC
and ODI
Preoperative musculoskeletal pain in the lower extremity
joints and low back is associated with poorer physical
function at 6 months after total knee replacement.
Feng JE, Gabor JA, Anoushiravani AA, Long WJ,
Vigdorchik JM, Meere PA, et al. Payer type does not
impact patient-reported outcomes after primary total
knee arthroplasty. Arthroplast Today. 2019;5:113-18.
KOOS and
Veterans RAND
12 Health Survey
Regardless of insurance type, the surgeon can expect
similar patient-reported outcomes if baseline
demographics are similar
Abbreviations: FGD, focus group discussion; HOOS, Hip disability and Osteoarthritis Outcome Score; KOOS, Knee injury and Osteoarthritis Outcome
Score; ODI, Oswestry Disability Index; RAND, RAND-36 scales; TKA, total knee arthroplasty; WOMAC, Western Ontario and McMaster Universities
Osteoarthritis Index.
Zacharia et al 3

various treatment methods used by them to overcome these
difficulties. They discussed about why they were reluctant to
come for operative treatment, how they felt after surgery,
and their satisfaction after TKR. We created new domains
and subdomains after each FGD by making a transcript of
the discussions in the patient’s own words and carefully
analyzing them. No fresh domains or subdomains emerged
after the fourth FGD.
During each FGD, the opinions of the participants in their
own words were taken down by a person. We used both written
and voice recordings of our FGD. The data obtained are ana-
lyzed by 2 different individuals who are not part of the FGD.
This was to ensure the naturality and credibility of the findings.
A thematic analysis of the findings was done. Thematic anal-
ysis is a qualitative descriptive method to identify and analyze
the narrative materials to report patterns or themes. This
method has the flexibility for analysis. These interpretations
and observations were combined and a conclusion was made.
We had obtained institutional research committee
approval for this study. The patients were informed about
the study and that data from the FGD would be submitted for
publication and their consent was taken.
Results
We have taken the results from 4 FGD because the opinions
plateaued thereafter. There were 24 participants between the
ages of 50 to 65 years. Among the 24 participants, 15 were
males and 9 females. The average knee society score was
1.18 with a standard deviation of 0.50. Five major domains
were evolved after our FGD. From the major domains, many
minor domains were also developed (Table 3). From the
FGD conducted, we found that the socioeconomic impact
of OA of the knee is worse than the clinical and radiological
severity of the disease. Patients with high preoperative
expectations have low satisfaction levels. Surgeon–patient
communication has a major impact on patient-reported out-
comes. The patient satisfaction level is different from those
measured using objective scoring systems. Patient satisfac-
tion levels are high for pain relief, pain-free movements, and
social independence. But they are not satisfied because of
their inability to returning to their original occupation and
performing activities that require knee flexion.
Discussion
From our analysis, we found that loss of function was a
major concern before surgery. The pain and deformity were
the next. One patient told us, “Walking caused severe pain
that I was restricted to my home. I was unable to squat in the
toilet.” Some of them even converted their squat toilets to
western type of toilets.
The social disabilities due to OA of the knee were far
more than we thought. The majority of patients were
restricted to their homes. They avoided attending family
functions. The majority said they needed help from their
children or others in climbing upstairs or for walking long
distances. The difficulty to use squat toilets was another
social issue. These issues were causing mental stress and
depression in some patients. Loss of income due to inability
to go to work was another problem. Some stopped going to
work while others went to work but were less efficient. They
had to take more leaves which led to reduced pay. Most of
these patients were belonging to a low- or middle-income
group. This affected their daily livelihood. There was a delay
of 2 to 3 years before surgery for most of the patients. The
affordability of total knee arthroplasty (TKA) was the major
issue. They tried different modalities like Ayurveda, massa-
ging, and acupuncture in-between. The majority were una-
ware of the results of TKR. Some were reluctant to do a TKR
due to the fear of undergoing surgery.
Most of them were happy after TKR as they could walk
and climb stairs independently. They had minimum pain
compared to the preoperative level. Some patients thought
they could go for manual work and use the squat toilet after
TKR. They opined low satisfaction levels because they
couldn’t do it after TKR. But some patients were aware
of these problems before surgery and their satisfaction
level was high. Proper preoperative education and expec-
tations have a bearing on postoperative outcomes. We also
came to know that most of the patients were not getting
proper postoperative rehabilitation. They were taught about
the rehabilitation protocol postoperatively but were not
doing it properly. Some said that they were hesitant to flex
the knee because they feared something might happen
to the implant. Some blamed the doctors for not explaining
these things.
Table 3. The Major and Minor Domains Emerged From our Focus
Group Discussion to Assess Patient Satisfaction After Total Knee
Replacement.
1. Patient complaints
(a) Knee pain
(b) Deformity of the knee
(c) Cosmetic properties
after surgery
2. Loss of function
(a) Inability to walk alone
(b) Inability to climb upstairs
(c) Inability to use Indian toilet
(d) Inability to do prayer
(kneeling)
3. Socioeconomic aspect
(a) Restricted to home
(b) Dependent on others
(c) Mental stress
(d) Inability to go to work
4. Delay in surgery.
(a) Tried alternative modalities
of treatment
(b) High cost of surgery
(c) Not aware of the results of
TKR
(d) Fear of failure of surgery
(e) Fear of undergoing surgery
5. Satisfaction level achieved
(a) Relief from pain
(b) Increased range of movements
(c) Social independence: (1) walk alone/(2) go for work
(d) Reasonable pre-operative expectations
(e) Preoperative education
(f) Postop rehabilitation
Abbreviation: TKR, total knee replacement.
4Journal of Patient Experience

There are some reasons behind selecting patients after
TKR for assessing their satisfaction. The number of patients
opting for TKR is increasing in our population. We are
working in a government medical college in a developing
country. Most of our patients for TKR hail from low socio-
economic status. Most of them are manual laborers and liv-
ing in rural areas having limited road connectivity to their
houses. They have to walk or climb hilly terrains. They have
to work on farms or fields to earn their livelihood. They use
squat toilets. After TKR, most of them want to return to their
prior occupation. They can’t change their living conditions.
Most patients become aware of the postoperative limitations
only after TKR. Many of our patients were unhappy after
TKR even when they are clinically and radiologically fine.
This prompted us to find out the patient-reported outcome of
our patients after TKR. We used FGD as a tool for knowing
our patient’s satisfaction and opinions regarding TKR. The
usually used measuring tools are surgeon-dependent and
originate from developed countries.
Practical Problems in Conducting an FGD
As in any research method, finding a representative sample
is very important in FGD. Make sure that all the participants
are similar in their regional, cultural, educational, language,
and socioeconomic status. Otherwise, there can be dispari-
ties in their opinions regarding the same issues. For example,
if we are conducting an FGD about strengthening public
transport and participants from rural and urban areas are
included, their perceptions and opinion may vary. The city
dwellers may be using their vehicles for travel they may be
worried about traffic blocks or pathetic situations on the
road, whereas the rural dwellers will be more worried about
the number of buses and the making of new roads. In
our case, all patients belonged to the same region, similar
age-group, same diagnosis, and similar socioeconomic
status (22,23).
Focus group discussion can be a powerful tool for gather-
ing data on experiences, beliefs, attitudes, and perceptions.
Asking sensitive questions is not at all a problem in the FGD.
As all the participants belong to the same cohort, hence the
topic of discussion becomes very simple for them (24). Usu-
ally, 1 or 2 questions for the starting of the discussion are
needed. Usually, they are simple and general questions.
Sometimes, new questions will be added which are emerging
from the analysis of previous FGD. The questions are
formed by the participants and the answers of which come
from themselves. We have not come across any difficult
situations where we have a problem with asking a sensitive
question. We have prepared a set of questions for our FGD
(Table 4).
Recruiting participants is not a difficult task in FGD. In
most cases, we can find out the participants from the cohort.
We can collect the details of the participants from the out-
patient clinic, from community nurses, hospital records, or
from registries (25). We have obtained the details about our
participants from the hospital records. We contacted them
over telephones. One of our residents was given the charge
of contacting the participants before each session.
Language barrier can be a problem. The participants and
the moderator need to be well-versed in the language in
which they are conducting FGD. Analysis of data and their
interpretations also becomes difficult if they are not using
the same language. We conducted the FGD in our mother
tongue Malayalam. We did have some difficulty in translat-
ing certain colloquial terms into the English language during
the publication of our results.
Maintaining quality and consistency during each session
is very important (26). The audio or video recording of the
FGD sessions helps to maintain the quality of the procedure.
Table 4. The Main Questions and the Probes Prepared for Our Focus Group Discussion.
Main questions (open-ended questions) Probes
What were the problems due to osteoarthritis of the knee? Pain, deformities, loss of earning, restriction of activities of daily living
Have you taken any treatment for osteoarthritis of the knee? Modern medicine, Ayurveda, Homeopathy, indigenous treatment modalities,
no treatment done
How did you come to know about TKA? Doctors, friends, magazines
What are the factors that delayed you from undergoing TKA Economic factors, fear of surgery, apprehension regarding loss/failure to
return to the occupation
What were your expectations about TKA?
Are you satisfied after TKA? Pain relief, functional improvement, activities of daily living, return to the
occupation
Are you dissatisfied after TKA? Pain relief, functional improvement, activities of daily living, return to the
occupation
Did you aware of these limitations before TKA? Did your
doctor explain it?
Have you got instruction regarding postoperative
rehabilitation?
Did you follow the rehabilitation protocol?
Abbreviation: TKA, total knee arthroplasty.
Zacharia et al 5

Quality control is the responsibility of the moderator. We
had an audio recording of all our proceedings. And the
moderator had full control of the whole team during the
entire session.
Our Experiences
Our journey started by searching the literature for a simple
but practical method for assessing patient satisfaction after
TKA. After deciding to conduct FGD, we collected patients
from the hospital records. They were randomly allocated to
6 groups. The date, time, and place of each session were
decided. There was a delay of 10 days between each FGD.
The moderator, a person for writing, and another one for
recording were identified. Two senior doctors from our
department were assigned for data analysis. A table with
7 chairs was arranged for the moderator and team members.
All the data collected were handed over to the team leader
after the end of each session. Each session lasted for about
1.5 to 3 hours. We can surely say that the success of our
project is the result of teamwork not only among the persons
involved in the conduct of the FGD but also among all the
participants. Since there are no interventions involved in this
research, there is little to worry about the safety aspect of the
researcher and participants. But great care was taken to pro-
tect the identity of the participants. Our greatest difficulty
was in translating the data during publication.
Assessment of patient-reported outcomes is important in
any health care intervention. This helps the treating doctor to
make necessary modifications in their practices which will
ultimately help the community. The regional, cultural,
social, and economic status of the patients have a bearing
on their level of satisfaction. It is better to develop tools that
can be used for various populations. From our experience,
we think that FGD is a very effective tool for measuring
patient-reported outcomes/satisfaction. It can be conducted
with a minimum number of participants. Planning and pre-
parations are less cumbersome. As we are ensuring the
homogeneity of the participants, we can get an emic perspec-
tive about the subject. Even information about certain sen-
sitive issues can be obtained during FGD. As there are no
interventions involved, it is well accepted and cost-effective.
We found that patient-based outcomes of TKR differ from
the Knee Society Score. Focus group discussion is a simple
and surgeon-friendly tool for measuring patient-reported
outcomes after TKR.
Conclusion
Patient-based outcome measurements are important for
the evaluation of any intervention. Focus group discus-
sion is a simple and effective way to find out the patient-
based outcomes. Focus group discussion is a simple and
surgeon-friendly tool for measuring patient-reported out-
comes after TKR.
Appendix A
Important Points to Be Noted While Planning a Focus Group
Discussion
Decide the number of groups*
Make sure all participants are homogenous
Assign the place, date, time of each focus group dis-
cussion (FGD)
Inform the participants early regarding the FGD**
Find out a moderator who is knowledgeable in the
topic and knows the vernacular language
Ask the moderator to prepare some leading
questions***
Arrange a person for writing and arrange an audiovi-
sual team.
*Better to create small groups and 5 to 6 groups are enough.
Too many participants make it difficult to control them dur-
ing FGD, also the discussion can get going out of context.
**So that they can come on time.
***These questions should be based on the experiences of
the moderator and also from the previously published liter-
ature about the topic.
Authors’ Note
The corresponding author Balaji Zacharia contributed to concep-
tualize the idea, helped in collecting data, analyzing, statistics,
writing, and editing the manuscript. The coauthors helped in col-
lecting data, analysis, statistics, writing, and editing the manuscript.
We have no conflict of interest for this manuscript and we have
not accepted any financial assistance from within or outside of our
institution for collecting data, writing the manuscript, and for its
publications. This study was approved by the institutional ethics
committee of Government Medical College, Kozhikode, Kerala,
India. Written informed consent was obtained from the patients for
their anonymised information to be published in this article. This
article does not contain any studies with human subjects.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Balaji Zacharia, MBBS, Dortho, MSortho https://orcid.org/
0000-0001-5080-1656
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