case study meaning in medical term

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

• Knowledge Base

Methodology

• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

Receive feedback on language, structure, and formatting

Professional editors proofread and edit your paper by focusing on:

• Academic style
• Vague sentences
• Style consistency

See an example

Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

Here's why students love Scribbr's proofreading services

Discover proofreading & editing

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

McCombes, S. (2023, November 20). What Is a Case Study? | Definition, Examples & Methods. Scribbr. Retrieved September 13, 2024, from https://www.scribbr.com/methodology/case-study/

Is this article helpful?

Shona McCombes

Other students also liked, primary vs. secondary sources | difference & examples, what is a theoretical framework | guide to organizing, what is action research | definition & examples, get unlimited documents corrected.

✔ Free APA citation check included ✔ Unlimited document corrections ✔ Specialized in correcting academic texts

• Open access
• Published: 27 June 2011

The case study approach

• Sarah Crowe 1 ,
• Kathrin Cresswell 2 ,
• Ann Robertson 2 ,
• Guro Huby 3 ,
• Anthony Avery 1 &
• Aziz Sheikh 2  

BMC Medical Research Methodology volume  11 , Article number:  100 ( 2011 ) Cite this article

793k Accesses

1115 Citations

42 Altmetric

Metrics details

The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Peer Review reports

Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables 2 , 3 and 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 – 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables 2 and 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 – 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table 8 )[ 8 , 18 – 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table 9 )[ 8 ].

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

Yin RK: Case study research, design and method. 2009, London: Sage Publications Ltd., 4

Google Scholar  

Keen J, Packwood T: Qualitative research; case study evaluation. BMJ. 1995, 311: 444-446.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J, et al: Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009, 6 (10): 1-11.

Article   Google Scholar  

Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, et al: The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). 2008, [ http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf ]

Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al: Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010, 41: c4564-

Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P, the Patient Safety Education Study Group: Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010, 15: 4-10. 10.1258/jhsrp.2009.009052.

Article   PubMed   Google Scholar  

van Harten WH, Casparie TF, Fisscher OA: The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002, 60 (1): 17-37. 10.1016/S0168-8510(01)00187-7.

Stake RE: The art of case study research. 1995, London: Sage Publications Ltd.

Sheikh A, Smeeth L, Ashcroft R: Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002, 52 (482): 746-51.

PubMed   PubMed Central   Google Scholar  

King G, Keohane R, Verba S: Designing Social Inquiry. 1996, Princeton: Princeton University Press

Doolin B: Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998, 13: 301-311. 10.1057/jit.1998.8.

George AL, Bennett A: Case studies and theory development in the social sciences. 2005, Cambridge, MA: MIT Press

Eccles M, the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG): Designing theoretically-informed implementation interventions. Implementation Science. 2006, 1: 1-8. 10.1186/1748-5908-1-1.

Article   PubMed Central   Google Scholar  

Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A: Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005, 365 (9456): 312-7.

Sheikh A, Panesar SS, Lasserson T, Netuveli G: Recruitment of ethnic minorities to asthma studies. Thorax. 2004, 59 (7): 634-

CAS   PubMed   PubMed Central   Google Scholar  

Hellström I, Nolan M, Lundh U: 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005, 4: 7-22. 10.1177/1471301205049188.

Som CV: Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005, 18: 463-477. 10.1108/09513550510608903.

Lincoln Y, Guba E: Naturalistic inquiry. 1985, Newbury Park: Sage Publications

Barbour RS: Checklists for improving rigour in qualitative research: a case of the tail wagging the dog?. BMJ. 2001, 322: 1115-1117. 10.1136/bmj.322.7294.1115.

Mays N, Pope C: Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000, 320: 50-52. 10.1136/bmj.320.7226.50.

Mason J: Qualitative researching. 2002, London: Sage

Brazier A, Cooke K, Moravan V: Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008, 7: 5-17. 10.1177/1534735407313395.

Miles MB, Huberman M: Qualitative data analysis: an expanded sourcebook. 1994, CA: Sage Publications Inc., 2

Pope C, Ziebland S, Mays N: Analysing qualitative data. Qualitative research in health care. BMJ. 2000, 320: 114-116. 10.1136/bmj.320.7227.114.

Cresswell KM, Worth A, Sheikh A: Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010, 10 (1): 67-10.1186/1472-6947-10-67.

Article   PubMed   PubMed Central   Google Scholar  

Malterud K: Qualitative research: standards, challenges, and guidelines. Lancet. 2001, 358: 483-488. 10.1016/S0140-6736(01)05627-6.

Article   CAS   PubMed   Google Scholar  

Yin R: Case study research: design and methods. 1994, Thousand Oaks, CA: Sage Publishing, 2

Yin R: Enhancing the quality of case studies in health services research. Health Serv Res. 1999, 34: 1209-1224.

Green J, Thorogood N: Qualitative methods for health research. 2009, Los Angeles: Sage, 2

Howcroft D, Trauth E: Handbook of Critical Information Systems Research, Theory and Application. 2005, Cheltenham, UK: Northampton, MA, USA: Edward Elgar

Book   Google Scholar  

Blakie N: Approaches to Social Enquiry. 1993, Cambridge: Polity Press

Doolin B: Power and resistance in the implementation of a medical management information system. Info Systems J. 2004, 14: 343-362. 10.1111/j.1365-2575.2004.00176.x.

Bloomfield BP, Best A: Management consultants: systems development, power and the translation of problems. Sociological Review. 1992, 40: 533-560.

Shanks G, Parr A: Positivist, single case study research in information systems: A critical analysis. Proceedings of the European Conference on Information Systems. 2003, Naples

Pre-publication history

The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2288/11/100/prepub

Download references

Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

Author information

Authors and affiliations.

Division of Primary Care, The University of Nottingham, Nottingham, UK

Sarah Crowe & Anthony Avery

Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Kathrin Cresswell, Ann Robertson & Aziz Sheikh

School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Sarah Crowe .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors' contributions

AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

Download citation

Received : 29 November 2010

Accepted : 27 June 2011

Published : 27 June 2011

DOI : https://doi.org/10.1186/1471-2288-11-100

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Case Study Approach
• Electronic Health Record System
• Case Study Design
• Case Study Site
• Case Study Report

BMC Medical Research Methodology

ISSN: 1471-2288

• General enquiries: [email protected]

Health Case Studies

(29 reviews)

Glynda Rees, British Columbia Institute of Technology

Rob Kruger, British Columbia Institute of Technology

Janet Morrison, British Columbia Institute of Technology

Copyright Year: 2017

Publisher: BCcampus

Language: English

Formats Available

Conditions of use.

Learn more about reviews.

Reviewed by Jessica Sellars, Medical assistant office instructor, Blue Mountain Community College on 10/11/23

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and... read more

Comprehensiveness rating: 5 see less

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and plan. There is an appendix to refer to as well if you are needing to find something specific quickly. I have been looking for something like this to help my students have a base to do their project on. This is the most comprehensive version I have found on the subject.

Content Accuracy rating: 5

This is a book compiled of medical case studies. It is very accurate and can be used to learn from great care and mistakes.

Relevance/Longevity rating: 5

This material is very relevant in this context. It also has plenty of individual case studies to utilize in many ways in all sorts of medical courses. This is a very useful textbook and it will continue to be useful for a very long time as you can still learn from each study even if medicine changes through out the years.

Clarity rating: 5

The author put a lot of thought into the ease of accessibility and reading level of the target audience. There is even a "how to use this resource" section which could be extremely useful to students.

Consistency rating: 5

The text follows a very consistent format throughout the book.

Modularity rating: 5

Each case study is individual broken up and in a group of similar case studies. This makes it extremely easy to utilize.

Organization/Structure/Flow rating: 5

The book is very organized and the appendix is through. It flows seamlessly through each case study.

Interface rating: 5

I had no issues navigating this book, It was clearly labeled and very easy to move around in.

Grammatical Errors rating: 5

I did not catch any grammar errors as I was going through the book

Cultural Relevance rating: 5

This is a challenging question for any medical textbook. It is very culturally relevant to those in medical or medical office degrees.

I have been looking for something like this for years. I am so happy to have finally found it.

Reviewed by Cindy Sun, Assistant Professor, Marshall University on 1/7/23

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and... read more

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and students. For faculty, the introduction section titled ‘How to use this resource’ and individual notes to educators before each case study contain application tips. An appendix overview lists key elements as issues / concepts, scenario context, and healthcare roles for each case study. For students, learning objectives are presented at the beginning of each case study to provide a framework of expectations.

The content is presented accurately and realistic.

The case studies read similar to ‘A Day In the Life of…’ with detailed intraprofessional communications similar to what would be overheard in patient care areas. The authors present not only the view of the patient care nurse, but also weave interprofessional vantage points through each case study by including patient interaction with individual professionals such as radiology, physician, etc.

In addition to objective assessment findings, the authors integrate standard orders for each diagnosis including medications, treatments, and tests allowing the student to incorporate pathophysiology components to their assessments.

Each case study is arranged in the same framework for consistency and ease of use.

This compilation of eight healthcare case studies focusing on new onset and exacerbation of prevalent diagnoses, such as heart failure, deep vein thrombosis, cancer, and chronic obstructive pulmonary disease advancing to pneumonia.

Each case study has a photo of the ‘patient’. Simple as this may seem, it gives an immediate mental image for the student to focus.

Interface rating: 4

As noted by previous reviewers, most of the links do not connect active web pages. This may be due to the multiple options for accessing this resource (pdf download, pdf electronic, web view, etc.).

Grammatical Errors rating: 4

A minor weakness that faculty will probably need to address prior to use is regarding specific term usages differences between Commonwealth countries and United States, such as lung sound descriptors as ‘quiet’ in place of ‘diminished’ and ‘puffers’ in place of ‘inhalers’.

The authors have provided a multicultural, multigenerational approach in selection of patient characteristics representing a snapshot of today’s patient population. Additionally, one case study focusing on heart failure is about a middle-aged adult, contrasting to the average aged patient the students would normally see during clinical rotations. This option provides opportunities for students to expand their knowledge on risk factors extending beyond age.

This resource is applicable to nursing students learning to care for patients with the specific disease processes presented in each case study or for the leadership students focusing on intraprofessional communication. Educators can assign as a supplement to clinical experiences or as an in-class application of knowledge.

Reviewed by Stephanie Sideras, Assistant Professor, University of Portland on 8/15/22

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five... read more

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five overarching learning objectives pulled from the Institute of Medicine core competencies will clearly resonate with any faculty familiar with Quality and Safety Education for Nurses curriculum.

The presentation of symptoms, treatments and management of the health alterations was accurate. Dialogue between the the interprofessional team was realistic. At times the formatting of lab results was confusing as they reflected reference ranges specific to the Canadian healthcare system but these occurrences were minimal and could be easily adapted.

The focus for learning from these case studies was communication - patient centered communication and interprofessional team communication. Specific details, such as drug dosing, was minimized, which increases longevity and allows for easy individualization of the case data.

While some vocabulary was specific to the Canadian healthcare system, overall the narrative was extremely engaging and easy to follow. Subjective case data from patient or provider were formatted in italics and identified as 'thoughts'. Objective and behavioral case data were smoothly integrated into the narrative.

The consistency of formatting across the eight cases was remarkable. Specific learning objectives are identified for each case and these remain consistent across the range of cases, varying only in the focus for the goals for each different health alterations. Each case begins with presentation of essential patient background and the progress across the trajectory of illness as the patient moves from location to location encountering different healthcare professionals. Many of the characters (the triage nurse in the Emergency Department, the phlebotomist) are consistent across the case situations. These consistencies facilitate both application of a variety of teaching methods and student engagement with the situated learning approach.

Case data is presented by location and begins with the patient's first encounter with the healthcare system. This allows for an examination of how specific trajectories of illness are manifested and how care management needs to be prioritized at different stages. This approach supports discussions of care transitions and the complexity of the associated interprofessional communication.

The text is well organized. The case that has two levels of complexity is clearly identified

The internal links between the table of contents and case specific locations work consistently. In the EPUB and the Digital PDF the external hyperlinks are inconsistently valid.

The grammatical errors were minimal and did not detract from readability

Cultural diversity is present across the cases in factors including race, ethnicity, socioeconomic status, family dynamics and sexual orientation.

The level of detail included in these cases supports a teaching approach to address all three spectrums of learning - knowledge, skills and attitudes - necessary for the development of competent practice. I also appreciate the inclusion of specific assessment instruments that would facilitate a discussion of evidence based practice. I will enjoy using these case to promote clinical reasoning discussions of data that is noticed and interpreted with the resulting prioritizes that are set followed by reflections that result from learner choices.

Reviewed by Chris Roman, Associate Professor, Butler University on 5/19/22

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various... read more

Comprehensiveness rating: 4 see less

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various learning strategies to be employed to leverage the cases for deeper student learning and application.

The narrative form of the cases is less subject to issues of accuracy than a more content-based book would be. That said, the cases are realistic and reasonable, avoiding being too mundane or too extreme.

These cases are narrative and do not include many specific mentions of drugs, dosages, or other aspects of clinical care that may grow/evolve as guidelines change. For this reason, the cases should be “evergreen” and can be modified to suit different types of learners.

Clarity rating: 4

The text is written in very accessible language and avoids heavy use of technical language. Depending on the level of learner, this might even be too simplistic and omit some details that would be needed for physicians, pharmacists, and others to make nuanced care decisions.

The format is very consistent with clear labeling at transition points.

The authors point out in the introductory materials that this text is designed to be used in a modular fashion. Further, they have built in opportunities to customize each cases, such as giving dates of birth at “19xx” to allow for adjustments based on instructional objectives, etc.

The organization is very easy to follow.

I did not identify any issues in navigating the text.

The text contains no grammatical errors, though the language is a little stiff/unrealistic in some cases.

Cases involve patients and members of the care team that are of varying ages, genders, and racial/ethnic backgrounds

Reviewed by Trina Larery, Assistant Professor, Pittsburg State University on 4/5/22

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand... read more

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand and apply to the classroom. The E-reader format included hyperlinks that bring the students to subsequent clinical studies.

Content Accuracy rating: 4

The treatments were explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse. The case studies were accurate in explanation. The DVT case study incorrectly identifies the location of the clot in the popliteal artery instead of in the vein.

The content is relevant to a variety of different types of health care providers and due to the general nature of the cases, will remain relevant over time. Updates should be made annually to the hyperlinks and to assure current standard of practice is still being met.

Clear, simple and easy to read.

Consistent with healthcare terminology and framework throughout all eight case studies.

The text is modular. Cases can be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point providing great flexibility. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

The book is well organized, presenting in a logical clear fashion. The appendix allows the student to move about the case study without difficulty.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change based on current guidelines. A few hyperlinks had "page not found".

Few grammatical errors were noted in text.

The case studies include people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. There are roughly 25 broken online links or "pages not found", care needs to be taken to update at least annually and assure links are valid and utilizing the most up to date information.

Reviewed by Benjamin Silverberg, Associate Professor/Clinician, West Virginia University on 3/24/22

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what... read more

Comprehensiveness rating: 3 see less

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what is going on where, especially since each case is largely conversation-based. Since this presents 8 cases (really 7 with one being expanded upon), there are many medical topics (and venues) that are not included. It's impossible to include every kind of situation, but I'd love to see inclusion of sexual health, renal pathology, substance abuse, etc.

Though there are differences in how care can be delivered based on personal style, changing guidelines, available supplies, etc, the medical accuracy seems to be high. I did not detect bias or industry influence.

Relevance/Longevity rating: 4

Medications are generally listed as generics, with at least current dosing recommendations. The text gives a picture of what care looks like currently, but will be a little challenging to update based on new guidelines (ie, it can be hard to find the exact page in which a medication is dosed/prescribed). Even if the text were to be a little out of date, an instructor can use that to point out what has changed (and why).

Clear text, usually with definitions of medical slang or higher-tier vocabulary. Minimal jargon and there are instances where the "characters" are sorting out the meaning as well, making it accessible for new learners, too.

Overall, the style is consistent between cases - largely broken up into scenes and driven by conversation rather than descriptions of what is happening.

There are 8 (well, again, 7) cases which can be reviewed in any order. Case #2 builds upon #1, which is intentional and a good idea, though personally I would have preferred one case to have different possible outcomes or even a recurrence of illness. Each scene within a case is reasonably short.

Organization/Structure/Flow rating: 4

These cases are modular and don't really build on concepts throughout. As previously stated, case #2 builds upon #1, but beyond that, there is no progression. (To be sure, the authors suggest using case #1 for newer learners and #2 for more advanced ones.) The text would benefit from thematic grouping, a longer introduction and debriefing for each case (there are learning objectives but no real context in medical education nor questions to reflect on what was just read), and progressively-increasing difficulty in medical complexity, ethics, etc.

I used the PDF version and had no interface issues. There are minimal photographs and charts. Some words are marked in blue but those did not seem to be hyperlinked anywhere.

No noticeable errors in grammar, spelling, or formatting were noted.

I appreciate that some diversity of age and ethnicity were offered, but this could be improved. There were Canadian Indian and First Nations patients, for example, as well as other characters with implied diversity, but there didn't seem to be any mention of gender diverse or non-heterosexual people, or disabilities. The cases tried to paint family scenes (the first patient's dog was fairly prominently mentioned) to humanize them. Including more cases would allow for more opportunities to include sex/gender minorities, (hidden) disabilities, etc.

The text (originally from 2017) could use an update. It could be used in conjunction with other Open Texts, as a compliment to other coursework, or purely by itself. The focus is meant to be on improving communication, but there are only 3 short pages at the beginning of the text considering those issues (which are really just learning objectives). In addition to adding more cases and further diversity, I personally would love to see more discussion before and after the case to guide readers (and/or instructors). I also wonder if some of the ambiguity could be improved by suggesting possible health outcomes - this kind of counterfactual comparison isn't possible in real life and could be really interesting in a text. Addition of comprehension/discussion questions would also be worthwhile.

Reviewed by Danielle Peterson, Assistant Professor, University of Saint Francis on 12/31/21

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare... read more

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare workers in acute hospital settings. The cases are primarily set in the inpatient hospital setting, so the bulk of the clinical information is basic emergency care and inpatient protocol: vitals, breathing, medication management, etc. The text provides a table of contents at opening of the text and a handy appendix at the conclusion of the text that outlines each case’s issue(s), scenario, and healthcare roles. No index or glossary present.

Although easy to update, it should be noted that the cases are taking place in a Canadian healthcare system. Terms may be unfamiliar to some students including “province,” “operating theatre,” “physio/physiotherapy,” and “porter.” Units of measurement used include Celsius and meters. Also, the issue of managed care, health insurance coverage, and length of stay is missing for American students. These are primary issues that dictate much of the healthcare system in the US and a primary job function of social workers, nurse case managers, and medical professionals in general. However, instructors that wish to add this to the case studies could do so easily.

The focus of this text is on healthcare communication which makes it less likely to become obsolete. Much of the clinical information is stable healthcare practice that has been standard of care for quite some time. Nevertheless, given the nature of text, updates would be easy to make. Hyperlinks should be updated to the most relevant and trustworthy sources and checked frequently for effectiveness.

The spacing that was used to note change of speaker made for ease of reading. Although unembellished and plain, I expect students to find this format easy to digest and interesting, especially since the script is appropriately balanced with ‘human’ qualities like the current TV shows and songs, the use of humor, and nonverbal cues.

A welcome characteristic of this text is its consistency. Each case is presented in a similar fashion and the roles of the healthcare team are ‘played’ by the same character in each of the scenarios. This allows students to see how healthcare providers prioritize cases and juggle the needs of multiple patients at once. Across scenarios, there was inconsistency in when clinical terms were hyperlinked.

The text is easily divisible into smaller reading sections. However, since the nature of the text is script-narrative format, if significant reorganization occurs, one will need to make sure that the communication of the script still makes sense.

The text is straightforward and presented in a consistent fashion: learning objectives, case history, a script of what happened before the patient enters the healthcare setting, and a script of what happens once the patient arrives at the healthcare setting. The authors use the term, “ideal interactions,” and I would agree that these cases are in large part, ‘best case scenarios.’ Due to this, the case studies are well organized, clear, logical, and predictable. However, depending on the level of student, instructors may want to introduce complications that are typical in the hospital setting.

The interface is pleasing and straightforward. With exception to the case summary and learning objectives, the cases are in narrative, script format. Each case study supplies a photo of the ‘patient’ and one of the case studies includes a link to a 3-minute video that introduces the reader to the patient/case. One of the highlights of this text is the use of hyperlinks to various clinical practices (ABG, vital signs, transfer of patient). Unfortunately, a majority of the links are broken. However, since this is an open text, instructors can update the links to their preference.

Although not free from grammatical errors, those that were noticed were minimal and did not detract from reading.

Cultural Relevance rating: 4

Cultural diversity is visible throughout the patients used in the case studies and includes factors such as age, race, socioeconomic status, family dynamics, and sexual orientation. A moderate level of diversity is noted in the healthcare team with some stereotypes: social workers being female, doctors primarily male.

As a social work instructor, I was grateful to find a text that incorporates this important healthcare role. I would have liked to have seen more content related to advance directives, mediating decision making between the patient and care team, emotional and practical support related to initial diagnosis and discharge planning, and provision of support to colleagues, all typical roles of a medical social worker. I also found it interesting that even though social work was included in multiple scenarios, the role was only introduced on the learning objectives page for the oncology case.

Reviewed by Crystal Wynn, Associate Professor, Virginia State University on 7/21/21

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied... read more

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied health care team members are represented within the case study. Key terms appear throughout the case study textbook and readers are able to click on a hyperlink which directs them to the definition and an explanation of the key term.

Content is accurate, error-free and unbiased.

The content is up-to-date, but not in a way that will quickly make the text obsolete within a short period of time. The text is written and/or arranged in such a way that necessary updates will be relatively easy and straightforward to implement.

The text is written in lucid, accessible prose, and provides adequate context for any jargon/technical terminology used

The text is internally consistent in terms of terminology and framework.

The text is easily and readily divisible into smaller reading sections that can be assigned at different points within the course. Each case can be divided into a chronic disease state unit, which will allow the reader to focus on one section at a time.

Organization/Structure/Flow rating: 3

The topics in the text are presented in a logical manner. Each case provides an excessive amount of language that provides a description of the case. The cases in this text reads more like a novel versus a clinical textbook. The learning objectives listed within each case should be in the form of questions or activities that could be provided as resources for instructors and teachers.

Interface rating: 3

There are several hyperlinks embedded within the textbook that are not functional.

The text contains no grammatical errors.

Cultural Relevance rating: 3

The text is not culturally insensitive or offensive in any way. More examples of cultural inclusiveness is needed throughout the textbook. The cases should be indicative of individuals from a variety of races and ethnicities.

Reviewed by Rebecca Hillary, Biology Instructor, Portland Community College on 6/15/21

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health... read more

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health care program. I read the textbook in E-reader format and this includes hyperlinks that bring the students to subsequent clinical study if the book is being used in a clinical classroom. This book is significantly more comprehensive in its approach from other case studies I have read because it provides a bird’s eye view of the many clinicians, technicians, and hospital staff working with one patient. The book also provides real time measurements for patients that change as they travel throughout the hospital until time of discharge.

Each case gave an accurate sense of the chaos that would be present in an emergency situation and show how the conditions affect the practitioners as well as the patients. The reader gets an accurate big picture--a feel for each practitioner’s point of view as well as the point of view of the patient and the patient’s family as the clock ticks down and the patients are subjected to a number of procedures. The clinical information contained in this textbook is all in hyperlinks containing references to clinical skills open text sources or medical websites. I did find one broken link on an external medical resource.

The diseases presented are relevant and will remain so. Some of the links are directly related to the Canadian Medical system so they may not be applicable to those living in other regions. Clinical links may change over time but the text itself will remain relevant.

Each case study clearly presents clinical data as is it recorded in real time.

Each case study provides the point of view of several practitioners and the patient over several days. While each of the case studies covers different pathology they all follow this same format, several points of view and data points, over a number of days.

The case studies are divided by days and this was easy to navigate as a reader. It would be easy to assign one case study per body system in an Anatomy and Physiology course, or to divide them up into small segments for small in class teaching moments.

The topics are presented in an organized way showing clinical data over time and each case presents a large number of view points. For example, in the first case study, the patient is experiencing difficulty breathing. We follow her through several days from her entrance to the emergency room. We meet her X Ray Technicians, Doctor, Nurses, Medical Assistant, Porter, Physiotherapist, Respiratory therapist, and the Lab Technicians running her tests during her stay. Each practitioner paints the overall clinical picture to the reader.

I found the text easy to navigate. There were not any figures included in the text, only clinical data organized in charts. The figures were all accessible via hyperlink. Some figures within the textbook illustrating patient scans could have been helpful but I did not have trouble navigating the links to visualize the scans.

I did not see any grammatical errors in the text.

The patients in the text are a variety of ages and have a variety of family arrangements but there is not much diversity among the patients. Our seven patients in the eight case studies are mostly white and all cis gendered.

Some of the case studies, for example the heart failure study, show clinical data before and after drug treatments so the students can get a feel for mechanism in physiological action. I also liked that the case studies included diet and lifestyle advice for the patients rather than solely emphasizing these pharmacological interventions. Overall, I enjoyed reading through these case studies and I plan to utilize them in my Anatomy and Physiology courses.

Reviewed by Richard Tarpey, Assistant Professor, Middle Tennessee State University on 5/11/21

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate... read more

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate for entry-level health care students. The book includes important health problems, but I would like to see coverage of at least one more chronic/lifestyle issue such as diabetes. The book covers adult issues only.

Content is accurate without bias

The content of the book is relevant and up-to-date. It addresses conditions that are prevalent in today's population among adults. There are no pediatric cases, but this does not significantly detract from the usefulness of the text. The format of the book lends to easy updating of data or information.

The book is written with clarity and is easy to read. The writing style is accessible and technical terminology is explained with links to more information.

Consistency is present. Lack of consistency is typically a problem with case study texts, but this book is consistent with presentation, format, and terminology throughout each of the eight cases.

The book has high modularity. Each of the case studies can be used independently from the others providing flexibility. Additionally, each case study can be partitioned for specific learning objectives based on the learning objectives of the course or module.

The book is well organized, presenting students conceptually with differing patient flow patterns through a hospital. The patient information provided at the beginning of each case is a wonderful mechanism for providing personal context for the students as they consider the issues. Many case studies focus on the problem and the organization without students getting a patient's perspective. The patient perspective is well represented in these cases.

The navigation through the cases is good. There are some terminology and procedure hyperlinks within the cases that do not work when accessed. This is troubling if you intend to use the text for entry-level health care students since many of these links are critical for a full understanding of the case.

There are some non-US variants of spelling and a few grammatical errors, but these do not detract from the content of the messages of each case.

The book is inclusive of differing backgrounds and perspectives. No insensitive or offensive references were found.

I like this text for its application flexibility. The book is useful for non-clinical healthcare management students to introduce various healthcare-related concepts and terminology. The content is also helpful for the identification of healthcare administration managerial issues for students to consider. The book has many applications.

Reviewed by Paula Baldwin, Associate Professor/Communication Studies, Western Oregon University on 5/10/21

The different case studies fall on a range, from crisis care to chronic illness care. read more

The different case studies fall on a range, from crisis care to chronic illness care.

The contents seems to be written as they occurred to represent the most complete picture of each medical event's occurence.

These case studies are from the Canadian medical system, but that does not interfere with it's applicability.

It is written for a medical audience, so the terminology is mostly formal and technical.

Some cases are shorter than others and some go in more depth, but it is not problematic.

The eight separate case studies is the perfect size for a class in the quarter system. You could combine this with other texts, videos or learning modalities, or use it alone.

As this is a case studies book, there is not a need for a logical progression in presentation of topics.

No problems in terms of interface.

I have not seen any grammatical errors.

I did not see anything that was culturally insensitive.

I used this in a Health Communication class and it has been extraordinarily successful. My studies are analyzing the messaging for the good, the bad, and the questionable. The case studies are widely varied and it gives the class insights into hospital experiences, both front and back stage, that they would not normally be able to examine. I believe that because it is based real-life medical incidents, my students are finding the material highly engaging.

Reviewed by Marlena Isaac, Instructor, Aiken Technical College on 4/23/21

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with... read more

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with a situation in clinical they are not surprised and now how to move through it effectively.

The case studies provided accurate information that relates to the named disease.

It is relevant to health care studies and the development of critical thinking.

Cases are straightforward with great clinical information.

Clinical information is provided concisely.

Appropriate for clinical case study.

Presented to facilitate information gathering.

Takes a while to navigate in the browser.

Cultural Relevance rating: 1

Text lacks adequate representation of minorities.

Reviewed by Kim Garcia, Lecturer III, University of Texas Rio Grande Valley on 11/16/20

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at... read more

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at different levels of clinical knowledge. The human element of both patient and health care provider is well captured. The cases are presented with a focus on interprofessional interaction and collaboration, more so than teaching medical content.

Content is accurate and un-biased. No errors noted. Most diagnostic and treatment information is general so it will remain relevant over time. The content of these cases is more appropriate for teaching interprofessional collaboration and less so for teaching the medical care for each diagnosis.

The content is relevant to a variety of different types of health care providers (nurses, radiologic technicians, medical laboratory personnel, etc) and due to the general nature of the cases, will remain relevant over time.

Easy to read. Clear headings are provided for sections of each case study and these section headings clearly tell when time has passed or setting has changed. Enough description is provided to help set the scene for each part of the case. Much of the text is written in the form of dialogue involving patient, family and health care providers, making it easy to adapt for role play. Medical jargon is limited and links for medical terms are provided to other resources that expound on medical terms used.

The text is consistent in structure of each case. Learning objectives are provided. Cases generally start with the patient at home and move with the patient through admission, testing and treatment, using a variety of healthcare services and encountering a variety of personnel.

The text is modular. Cases could be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

Each case follows a patient in a logical, chronologic fashion. A clear table of contents and appendix are provided which allows the user to quickly locate desired content. It would be helpful if the items in the table of contents and appendix were linked to the corresponding section of the text.

The hyperlinks to content outside this book work, however using the back arrow on your browser returns you to the front page of the book instead of to the point at which you left the text. I would prefer it if the hyperlinks opened in a new window or tab so closing that window or tab would leave you back where you left the text.

No grammatical errors were noted.

The text is culturally inclusive and appropriate. Characters, both patients and care givers are of a variety of races, ethnicities, ages and backgrounds.

I enjoyed reading the cases and reviewing this text. I can think of several ways in which I will use this content.

Reviewed by Raihan Khan, Instructor/Assistant Professor, James Madison University on 11/3/20

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients. read more

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients.

The health information contained in the textbook is mostly accurate.

I think the book is written focusing on the current culture and health issues faced by the patients. To keep the book relevant in the future, the contexts especially the culture/lifestyle/health care modalities, etc. would need to be updated regularly.

The language is pretty simple, clear, and easy to read.

There is no complaint about consistency. One of the main issues of writing a book, consistency was well managed by the authors.

The book is easy to explore based on how easy the setup is. Students can browse to the specific section that they want to read without much hassle of finding the correct information.

The organization is simple but effective. The authors organized the book based on what can happen in a patient's life and what possible scenarios students should learn about the disease. From that perspective, the book does a good job.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change that is beyond the author's control. It's frustrating for the reader when the external link shows no information.

The book is free of any major language and grammatical errors.

The book might do a little better in cultural competency. e.g. Last name Singh is mainly for Sikh people. In the text Harj and Priya Singh are Muslim. the authors can consult colleagues who are more familiar with those cultures and revise some cultural aspects of the cases mentioned in the book.

The book is a nice addition to the open textbook world. Hope to see more health issues covered by the book.

Reviewed by Ryan Sheryl, Assistant Professor, California State University, Dominguez Hills on 7/16/20

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality... read more

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality improvement, and informatics. While the case studies do not cover all medical conditions or bodily systems, the book is thorough in conveying details of various patients and medical team members in a hospital environment. Rather than an index or glossary at the end of the text, it contains links to outside websites for more information on medical tests and terms referenced in the cases.

The content provided is reflective of best practices in patient care, interdisciplinary collaboration, and communication at the time of publication. It is specifically accurate for the context of hospitals in Canada. The links provided throughout the text have the potential to supplement with up-to-date descriptions and definitions, however, many of them are broken (see notes in Interface section).

The content of the case studies reflects the increasingly complex landscape of healthcare, including a variety of conditions, ages, and personal situations of the clients and care providers. The text will require frequent updating due to the rapidly changing landscape of society and best practices in client care. For example, a future version may include inclusive practices with transgender clients, or address ways medical racism implicitly impacts client care (see notes in Cultural Relevance section).

The text is written clearly and presents thorough, realistic details about working and being treated in an acute hospital context.

The text is very straightforward. It is consistent in its structure and flow. It uses consistent terminology and follows a structured framework throughout.

Being a series of 8 separate case studies, this text is easily and readily divisible into smaller sections. The text was designed to be taken apart and used piece by piece in order to serve various learning contexts. The parts of each case study can also be used independently of each other to facilitate problem solving.

The topics in the case studies are presented clearly. The structure of each of the case studies proceeds in a similar fashion. All of the cases are set within the same hospital so the hospital personnel and service providers reappear across the cases, giving a textured portrayal of the experiences of the various service providers. The cases can be used individually, or one service provider can be studied across the various studies.

The text is very straightforward, without complex charts or images that could become distorted. Many of the embedded links are broken and require updating. The links that do work are a very useful way to define and expand upon medical terms used in the case studies.

Grammatical errors are minimal and do not distract from the flow of the text. In one instance the last name Singh is spelled Sing, and one patient named Fred in the text is referred to as Frank in the appendix.

The cases all show examples of health care personnel providing compassionate, client-centered care, and there is no overt discrimination portrayed. Two of the clients are in same-sex marriages and these are shown positively. It is notable, however, that the two cases presenting people of color contain more negative characteristics than the other six cases portraying Caucasian people. The people of color are the only two examples of clients who smoke regularly. In addition, the Indian client drinks and is overweight, while the First Nations client is the only one in the text to have a terminal diagnosis. The Indian client is identified as being Punjabi and attending a mosque, although there are only 2% Muslims in the Punjab province of India. Also, the last name Singh generally indicates a person who is a Hindu or Sikh, not Muslim.

Reviewed by Monica LeJeune, RN Instructor, LSUE on 4/24/20

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process. read more

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process.

Accurately presents health scenarios with real life assessment techniques and patient outcomes.

Relevant to nursing practice.

Clearly written and easily understood.

Consistent with healthcare terminology and framework

Has a good reading flow.

Topics presented in logical fashion

Easy to read.

No grammatical errors noted.

Text is not culturally insensitive or offensive.

Good book to have to teach nursing students.

Reviewed by april jarrell, associate professor, J. Sargeant Reynolds Community College on 1/7/20

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process. read more

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process.

The content is accurate and evidence based. There is no bias noted

The content in the text is relevant, up to date for nursing students. It will be easy to update content as needed because the framework allows for addition to the content.

The text is clear and easy to understand.

Framework and terminology is consistent throughout the text; the case study is a continual and takes the student on a journey with the patient. Great for learning!

The case studies can be easily divided into smaller sections to allow for discussions, and weekly studies.

The text and content progress in a logical, clear fashion allowing for progression of learning.

No interface issues noted with this text.

No grammatical errors noted in the text.

No racial or culture insensitivity were noted in the text.

I would recommend this text be used in nursing schools. The use of case studies are helpful for students to learn and practice the nursing process.

Reviewed by Lisa Underwood, Practical Nursing Instructor, NTCC on 12/3/19

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own... read more

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own set of learning objectives that can be tweaked to fit several allied health courses. Although the case studies are designed around the Canadian Healthcare System, they are quite easily adaptable to fit most any modern, developed healthcare system.

Content Accuracy rating: 3

Overall, the text is quite accurate. There is one significant error that needs to be addressed. It is located in the DVT case study. In the study, a popliteal artery clot is mislabeled as a DVT. DVTs are located in veins, not in arteries. That said, the case study on the whole is quite good. This case study could be used as a learning tool in the classroom for discussion purposes or as a way to test student understanding of DVTs, on example might be, "Can they spot the error?"

At this time, all of the case studies within the text are current. Healthcare is an ever evolving field that rests on the best evidence based practice. Keeping that in mind, educators can easily adapt the studies as the newest evidence emerges and changes practice in healthcare.

All of the case studies are well written and easy to understand. The text includes several hyperlinks and it also highlights certain medical terminology to prompt readers as a way to enhance their learning experience.

Across the text, the language, style, and format of the case studies are completely consistent.

The text is divided into eight separate case studies. Each case study may be used independently of the others. All case studies are further broken down as the focus patient passes through each aspect of their healthcare system. The text's modularity makes it possible to use a case study as individual work, group projects, class discussions, homework or in a simulation lab.

The case studies and the diagnoses that they cover are presented in such a way that educators and allied health students can easily follow and comprehend.

The book in itself is free of any image distortion and it prints nicely. The text is offered in a variety of digital formats. As noted in the above reviews, some of the hyperlinks have navigational issues. When the reader attempts to access them, a "page not found" message is received.

There were minimal grammatical errors. Some of which may be traced back to the differences in our spelling.

The text is culturally relevant in that it includes patients from many different backgrounds and ethnicities. This allows educators and students to explore cultural relevance and sensitivity needs across all areas in healthcare. I do not believe that the text was in any way insensitive or offensive to the reader.

By using the case studies, it may be possible to have an open dialogue about the differences noted in healthcare systems. Students will have the ability to compare and contrast the Canadian healthcare system with their own. I also firmly believe that by using these case studies, students can improve their critical thinking skills. These case studies help them to "put it all together".

Reviewed by Melanie McGrath, Associate Professor, TRAILS on 11/29/19

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case. read more

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case.

I saw no areas of inaccuracy

As in all healthcare texts, treatments and/or tests will change frequently. However, everything is currently up-to-date thus it should be a good reference for several years.

Each case is written so that any level of healthcare student would understand. Hyperlinks in the text is also very helpful.

All of the cases are written in a similar fashion.

Although not structured as a typical text, each case is easily assigned as a stand-alone.

Each case is organized clearly in an appropriate manner.

I did not see any issues.

I did not see any grammatical errors

The text seemed appropriately inclusive. There are no pediatric cases and no cases of intellectually-impaired patients, but those types of cases introduce more advanced problem-solving which perhaps exceed the scope of the text. May be a good addition to the text.

I found this text to be an excellent resource for healthcare students in a variety of fields. It would be best utilized in inter professional courses to help guide discussion.

Reviewed by Lynne Umbarger, Clinical Assistant Professor, Occupational Therapy, Emory and Henry College on 11/26/19

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational... read more

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational purposes. The material was easily understood by the students but challenging enough for classroom discussion. There are no mentions in the book about occupational therapy, but it is easy enough to add a couple words and make inclusion simple.

Very nice lab values are provided in the case study, making it more realistic for students.

These case studies focus on commonly encountered diagnoses for allied health and nursing students. They are comprehensive, realistic, and easily understood. The only difference is that the hospital in one case allows the patient's dog to visit in the room (highly unusual in US hospitals).

The material is easily understood by allied health students. The cases have links to additional learning materials for concepts that may be less familiar or should be explored further in a particular health field.

The language used in the book is consistent between cases. The framework is the same with each case which makes it easier to locate areas that would be of interest to a particular allied health profession.

The case studies are comprehensive but well-organized. They are short enough to be useful for class discussion or a full-blown assignment. The students seem to understand the material and have not expressed that any concepts or details were missing.

Each case is set up like the other cases. There are learning objectives at the beginning of each case to facilitate using the case, and it is easy enough to pull out material to develop useful activities and assignments.

There is a quick chart in the Appendix to allow the reader to determine the professions involved in each case as well as the pertinent settings and diagnoses for each case study. The contents are easy to access even while reading the book.

As a person who attends carefully to grammar, I found no errors in all of the material I read in this book.

There are a greater number of people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book. With each case, I could easily picture the person in the case. This book appears to be Canadian and more inclusive than most American books.

I was able to use this book the first time I accessed it to develop a classroom activity for first-year occupational therapy students and a more comprehensive activity for second-year students. I really appreciate the links to a multitude of terminology and medical lab values/issues for each case. I will keep using this book.

Reviewed by Cindy Krentz, Assistant Professor, Metropolitan State University of Denver on 6/15/19

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some... read more

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some understanding of the patient's background. I think it could benefit from having a glossary. I liked how the authors included the vital signs in an easily readable bar. I would have liked to see the labs also highlighted like this. I also felt that it would have been good written in a 'what would you do next?' type of case study.

The book is very accurate in language, what tests would be prudent to run and in the day in the life of the hospital in all cases. One inaccuracy is that the authors called a popliteal artery clot a DVT. The rest of the DVT case study was great, though, but the one mistake should be changed.

The book is up to date for now, but as tests become obsolete and new equipment is routinely used, the book ( like any other health textbook) will need to be updated. It would be easy to change, however. All that would have to happen is that the authors go in and change out the test to whatever newer, evidence-based test is being utilized.

The text is written clearly and easy to understand from a student's perspective. There is not too much technical jargon, and it is pretty universal when used- for example DVT for Deep Vein Thrombosis.

The book is consistent in language and how it is broken down into case studies. The same format is used for highlighting vital signs throughout the different case studies. It's great that the reader does not have to read the book in a linear fashion. Each case study can be read without needing to read the others.

The text is broken down into eight case studies, and within the case studies is broken down into days. It is consistent and shows how the patient can pass through the different hospital departments (from the ER to the unit, to surgery, to home) in a realistic manner. The instructor could use one or more of the case studies as (s)he sees fit.

The topics are eight different case studies- and are presented very clearly and organized well. Each one is broken down into how the patient goes through the system. The text is easy to follow and logical.

The interface has some problems with the highlighted blue links. Some of them did not work and I got a 'page not found' message. That can be frustrating for the reader. I'm wondering if a glossary could be utilized (instead of the links) to explain what some of these links are supposed to explain.

I found two or three typos, I don't think they were grammatical errors. In one case I think the Canadian spelling and the United States spelling of the word are just different.

This is a very culturally competent book. In today's world, however, one more type of background that would merit delving into is the trans-gender, GLBTQI person. I was glad that there were no stereotypes.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. Since we are becoming more interprofessional, I liked that we saw what the phlebotomist and other ancillary personnel (mostly different technicians) did. I think that it could become even more interdisciplinary so colleges and universities could have more interprofessional education- courses or simulations- with the addition of the nurse using social work, nutrition, or other professional health care majors.

Reviewed by Catherine J. Grott, Interim Director, Health Administration Program, TRAILS on 5/5/19

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this. read more

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this.

The book is accurate, however it has numerous broken online links.

Relevance/Longevity rating: 3

The content is very relevant, but some links are out-dated. For example, WHO Guidelines for Safe Surgery 2009 (p. 186) should be updated.

The book is written in clear and concise language. The side stories about the healthcare workers make the text interesting.

The book is consistent in terms of terminology and framework. Some terms that are emphasized in one case study are not emphasized (with online links) in the other case studies. All of the case studies should have the same words linked to online definitions.

Modularity rating: 3

The book can easily be parsed out if necessary. However, the way the case studies have been written, it's evident that different authors contributed singularly to each case study.

The organization and flow are good.

Interface rating: 1

There are numerous broken online links and "pages not found."

The grammar and punctuation are correct. There are two errors detected: p. 120 a space between the word "heart" and the comma; also a period is needed after Dr (p. 113).

I'm not quite sure that the social worker (p. 119) should comment that the patient and partner are "very normal people."

There are roughly 25 broken online links or "pages not found." The BC & Canadian Guidelines (p. 198) could also include a link to US guidelines to make the text more universal . The basilar crackles (p. 166) is very good. Text could be used compare US and Canadian healthcare. Text could be enhanced to teach "soft skills" and interdepartmental communication skills in healthcare.

Reviewed by Lindsey Henry, Practical Nursing Instructor, Fletcher on 5/1/19

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning... read more

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning objectives, which were effectively met in the readings.

As a seasoned nurse, I believe that the content regarding pathophysiology and treatments used in the case studies were accurate. I really appreciated how many of the treatments were also explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse.

The case studies are up to date and correlate with the current time period. They are easily understood.

I really loved how several important medical terms, including specific treatments were highlighted to alert the reader. Many interventions performed were also explained further, which is great to enhance learning for the nursing student or novice nurse. Also, with each scenario, a background and history of the patient is depicted, as well as the perspectives of the patient, patients family member, and the primary nurse. This really helps to give the reader a full picture of the day in the life of a nurse or a patient, and also better facilitates the learning process of the reader.

These case studies are consistent. They begin with report, the patient background or updates on subsequent days, and follow the patients all the way through discharge. Once again, I really appreciate how this book describes most if not all aspects of patient care on a day to day basis.

Each case study is separated into days. While they can be divided to be assigned at different points within the course, they also build on each other. They show trends in vital signs, what happens when a patient deteriorates, what happens when they get better and go home. Showing the entire process from ER admit to discharge is really helpful to enhance the students learning experience.

The topics are all presented very similarly and very clearly. The way that the scenarios are explained could even be understood by a non-nursing student as well. The case studies are very clear and very thorough.

The book is very easy to navigate, prints well on paper, and is not distorted or confusing.

I did not see any grammatical errors.

Each case study involves a different type of patient. These differences include race, gender, sexual orientation and medical backgrounds. I do not feel the text was offensive to the reader.

I teach practical nursing students and after reading this book, I am looking forward to implementing it in my classroom. Great read for nursing students!

Reviewed by Leah Jolly, Instructor, Clinical Coordinator, Oregon Institute of Technology on 4/10/19

Good variety of cases and pathologies covered. read more

Good variety of cases and pathologies covered.

Content Accuracy rating: 2

Some examples and scenarios are not completely accurate. For example in the DVT case, the sonographer found thrombus in the "popliteal artery", which according to the book indicated presence of DVT. However in DVT, thrombus is located in the vein, not the artery. The patient would also have much different symptoms if located in the artery. Perhaps some of these inaccuracies are just typos, but in real-life situations this simple mistake can make a world of difference in the patient's course of treatment and outcomes.

Good examples of interprofessional collaboration. If only it worked this way on an every day basis!

Clear and easy to read for those with knowledge of medical terminology.

Good consistency overall.

Broken up well.

Topics are clear and logical.

Would be nice to simply click through to the next page, rather than going through the table of contents each time.

Minor typos/grammatical errors.

No offensive or insensitive materials observed.

Reviewed by Alex Sargsyan, Doctor of Nursing Practice/Assistant Professor , East Tennessee State University on 10/8/18

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study. read more

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study.

Overall the book is accurately depicting the clinical environment. There are numerous references to external sites. While most of them are correct, some of them are not working. For example Homan’s test link is not working "404 error"

Book is relevant in its current version and can be used in undergraduate and graduate classes. That said, the longevity of the book may be limited because of the character of the clinical education. Clinical guidelines change constantly and it may require a major update of the content.

Cases are written very clearly and have realistic description of an inpatient setting.

The book is easy to read and consistent in the language in all eight cases.

The cases are very well written. Each case is subdivided into logical segments. The segments reflect different setting where the patient is being seen. There is a flow and transition between the settings.

Book has eight distinct cases. This is a great format for a book that presents distinct clinical issues. This will allow the students to have immersive experiences and gain better understanding of the healthcare environment.

Book is offered in many different formats. Besides the issues with the links mentioned above, overall navigation of the book content is very smooth.

Book is very well written and has no grammatical errors.

Book is culturally relevant. Patients in the case studies come different cultures and represent diverse ethnicities.

Reviewed by Justin Berry, Physical Therapist Assistant Program Director, Northland Community and Technical College, East Grand Forks, MN on 8/2/18

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles,... read more

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles, interprofessional roles, when to initiate communication with other healthcare practitioners due to a change in patient status, and treatment ideas. Some additional patient information, such as lab values, would have been beneficial to include.

Case study information is accurate and unbiased.

Content is up to date. The case studies are written in a way so that they will not be obsolete soon, even with changes in healthcare.

The case studies are well written, and can be utilized for a variety of classroom assignments, discussions, and projects. Some additional lab value information for each patient would have been a nice addition.

The case studies are consistently organized to make it easy for the reader to determine the framework.

The text is broken up into eight different case studies for various patient diagnoses. This design makes it highly modular, and would be easy to assign at different points of a course.

The flow of the topics are presented consistently in a logical manner. Each case study follows a patient chronologically, making it easy to determine changes in patient status and treatment options.

The text is free of interface issues, with no distortion of images or charts.

The text is not culturally insensitive or offensive in any way. Patients are represented from a variety of races, ethnicities, and backgrounds

This book would be a good addition for many different health programs.

Reviewed by Ann Bell-Pfeifer, Instructor/Program Director, Minnesota State Community and Technical College on 5/21/18

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical... read more

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical laboratory technologists, medical radiology technologists, and respiratory therapists and their roles in caring for patients. Most of the overview is accurate. One suggestion is to provide an embedded radiologist interpretation of the exams which are performed which lead to the patients diagnosis.

Overall the book is accurate. Would like to see updates related to the addition of direct radiography technology which is commonly used in the hospital setting.

Many aspects of medicine will remain constant. The case studies seem fairly accurate and may be relevant for up to 3 years. Since technology changes so quickly in medicine, the CT and x-ray components may need minor updates within a few years.

The book clarity is excellent.

The case stories are consistent with each scenario. It is easy to follow the structure and learn from the content.

The book is quite modular. It is easy to break it up into cases and utilize them individually and sequentially.

The cases are listed by disease process and follow a logical flow through each condition. They are easy to follow as they have the same format from the beginning to the end of each case.

The interface seems seamless. Hyperlinks are inserted which provide descriptions and references to medical procedures and in depth definitions.

The book is free of most grammatical errors. There is a place where a few words do not fit the sentence structure and could be a typo.

The book included all types of relationships and ethnic backgrounds. One type which could be added is a transgender patient.

I think the book was quite useful for a variety of health care professionals. The authors did an excellent job of integrating patient cases which could be applied to the health care setting. The stories seemed real and relevant. This book could be used to teach health care professionals about integrated care within the emergency department.

Reviewed by Shelley Wolfe, Assistant Professor, Winona State University on 5/21/18

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should... read more

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should be noted that the authors include a statement that conveys that this text is not like traditional textbooks and is not meant to be read in a linear fashion. This allows the educator more flexibility to use the text as a supplement to enhance learning opportunities.

The content of the text appears accurate and unbiased. The “five overarching learning objectives” provide a clear aim of the text and the educator is able to glean how these objectives are captured into each of the case studies. While written for the Canadian healthcare system, this text is easily adaptable to the American healthcare system.

Overall, the content is up-to-date and the case studies provide a variety of uses that promote longevity of the text. However, not all of the blue font links (if using the digital PDF version) were still in working order. I encountered links that led to error pages or outdated “page not found” websites. While the links can be helpful, continued maintenance of these links could prove time-consuming.

I found the text easy to read and understand. I enjoyed that the viewpoints of all the different roles (patient, nurse, lab personnel, etc.) were articulated well and allowed the reader to connect and gain appreciation of the entire healthcare team. Medical jargon was noted to be appropriate for the intended audience of this text.

The terminology and organization of this text is consistent.

The text is divided into 8 case studies that follow a similar organizational structure. The case studies can further be divided to focus on individual learning objectives. For example, the case studies could be looked at as a whole for discussing communication or could be broken down into segments to focus on disease risk factors.

The case studies in this text follow a similar organizational structure and are consistent in their presentation. The flow of individual case studies is excellent and sets the reader on a clear path. As noted previously, this text is not meant to be read in a linear fashion.

This text is available in many different forms. I chose to review the text in the digital PDF version in order to use the embedded links. I did not encounter significant interface issues and did not find any images or features that would distract or confuse a reader.

No significant grammatical errors were noted.

The case studies in this text included patients and healthcare workers from a variety of backgrounds. Educators and students will benefit from expanding the case studies to include discussions and other learning opportunities to help develop culturally-sensitive healthcare providers.

I found the case studies to be very detailed, yet written in a way in which they could be used in various manners. The authors note a variety of ways in which the case studies could be employed with students; however, I feel the authors could also include that the case studies could be used as a basis for simulated clinical experiences. The case studies in this text would be an excellent tool for developing interprofessional communication and collaboration skills in a variety healthcare students.

Reviewed by Darline Foltz, Assistant Professor, University of Cincinnati - Clermont College on 3/27/18

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks... read more

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks Clinical Procedures for Safer Patient Care and Anatomy and Physiology: OpenStax" as noted by the authors.

The book appears to be accurate. Although one of the learning outcomes is as follows: "Demonstrate an understanding of the Canadian healthcare delivery system.", I did not find anything that is ONLY specific to the Canadian healthcare delivery system other than some of the terminology, i.e. "porter" instead of "transporter" and a few french words. I found this to make the book more interesting for students rather than deter from it. These are patient case studies that are relevant in any country.

The content is up-to-date. Changes in medical science may occur, i.e. a different test, to treat a diagnosis that is included in one or more of the case studies, however, it would be easy and straightforward to implement these changes.

This book is written in lucid, accessible prose. The technical/medical terminology that is used is appropriate for medical and allied health professionals. Something that would improve this text would to provide a glossary of terms for the terms in blue font.

This book is consistent with current medical terminology

This text is easily divided into each of the 6 case studies. The case studies can be used singly according to the body system being addressed or studied.

Because this text is a collection of case studies, flow doesn't pertain, however the organization and structure of the case studies are excellent as they are clear and easy to read.

There are no distractions in this text that would distract or confuse the reader.

I did not identify any grammatical errors.

This text is not culturally insensitive or offensive in any way and uses patients and healthcare workers that are of a variety of races, ethnicities and backgrounds.

I believe that this text would not only be useful to students enrolled in healthcare professions involved in direct patient care but would also be useful to students in supporting healthcare disciplines such as health information technology and management, medical billing and coding, etc.

Table of Contents

• Introduction

Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)

• Learning Objectives
• Patient: Erin Johns
• Emergency Room

Case Study #2: Pneumonia

• Day 0: Emergency Room
• Day 1: Emergency Room
• Day 1: Medical Ward
• Day 2: Medical Ward
• Day 3: Medical Ward
• Day 4: Medical Ward

Case Study #3: Unstable Angina (UA)

• Patient: Harj Singh

Case Study #4: Heart Failure (HF)

• Patient: Meryl Smith
• In the Supermarket
• Day 0: Medical Ward

Case Study #5: Motor Vehicle Collision (MVC)

• Patient: Aaron Knoll
• Crash Scene
• Operating Room
• Post Anaesthesia Care Unit (PACU)
• Surgical Ward

Case Study #6: Sepsis

• Patient: George Thomas
• Sleepy Hollow Care Facility

Case Study #7: Colon Cancer

• Patient: Fred Johnson
• Two Months Ago
• Pre-Surgery Admission

Case Study #8: Deep Vein Thrombosis (DVT)

• Patient: Jamie Douglas

Appendix: Overview About the Authors

Ancillary Material

About the book.

Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.

The case studies can be used online in a learning management system, in a classroom discussion, in a printed course pack or as part of a textbook created by the instructor. This flexibility is intentional and allows the educator to choose how best to convey the concepts presented in each case to the learner.

Because these case studies were primarily developed for an electronic healthcare system, they are based predominantly in an acute healthcare setting. Educators can augment each case study to include primary healthcare settings, outpatient clinics, assisted living environments, and other contexts as relevant.

About the Contributors

Glynda Rees teaches at the British Columbia Institute of Technology (BCIT) in Vancouver, British Columbia. She completed her MSN at the University of British Columbia with a focus on education and health informatics, and her BSN at the University of Cape Town in South Africa. Glynda has many years of national and international clinical experience in critical care units in South Africa, the UK, and the USA. Her teaching background has focused on clinical education, problem-based learning, clinical techniques, and pharmacology.

Glynda‘s interests include the integration of health informatics in undergraduate education, open accessible education, and the impact of educational technologies on nursing students’ clinical judgment and decision making at the point of care to improve patient safety and quality of care.

Faculty member in the critical care nursing program at the British Columbia Institute of Technology (BCIT) since 2003, Rob has been a critical care nurse for over 25 years with 17 years practicing in a quaternary care intensive care unit. Rob is an experienced educator and supports student learning in the classroom, online, and in clinical areas. Rob’s Master of Education from Simon Fraser University is in educational technology and learning design. He is passionate about using technology to support learning for both faculty and students.

Part of Rob’s faculty position is dedicated to providing high fidelity simulation support for BCIT’s nursing specialties program along with championing innovative teaching and best practices for educational technology. He has championed the use of digital publishing and was the tech lead for Critical Care Nursing’s iPad Project which resulted in over 40 multi-touch interactive textbooks being created using Apple and other technologies.

Rob has successfully completed a number of specialist certifications in computer and network technologies. In 2015, he was awarded Apple Distinguished Educator for his innovation and passionate use of technology to support learning. In the past five years, he has presented and published abstracts on virtual simulation, high fidelity simulation, creating engaging classroom environments, and what the future holds for healthcare and education.

Janet Morrison is the Program Head of Occupational Health Nursing at the British Columbia Institute of Technology (BCIT) in Burnaby, British Columbia. She completed a PhD at Simon Fraser University, Faculty of Communication, Art and Technology, with a focus on health information technology. Her dissertation examined the effects of telehealth implementation in an occupational health nursing service. She has an MA in Adult Education from St. Francis Xavier University and an MA in Library and Information Studies from the University of British Columbia.

Janet’s research interests concern the intended and unintended impacts of health information technologies on healthcare students, faculty, and the healthcare workforce.

She is currently working with BCIT colleagues to study how an educational clinical information system can foster healthcare students’ perceptions of interprofessional roles.

Contribute to this Page

• Privacy Policy

Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

You may also like

Explanatory Research – Types, Methods, Guide

Applied Research – Types, Methods and Examples

Quasi-Experimental Research Design – Types...

Triangulation in Research – Types, Methods and...

Qualitative Research Methods

Textual Analysis – Types, Examples and Guide

AI Detector

What is a Case Study?: Definition, Examples, & Methods

Published on July 9th, 2024

I. What is a Case Study?: Introduction

Case study definition.

A case study is a research method involving an in-depth examination of a single subject, group, event, or phenomenon within its real-world context. Widely used across various disciplines such as social sciences, business, law, medicine, and education, case studies provide comprehensive insights into complex issues that broader surveys or experimental research cannot capture. The essence of a case study is to explore and analyze real-life situations to uncover patterns, identify causes, and propose practical solutions. Case study examples illustrate how theoretical knowledge can be applied to practical scenarios, making them invaluable for both academic research and problem-solving.

Importance in Research and Business

Case studies are crucial in both research and business due to their ability to provide detailed and nuanced insights. In academic research, case studies enable in-depth analysis of complex issues, helping researchers understand the how and why of phenomena, and leading to the development of new theories or the refinement of existing ones. In business, case studies help understand market dynamics, consumer behavior, and the effectiveness of strategies. They showcase successes and failures, offering valuable lessons for future projects. In education, especially in business schools, case studies help students develop critical thinking and problem-solving skills by analyzing real-world scenarios.

Brief History of Case Study Methodology

The case study methodology has a rich history, originating in the early 20th century in sociology. The Chicago School of Sociology used case studies to explore urban life and social issues. This approach was later adopted in psychology by figures like Sigmund Freud, who used detailed case studies to develop his theories on psychoanalysis. By the mid-20th century, Harvard Business School had popularized case studies as a teaching tool, encouraging students to analyze real-world business scenarios. Over the years, standardized templates have been developed to ensure consistency in data collection and analysis.

In modern times, case studies have adapted to the digital age with advanced data analysis software and AI tools, which ensures the originality and accuracy of case study content. This evolution highlights the adaptability and enduring relevance of case studies as a powerful tool for gaining in-depth understanding and generating valuable insights across various fields.

II. Types of Case Studies

Let’s learn about the different types of case studies that help researchers choose the appropriate method to gain deep insights into their subject.

A. Explanatory Case Studies

Explanatory case studies are designed to explore cause-and-effect relationships. They aim to explain how and why certain events occur and what factors influence these outcomes. This type of case study is often used in social sciences, business, and policy research to test theories and develop new insights. For example, an explanatory case study might investigate how a specific business strategy led to increased market share or how a new policy affected public health outcomes. By focusing on detailed and comprehensive analysis, explanatory case studies help researchers define case study contexts and understand complex phenomena.

B. Exploratory Case Studies

Exploratory case studies are used to explore a topic or issue when there are no clear outcomes or established theories. They serve as a preliminary step that can help to identify research questions and hypotheses for further study. This type of case study is particularly useful when the subject matter is new or not well understood. For instance, researchers might conduct an exploratory case study to investigate the impact of emerging technologies on consumer behavior. Exploratory case studies are flexible and open-ended, allowing researchers to gather rich, qualitative data that can guide future research directions.

C. Descriptive Case Studies

Descriptive case studies provide a detailed account of a specific subject, event, or phenomenon. They aim to describe the context, characteristics, and outcomes without necessarily investigating causal relationships. This type of case study is useful for documenting and understanding the particulars of a situation. For example, a descriptive case study might provide an in-depth look at a company's organizational structure and culture. By offering a comprehensive overview, descriptive case studies help to illustrate and contextualize complex issues, making them easier to understand and analyze.

D. Multiple-Case Studies

Multiple-case studies, also known as comparative case studies, involve the analysis of several cases to understand similarities and differences. This type of case study allows researchers to compare and contrast different instances of a phenomenon, which can lead to more robust and generalizable findings. For example, a multiple-case study might examine several companies that have implemented similar business strategies to identify common factors that contribute to success. By analyzing multiple cases, researchers can draw broader conclusions and develop more nuanced insights.

E. Intrinsic Case Studies

Intrinsic case studies focus on a specific case because it is unique or interesting in its own right. The primary aim is to gain a deeper understanding of the case itself, rather than to generalize findings to other contexts. This type of case study is often used when the case has particular significance or offers unique insights. For example, an intrinsic case study might investigate a rare medical condition to understand its characteristics and implications. By delving deeply into the specifics of the case, intrinsic case studies provide valuable, detailed knowledge that can inform practice and theory.

F. Instrumental Case Studies

Instrumental case studies use a specific case to gain insights into a broader issue or to refine a theoretical concept. The case itself is of secondary interest; it serves as a means to understand something else. For example, a researcher might use an instrumental case study of a particular organization to explore general principles of organizational behavior. This type of case study is useful for developing and testing theories, as it allows researchers to apply and examine theoretical frameworks in real-world contexts.

G. Collective Case Studies

Collective case studies, also known as multiple-case studies, involve studying a group of cases simultaneously or sequentially. This approach aims to investigate a phenomenon, population, or general condition by analyzing multiple instances. Collective case studies are valuable for identifying patterns and trends across different cases. For instance, a collective case study might examine several educational programs across different schools to understand common factors that contribute to student success. By studying multiple cases, researchers can enhance the reliability and validity of their findings and develop a more comprehensive understanding of the topic.

Each type of case study offers unique advantages and serves different research purposes. Whether researchers aim to explain causal relationships, explore new topics, provide detailed descriptions, compare multiple instances, or gain insights into broader issues, case studies are versatile tools that can be tailored to fit various research needs. Using tools like case study templates and following a structured case study format can help ensure that the research is thorough and well-organized. By understanding the different types of case studies, researchers can choose the most appropriate method to achieve their objectives and generate meaningful insights.

Also read: Uncover the power of our recruitment automation through customer stories, read our customer stories .

III. The Structure of a Case Study

A well-structured case study is essential for effectively communicating the research findings and insights, ensuring clarity and comprehensiveness.

Title and Abstract : The title should be clear, concise, and reflective of the main focus of the case study. The abstract provides a summary, usually between 150-250 words, outlining the purpose, methodology, key findings, and conclusions of the study. This section helps readers quickly understand the essence of the case study.

B. Background Information

Background Information : This section sets the context for the case study by providing relevant information about the subject being studied. It includes details about the history, environment, and circumstances surrounding the case. For example, if the case study is about a business, the background information might cover the company’s history, industry context, and market conditions.

C. Introduction and Problem Statement

Introduction and Problem Statement : The introduction offers an overview of the case study’s purpose and scope. The problem statement clearly defines the specific issue or research question that the case study aims to address. This section explains why the problem is significant and warrants investigation. For example, a problem statement might highlight a decline in customer satisfaction at a company and the need to understand the underlying causes.

D. Methodology

Methodology : The methodology section details the research design and approach used to conduct the study. It includes the methods and procedures for data collection and analysis. This section should provide enough detail to allow replication of the study. Common methodologies include qualitative methods like interviews and observations, quantitative methods like surveys and statistical analysis, or a combination of both.

E. Data Collection and Analysis

Data Collection and Analysis : This section describes the specific techniques used to gather data and the process of analyzing it. It includes information on data sources, sampling methods, and data collection instruments. The analysis part explains how the data was processed and interpreted to arrive at the findings. For example, in a business case study, data collection might involve employee interviews and customer surveys, while analysis might involve thematic coding and statistical correlation.

F. Findings and Analysis

Findings and Analysis : The findings section presents the results of the study, detailing what the data revealed about the problem. The analysis interprets these findings, explaining their significance and implications. This section should be organized logically, often using headings and subheadings to guide the reader through different aspects of the findings. For instance, findings might show a correlation between employee training and customer satisfaction, with the analysis explaining how training improves service quality.

G. Proposed Solutions and Recommendations

Proposed Solutions and Recommendations : Based on the findings, this section suggests practical actions or strategies to address the identified problems. It outlines specific steps that stakeholders can take to implement these solutions. Recommendations should be feasible, backed by the data, and aligned with the study’s goals. For example, recommendations might include implementing a new training program for employees or adopting new customer service policies.

H. Conclusion

Conclusion : The conclusion summarizes the main findings and their implications. It reinforces the significance of the study and may suggest areas for further research. This section ties together the entire case study, providing a final perspective on the problem and the proposed solutions. The conclusion should leave the reader with a clear understanding of what was learned and why it matters.

I. References and Appendices

References and Appendices : The references section lists all the sources cited in the case study, following a standard citation format (e.g., APA, MLA). This ensures proper attribution and allows readers to locate the original sources. The appendices include supplementary materials that support the case study, such as raw data, detailed tables, questionnaires, or interview transcripts. These materials provide additional context and evidence for the study’s findings and conclusions.

By adhering to this comprehensive structure, researchers can ensure their case studies are thorough, and well-organized, and effectively communicate their findings and insights to the audience.

IV. The Case Study Process

The process of conducting a case study involves several systematic steps that ensure thorough and credible research.

A. Identifying the Research Question

The first step in the case study process is to define a clear and focused research question. This question should address a specific issue or problem that the case study aims to explore. The research question guides the entire study, helping to determine the scope and objectives. For instance, a business case study might pose the question, "How does employee training impact customer satisfaction in retail settings?"

B. Selecting the Case and Determining Data-Gathering Techniques

Once the research question is established, the next step is to select a case that provides the best opportunity to explore this question. The case can be an individual, group, organization, event, or phenomenon. The selection should be purposeful and based on specific criteria relevant to the research question. Additionally, researchers must determine the most appropriate data-gathering techniques, such as interviews, surveys, observations, or document analysis, to collect the necessary information.

C. Preparing to Collect Data

Before data collection begins, researchers must develop a detailed plan outlining the procedures and tools to be used. This preparation includes creating data collection instruments (e.g., interview guides, and survey questionnaires), obtaining necessary permissions and ethical approvals, and ensuring logistical arrangements are in place. Proper preparation ensures that data collection is systematic and consistent, minimizing potential biases and errors.

D. Collecting Data in the Field

Data collection involves gathering information directly from the selected case using predetermined techniques. This phase requires careful attention to detail and adherence to the planned methods. For example, conducting interviews requires skilled questioning and active listening, while observations necessitate systematic note-taking. Ensuring data quality and integrity is crucial during this phase to maintain the credibility of the study.

E. Evaluating and Analyzing the Data

After data collection, researchers must evaluate and analyze the gathered information to draw meaningful conclusions. This process involves organizing the data, coding for themes and patterns, and using analytical techniques to interpret the findings. Qualitative data might be analyzed through thematic analysis, while quantitative data could be subjected to statistical analysis. The goal is to identify key insights that address the research question and provide a deeper understanding of the case.

F. Reporting the Findings

The final step in the case study process is to compile the findings into a comprehensive report. This report should follow a structured format, including sections such as the introduction, methodology, findings, analysis, proposed solutions, and conclusion. The report should clearly communicate the research question, the process followed, the data collected, and the insights gained. Visual aids like charts, graphs, and tables can enhance the presentation of data. Additionally, the report should provide actionable recommendations based on the findings, and it should be tailored to the intended audience, whether academic, professional, or general readers.

By following these steps, researchers can ensure a rigorous and systematic approach to conducting case studies, resulting in credible and valuable insights that contribute to knowledge and practice in their respective fields.

V. Benefits of Case Studies

Case studies offer numerous benefits that make them a valuable research method in various fields.

A. In-depth Analysis of Complex Issues

In-depth Analysis of Complex Issues : Case studies allow researchers to conduct a thorough and detailed examination of complex issues. This method provides a deep understanding of the subject matter by exploring multiple facets and perspectives. For instance, a case study on a company’s turnaround strategy can delve into the financial, operational, and cultural changes that contributed to its success. This in-depth analysis is often impossible to achieve through other research methods that provide more generalized data.

B. Real-world Application of Theories

Real-world Application of Theories : Case studies bridge the gap between theory and practice by applying theoretical concepts to real-world scenarios. They demonstrate how abstract theories can be implemented and tested in practical situations. For example, a case study on leadership styles in crisis management can show how different theoretical approaches to leadership are applied in real-life crises, providing valuable insights for both academics and practitioners.

C. Generation of New Hypotheses

Generation of New Hypotheses : Through detailed investigation and observation, case studies often reveal new insights and patterns that can lead to the generation of new hypotheses. These hypotheses can then be tested in future research, contributing to the advancement of knowledge in the field. For example, a case study on consumer behavior might uncover new trends or factors influencing purchasing decisions, prompting further research into these areas.

D. Versatility Across Various Fields

Versatility Across Various Fields : Case studies are a versatile research method that can be applied in various fields, including business, education, medicine, law, and social sciences. They can be used to study a wide range of topics, from individual behaviors to organizational practices and societal phenomena. This versatility makes case studies a popular choice for researchers seeking to understand diverse and complex issues.

VI. Challenges in Conducting Case Studies

Despite their benefits, conducting case studies also presents several challenges that researchers need to be aware of and address.

A. Potential for Researcher Bias

Potential for Researcher Bias : One of the primary challenges of case studies is the potential for researcher bias. Since case studies often involve close interaction between the researcher and the subject, there is a risk that the researcher’s perspectives and preconceptions may influence the findings. To mitigate this, researchers must strive for objectivity, use multiple sources of evidence, and employ techniques like triangulation to validate their findings.

B. Limited Generalizability

Limited Generalizability : Case studies typically focus on a single case or a small number of cases, which can limit the generalizability of the findings. The insights gained from a specific case may not necessarily apply to other contexts or populations. To address this limitation, researchers should clearly define the scope of their study and acknowledge the extent to which their findings can be generalized.

C. Time-consuming Nature

Time-consuming Nature : Conducting a thorough case study can be time-consuming, requiring extensive data collection, analysis, and reporting. This can be a significant drawback, especially for researchers with limited time and resources. To manage this challenge, researchers should plan their study carefully, set realistic timelines, and ensure they have the necessary resources to complete the study effectively.

D. Ethical Considerations

Ethical Considerations : Case studies often involve collecting detailed information about individuals or organizations, which raises important ethical considerations. Researchers must ensure that they obtain informed consent from participants, protect their privacy and confidentiality, and avoid any potential harm. Adhering to ethical guidelines and obtaining necessary approvals from ethics committees are crucial steps in conducting ethical case study research.

By understanding and addressing these challenges, researchers can enhance the reliability and credibility of their case studies, ensuring that their findings provide valuable contributions to their respective fields.

VII. Case Studies in Different Fields

Case studies are a versatile research method that can be applied across a wide range of fields, each benefiting from the in-depth analysis and practical insights they provide.

Business and Management : In the field of business and management, case studies are widely used to analyze organizational strategies, market dynamics, leadership practices, and operational processes. They offer detailed insights into how companies address challenges, implement changes, and achieve success. 

For example, a business case study might explore how a company successfully navigated a financial crisis, providing lessons on crisis management, financial planning, and leadership. These case studies are valuable for both academic purposes and practical applications, helping managers and executives learn from real-world examples.

Psychology and Social Sciences : Case studies in psychology and social sciences provide an in-depth examination of individual or group behavior, social phenomena, and cultural practices. They are particularly useful for exploring complex psychological conditions, social interactions, and cultural contexts. 

For instance, a psychological case study might investigate the development and treatment of a specific mental health disorder in a patient, offering insights into therapeutic approaches and patient experiences. In social sciences, case studies can explore social issues such as poverty, education, and community development, contributing to a deeper understanding of societal challenges and potential solutions.

Medicine and Healthcare : In medicine and healthcare, case studies are essential for understanding unique medical conditions, treatment outcomes, and healthcare practices. They provide detailed accounts of patient histories, diagnoses, treatments, and responses, contributing to medical knowledge and practice. 

For example, a medical case study might document a rare disease, detailing the symptoms, diagnostic process, treatment plan, and patient recovery. These studies are valuable for medical education, helping practitioners learn from specific cases and improve patient care. They also play a crucial role in advancing medical research by highlighting unusual cases that can lead to new discoveries.

Law and Criminal Justice : Case studies in law and criminal justice offer comprehensive analyses of legal cases, criminal behavior, law enforcement practices, and judicial decisions. They help understand the intricacies of legal principles, the application of laws, and the effectiveness of criminal justice policies. 

For instance, a legal case study might analyze a landmark Supreme Court decision, examining the legal arguments, judicial reasoning, and broader implications for society. In criminal justice, case studies can explore crime patterns, investigative techniques, and rehabilitation programs, providing valuable insights for law enforcement and policy-making.

Education : In the field of education, case studies are used to explore teaching methods, learning outcomes, educational policies, and institutional practices. They provide detailed examinations of specific educational settings, programs, and student experiences. 

For example, an educational case study might investigate the implementation of a new teaching strategy in a classroom, analyzing its impact on student engagement and academic performance. These studies are valuable for educators, administrators, and policymakers, offering practical insights into effective educational practices and innovations. Case studies in education help identify best practices, address challenges, and improve the overall quality of education.

VIII. Tools and Techniques for Case Study Research

The effectiveness of case study research often hinges on the tools and techniques used for data collection and analysis. Here are some key methods and tools that enhance the quality and depth of case study research.

Interviews and Surveys : 

Interviews and surveys are fundamental techniques for gathering qualitative and quantitative data in case studies. Interviews allow for in-depth exploration of subjects' experiences, perspectives, and insights. They can be structured, semi-structured, or unstructured, depending on the research goals. Surveys, on the other hand, provide a means to collect data from a larger sample, offering quantifiable insights that can complement qualitative findings. For example, in a business case study, interviews with key stakeholders can reveal detailed insights into organizational culture, while surveys can gauge employee satisfaction across the company.

Observation Methods : 

Observation involves systematically recording behaviors, events, and interactions as they occur naturally. This method is particularly useful for understanding the context and dynamics of the case under study. Participant observation, where the researcher becomes part of the group being studied, and non-participant observation, where the researcher observes from a distance, are common techniques. For instance, in an educational case study, observing classroom interactions can provide valuable data on teaching methods and student engagement.

Document Analysis : 

Document analysis involves reviewing and interpreting existing documents related to the case. These documents can include reports, memos, letters, emails, meeting minutes, policy documents, and other records. Analyzing these documents can provide insights into the historical context, organizational processes, and key events relevant to the case. For example, in a legal case study, analyzing court documents, legal briefs, and case law can help understand the legal arguments and judicial decisions.

Data Analysis Software : 

Data analysis software helps researchers organize, code, and analyze qualitative and quantitative data efficiently. Tools like NVivo, ATLAS.ti, and MAXQDA are commonly used for qualitative data analysis, enabling researchers to code text, identify themes, and visualize relationships. For quantitative data, software like SPSS, Stata, and R can perform statistical analysis, providing detailed insights into data patterns and correlations. These tools enhance the rigor and reliability of the analysis, making it easier to manage large volumes of data and derive meaningful conclusions.

AI Tools like HireQuotient's AI Detector :

HireQuotient's AI Detector is an advanced tool designed to ensure the originality and integrity of written content. It uses artificial intelligence to detect plagiarism, analyze text for unique patterns, and verify the authenticity of research material.

How It Can Be Used in Case Study Research : In case study research, HireQuotient's AI Detector can be used to check the originality of the case study report, ensuring that the content is free from plagiarism. This tool can also help in verifying the authenticity of sources and data used in the case study, providing an additional layer of validation. By analyzing text for unique patterns, the AI Detector can assist researchers in maintaining the quality and credibility of their work.

Benefits of Using AI in Case Study Analysis : Using AI tools like HireQuotient's AI Detector in case study analysis offers several benefits. First, it enhances the credibility and reliability of the research by ensuring that all content is original and properly cited. Second, it saves time and effort in manually checking for plagiarism and verifying sources, allowing researchers to focus on more critical aspects of the study. Third, AI tools can process large volumes of data quickly and accurately, identifying patterns and insights that might be missed through manual analysis. Overall, integrating AI into case study research improves the efficiency, accuracy, and integrity of the research process.

By leveraging these tools and techniques, researchers can conduct comprehensive and rigorous case studies that provide valuable insights and contribute to the advancement of knowledge in their respective fields.

IX. Writing and Presenting Case Studies

Effectively writing and presenting case studies is crucial for conveying research findings in a clear and impactful manner. Here are key considerations for each aspect of this process.

A. Choosing a Compelling Narrative Style

The narrative style chosen for a case study can significantly influence its readability and engagement. A compelling narrative weaves facts and analysis into a cohesive story that captures the reader’s attention. Depending on the audience and purpose, the narrative style can be:

• Descriptive : Providing a detailed account of events and contexts, often used for educational purposes.
• Analytical : Focusing on the interpretation and implications of the findings, suitable for academic and research audiences.
• Persuasive : Aiming to convince the reader of a particular viewpoint or course of action, commonly used in business and policy-making contexts.
• Reflective : Incorporating personal insights and reflections, which can be effective in educational and professional development settings.

Selecting a narrative style that aligns with the objectives of the case study and the preferences of the target audience helps ensure that the message is conveyed effectively.

B. Structuring the Case Study Report

A well-structured case study report enhances clarity and coherence, making it easier for readers to follow the research process and understand the findings. A typical structure includes:

• Title and Abstract : Concise summary of the study’s focus and key findings.
• Introduction : Overview of the research question, objectives, and significance of the study.
• Background Information : Contextual information about the subject or case being studied.
• Problem Statement : Clear definition of the problem or issue addressed by the study.
• Methodology : Detailed description of the research methods and procedures used for data collection and analysis.
• Findings and Analysis : Presentation and interpretation of the research results.
• Proposed Solutions and Recommendations : Practical suggestions based on the findings.
• Conclusion : Summary of the main insights and their implications.
• References and Appendices : List of sources cited and supplementary materials.

Using headings and subheadings to organize these sections helps guide the reader through the report and ensures all key components are covered.

C. Using Visuals and Data Representation

Visual aids such as charts, graphs, tables, and diagrams can significantly enhance the presentation of data and findings in a case study. Effective use of visuals can:

• Clarify Complex Information : Simplifying complex data and relationships.
• Highlight Key Points : Drawing attention to important findings and trends.
• Enhance Engagement : Making the report more visually appealing and easier to digest.

When using visuals, it’s important to ensure they are clearly labeled, accurately represent the data, and are integrated seamlessly into the narrative. Visuals should complement and reinforce the textual content rather than distract from it.

D. Tailoring the Presentation to the Audience

The presentation of a case study should be tailored to the specific needs and preferences of the intended audience. Consider the following:

• Academic Audience : Focus on methodological rigor, theoretical contributions, and detailed analysis. Use formal language and provide extensive references.
• Business Audience : Emphasize practical implications, actionable recommendations, and real-world applications. Use clear, concise language and highlight key insights and solutions.
• General Audience : Make the content accessible and engaging by using simple language, storytelling techniques, and relatable examples. Avoid jargon and technical terms that may be unfamiliar.

By paying careful attention to narrative style, report structure, use of visuals, and audience tailoring, researchers can create compelling and impactful case studies that effectively convey their findings and insights.

X. Case Studies vs. Other Research Methods

Experimental research involves manipulating one or more variables to observe the effect on another variable, typically in a controlled environment. This method is highly effective for establishing cause-and-effect relationships and testing hypotheses. In contrast, case studies focus on the in-depth exploration of a single subject or small group within its real-life context. While experiments prioritize control and generalizability, case studies emphasize detailed understanding and contextual relevance. Case studies are particularly valuable when the research question requires exploring complex phenomena that cannot be easily isolated in an experimental setting.

Surveys and questionnaires are quantitative research methods designed to gather data from a large population, often through structured questions with predefined response options. These methods are useful for identifying trends, measuring attitudes, and making statistical generalizations. In contrast, case studies employ qualitative methods such as interviews and observations to provide rich, detailed insights into a specific case. While surveys and questionnaires offer breadth, case studies provide depth, allowing researchers to uncover nuanced information and develop a comprehensive understanding of the subject.

Ethnographic studies involve immersive, long-term fieldwork where researchers observe and interact with participants in their natural environment to understand cultural practices and social behaviors. Both ethnographic studies and case studies prioritize in-depth, qualitative analysis and contextual understanding. However, ethnography typically focuses on entire communities or cultures, while case studies concentrate on specific individuals, groups, or events. Case studies may use ethnographic techniques but are usually narrower in scope and duration.

Mixed methods research combines qualitative and quantitative approaches to provide a more comprehensive understanding of the research problem. Case studies can be an integral part of mixed methods research by incorporating both qualitative data (e.g., interviews, observations) and quantitative data (e.g., surveys, statistical analysis). This integration allows researchers to explore the case in detail while also quantifying certain aspects, enhancing the robustness and validity of the findings. Mixed methods research benefits from the detailed insights of case studies and the generalizability of quantitative data.

XI. The Future of Case Study Research

Technological Advancements in Data Collection and Analysis : Advances in technology are revolutionizing the way data is collected and analyzed in case study research. Tools such as mobile apps, online surveys, and digital recording devices facilitate efficient and accurate data collection. Data analysis software like NVivo and ATLAS.ti enables researchers to organize, code, and interpret large volumes of qualitative data. Additionally, big data analytics and machine learning algorithms offer new possibilities for identifying patterns and insights from complex datasets, enhancing the depth and precision of case study analysis.

Increasing Focus on Cross-Cultural Case Studies : Globalization and interconnectedness have heightened the importance of understanding cultural differences and similarities. Cross-cultural case studies are gaining prominence as researchers seek to compare and contrast cases from different cultural contexts. These studies provide valuable insights into how cultural factors influence behaviors, practices, and outcomes. By examining cases from diverse settings, researchers can develop more comprehensive and culturally sensitive theories and solutions.

The Role of AI and Machine Learning in Case Study Research : AI and machine learning are transforming case study research by automating data analysis and enhancing accuracy. Tools like HireQuotient's AI Detector help ensure the originality and integrity of case study content by detecting plagiarism and verifying sources. AI algorithms can analyze large datasets quickly, identifying patterns and correlations that may be overlooked by human researchers. These technologies enable more efficient data processing, allowing researchers to focus on interpreting and applying the findings.

Emerging Trends in Case Study Methodology : New trends in case study methodology are shaping the future of research. One trend is the increasing use of digital ethnography, where researchers study online communities and virtual environments. Another trend is the emphasis on participatory case studies, involving stakeholders in the research process to ensure their perspectives are represented. Additionally, there is a growing interest in longitudinal case studies that track changes over time, providing deeper insights into dynamic processes and long-term outcomes.

XII. Conclusion

Case studies are a versatile and valuable research method that offers in-depth analysis, real-world applications, and the ability to generate new hypotheses. They differ from other research methods in their focus on detailed, contextual understanding.

Thus, undertake your own case studies, leveraging the tools and techniques discussed to explore complex issues and contribute to their fields. With advancements in technology and methodology, conducting case studies is more accessible and impactful than ever. Whether for academic research, business analysis, or personal interest, case studies offer a powerful means to gain deep, actionable insights.

Soujanya Varada

As a technical content writer and social media strategist, Soujanya develops and manages strategies at HireQuotient. With strong technical background and years of experience in content management, she looks for opportunities to flourish in the digital space. Soujanya is also a dance fanatic and believes in spreading light!

Hire the best without stress

Never Miss The Updates

We cover all recruitment, talent analytics, L&D, DEI, pre-employment, candidate screening, and hiring tools. Join our force & subscribe now!

Stay On Top Of Everything In HR

• TheFreeDictionary
• Word / Article
• Starts with
• Free toolbar & extensions
• Word of the Day
• Free content
• cooperative learning
• elder abuse
• experimental design
• Flower Remedies
• histiocytosis X
• hydrotherapy
• intervention studies
• Intestinal Obstructions
• Krafft-Ebing Richard von
• molecular epidemiology
• movement therapy
• N of 1 trial
• polycystic ovary syndrome
• case report form paper
• case report rarity
• case report tabulations
• case reserve
• case review
• case series
• caseation necrosis
• case-based discussion
• case-based reasoning
• case-control study
• case-fatality ratio
• Casein hydrolysate
• casein iodine
• caseous abscess
• caseous necrosis
• caseous osteitis
• caseous pneumonia
• case-to-infection ratio
• Caslick, Edward
• Casoni antigen
• Casoni intradermal test
• Casoni test
• Casoni, Tommaro
• Casoni's test
• Case-hardening
• case-hardens
• Case-insensitiv
• Case-insensitive
• Case-Insensitive and Accent-Insensitive
• Case-Mix Index
• Case-sensitiv
• Case-sensitive
• case-sensitive language
• Case-sensitivity
• Case-Shiller index
• Case-Shiller Indexes
• Case-studies
• case-to-infection proportion
• Case/New Holland NV
• Case/Throat/Nozzle
• caseating degeneration
• caseating necrosis
• Facebook Share

• Skip to secondary menu
• Skip to main content
• Skip to primary sidebar

Statistics By Jim

Making statistics intuitive

What is a Case Study? Definition & Examples

By Jim Frost Leave a Comment

Case Study Definition

A case study is an in-depth investigation of a single person, group, event, or community. This research method involves intensively analyzing a subject to understand its complexity and context. The richness of a case study comes from its ability to capture detailed, qualitative data that can offer insights into a process or subject matter that other research methods might miss.

A case study strives for a holistic understanding of events or situations by examining all relevant variables. They are ideal for exploring ‘how’ or ‘why’ questions in contexts where the researcher has limited control over events in real-life settings. Unlike narrowly focused experiments, these projects seek a comprehensive understanding of events or situations.

In a case study, researchers gather data through various methods such as participant observation, interviews, tests, record examinations, and writing samples. Unlike statistically-based studies that seek only quantifiable data, a case study attempts to uncover new variables and pose questions for subsequent research.

A case study is particularly beneficial when your research:

• Requires a deep, contextual understanding of a specific case.
• Needs to explore or generate hypotheses rather than test them.
• Focuses on a contemporary phenomenon within a real-life context.

Learn more about Other Types of Experimental Design .

Case Study Examples

Various fields utilize case studies, including the following:

• Social sciences : For understanding complex social phenomena.
• Business : For analyzing corporate strategies and business decisions.
• Healthcare : For detailed patient studies and medical research.
• Education : For understanding educational methods and policies.
• Law : For in-depth analysis of legal cases.

For example, consider a case study in a business setting where a startup struggles to scale. Researchers might examine the startup’s strategies, market conditions, management decisions, and competition. Interviews with the CEO, employees, and customers, alongside an analysis of financial data, could offer insights into the challenges and potential solutions for the startup. This research could serve as a valuable lesson for other emerging businesses.

See below for other examples.

Types of Case Studies

Several standard types of case studies exist that vary based on the objectives and specific research needs.

Illustrative Case Study : Descriptive in nature, these studies use one or two instances to depict a situation, helping to familiarize the unfamiliar and establish a common understanding of the topic.

Exploratory Case Study : Conducted as precursors to large-scale investigations, they assist in raising relevant questions, choosing measurement types, and identifying hypotheses to test.

Cumulative Case Study : These studies compile information from various sources over time to enhance generalization without the need for costly, repetitive new studies.

Critical Instance Case Study : Focused on specific sites, they either explore unique situations with limited generalizability or challenge broad assertions, to identify potential cause-and-effect issues.

Pros and Cons

As with any research study, case studies have a set of benefits and drawbacks.

• Provides comprehensive and detailed data.
• Offers a real-life perspective.
• Flexible and can adapt to discoveries during the study.
• Enables investigation of scenarios that are hard to assess in laboratory settings.
• Facilitates studying rare or unique cases.
• Generates hypotheses for future experimental research.
• Time-consuming and may require a lot of resources.
• Hard to generalize findings to a broader context.
• Potential for researcher bias.
• Cannot establish causality .
• Lacks scientific rigor compared to more controlled research methods .

Crafting a Good Case Study: Methodology

While case studies emphasize specific details over broad theories, they should connect to theoretical frameworks in the field. This approach ensures that these projects contribute to the existing body of knowledge on the subject, rather than standing as an isolated entity.

The following are critical steps in developing a case study:

• Define the Research Questions : Clearly outline what you want to explore. Define specific, achievable objectives.
• Select the Case : Choose a case that best suits the research questions. Consider using a typical case for general understanding or an atypical subject for unique insights.
• Data Collection : Use a variety of data sources, such as interviews, observations, documents, and archival records, to provide multiple perspectives on the issue.
• Data Analysis : Identify patterns and themes in the data.
• Report Findings : Present the findings in a structured and clear manner.

Analysts typically use thematic analysis to identify patterns and themes within the data and compare different cases.

• Qualitative Analysis : Such as coding and thematic analysis for narrative data.
• Quantitative Analysis : In cases where numerical data is involved.
• Triangulation : Combining multiple methods or data sources to enhance accuracy.

A good case study requires a balanced approach, often using both qualitative and quantitative methods.

The researcher should constantly reflect on their biases and how they might influence the research. Documenting personal reflections can provide transparency.

Avoid over-generalization. One common mistake is to overstate the implications of a case study. Remember that these studies provide an in-depth insights into a specific case and might not be widely applicable.

Don’t ignore contradictory data. All data, even that which contradicts your hypothesis, is valuable. Ignoring it can lead to skewed results.

Finally, in the report, researchers provide comprehensive insight for a case study through “thick description,” which entails a detailed portrayal of the subject, its usage context, the attributes of involved individuals, and the community environment. Thick description extends to interpreting various data, including demographic details, cultural norms, societal values, prevailing attitudes, and underlying motivations. This approach ensures a nuanced and in-depth comprehension of the case in question.

Learn more about Qualitative Research and Qualitative vs. Quantitative Data .

Morland, J. & Feagin, Joe & Orum, Anthony & Sjoberg, Gideon. (1992). A Case for the Case Study . Social Forces. 71(1):240.

Share this:

Reader Interactions

Comments and questions cancel reply.

What Is a Case Study and Why You Should Use Them

Case studies can provide more insights into your business while helping you conduct further research with robust qualitative data analysis to learn more.

If you're in charge of running a company, then you're likely always looking for new ways to run your business more efficiently and increase your customer base while streamlining as many processes as possible.

Unfortunately, it can sometimes be difficult to determine how to go about implementing the proper program in order to be successful. This is why many business owners opt to conduct a case study, which can help significantly. Whether you've been struggling with brand consistency or some other problem, the right case study can identify why your problem exists as well as provide a way to rectify it.

A case study is a great tool that many businesses aren't even aware exists, and there are marketing experts like Mailchimp who can provide you with step-by-step assistance with implementing a plan with a case study. Many companies discover that not only do they need to start a blog in order to improve business, but they also need to create specific and relevant blog titles.

If your company already has a blog, then optimizing your blog posts may be helpful. Regardless of the obstacles that are preventing you from achieving all your professional goals, a case study can work wonders in helping you reverse this issue.

What is a case study?

A case study is a comprehensive report of the results of theory testing or examining emerging themes of a business in real life context. Case studies are also often used in the healthcare industry, conducting health services research with primary research interest around routinely collected healthcare data.

However, for businesses, the purpose of a case study is to help small business owners or company leaders identify the issues and conduct further research into what may be preventing success through information collection, client or customer interviews, and in-depth data analysis.

Knowing the case study definition is crucial for any business owner. By identifying the issues that are hindering a company from achieving all its goals, it's easier to make the necessary corrections to promote success through influenced data collection.

Why are case studies important?

Now that we've answered the questions, "what is a case study?" Why are case studies important? Some of the top reasons why case studies are important include:

• Understand complex issues: Even after you conduct a significant amount of market research , you might have a difficult time understanding exactly what it means. While you might have the basics down, conducting a case study can help you see how that information is applied. Then, when you see how the information can make a difference in business decisions, it could make it easier to understand complex issues.
• Collect data: A case study can also help with data tracking . A case study is a data collection method that can help you describe the information that you have available to you. Then, you can present that information in a way the reader can understand.
• Conduct evaluations: As you learn more about how to write a case study, remember that you can also use a case study to conduct evaluations of a specific situation. A case study is a great way to learn more about complex situations, and you can evaluate how various people responded in that situation. By conducting a case study evaluation, you can learn more about what has worked well, what has not, and what you might want to change in the future.
• Identify potential solutions: A case study can also help you identify solutions to potential problems. If you have an issue in your business that you are trying to solve, you may be able to take a look at a case study where someone has dealt with a similar situation in the past. For example, you may uncover data bias in a specific solution that you would like to address when you tackle the issue on your own. If you need help solving a difficult problem, a case study may be able to help you.

Remember that you can also use case studies to target your audience . If you want to show your audience that you have a significant level of expertise in a field, you may want to publish some case studies that you have handled in the past. Then, when your audience sees that you have had success in a specific area, they may be more likely to provide you with their business. In essence, case studies can be looked at as the original method of social proof, showcasing exactly how you can help someone solve their problems.

What are the benefits of writing a business case study?

Although writing a case study can seem like a tedious task, there are many benefits to conducting one through an in depth qualitative research process.

• Industry understanding: First of all, a case study can give you an in-depth understanding of your industry through a particular conceptual framework and help you identify hidden problems that are preventing you from transcending into the business world.
• Develop theories: If you decide to write a business case study, it provides you with an opportunity to develop new theories. You might have a theory about how to solve a specific problem, but you need to write a business case study to see exactly how that theory has unfolded in the past. Then, you can figure out if you want to apply your theory to a similar issue in the future.
• Evaluate interventions: When you write a business case study that focuses on a specific situation you have been through in the past, you can uncover whether that intervention was truly helpful. This can make it easier to figure out whether you want to use the same intervention in a similar situation in the future.
• Identify best practices: If you want to stay on top of the best practices in your field, conducting case studies can help by allowing you to identify patterns and trends and develop a new list of best practices that you can follow in the future.
• Versatility: Writing a case study also provides you with more versatility. If you want to expand your business applications, you need to figure out how you respond to various problems. When you run a business case study, you open the door to new opportunities, new applications, and new techniques that could help you make a difference in your business down the road.
• Solve problems: Writing a great case study can dramatically improve your chances of reversing your problem and improving your business.
• These are just a few of the biggest benefits you might experience if you decide to publish your case studies. They can be an effective tool for learning, showcasing your talents, and teaching some of your other employees. If you want to grow your audience , you may want to consider publishing some case studies.

What are the limitations of case studies?

Case studies can be a wonderful tool for any business of any size to use to gain an in-depth understanding of their clients, products, customers, or services, but there are limitations.

One limitation of case studies is the fact that, unless there are other recently published examples, there is nothing to compare them to since, most of the time, you are conducting a single, not multiple, case studies.

Another limitation is the fact that most case studies can lack scientific evidence.

Types of case studies

There are specific types of case studies to choose from, and each specific type will yield different results. Some case study types even overlap, which is sometimes more favorable, as they provide even more pertinent data.

Here are overviews of the different types of case studies, each with its own theoretical framework, so you can determine which type would be most effective for helping you meet your goals.

Explanatory case studies

Explanatory case studies are pretty straightforward, as they're not difficult to interpret. This type of case study is best if there aren't many variables involved because explanatory case studies can easily answer questions like "how" and "why" through theory development.

Exploratory case studies

An exploratory case study does exactly what its name implies: it goes into specific detail about the topic at hand in a natural, real-life context with qualitative research.

The benefits of exploratory case studies are limitless, with the main one being that it offers a great deal of flexibility. Having flexibility when writing a case study is important because you can't always predict what obstacles might arise during the qualitative research process.

Collective case studies

Collective case studies require you to study many different individuals in order to obtain usable data.

Case studies that involve an investigation of people will involve many different variables, all of which can't be predicted. Despite this fact, there are many benefits of collective case studies, including the fact that it allows an ongoing analysis of the data collected.

Intrinsic case studies

This type of study differs from the others as it focuses on the inquiry of one specific instance among many possibilities.

Many people prefer these types of case studies because it allows them to learn about the particular instance that they wish to investigate further.

Instrumental case studies

An instrumental case study is similar to an intrinsic one, as it focuses on a particular instance, whether it's a person, organization, or something different.

One thing that differentiates instrumental case studies from intrinsic ones is the fact that instrumental case studies aren't chosen merely because a person is interested in learning about a specific instance.

Tips for writing a case study

If you have decided to write case studies for your company, then you may be unsure of where to start or which type to conduct.

However, it doesn't have to be difficult or confusing to begin conducting a case study that will help you identify ways to improve your business.

Here are some helpful tips for writing your case studies:

1. Your case study must be written in the proper format

When writing a case study, the format that you should be similar to this:

Administrative summary

The executive summary is an overview of what your report will contain, written in a concise manner while providing real-life context.

Despite the fact that the executive summary should appear at the beginning of your case studies, it shouldn't be written until you've completed the entire report because if you write it before you finish the report, this summary may not be completely accurate.

Key problem statement

In this section of your case study, you will briefly describe the problem that you hope to solve by conducting the study. You will have the opportunity to elaborate on the problem that you're focusing on as you get into the breadth of the report.

Problem exploration

This part of the case study isn't as brief as the other two, and it goes into more detail about the problem at hand. Your problem exploration must include why the identified problem needs to be solved as well as the urgency of solving it.

Additionally, it must include justification for conducting the problem-solving, as the benefits must outweigh the efforts and costs.

Proposed resolution

This case study section will also be lengthier than the first two. It must include how you propose going about rectifying the problem. The "recommended solution" section must also include potential obstacles that you might experience, as well as how these will be managed.

Furthermore, you will need to list alternative solutions and explain the reason the chosen solution is best. Charts can enhance your report and make it easier to read, and provide as much proof to substantiate your claim as possible.

Overview of monetary consideration

An overview of monetary consideration is essential for all case studies, as it will be used to convince all involved parties why your project should be funded. You must successfully convince them that the cost is worth the investment it will require. It's important that you stress the necessity for this particular case study and explain the expected outcome.

Execution timeline

In the execution times of case studies, you explain how long you predict it will take to implement your study. The shorter the time it will take to implement your plan, the more apt it is to be approved. However, be sure to provide a reasonable timeline, taking into consideration any additional time that might be needed due to obstacles.

Always include a conclusion in your case study. This is where you will briefly wrap up your entire proposal, stressing the benefits of completing the data collection and data analysis in order to rectify your problem.

2. Make it clear and comprehensive

You want to write your case studies with as much clarity as possible so that every aspect of the report is understood. Be sure to double-check your grammar, spelling, punctuation, and more, as you don't want to submit a poorly-written document.

Not only would a poorly-written case study fail to prove that what you are trying to achieve is important, but it would also increase the chances that your report will be tossed aside and not taken seriously.

3. Don't rush through the process

Writing the perfect case study takes time and patience. Rushing could result in your forgetting to include information that is crucial to your entire study. Don't waste your time creating a study that simply isn't ready. Take the necessary time to perform all the research necessary to write the best case study possible.

Depending on the case study, conducting case study research could mean using qualitative methods, quantitative methods, or both. Qualitative research questions focus on non-numerical data, such as how people feel, their beliefs, their experiences, and so on.

Meanwhile, quantitative research questions focus on numerical or statistical data collection to explain causal links or get an in-depth picture.

It is also important to collect insightful and constructive feedback. This will help you better understand the outcome as well as any changes you need to make to future case studies. Consider using formal and informal ways to collect feedback to ensure that you get a range of opinions and perspectives.

4. Be confident in your theory development

While writing your case study or conducting your formal experimental investigation, you should have confidence in yourself and what you're proposing in your report. If you took the time to gather all the pertinent data collected to complete the report, don't second-guess yourself or doubt your abilities. If you believe your report will be amazing, then it likely will be.

5. Case studies and all qualitative research are long

It's expected that multiple case studies are going to be incredibly boring, and there is no way around this. However, it doesn't mean you can choose your language carefully in order to keep your audience as engaged as possible.

If your audience loses interest in your case study at the beginning, for whatever reason, then this increases the likelihood that your case study will not be funded.

Case study examples

If you want to learn more about how to write a case study, it might be beneficial to take a look at a few case study examples. Below are a few interesting case study examples you may want to take a closer look at.

• Phineas Gage by John Martin Marlow : One of the most famous case studies comes from the medical field, and it is about the story of Phineas Gage, a man who had a railroad spike driven through his head in 1848. As he was working on a railroad, an explosive charge went off prematurely, sending a railroad rod through his head. Even though he survived this incident, he lost his left eye. However, Phineas Gage was studied extensively over the years because his experiences had a significant, lasting impact on his personality. This served as a case study because his injury showed different parts of the brain have different functions.
• Kitty Genovese and the bystander effect : This is a tragic case study that discusses the murder of Kitty Genovese, a woman attacked and murdered in Queens, New York City. Shockingly, while numerous neighbors watched the scene, nobody called for help because they assumed someone else would. This case study helped to define the bystander effect, which is when a person fails to intervene during an emergency because other people are around.
• Henry Molaison and the study of memory : Henry Molaison lost his memory and suffered from debilitating amnesia. He suffered from childhood epilepsy, and medical professionals attempted to remove the part of his brain that was causing his seizures. He had a portion of his brain removed, but it completely took away his ability to hold memories. Even though he went on to live until the age of 82, he was always forced to live in the present moment, as he was completely unable to form new memories.

Case study FAQs

When should you do a case study.

There are several scenarios when conducting a case study can be beneficial. Case studies are often used when there's a "why" or "how" question that needs to be answered. Case studies are also beneficial when trying to understand a complex phenomenon, there's limited research on a topic, or when you're looking for practical solutions to a problem.

How can case study results be used to make business decisions?

You can use the results from a case study to make future business decisions if you find yourself in a similar situation. As you assess the results of a case study, you can identify best practices, evaluate the effectiveness of an intervention, generate new and creative ideas, or get a better understanding of customer needs.

How are case studies different from other research methodologies?

When compared to other research methodologies, such as experimental or qualitative research methodology, a case study does not require a representative sample. For example, if you are performing quantitative research, you have a lot of subjects that expand your sample size. If you are performing experimental research, you may have a random sample in front of you. A case study is usually designed to deliberately focus on unusual situations, which allows it to shed new light on a specific business research problem.

Writing multiple case studies for your business

If you're feeling overwhelmed by the idea of writing a case study and it seems completely foreign, then you aren't alone. Writing a case study for a business is a very big deal, but fortunately, there is help available because an example of a case study doesn't always help.

Mailchimp, a well-known marketing company that provides comprehensive marketing support for all sorts of businesses, can assist you with your case study, or you can review one of their own recently published examples.

Mailchimp can assist you with developing the most effective content strategy to increase your chances of being as successful as possible. Mailchimp's content studio is a great tool that can help your business immensely.

Loading to Case Study For Medical Terminology....

• Advanced search

Advanced Search

Managing “socially admitted” patients in hospital: a qualitative study of health care providers’ perceptions

• Find this author on Google Scholar
• Find this author on PubMed
• Search for this author on this site
• Figures & Tables
• Related Content

Background: Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as “socially admitted” patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as “social admissions.”

Methods: This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with “socially admitted” patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework.

Results: We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female ( n = 11) and White ( n = 13), and were in their mid to late career ( n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for “socially admitted” patients, perceptions and assumptions underlying “social” presentations, system barriers to care delivery, and suggestions of potential solutions.

Interpretation: Health care providers viewed “socially admitted” patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for “socially admitted” patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.

See related editorial at www.cmaj.ca/lookup/doi/10.1503/cmaj.240577

Emergency departments have become a destination of last resort for some patients who are made vulnerable by social circumstances, resulting in their occupying hospital beds typically designated for people with acute medical issues. 1 “Social admission” is a colloquial, nondiagnostic label used to describe a person for whom no acute medical issues are recognized to be contributing to their seeking health care. However, many health care providers understand that patients who are admitted for social reasons face challenges such as a breakdown of care supports or an inability of the patient or family to cope with the demands of living at home. 2 These patients often have lengthy stays in emergency departments or hospital wards, and frequently encounter barriers (e.g., housing or home support) delaying safe discharge from hospital. The colloquial terms “failure to cope,” “acopia,” “orphan patient,” or “home care impossible,” among others, are sometimes used to refer to these patients. 3 – 5 Such terminology can be stigmatizing because it indicates a value judgment that patients require admission solely on “social” grounds, sometimes failing to account for underlying medical complexity. 6

The “social admission” phenomenon is an under-researched area in health care. These patients, often categorized by health care providers as not being acutely ill, experience in-hospital death rates as high as 22.2%–34.9%. 7 , 8 Explanations may include under-triaging in the emergency department owing to poor recognition of atypical clinical presentations and delays in timely assessments. 5 Patients may be misdiagnosed or develop acute illness during their hospital stay. In 2 international studies, by the end of hospitalization, an admission diagnosis of “acopia” was no longer the discharge diagnosis in 88%–92.5% of cases. 7 , 9 Diagnoses of falls, delirium, and mobility problems were common, but sepsis was initially undiagnosed in almost one-third of these patients. 7 This raises questions about health care providers’ awareness of atypical presentations and decision-making for “social” presentations, which often require a nuanced understanding of both medical and social care needs.

Health care providers face challenges providing high-quality care to this patient population across Canada 1 , 10 and internationally. 1 , 4 , 10 – 13 “Social admissions” may account for as many as 1 in 10 patients (0.57%–9.3%) presenting to the emergency department and 1 in 25 admissions to hospital, with increasing prevalence with age. 14 A survey from Wales showed that 51.8% of hospital physicians consider that they frequently care for these patients, encountering them several times per week. 15

Since “social admission” is a nondiagnostic label, its definition varies across regions and health care systems, meaning no guidelines exist to standardize approaches to meet medical or social care needs. Qualitative data evaluating how health care providers perceive and care for these patients are lacking. Therefore, we aimed to explore the perceptions of health care providers regarding patients admitted as “social admissions.”

Study design

This qualitative study was informed by constructivist grounded theory, which uses inductive analysis of data collected from participants to generate new theories. 16 , 17 We conducted semistructured interviews with clinicians and health care administrators between October 2022 and July 2023. Given that little is known about “social admissions,” grounded theory was best suited to our objective to generate an explanatory theory about this phenomenon. 17

The research team included qualitative methods experts, geriatric medicine specialists, clinician scientists, primary care and emergency department clinicians, and members with administrative leadership roles. We also included nursing students, medical students, and internal medicine residents of diverse backgrounds.

We reported this study using the Consolidated Criteria for Reporting Qualitative Research Checklist (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content ). 18

Setting and participants

Studying “social admissions” can be challenging because of the variability in terminology and admission policies across different jurisdictions. 19 The Orphan Patient Policy is a standardized “social admission” pathway used at the Queen Elizabeth II Health Sciences Centre, a tertiary care centre in Halifax, Nova Scotia. Halifax is the provincial capital and the largest city in the Atlantic region of Canada. In Nova Scotia, health care is provided through a publicly funded health care system.

Since March 2012, any patient, regardless of age or living situation, can be admitted to the Queen Elizabeth II Health Sciences Centre under the Orphan Patient Policy if they have undergone a medical assessment by a physician in the emergency department, are determined to have no acute or new medical conditions, and have been seen by a social worker or discharge planning nurse to exhaust all home care options. Inability to return home includes situations of homelessness, unavailable community supports, or waiting for transitions to long-term care. These patients are admitted to the first available inpatient bed, based on a rotating roster of all hospital admission services (e.g., medicine, psychiatry, surgery, subspecialty medicine or surgery, and hospitalist). The admitting service and its allied health care team become responsible for the patient’s care and disposition, with the expectation that discharge planning is the primary issue. Although these patients are locally called “orphan patients,” we use the terminology “social admission” throughout this paper.

Eligible participants included any clinical provider or administrator who worked directly with “socially admitted” patients. To identify potential participants for our study, we held initial interviews with hospital nursing bed flow managers who are responsible for administering the Orphan Patient Policy.

To recruit participants, we used snowball sampling: we emailed each health care provider or department that had been recommended by the initial interviewees (i.e., the nursing bed flow managers), and those suggested by study participants during their interviews or by key knowledge users with whom we shared preliminary findings (see Data analysis). Preliminary analyses also informed recruitment, and we used purposive and theoretical sampling 20 , 21 to ensure that the perspectives of multiple health care professionals within the “social admission” care pathway were included, with the aim of data saturation. We approached several departments and individuals who declined to participate or did not respond to our requests for interviews. These included recreation therapy, physiotherapy, occupational therapy, some administrative positions, and several subspecialty medicine divisions.

Data collection

The interview guide (Appendix 2a, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content ) was based on our literature review of “social admissions” 14 and informed by our chart reviews of more than 350 “social admissions” in Nova Scotia (unpublished data, 2021). The entire research team gave input on the interview guide through several iterative processes: multiple meetings to develop the guide, a pilot test with non-author colleagues, and a meeting after all interviewers had conducted at least 1 interview to discuss whether the guide was robust enough to elicit the information we were seeking. We revised the interview guide wording for clarity and understanding, and we added 2 major questions (interview guide questions 7 and 8) and several prompting questions.

Experienced qualitative researchers (C.S. and E.G.M.) provided training. We held 2 group and 1 individual interactive training and practice sessions, which provided methodological context, and practical approaches and techniques in qualitative interviewing. One research team member (J.C.M., L.E., G.A., or M.K.) administered individual interviews. Interviews occurred virtually (via Microsoft Teams) or in person in quiet rooms on hospital wards or participants’ offices. After interviews were completed, we contacted participants by email to provide self-identified demographic data. The survey was voluntary and anonymous, and participants selected from predefined categories or supplied free text for sex, gender, ethnicity, role, and profession (Appendix 2b).

Interviews were audio-recorded and transcribed verbatim. For additional rigour and contextualization during analysis, interviewers kept detailed field notes of their reflections during the interviews.

Data analysis

Data collection and analysis occurred simultaneously. All participants were invited to review their transcripts before analysis (1 participant opted to). We used Dedoose software for data coding and organization.

Two team members independently coded interview transcripts using an inductive approach. 16 , 17 Throughout the initial coding process, the coders (J.C.M., C.S., G.A., and M.K.) met regularly to refine, merge and expand codes, come to consensus about any disagreements and interpretations, add context to certain transcripts with their field notes from the interviews, and identify additional participants suggested by the participants. Using constant comparative and selective coding processes, 16 , 17 we generated categories and subcategories to form themes to reflect participants’ perspectives on “social admissions.”

We used several strategies to ensure rigour and trustworthiness throughout the research process. As per the grounded theory approach, we incorporated reflexivity into our analytic process and acknowledged our dual roles as researchers and health care providers delivering care. Most members of the research team were affiliated with the research site and possessed an in-depth understanding of the local context and providers involved in “social admission” care. This intimate understanding enabled us to add context to the findings. However, we also challenged our preconceptions and biases by recruiting participants with diverse experiences and perspectives, and scheduling regular meetings among research team members to triangulate findings with our internal chart review, knowledge user feedback, and data analysis. 22

We put participant narratives at the forefront by presenting the data (from preliminary interviews and after completion of interviews) to engaged key knowledge users within our hospital and university network (e.g., experienced researchers, clinicians, social workers, and administrators) in a variety of settings (e.g., individual communications, small group sessions, or internal department presentations). The knowledge users provided feedback and suggested further participants. The data were also triangulated with findings from our recent literature review. 14

After data saturation was achieved, we mapped our findings on the Quintuple Aim conceptual framework at the suggestion of a knowledge user and as per consensus with the research group. 23 , 24 This framework adequately organized and contextualized our findings and is a well-known approach to optimizing health system performance and defines 5 fundamental domains (definitions in Appendix 1) for transforming health care: enhance patient experience, better population health, optimize cost of care, improve care team well-being, and advance health equity. 23 , 24

Ethics approval

Nova Scotia Health granted institutional research ethics approval (REB no. 1027628).

We conducted 20 interviews (9 in person and 11 virtual) among hospital administrators and clinicians ( Table 1 ). Clinicians were nurses (charge, discharge planning, and inpatient), physicians (residents and staff physicians), and social workers, representing the following services: emergency department, internal medicine, medical subspecialties (cardiology, neurology, and geriatric medicine), psychiatry, hospitalist, and surgical specialties (orthopedics, general surgery, cardiovascular surgery, and vascular surgery). Administrators included nursing bed managers and directors of hospital divisions and long-term care. The mean interview length was 38 (range 16–76) minutes.

• View inline

Demographic information of hospital administrators and clinicians who were interviewed

We categorized 9 themes into each of the 5 domains of the Quintuple Aim framework as shown in Figure 1 : patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes for addressing “social admissions”). Additional illustrative quotations are presented in Appendix 3, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content .

• Download figure
• Open in new tab
• Download powerpoint

Domains (in the circle) and themes (outside the circle) using the Quintuple Aim framework. 23 , 24

Patient experience

Participants’ description of patients.

Participants provided diverse descriptions of these patients ( Table 2 ). One cited financial precarity as a key problem faced by these patients. Another highlighted recurrent health care system interactions as being important. Some mentioned these patients had a mix of medical, mental health, and social problems. Most equated “social admissions” with older patients or those who were cognitively impaired. Some deemed them the most frail, vulnerable, or complex cases. Few considered that “socially admitted” patients had no medical conditions involved (Appendix 3) or that the medical conditions could wholly be managed at a primary care level.

Descriptions and illustrative quotations of the patient description and provision of care themes in the patient experience domain

Provision of care

Participants described “socially admitted” patients as receiving passive and hands-off care, contrasting this with active approaches for medical and surgical cases. Participants reported that patients, especially those who were older or confused, often received limited attention and workup, leaving their needs unaddressed ( Table 2 ). The approach to care was characterized by patients being left in their beds, being the last person rounded on by the care team, and not being chosen to participate in rehabilitative programs or exercises. In short, these patients’ care needs were the last in the queue of nursing and physician priorities. Beyond direct provision of care, participants identified that hospital programs (e.g., recreation therapy) benefitting these patients had been discontinued or under-resourced (Appendix 3). Almost all clinical participants considered their ward was not the place to care for these patients.

Care team well-being

Moral distress.

Health care providers described their roles as acute care or sub-specialized experts but said they felt helpless when they were unable to provide care for “socially admitted” patients, who often had complex, unrecognized, or chronic health issues. They often stated that better care should be offered yet described challenges when caring for “socially admitted” patients. These included a lack of appropriate training, struggles to arrange suitable care, and resistance when attempting to involve other services, allied health care, or social work, leading to delays in appropriate management ( Table 3 ). As articulated by 1 participant (HC605): “I think that’s a lot to ask of different providers who may not have that skill set. So, sometimes I think it does cause, you know, moral distress and challenge for people sometimes, which then gets perhaps articulated as being ‘they shouldn’t be here.’” Many reported feeling negative toward the policy and labelling of these patients, and acknowledged it was used primarily to communicate with other health care providers. One participant suggested the policy prevented blame on clinicians for “admitting this [patient]” (HC840).

Descriptions and illustrative quotations of the moral distress and hierarchy of care themes in the care team well-being domain

Hierarchy of care

Participants highlighted a hierarchy in health care, prioritizing acute care patients over “social admissions.” One participant reflected on how hospitals rely on pathways with these patients not fitting into a clear “slot,” representing individuals not well differentiated, individuals with complexity, or individuals with issues that are not specialty specific. Consequently, “social admissions” were passed down the hierarchy, from physicians to residents, and sometimes to nursing assistants, implying they were less worthy of routine medical attention ( Table 3 ).

Health equity

Stigma and missed opportunities.

The term “social admission” led to incorrect assumptions about medical needs and cognitive abilities. Beliefs about behaviours were noted by several participants. These assumptions were propagated as early as handovers from paramedics to emergency nursing teams ( Table 4 ). Participants highlighted instances where these patients were not medically stable and emphasized that social stressors did not exempt patients from becoming medically ill during the admission. The label was reported to be an impediment to opportunities to look for underlying treatable medical issues, compounded by the need to make timely decisions because of pressures to free up beds.

Descriptions and illustrative quotations of the stigma and missed opportunities, and prejudices themes in the health equity domain

Ageist beliefs underpinned assumptions about capacity, especially for older “socially admitted” patients. Some participants recognized that these patients could not effectively advocate for themselves, and others pointed out that older patients were often assumed to be cognitively or functionally impaired, and decisions were made without them. Participants provided examples of premature capacity determinations made without proper medical evaluation or consultation ( Table 4 ). One participant described the invisibility of these patients, especially for women and minorities, and another noted how the care of “socially admitted” patients is undermined by negative attitudes similar to those encountered by individuals with substance use disorders (Appendix 3).

Cost of care

Wait-lists and scarcity of alternatives.

Inadequate community support often resulted in emergency department visits and hospital admissions, with the perception that hospitals are the safest place. Participants noted lengthy wait-lists for community services like home care, physiotherapy, or occupational therapy, which led to deconditioning ( Table 5 ). The transition to long-term care was described as “abysmal,” leaving patients in challenging situations for extended periods. Admissions were a “last resort” after all other options were exhausted, with patients and families struggling to access necessary care. The lack of alternatives contributed to participants’ distress when caring for “socially admitted” patients (Appendix 3).

Description and illustrative quotations of the wait-list and scarcity of alternatives theme in the cost of care domain

Population health

Factors leading to vulnerability.

Participants identified many issues that were associated with the “social admission” label, particularly for patients with cognitive impairment ( Table 6 ). These included physical barriers (e.g., inaccessible homes), homelessness, and financial challenges. Social isolation left individuals unsupported, managing alone until emergencies, such as falls, catalyzed hospital admission. The inability to advocate for oneself was also a common observation.

Descriptions and illustrative quotations of factors leading to vulnerability and system changes for addressing “social admission” themes in the population health domain

System changes for addressing “social admissions”

Participants identified systemic barriers that they considered disadvantaged “socially admitted” patients. Participants were concerned that the health care system is currently in crisis (e.g., with a lack of primary care and home support), and emergency departments cannot function as intended, causing the acute care system to become the community system or “the [inter]mediate pathway between community and long-term care” ( Table 6 ). Some called for specialized seniors’ care teams to address the unique needs of older adults. Participants emphasized the importance of understanding these patients’ situations holistically, with a multidisciplinary approach to assess medical history, social factors, and available resources; several examples of ideal approaches were shared. The system’s focus on individuals with higher functioning left “socially admitted” patients underserved, with emphases on services that are “organized from a provider lens, not from a patient-need lens” (HC605).

• Interpretation

We sought to understand how health care providers perceive patients labelled as “socially admitted” in hospital, and we identified 9 key themes across the Quintuple Aim framework. 23 , 24 The themes in the patient experience domain highlighted inconsistent definitions and passive care approaches for these patients, who are often seen as low priority in hospital. Under the care team well-being domain, themes of moral distress and hierarchy of care showed the challenges and dilemmas faced by health care providers. Issues of stigma (e.g., “they have dementia”), prejudices (e.g., ageism), wait-lists, and scarcity of alternatives underscored systemic challenges under the health equity and cost of care domains. Finally, factors leading to vulnerability and potential system changes were described by participants as ways to better the health of this population.

Our findings highlight the potential adverse effects on care when patients are labelled as “socially admitted” (or as “orphan patients” in the study hospital), such as incorrect assumptions about medical needs and cognitive abilities, which impedes opportunities to look for treatable medical issues. Despite a “social admission” pathway ostensibly designed to ensure there are no acute or new medical issues, patients were still perceived as having “multiple comorbidities” or being “the most frail … the most complex” ( Table 2 ). This finding is in keeping with the results of a case–control study (in London, Ontario), in which medical comorbidity played a minimal role in the label of a “failure to cope” admission among adults aged 70 years or older. Instead, recent failed discharge from hospital was significantly associated with a “social admission” label, leading the authors to suggest blame was an important part of the use of this label in a system that prizes efficiency. 3 This supports the viewpoint that it is more a system’s failure to cope than the patient’s. 10

Our findings also demonstrate possible negative impacts on health care providers not addressed in previous research. Although similar patient populations (“failure to thrive” or “failure to cope”) in British Columbia 25 and Ontario, 3 and “acopia” admissions in the United Kingdom and Australia, 7 , 9 have been researched, these studies did not consider the insights of providers directly caring for these patients. We highlight some structures (e.g., propagation of the label early in care) or cultures (e.g., ageism) in our health care systems, leading to system and individual tensions caring for “socially admitted” patients, especially in the context of few readily available alternatives. We observed that participants frequently reported feeling conflicted defining, prioritizing, and managing this patient population, yet unequivocally considered these patients deserved care — albeit care delivered by someone else. This latter finding contrasts with a survey of physicians in Wales in which two-thirds (62.7%) considered patients labelled as “social admissions/acopia” were a burden on national health resources, with 44.8% of physicians admitted to feeling that these patients were a burden on their time. 15

Despite considering that “socially admitted” patients were deserving of care, our participants recounted how care was passed down to less-senior members of the health care team. This pattern of downgrading care can lead to situations in which “socially admitted” patients are looked after by team members who possess minimal experience recognizing evolving medical presentations or lack the authority to advocate strongly for clinical reassessments when needed. The implication that the care of “social admissions” should be delegated to others reflects an implicit attitude of hierarchy and detachment from the needs associated with this patient population. Not being able to provide the care that is warranted while at the same time believing that the needed care is beneath the care they provide is in keeping with cognitive dissonance literature in medicine (i.e., holding 2 or more inconsistent beliefs or behaving in a way that is inconsistent with core beliefs). 26 Cognitive dissonance can trigger negative emotions and subsequent defensive reactions resulting in fault finding in others (e.g., blaming “social admissions”), reinforced commitment to wrong actions (e.g., propagating labels), and overlooked medical errors, 26 , 27 offering some explanations for understanding how stigma and hierarchies of care can lead to missed acute medical illnesses (e.g., sepsis, malignancy, and strokes) in previous “social admission” populations. 5 , 7 , 9

Existing literature indicates that “social admission” labelling may harm patients. 14 Our findings suggest that the use of this label appears to have little benefit for the health care providers who care for this patient population. Moreover, no evidence exists to date that “social admissions” labelling or pathways help the health care system. Therefore, re-evaluating an approach to caring for “socially admitted” patients is imperative, and this may include abandoning the nondiagnostic label.

Better support for this patient population may be achieved through enhanced policies that propose feasible solutions to support these patients. To achieve this, further steps are required to define “social admissions,” and to highlight the importance and scope of the issues surrounding the patient population captured under this label. 28 However, we found inconsistencies in how “social admissions” are described, which adds to the challenge in developing effective policies for these patients, and in comparing similar presentations across Canada. 29 Developing a consistent definition for “social admissions” may also prompt clinical specialties to claim responsibility for this population, as champions are key to raising issues for prioritization in health care. 30

“Social admissions” can be considered a “wicked problem” with no single easy solution. 31 A previously proposed ecological approach can guide clinicians in managing “social” presentations. 2 , 32 Participants in our study made suggestions about community- and institutional-level solutions such as home care and primary care teams that support social integration, more multidisciplinary care teams in and out of the hospital, and “geriatrizing” acute care. These suggestions reflect many of the same calls for action made by previous scholars and advocates, 33 , 34 and are similar to solutions proposed by the National Institute on Ageing’s “Ageing in the Right Place” report. 35 Scholars in France have proposed a societal-level solution involving the procedural and financial restructuring of ultraspecialized medicine, coupled with a revival of historic values combining medicine and social work to address the needs of an increasingly frail and socially complex population. 36

Limitations

Our study was conducted in a single tertiary health centre in Nova Scotia, where “socially admitted” patients are admitted under an institution-specific Orphan Patient Policy, which likely limits the generalizability of our findings. Our participants were mainly White and female, which also limits the generalizability to other settings across the country and internationally. Furthermore, the participant sample did not include recreational therapists, volunteers, physiotherapists, or occupational therapists. In the study centre, recreation and volunteer programs had been discontinued or reduced following the COVID-19 pandemic, and there were no occupational or physiotherapists specifically assigned to this patient population. Another limitation of our study is that some interviewers had prior acquaintance with the participants they interviewed. This familiarity may introduce bias in the data collection and interpretation, although this should be balanced with constructivist grounded theory’s emphasis on researchers as co-participants in the research process.

Our research draws attention to health care providers’ challenges in managing care for “socially admitted” patients, and to perceptions regarding “social” presentations, perceived system barriers and resource shortages, and some potential solutions for better patient care. Overall, no consensus emerged as to what constitutes a “social admission” (who are the patients labelled as “socially admitted”?) or ownership for “social admissions” (who cares for these patients?), and participants reported inconsistencies in care delivered for such patients (how to care for “socially admitted” patients). To improve the patient experience and alleviate the moral distress of staff who care for “socially admitted” patients in hospital, the inherent structures of our health care system, such as hierarchies and stigmatization, should be reformed to better address the needs of patients with increasingly complex social problems who present to hospitals.

Competing interests: Jasmine Mah receives scholarships supporting her PhD research from the Department of Medicine at Dalhousie University, Dalhousie Medical Research Foundation, Dr. Patrick Madore Traineeship, and the Pierre Elliott Trudeau Foundation. Kenneth Rockwood has asserted copyright of the Clinical Frailty Scale through Dalhousie University’s Industry, Liaison, and Innovation Office. In addition to academic and hospital appointments, Kenneth Rockwood is cofounder of Ardea Outcomes, which (as DGI Clinical) in the last 3 years has contracts with pharmaceutical and device manufacturers (Danone, Hollister, INmune, Novartis, Takeda) on individualized outcome measurement. In 2020, he attended an advisory board meeting with Nutricia on dementia and chaired a Scientific Workshop & Technical Review Panel on frailty for the Singapore National Research Foundation. He is associate director of the Canadian Consortium on Neurodegeneration in Aging, itself funded by the Canadian Institutes for Health Research, the Alzheimer Society of Canada, and several other charities. He holds the Kathryn Allen Weldon Chair in Alzheimer Research, funded by the Dalhousie Medical Research Foundation. Kenneth Rockwood also reports personal fees from Ardea Outcomes, the Chinese Medical Association, Wake Forest University Medical School Centre, the University of Nebraska Omaha, the Australia and New Zealand Society for Geriatric Medicine, Atria Institute, Fraser Health Authority, McMaster University, and EpiPharma. In addition, Dr. Rockwood has licensed the Clinical Frailty Scale to Enanta Pharmaceuticals, Synairgen Research, Faraday Pharmaceuticals, KCR S.A., Icosavax, BioAge Labs, Biotest AG, Qu Biologics, AstraZeneca UK, Cellcolabs AB, Pfizer, W.L. Gore & Associates, pending to Cook Research Incorporated, Renibus Therapeutics, and, as part of Ardea Outcomes, has a pending patent for Electronic Goal Attainment Scaling. He also reports permission for the Pictorial Fit-Frail Scale licensed to Congenica. Use of both the Clinical Frailty Scale and Pictorial Fit-Frail Scale is free for education, research, and nonprofit health care with completion of a permission agreement stipulating users will not change, charge for, or commercialize the scales. For-profit entities pay a licensing fee, 15% of which is is retained by the Dalhousie University Office of Commercialization and Industry Engagement. The remainder of the licence fees are donated to the Dalhousie Medical Research Foundation. Melissa Andrew reports grants from Sanofi, grants and support to attend meetings from GSK, grants from Pfizer, grants from Canadian Frailty Network, personal fees from Sanofi, personal fees from Pfizer, personal fees from Seqirus, grants from Merck, grants from Public Health Agency of Canada, and grants from Canadian Institutes of Health Research, outside the submitted work. Dr. Andrew is a volunteer board member for the Alzheimer Society of Nova Scotia and the National Advisory Committee on Immunization. Sheliza Khan declares leadership in the patient flow department at Queen Elizabeth II Hospital. No other competing interests were declared.

This article has been peer reviewed.

Contributors: Jasmine Mah and Christie Stilwell contributed equally as co–first authors. Jasmine Mah contributed to the conceptualization and design, procurement of data, analysis of data, drafting of the original manuscript, and review of the manuscript. Christie Stilwell and Emily Marshall contributed to the conceptualization and design, analysis of data, drafting of the original manuscript, and review of the manuscript. Madeline Kubiseski and Gaurav Arora contributed to the conceptualization and design, procurement of data, analysis of data, and review of the manuscript. Karen Nicholls, Sheliza Khan, Jonathan Veinot, Lucy Eum, Susan Freter, Katalin Koller, Maia von Maltzahn, Kenneth Rockwood, Samuel Searle, and Melissa Andrew contributed to the conceptualization and design, analysis of data, and drafting of the original manuscript or review of manuscript drafts. All authors approved the final version to be published and agreed to be accountable for its accuracy and integrity.

Data sharing: Anonymized data from our study may be available on request. Interested parties are encouraged to contact the lead author via email to access these data or to obtain a copy of the Orphan Patient Policy. The data will be shared under terms that ensure the protection of participant privacy and compliance with relevant data protection regulations.

Funding: This study is supported by Nova Scotia Health, through a grant from the Nova Scotia Health Research Fund. Nova Scotia Health is the provincial health authority.

• Accepted March 5, 2024.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

• Luther RA ,
• Richardson L ,
• Andrew MK ,
• Burrell A ,
• Chahine S ,
• Rutschmann OT ,
• Chevalley T ,
• Zumwald C ,
• Rippingale C
• Bielawska C ,
• Murphy PJ ,
• Campbell SG
• Searle SD ,
• Chattopadhyay I
• Sainsbury P ,
• Furlong KR ,
• O’Donnell K ,
• Farrell A ,
• Strauss A ,
• Cooper LA ,
• Itchhaporia D
• Harmon-Jones E ,
• Shiffman J ,
• Sinskey JL ,
• Margolis RD ,
• Bronfenbrenner U
• Reuben DB ,
• Auerbach J ,
• ↵ Ageing in the right place: supporting older Canadians to live where they want . Toronto : National Institute on Ageing, Toronto Metropolitan University 2022 : 1 – 148 . Available: https://static1.squarespace.com/static/5c2fa7b03917eed9b5a436d8/t/638e0857c959d1546d9f6f3a/1670252637242/AIRP+Report+Final2022-.pdf ( accessed 2023 Dec. 18 ).

In this issue

• Table of Contents
• Index by author

Article tools

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Citation Manager Formats

• EndNote (tagged)
• EndNote 8 (xml)
• RefWorks Tagged
• Ref Manager

• Tweet Widget
• Facebook Like

Jump to section

Related articles.

• “Social admissions” to hospital are not personal failures but policy ones
• « Admissions pour manque de soutien social » dans les hôpitaux: un échec des politiques, et non des personnes
• Google Scholar

Cited By...

• << Admissions pour manque de soutien social >> dans les hopitaux: un echec des politiques, et non des personnes
• "Social admissions" to hospital are not personal failures but policy ones

More in this TOC Section

• Respiratory syncytial virus vaccination strategies for older Canadian adults: a cost–utility analysis
• Public funding for private for-profit centres and access to cataract surgery by patient socioeconomic status: an Ontario population-based study
• Renin–angiotensin system inhibitors and risk of hepatocellular carcinoma among patients with hepatitis B virus infection

Similar Articles

Collections.

• Access to health care
• Geriatric medicine
• Health policy
• Homelessness
• Internal medicine
• Mental health
• Patient safety & quality improvement
• Physician health
• Vulnerable populations

Case report

• Open access
• Published: 13 September 2024

Fungating synovial sarcoma at the posterior aspect of neck: a case report

• Badaruddin Sahito 1 ,
• Sajjad Ahmed 1 ,
• Fahad Hanif Khan 1 ,
• Awais Abro 1 ,
• Jugdesh Kumar 1 ,
• Muhammad Waqas Khan 1 &
• Malik Olatunde Oduoye   ORCID: orcid.org/0000-0001-9635-9891 2  

Journal of Medical Case Reports volume  18 , Article number:  440 ( 2024 ) Cite this article

Metrics details

In this report, we describe an uncommon instance of fungating synovial sarcoma affecting the posterior aspect of the neck. Although the existing literature has documented a limited number of cases, this particular case contributes to the knowledge about it, which is scarce.

Case presentation

A total of 5 months before the examination, a Pakistani-Asian male, age 20 years, complained of a malodorous fungating swelling on the posterior aspect of his neck. An examination revealed a foul-smelling, 10 × 13 cm fungating enlargement surrounded by maggots and hemorrhaging at the site of the incision. A hemoglobin level of 6 and a total leukocyte count (TLC) of 23,000 indicated the patient’s disoriented and pallid appearance. He was expeditiously admitted, and preoperatively, the general well-being of the patient was optimized. After a comprehensive discussion with the medical team, a strategy for marginal excision and coverage with a latissimus dorsi (LD) flap and grafting was devised. The tumor was successfully excised, and an LD flap with graft was conducted on the patient during surgery; however, the infection caused the failure of half of the graft. Following that, the lesion was debrided, and re-grafting was performed. The patient was subsequently administered 5 cycles of chemotherapy and 32 cycles of radiotherapy. He was diagnosed with pulmonary metastasis 2 years later. Sadly, the patient died during a follow-up visit 3.5 years later.

Conclusions

The patient’s unfavorable prognosis after surgical intervention, radiotherapy, and chemotherapy, despite undergoing all-encompassing treatments, underscores the importance of early detection and intervention in fungating tumor cases.

Peer Review reports

Introduction

Synovial sarcoma (SS) is a high-grade malignant tumor with a global prevalence of 0.0001–0.0002%, constituting only 800–1000 cases reported annually [ 1 ]. Synovial sarcoma is a misnomer primarily arising from primitive mesenchymal cells around joints instead of intra-articular synovium [ 2 ]. SS is commonly soft tissue sarcoma, but bony cases are also reported [ 2 ]. The lower limb is frequently involved, especially around the knee joint.

Only 3–10% of SS arise from the head and neck, contributing to only 2.5–3.5% of all sarcomas in the region [ 3 ]. However, SS can be primarily distinguished from other neck tumors on the basis of the histological appearance and presence of the characteristic chromosomal translocation; t(X;18). The translocation resulting from the fusion of the SYT gene with the SSX1 or SSX2 gene drives several histopathological variants, including monophasic, biphasic, and poorly differentiated tumors [ 2 ]. Although only a few cases have been reported on SS arising from the head and neck region, SS occurrence at the posterior aspect of the cervical spine is an extremely rare presentation [ 4 , 5 ]. Therefore, due to the limited literature availability on the subject, the optimal management strategy for cervical spine SS has not been established. However, total surgical excision with a wide margin followed by postoperative radiation is widely recommended in the previously published reported cases. In this case report, we present a usual case of a large fungating SS originating from the posterior aspect of the spine managed with marginal excision and highlighting the diagnostic and management challenges.

A 20-year-old Pakistani-Asian male presented with fungating swelling at the posterior aspect of his neck for 5 months, with foul-smelling discharge from the swelling for 2 months. The swelling was initially small and progressed rapidly once operated by a local center. As the tumor progressed, it became fungated out of the skin (Figs.  1 and 2 ). The swelling was associated with foul smells, fever, weight loss, and continuous fever for the last few days of presentation. The patient’s attendant also noted bleeding from the tumor on and off.

Foul-smelling fungating swelling of 15 × 10 cm (black arrow)

Swelling extends from the occipital region to the base of the neck

The patient was a laborer by profession, with no known co-morbidities. He was taking antipyretics and antibiotics for this problem. His systemic examination was unremarkable. His hemoglobin was 6.0 g/dl, his total leukocyte count (TLC) 20,000, his erythrocyte sedimentation rate (ESR) 52, and his C-reactive protein (CRP) 15. Other labs were within normal limits. The x-ray of his cervical spine was normal, and magnetic resonance imaging (MRI) cervical spine contrast showed a mixed density soft tissue tumor arising from the paraspinal muscle extending from the occiput to the C7 vertebrae (Figs.  3 and 4 ). Computed tomography (CT) scan of the chest at the time of presentation was negative for metastasis. His bone scan was also unremarkable. His biopsy suggested monophasic synovial sarcoma.

MRI showing mixed density soft tissue tumor arising from the paraspinal muscle extending from the occiput to the C7 vertebrae

Axial MRI image showing vertebrae were spared with paraspinal cervical muscle involvement. The tumor did not extend into the cord

Preoperatively, the general well-being of the patient was optimized, and antibiotics prophylactically started. The case was discussed in a tumor board meeting including the neurosurgeon, plastic surgeon, orthopedic and once-radiologist team, and a plan was made to do marginal/wide margin resection and cover the defect with a latissimus dorsi flap and skin graft. After consent and counseling, the patient was operated on under general anesthesia in the prone position. The tumor was slowly dissected, and the wound was washed and hemostasis secured. A split-thickness skin graft (SSG) was taken from the thigh and applied over the flap.

The patient’s immediate recovery from anesthesia was smooth, but at 2 weeks, he developed discharge from the wound. The skin graft failed, and part of the LD got infected and debrided (Figs.  5 and 6 ). The patient was kept on vancomycin for 2 weeks, and vacuum-assisted closure (VAC) dressing was applied. The wound was granulated, and re-skin grafting was done (Fig.  7 ). His musculoskeletal tumor score was 28.

First infected SSG. Necrosis of graft is circled

Wound after debridement

Status of the wound after the second SSG

The patient recovered normally within 3 months of surgery, and then underwent 30 cycles of radiotherapy and 5 cycles of chemotherapy. He was kept under routine follow-up with a CT scan chest. Despite all the treatment, he developed lung metastasis after 20 months of surgery, for which he received treatment from an oncologist. He died of lung metastasis after 3.5 years of surgical follow-up.

Synovial sarcoma (SS) mostly impacts young individuals, with the extremities, particularly around the knee, which is the most common location (70%). While uncommon in the head and neck, SS in this area is known for its aggressive nature and high likelihood of recurrence. The precise etiology of SS remains uncertain; however, variables such as radiation and genetic susceptibility have been linked to an elevated risk [ 6 ].

There is limited information available on SS in the posterior cervical area. Shah et al . reported a case of SS that originated from the cervical spine and resulted in neurological impairments characterized by widespread paralysis and loss of sensation at the T4 level. Nevertheless, the author’s ability to provide comprehensive follow-up information was hindered by a lack of connection with the center. Tragically, the patient succumbed to fever and diarrhea after 2 years [ 5 ]. Foreman et al . reported a case of biphasic synovial sarcoma that was managed with surgical intervention, radiation treatment, and chemotherapy. The patient was free of disease recurrence for 6 years. Their approach included performing subtotal resection to remove the small-sized tumors, followed by postoperative radiation treatment and chemotherapy. There were no instances of tumor recurrence reported throughout the 6-year follow-up period. Kim et al . documented the effective management of SS using MRI, which revealed a tumor measuring 6.6 × 4 cm in the cervical spine muscles. The treatment included surgical intervention and further radiation. Remarkably, there was no recurrence of the tumor after a 2-year follow-up [ 7 ]. Spinal synovial sarcoma is an uncommon ailment that might be challenging to promptly detect in the absence of contemporary imaging methods.

The detection of cancer at a smaller size is believed to influence the long-term prognosis, which was seen to be more advantageous in individuals whose tumors were 4 cm or less [ 6 ].

A literature analysis by Standbouly et al . emphasized that surgical excision is the primary treatment for 91 cases of head and neck SS. Additional radiation and chemotherapy may be used depending on the size of the tumor. The overall survival rates at 1, 3, and 5 years were 87.5%, 61.4%, and 40.9%, respectively [ 8 ].

Synovial sarcoma poses distinct issues due to its tendency to return much later in comparison to other types of sarcomas. Krieg et al . (2011) found that local recurrence usually occurs around 3.6 years on average (ranging from 0.5 to 15 years), whereas metastases tend to arise around 5.7 years on average (ranging from 0.5 to 16.3 years). Furthermore, the location of the tumor also influences the prognosis, since synovial sarcomas found outside of the extremities are often linked to lower overall survival rates. However, this might be attributed to a delay in the appearance of symptoms and the presentation of the disease at a more advanced stage [ 2 ].

Although the surgical excision was successful, the patient eventually died because of lung metastases. Although synovial sarcoma is not common in certain areas, it has the potential to be life-threatening. Hence, it is important to promptly evaluate it as a probable diagnosis, while also seeking immediate advice and adopting a thorough strategy to promptly diagnose lesions and enhance prognosis.

The patient’s poor prognosis, caused by delayed presentation, a large tumor size upon arrival, and the negative effects of erroneous first excision, highlights the crucial significance of the early discovery and timely, suitable management in instances with fungating synovial sarcoma in the cervical region.

Availability of data and materials

All data were obtained from the Orthopedic Surgery Department of Dr. Ruth KM Pfau Civil Hospital Karachi, Pakistan.

Abbreviations

Synovial sarcoma

Computerized tomography

Ammar AS, Khalid R. Neck exploration for a huge synovial sarcoma, case report, and literature review. J Pak Med Assoc. 2021;71(2B):766–8. https://doi.org/10.47391/JPMA.1283 .

Article   PubMed   Google Scholar  

Gazendam AM, Popovic S, Munir S, Parasu N, Wilson D, Ghert M. Synovial sarcoma: a clinical review. Curr Oncol (Toronto, Ont). 2021;28(3):1909–20. https://doi.org/10.3390/curroncol28030177 .

Article   PubMed Central   Google Scholar  

Jang JW, Lee JK, Seo BR, Kim SH. Synovial sarcoma of the posterior neck: a case report and review of literature. J Korean Neurosurg Soc. 2010;47(4):306–9. https://doi.org/10.3340/jkns.2010.47.4.306 .

Article   PubMed   PubMed Central   Google Scholar  

Shah WU, Shujaat SD, Ullah N, Mansoor S. Synovial sarcoma of cervicodorsal spine: a case report. J Pak Med Assoc. 2018;68(7):1100–4.

PubMed   Google Scholar  

Puffer RC, Daniels DJ, Giannini C, Pichelmann MA, Rose PS, Clarke MJ. Synovial sarcoma of the spine: a report of three cases and review of the literature. Surg Neurol Int. 2011;2:18. https://doi.org/10.4103/2152-7806.76939 .

Quan H, Sreekissoon S, Wang Y. Synovial sarcoma of the head and neck: a review of reported cases on the clinical characteristics and treatment methods. Front Cell Dev Biol. 2023;10:1077756. https://doi.org/10.3389/fcell.2022.1077756 .

Foreman SM, Stahl MJ. Biphasic synovial sarcoma in the cervical spine: case report. Chiropr Man Ther. 2011;19(1):12. https://doi.org/10.1186/2045-709X-19-12 .

Article   Google Scholar  

Kim J, Lee SH, Choi YL, Bae GE, Kim ES, Eoh W. Synovial sarcoma of the spine: a case involving paraspinal muscle with extensive calcification and the surgical consideration in treatment. Eur Spine J. 2014;23(1):27–31. https://doi.org/10.1007/s00586-013-3034-8 .

Stanbouly D, Litman E, Lee KC, Philipone E. Synovial sarcoma of the head and neck: a review of reported cases in the literature. J Stomatol Oral Maxillofac Surg. 2021;122(5):505–10. https://doi.org/10.1016/j.jormas.2020.12.001 .

Download references

Acknowledgements

We would like to acknowledge Dr. Jaazba Qamar.

Author information

Authors and affiliations.

Dow University of Health Sciences, Karachi, Pakistan

Badaruddin Sahito, Sajjad Ahmed, Fahad Hanif Khan, Awais Abro, Jugdesh Kumar & Muhammad Waqas Khan

The Medical Research Circle, Goma, Democratic Republic of Congo

Malik Olatunde Oduoye

You can also search for this author in PubMed   Google Scholar

Contributions

AA and MWK worked on the conception and designing, while NP and ZF performed drafting, data collection, acquisition, analysis, and interpretation of data. AA, MWK, and SAI played a role in critical revision and appraisal and contributed equally to all the tasks. All the authors approved the final draft and stand accountable for the validity of the data.

Corresponding author

Correspondence to Malik Olatunde Oduoye .

Ethics declarations

Ethics approval and consent to participate.

This case report was approved by the institutional ethical board at the Dow University of Health Science Orthopedic Department.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interest.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ .

Reprints and permissions

About this article

Cite this article.

Sahito, B., Ahmed, S., Khan, F.H. et al. Fungating synovial sarcoma at the posterior aspect of neck: a case report. J Med Case Reports 18 , 440 (2024). https://doi.org/10.1186/s13256-024-04747-1

Download citation

Received : 23 March 2024

Accepted : 25 July 2024

Published : 13 September 2024

DOI : https://doi.org/10.1186/s13256-024-04747-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Chromosomal translocation
• Chemotherapy

Journal of Medical Case Reports

ISSN: 1752-1947

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMC Med Res Methodol

The case study approach

Sarah crowe.

1 Division of Primary Care, The University of Nottingham, Nottingham, UK

Kathrin Cresswell

2 Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Ann Robertson

3 School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

Anthony Avery

Aziz sheikh.

The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables ​ Tables1, 1 , ​ ,2, 2 , ​ ,3 3 and ​ and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

Example of a case study investigating the introduction of the electronic health records[ 5 ]

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table ​ (Table5), 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Definitions of a case study

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table ​ (Table1), 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables ​ Tables2, 2 , ​ ,3 3 and ​ and4) 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 - 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table ​ (Table2) 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables ​ Tables2 2 and ​ and3, 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table ​ (Table4 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table ​ (Table6). 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

Example of epistemological approaches that may be used in case study research

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table ​ Table7 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

Example of a checklist for rating a case study proposal[ 8 ]

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table ​ (Table3), 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table ​ (Table1) 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table ​ Table3) 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 - 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table ​ (Table2 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table ​ (Table1 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table ​ (Table3 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table ​ (Table4 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table ​ Table3, 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table ​ (Table4), 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table ​ Table8 8 )[ 8 , 18 - 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table ​ (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Stake's checklist for assessing the quality of a case study report[ 8 ]

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

• Yin RK. Case study research, design and method. 4. London: Sage Publications Ltd.; 2009. [ Google Scholar ]
• Keen J, Packwood T. Qualitative research; case study evaluation. BMJ. 1995; 311 :444–446. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J. et al. Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009; 6 (10):1–11. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO) 2008. http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf
• Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T. et al. Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010; 41 :c4564. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P. the Patient Safety Education Study Group. Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010; 15 :4–10. doi: 10.1258/jhsrp.2009.009052. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van Harten WH, Casparie TF, Fisscher OA. The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002; 60 (1):17–37. doi: 10.1016/S0168-8510(01)00187-7. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stake RE. The art of case study research. London: Sage Publications Ltd.; 1995. [ Google Scholar ]
• Sheikh A, Smeeth L, Ashcroft R. Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002; 52 (482):746–51. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• King G, Keohane R, Verba S. Designing Social Inquiry. Princeton: Princeton University Press; 1996. [ Google Scholar ]
• Doolin B. Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998; 13 :301–311. doi: 10.1057/jit.1998.8. [ CrossRef ] [ Google Scholar ]
• George AL, Bennett A. Case studies and theory development in the social sciences. Cambridge, MA: MIT Press; 2005. [ Google Scholar ]
• Eccles M. the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG) Designing theoretically-informed implementation interventions. Implementation Science. 2006; 1 :1–8. doi: 10.1186/1748-5908-1-1. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A. Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005; 365 (9456):312–7. [ PubMed ] [ Google Scholar ]
• Sheikh A, Panesar SS, Lasserson T, Netuveli G. Recruitment of ethnic minorities to asthma studies. Thorax. 2004; 59 (7):634. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Hellström I, Nolan M, Lundh U. 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005; 4 :7–22. doi: 10.1177/1471301205049188. [ CrossRef ] [ Google Scholar ]
• Som CV. Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005; 18 :463–477. doi: 10.1108/09513550510608903. [ CrossRef ] [ Google Scholar ]
• Lincoln Y, Guba E. Naturalistic inquiry. Newbury Park: Sage Publications; 1985. [ Google Scholar ]
• Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001; 322 :1115–1117. doi: 10.1136/bmj.322.7294.1115. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mays N, Pope C. Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000; 320 :50–52. doi: 10.1136/bmj.320.7226.50. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mason J. Qualitative researching. London: Sage; 2002. [ Google Scholar ]
• Brazier A, Cooke K, Moravan V. Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008; 7 :5–17. doi: 10.1177/1534735407313395. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Miles MB, Huberman M. Qualitative data analysis: an expanded sourcebook. 2. CA: Sage Publications Inc.; 1994. [ Google Scholar ]
• Pope C, Ziebland S, Mays N. Analysing qualitative data. Qualitative research in health care. BMJ. 2000; 320 :114–116. doi: 10.1136/bmj.320.7227.114. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cresswell KM, Worth A, Sheikh A. Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010; 10 (1):67. doi: 10.1186/1472-6947-10-67. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001; 358 :483–488. doi: 10.1016/S0140-6736(01)05627-6. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yin R. Case study research: design and methods. 2. Thousand Oaks, CA: Sage Publishing; 1994. [ Google Scholar ]
• Yin R. Enhancing the quality of case studies in health services research. Health Serv Res. 1999; 34 :1209–1224. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Green J, Thorogood N. Qualitative methods for health research. 2. Los Angeles: Sage; 2009. [ Google Scholar ]
• Howcroft D, Trauth E. Handbook of Critical Information Systems Research, Theory and Application. Cheltenham, UK: Northampton, MA, USA: Edward Elgar; 2005. [ Google Scholar ]
• Blakie N. Approaches to Social Enquiry. Cambridge: Polity Press; 1993. [ Google Scholar ]
• Doolin B. Power and resistance in the implementation of a medical management information system. Info Systems J. 2004; 14 :343–362. doi: 10.1111/j.1365-2575.2004.00176.x. [ CrossRef ] [ Google Scholar ]
• Bloomfield BP, Best A. Management consultants: systems development, power and the translation of problems. Sociological Review. 1992; 40 :533–560. [ Google Scholar ]
• Shanks G, Parr A. Proceedings of the European Conference on Information Systems. Naples; 2003. Positivist, single case study research in information systems: A critical analysis. [ Google Scholar ]

• Introduction
• Conclusions
• Article Information

AD indicates atopic dermatitis.

Consensus was set at 70% or more of participants agreeing (dotted line).

Lower score indicates higher (more important) ranked position. AD indicates atopic dermatitis.

eMethods. AD Flare Definition Survey

eTable 1. List of 98 Statements, Where All Statements Begin With “An Atopic Dermatitis Flare Is…”

eTable 2. Demographic Characteristics of Participants in the Modified eDelphi Exercise

eTable 3. Fifteen Statements Identified by the Modified eDelphi Consensus Activities as Critically Important to Include in a Definition of Flare: Mean Rating and Ranking From the Focus Group

eFigure 1. Acute Worsening of Symptoms of AD

eFigure 2. An Eruption of Some Area of My Body

eFigure 3. A Change in Physical Health Associated With AD That Interrupts My Day to Day

eFigure 4. A Worsening of Itching Associated With AD

eFigure 5. When My Signs Go From Being Background Noise to Being in the Foreground

eFigure 6. When My Symptoms Go From Being Background Noise to Being in the Foreground

eFigure 7. When My Symptoms Take Significantly More of My Attention Than Normal

eFigure 8. (Did Not Meet Consensus) When I Start Thinking About My Signs Constantly

eFigure 9. When I Start Thinking About My Symptoms Constantly

eFigure 10. When I Lose My Sense of Control Over My Disease Management

eFigure 11. When Symptoms Affect My Quality of Life

eFigure 12. When Symptoms Affect My Daily Activities

eFigure 13. (Did Not Meet Consensus) When My Condition Is Unacceptable to Me

eFigure 14. (Did Not Meet Consensus) a Change in My Condition That Causes Me to Make Decisions About Daily Life Activities That Are Out of the Norm

eFigure 15. A Worsening of Physical Symptoms Associated With AD

Data Sharing Statement

See More About

Select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Others Also Liked

• Download PDF
• X Facebook More LinkedIn

Drucker AM , Thibau IJC , Mantell B , Dainty KN , Wyke M , Smith Begolka W. Consensus on a Patient-Centered Definition of Atopic Dermatitis Flare. JAMA Dermatol. Published online September 11, 2024. doi:10.1001/jamadermatol.2024.3054

Manage citations:

© 2024

• Permissions

Consensus on a Patient-Centered Definition of Atopic Dermatitis Flare

• 1 Division of Dermatology, Department of Medicine, University of Toronto, Ontario, Canada
• 2 Women’s College Research Institute and Department of Medicine, Women’s College Hospital, Toronto, Ontario, Canada
• 3 National Eczema Association, Novato, California
• 4 Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
• 5 Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
• 6 Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, Florida

Question   What components are essential to include in a patient-centered definition of an atopic dermatitis flare?

Findings   In this consensus survey study of 657 US adults with atopic dermatitis (26 completing focus groups and 631 survey participants), 12 statements were agreed on for inclusion in a patient-centered definition of flare. More than half of participants aligned with their health care practitioner on what a flare is, and most reported that a patient-centered definition would be useful when communicating with their health care practitioner.

Meaning   These findings suggest that while various definitions of atopic dermatitis flare exist, a patient-centered definition may be useful for clinical practice and research.

Importance   Flare is a term commonly used in atopic dermatitis (AD) care settings and clinical research, but little consensus exists on what it means. Meanwhile, flare management is an important unmet research and treatment need. Understanding how various therapies might comparatively improve AD flares as a measure of treatment effectiveness may facilitate shared decision-making and enable assessment of effectiveness within and outside clinical settings.

Objective   To identify patient-reported attributes associated with an AD flare to develop a patient-centered, consensus-based working definition.

Design, Setting, and Participants   This consensus survey study used a modified eDelphi method involving consensus-building focus groups and a survey conducted from January 10 through October 24, 2023. Focus groups were conducted virtually, and the online survey was advertised to National Eczema Association members. US adults aged 18 years or older with AD were recruited via convenience sampling.

Exposure   Lived experience of AD.

Main Outcomes and Measures   The main outcome was consensus on which attributes of AD to include in a patient-centric definition of flare. Using a rating scale (range, 1-9), consensus for the modified eDelphi statement rating was defined as at least 70% of participants rating a statement as 7 to 9 (critical to a flare definition) and less than 15% rating it as 1 to 3 (not important).

Results   Twenty-six participants with AD who completed focus group activities (24 aged 18-44 years [92.3%] and 2 aged 45-64 years [7.7%]; 18 women [69.2%]) and 631 participants with AD (mean [SD] age, 45.5 [18.1] years; 533 women [84.5%]) who completed the survey were included in the analysis. Fifteen statements reached consensus from the focus groups, and of those, 12 reached consensus from survey participants. More than half (334 of 631 [52.9%]) of survey participants reported alignment with their health care practitioner on what a flare is, and most (478 of 616 [77.6%]) reported that a patient-centered definition would be useful when communicating with their health care practitioner about their condition.

Conclusions and Relevance   In this study, participants with AD reached consensus on what an AD flare means from the patient perspective. This understanding may improve research and care by addressing this key patient-centered aspect of evaluating treatment effectiveness.

Atopic dermatitis (AD) is one of the most common chronic inflammatory conditions, affecting over 31 million US adults and children with more than 55% experiencing inadequately controlled symptoms. 1 - 6 Until recently, there have been limited effective and long-term therapeutic options, leaving many patients with the ongoing lived experience of periodically worsening disease and poor alleviation of burdensome symptoms. 7

Flare is a term commonly used by health care practitioners (HCPs), researchers, and patients to refer to an AD disease exacerbation, although there is little consensus on the meaning of this term when it is used in clinical trials or in care settings. 8 - 10 Atopic dermatitis flares may occur because of exposure to a wide variety of external triggers that are often patient specific 11 , 12 and as a result of ongoing immune dysregulation. 13 Patients with moderate to severe AD experience an average of 9 flare episodes a year, with flare intensity and duration (days to weeks) typically increasing with underlying AD severity. 14 Despite the lack of a clear definition for AD flares, patients may harbor an adverse emotional burden associated with the term. 15 The potential for future flares and the reoccurrence of flares contribute to considerable patient anxiety 6 , 16 and unfavorable emotional sentiment, 14 making reductions in flare frequency the second most important treatment outcome for patients with AD. 7 Atopic dermatitis flares and their management are important unmet research and treatment needs. 7 - 9 , 17

A 2014 systematic review highlighted substantial heterogeneity in how flares are defined in AD research. Among 26 studies including AD flares as outcome measures, 22 relied on arbitrary cutoffs of an existing severity scale, composite investigator-rated definitions, or behavior change (need to change therapy), with only 4 studies incorporating a patient-reported outcome. 9 Efforts to standardize outcome measures for clinical trials and clinical practice, such as the Harmonizing Outcomes Measures for Eczema initiative, have pivoted to the concept of control, wherein disease activity (ie, flare-related increases in itching) is considered as one component of a multifaceted assessment for short- and long-term treatment effectiveness. 18 While measures of AD control have been validated 19 , 20 and are helpful patient-reported outcome measures for clinical trials and, potentially, care settings, patients may be interested in flare management as a component of patient-centered care. An understanding of how various therapies might comparatively prevent AD flares or reduce their intensity, number, frequency, and duration as a measure of treatment effectiveness could facilitate shared decision-making and serve as a foundation to document clinical effectiveness. 7 , 21

Focus groups run by the National Eczema Association (NEA), a US-based patient advocacy group, identified 6 key concepts for a patient-centered definition of flare, including changes from the patient’s baseline or normal experience; mental, emotional, and social consequences; physical changes in skin; attention needed or all-consuming focus; itch-scratch-burn cycle; and control or loss of control and quality of life. 22 Despite the importance of flares to patients and work to date in understanding what flares mean to people living with AD, there remains no standardized definition of AD flare from the patient perspective. The objective of this study was to identify patient-reported attributes associated with the term flare and to achieve consensus on what features are critical to defining AD flares from the patient perspective.

In this consensus survey study, we used a modified eDelphi process to achieve consensus among adult patients (aged ≥18 years) with AD and diverse lived experiences and demographics. The process was supplemented with a preliminary evaluation of the validity of the newly identified definition of flare based on a survey among a large, heterogeneous population of people with AD. A patient with AD who was not a participant in the study was recruited from the NEA membership to contribute the patient perspective as coauthor of this article (M.W.). Figure 1 depicts how this study fits within NEA’s overall research plan to develop a patient-centered definition of flare.

The focus groups and survey were considered exempt research by the Western Copernicus Group Institutional Review Board per the Common Rule. Prior to participating in the focus group and eDelphi process consensus activities or the survey, participants provided electronic informed consent. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We used themes identified in our group’s previous qualitative study and the resulting conceptual framework to support focus group ratings of concepts important to AD flares. 22 A list of 98 statements (eTable 1 in Supplement 1 ) was developed, with each statement structured as “An atopic dermatitis flare is…,” that specifically addressed each of the 6 key concepts from the conceptual framework.

The same focus group from the previous qualitative study conducted from May 17 to June 3, 2022, 22 participated in the modified eDelphi process consensus activities from January 10 to June 6, 2023, to determine the most and least important aspects of an AD flare. Participants were eligible for the focus group if they were aged 18 years or older and a US resident diagnosed with AD with a self-reported AD flare in the past 12 months. Participants were recruited from the NEA Ambassadors program, a volunteer program that engages patients in eczema advocacy, research, and community activities, and from the NEA’s scholarship recipient list to select patients with high engagement in and demonstrated contribution to projects.

Recruitment involved an online screening questionnaire, which collected basic demographics and AD history to allow for selection of a broad representation of the AD lived experience (eg, personal demographics and disease history). We recruited 29 participants in total, a number based on our past research experience at reaching discussion saturation. Some potential participants were excluded once proportional saturation was met for certain characteristics, such as race and ethnicity and gender. Partial completion of focus group and eDelphi process consensus activities was compensated $100 for each activity, with participants completing all 4 activities being compensated $750.

Consensus activity 1 was an online independent rating activity conducted using SurveyMonkey software (SurveyMonkey Inc). Participants rated the 98 statements on a scale from 1 to 9, with scores of 1 to 3 considered not important, 4 to 6 considered important but not critical, and 7 to 9 considered critically important to a definition of AD flare. A do not understand answer option was also available. The survey also asked several other questions about flaring. Consensus for a statement was defined a priori as a 70% or higher rating of 7 to 9 and less than a 15% rating of 1 to 3.

We regrouped online with the focus group via Zoom meeting software, version 5.10.7 (Zoom Video Communications, Inc) to discuss statements that did not reach, but were close to reaching, consensus (15 statements with a 60%-70% rating of 7-9). Following the meeting, all participants independently rerated those statements through the online survey.

The final consensus activity was an online exercise to rank unique pairs of the statements that reached consensus against each other to create a final ranked order of statements important to include in a definition of flare from the patient perspective. Ranking was used in a final consensus activity to elucidate the relative importance of concepts patients felt were important to include in a definition.

We created an online survey administered via Qualtrics, version 09.2023 software (Qualtrics) between September 7 and October 24, 2023. The survey assessed agreement of the broader community of patients with AD with the working concepts essential to a definition identified in the modified eDelphi exercise.

Participants in the survey included adults aged 18 years or older who were US residents diagnosed with AD and could speak, read, and comprehend English. The survey was disseminated via posting to the NEA website (home page, research page, and banner), email to the general NEA and Ambassador program membership, social media, the NEA print magazine, and the NEA EczemaWise smartphone and web application. Respondents who fully completed the 52- to 56-question survey (eMethods in Supplement 1 ) were eligible for 1 of 20 $25 online shopping gift cards. Survey responses were not linked in any way to the gift cards. All data were anonymized for analysis and treated confidentially.

We used Qualtrics’ cookies and bot detection services, such as honeypot questions and reCAPTCHA (Google LLC), to prevent duplicate entries and disingenuous responses. We further excluded respondents if they met subjective bot detection criteria during data cleaning, such as if write-in responses were off topic or phrases were repeated verbatim in another respondent write-in, if time to complete was too fast, or multiple similar submissions happened close together on days where the survey was not promoted through recruitment channels. The survey had dynamic questions based on how respondents answered.

Survey respondents were asked to rate their level of agreement for whether the statements that reached consensus from the focus groups were critically important to include in a definition of AD (strongly disagree, disagree, undecided, agree, or strongly agree). Consensus for a statement was defined a priori as 70% or higher indicating agree or strongly agree and less than 15% indicating disagree or strongly disagree. Statements rated as agree or strongly agree were displayed in a follow-up question where participants ranked the statements in order of importance (1 being the most important) compared with one another.

Several survey questions were included to further understand the patient perspective of flare. We asked respondents about whether 3 existing definitions of flare resonated with them (yes or no) (previous definitions listed in the eMethods in Supplement 1 ), whether they and their HCP agreed on what an AD flare is (HCP alignment [yes, no, or unsure]), whether their definition of a flare changed over time (flare definition changed [yes or no]), and how they wanted or expected to use a patient-centered definition of flare (select all that apply grouped by “don’t know/unsure,” “for myself to self-manage,” “to explain my condition to family/friends,” “with a doctor to communicate about my care,” “a definition wouldn’t be useful for me,” and “other”).

We stratified agreement rating scores of the final consensus statements shown to survey participants by patient characteristics and perspectives to visually identify within each strata for which groups the statement did not reach the agreement consensus criteria (eFigures 1-15 in Supplement 1 ). These variables included gender (man, woman, nonbinary, other [presented without further definition], and preferred not to say), patient age, self-selected race (Asian or Asian American, Black or African American, Native American or Alaska Native, Native Hawaiian or Pacific Islander, White, multiracial, other [presented without further definition], and did not know or preferred not to say) and Hispanic or Latino ethnicity, past month AD severity, typical disease severity, worst disease severity, currently flaring, time since last flare, age at diagnosis, time since diagnosis, HCP alignment, flare definition changed, general knowledge of AD, urbanicity as determined by Rural-Urban Commuting Area Code 23 from zip code, and education level.

For general knowledge of AD, respondents could select excellent, good, average, poor, or terrible; their responses were converted to a binary variable of average or above vs below average for analysis. Respondents who indicated being unsure of when they were diagnosed with AD (sometime in childhood, sometime in adulthood) were assigned a value of 6 (childhood) and 18 (adulthood). Respondent disease and sociodemographic variables, rating score, and ranking position score were described using means and SDs for continuous variables and counts and percentages for categorical variables. The data were analyzed using R, version 4.3.2 software (R Core Team).

Of the 29 originally recruited participants, 22 1 dropped out before consensus activity 1 (statement rating), a second dropped out before consensus activity 2 (discussion and rerating of the statement list), and a third dropped out before consensus activity 3 (ranking statements), yielding 26 participants (aged 18-24 years, 8 [30.8%]; aged 25-34 years, 9 [34.6%]; aged 35-44 years, 7 [26.9%]; aged 45-54 years, and 1 [3.8%]; aged 55-64 years, 1 [3.8%]) who completed the entire eDelphi process (eTable 2 in Supplement 1 ). Of these participants, 8 (30.8%) identified as men and 18 (69.2%) as women; 10 (38.5%) as Asian or Asian American; 5 (19.2%) as Black or African American; 4 (15.4%) as Hispanic or Latino; 1 (3.8%) each as Native Hawaiian or Pacific Islander, Native American or Alaska Native; 7 (26.9%) as White; and 3 (11.5%) multiracial, other, and do not know or prefer not to say.

Activity 1 yielded 14 of the 98 statements as reaching initial consensus. After activity 2, 1 additional statement from the subgroup of 15 statements at 60% to 70% rated 7 to 9 reached consensus for a final consensus of 15 statements. Activity 3 yielded a final ranked order of those 15 statements (eTable 3 in Supplement 1 ).

Over 2 months, there were 4149 respondents to the survey. Bot detection identified 2970 entries for exclusion, leaving 1179 respondents who were eligible and consented to participate. The survey completion rate was 51.0% (601 of 1179 participants). We excluded 548 respondents who did not respond to the outcome question on statement ranking, leaving a total of 631 respondents (mean [SD] age, 45.5 [18.1] years) included for analysis. Most respondents identified as women (533 [84.5%]; 86 identified as men [13.6%] and 12 identified as nonbinary, other, or prefer not to say [1.9%]). A total of 62 (9.8%) respondents identified as Asian or Asian American, 53 (8.4%) as Black or African American, 62 (9.8%) as Hispanic or Latino, 8 (1.3%) as Native American or Alaska Native, 569 (90.2%) as non-Hispanic or Latino, 444 (70.4%) as White, 64 (10.1%) identified as multiracial, other, and not knowing or preferring not to say. The mean (SD) time since diagnosis was 24.7 (18.5) years ( Table 1 ).

More than 40% of participants (268 of 610 participants [43.9%]) reported having moderately severe AD vs 197 reporting mild AD (32.3%) and 105 reporting severe AD (17.2%). A total of 345 of 630 participants (54.8%) reported that their AD was currently flaring ( Table 1 ). The majority of participants (583 of 610 [95.6%]) described their general knowledge of AD as average or above average.

Consensus was reached for 12 of the 15 statements ( Figure 2 ). The 3 statements that did not reach consensus were “when I start thinking about my signs constantly,” “when my condition is unacceptable to me,” and “a change in my condition that causes me to make decisions about daily life activities that are out of the norm.” The 3 statements with the highest agreement were “when my symptoms take significantly more of my attention than normal,” “a worsening of physical symptoms associated with AD,” and “a worsening of itching associated with AD.” Ranking scores (that determine ranking order) are shown in Figure 3 . The statement “acute worsening of symptoms of AD” was ranked most important compared with the others (mean rank position, 3.2; 95% CI, 2.9-3.5), and “a worsening of physical symptoms associated with AD” was ranked the least important (mean rank position, 7.0; 95% CI, 6.6-7.4).

Consensus results were similar across most subgroups of interest. Subgroups that consistently did not reach consensus on statements agreed upon in the larger group were those whose AD was mild (clear at its worst severity), who completed some high school (compared with graduated high school or completed some postsecondary education), and who identified as Native American or Alaska Native. These subgroups had low numbers of respondents ( Table 1 ). The statement “when I lose my sense of control over my disease management” (eFigure 10 in Supplement 1 ) was close to the consensus cutoff in the overall survey population, but many subgroups did not reach consensus that it should be included.

Most participants (503 of 631 [79.7%]) reported that at least 1 previously published definition of AD flares did not resonate with them. More than half (334 of 631 [52.9%]) agreed with their HCP on what an AD flare is, and 334 of 631 (52.9%) reported that their definition of flare did not change over time. Few participants (30 of 616 [4.9%]) did not think a patient-centered definition would be useful for them; most reported that they would use the definition to communicate with an HCP (478 of 616 [77.6%]) and/or for themselves (416 of 616 [67.5%]) to self-manage their symptoms. Nearly half (303 of 616 [49.2%]) also indicated that they would want or expect to use a patient-centered definition to explain their condition to family and friends ( Table 2 ).

The modified eDelphi process and subsequent consensus survey of US adults living with AD used in this consensus survey study resulted in 12 statements that participants agreed are critical to a conceptualization of AD flare. Statements with the most agreement were symptoms taking more attention than normal, a worsening of physical symptoms, and a worsening of itching. Statements ranked as the most important to a definition were acute worsening of AD symptoms, a change in physical health that interrupts daily living, and an eruption on the body. In contrast to previously published definitions of flare that focused solely on increased intensity of signs and symptoms of AD, 14 , 17 , 24 , 25 participants in this study with lived experience with AD highlighted the importance of downstream consequences, including the increased attention required to manage the condition and interruption of daily activities. To improve communication and shared decision-making, clinicians should be aware of these discrepancies and elicit individual patients’ understanding of flare.

A term such as flare may seem like an intuitive concept for patients and HCPs to discuss when assessing and managing AD. The heterogeneous concepts that our study identified as critical to the definition of flare from the patient perspective indicate that flare as a single word may not convey a patient’s experience when communicating their disease state and treatment response with their HCP. Participants in our study emphasized detriments to quality of life, changes in lifestyle, and a sense of losing control over their disease as important to their conception of flare in addition to worsening of signs and symptoms. Clinician awareness of these concepts may increase empathy and understanding of the patient’s condition, build a foundation of trust, and motivate a shared management goal to regain lost control.

While we achieved consensus on 12 statements using rigorous consensus cutoffs defined a priori, even statements with the highest agreement were not deemed as critical by every participant, and some statements that did not meet the consensus threshold were believed to be critical for some participants. As such, HCPs should be aware that flare may not have the same meaning for each individual patient. Thus, during patient-HCP consultation, individualized discussion of a patient’s nuanced perspective on their flares may be necessary. The threshold for the patient’s labeling of flare may also be subject to change over time due to their ongoing disease process and lived experience.

These findings also have implications for clinical trials and clinical effectiveness research. The influential and holistic aspects of living with a chronic condition identified by patients should be taken into consideration, as care often extends beyond physical well-being into social and psychological domains and can further a shift in evidence-based medicine toward a more patient-centered approach. As we look to enhance our understanding of short- and long-term AD treatment benefits, additional efforts are needed to best characterize therapeutic effects on AD flares from the patient perspective.

Strengths of this study were its staged approach and use of granular focus groups among a small group of patients with AD, followed by a consensus exercise among a larger, diverse population. However, some limitations exist. Our findings may not be generalizable to all people with AD. eDelphi participants were members of NEA’s Ambassador program and, therefore, may have higher-than-average knowledge about AD and engagement with their disease. While the survey included a much larger pool of participants, the sample had a high proportion of people identifying as White and women and reporting high levels of education and average or above-average knowledge of AD. While one-third of survey participants reported having mild AD, there was a higher proportion of moderate to severe disease than in the general population, and responder bias may have yielded a population more engaged with their AD. Furthermore, our findings may not be generalizable to children or caregivers or to other countries.

In this consensus survey study, we identified statements that are critical to the definition of an AD flare from the patient perspective. Our findings may be useful in clinical practice to improve communication between patients and HCPs who may be using the term flare without a mutual understanding of its meaning. The findings may also be applied to the development of outcome measures focused on AD flares, which is an important treatment outcome for people with AD.

Accepted for Publication: July 3, 2024.

Published Online: September 11, 2024. doi:10.1001/jamadermatol.2024.3054

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License . © 2024 Drucker AM et al. JAMA Dermatology .

Corresponding Author: Wendy Smith Begolka, MBS, National Eczema Association, 505 San Marin Dr, Ste B300, Novato, CA 94945 ( [email protected] ).

Author Contributions: Ms Smith Begolka 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. Dr Drucker and Ms Thibau contributed equally to this work.

Concept and design: Drucker, Thibau, Dainty, Smith Begolka.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Drucker, Thibau, Mantell, Dainty, Wyke.

Critical review of the manuscript for important intellectual content: Drucker, Thibau, Mantell, Dainty, Smith Begolka.

Statistical analysis: Thibau, Mantell.

Obtained funding: Smith Begolka.

Administrative, technical, or material support: Thibau, Mantell.

Supervision: Dainty, Smith Begolka.

Conflict of Interest Disclosures: Dr Drucker reported receiving compensation from the British Journal of Dermatology , American Academy of Dermatology, and Canadian Dermatology Today and consultant fees from the National Eczema Association and Canadian Agency for Drugs and Technologies in Health. Ms Smith Begolka reported receiving personal fees paid to her institution from Pfizer, Sanofi, and Amgen outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by research grant 69690227 to the National Eczema Association from Pfizer.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: The authors acknowledge and are grateful for the patients with atopic dermatitis who participated in the focus groups to share their lived experience with the disease.

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

• TALKING POINTS
• RESEARCH AFRICA
• Newsletter Archive
• Website Archive
• Sign in / Join

AI and what it might mean for healthcare in SA

With varying degrees of success, artificial intelligence (AI) has begun to play the role of research assistant, radiologist, health educator and even therapist more than most of us realise, but with rapid advancements in the technology, the implications for healthcare, especially in countries like SA, are mixed.

Jesse Copelyn, writing in Spotlight , pinpoints the most immediate implications of these new technologies for healthcare in South Africa.

AI can perform various tasks that were previously the sole purview of qualified doctors, according to a growing body of research. For instance, several recent studies show that more tumours can be found during routine breast x-rays and colonoscopies when AI detection software assists in scanning images.

Other research has looked at whether large language models (along the lines of ChatGPT) can correctly diagnose patients after being given information such as their symptoms and medical history. Researchers at Google  tested this and found that an AI model that they developed could provide a list of possible diagnoses for real-world patients that were significantly more accurate than those offered by doctors who were given the same information.

This is just one study and by no means the last word, but even so, it seems likely that doctors will increasingly turn to such models to help them get diagnoses right.

And new developments aren’t just confined to diagnostics. For instance, various health services in the US now deploy chatbots that do everything from answering patients’ medical questions to booking their appointments.

In other cases, chatbots have even been developed to act as therapists, talking to patients via phone apps and providing them with techniques to overcome harmful thoughts. There are some signs that this kind of thing might be effective, but most studies in this area have been small, so whether it works is far from settled.

Meanwhile, various AI tools are being used for medical research. This includes Google DeepMind’s AlphaFold , which can predict the structure of protein molecules. An Oxford research team working to develop a more effective malaria vaccine used this software to model a crucial protein found in malaria parasites. This means researchers have more information about how to target the protein, which the parasite needs to reproduce.

The jury is still out on what exactly these various types of AI will mean for healthcare services and whether they will live up to the hype. For example, chatbots still occasionally generate false information, often with perfect confidence – such hallucinations can have devastating consequences in a healthcare context. It is unclear if, or when, this problem will be solved.

Chances are that some applications will become a day-to-day part of 21st-century healthcare, while others will fall by the wayside.

It is also still unclear what impact AI could make in health systems in developing countries. A technology that works well at a private hospital in the US may not always be appropriate for a rural Eastern Cape clinic with unreliable power supply. Some AI products will inevitably cross the divide and flourish – in fact, some already have.

We take a look at some examples.

AI is already helping to tackle TB

The area where AI appears to be making the biggest impact in South Africa is in screening TB – by some measures the country’s leading cause of death. The bacterial disease is usually tested by analysing sputum using a molecular test, typically in a lab. But because people who have TB in South Africa are often asymptomatic, many simply never get tested.

To get around this, screening initiatives have been developed in which health workers take vans containing mobile X-ray units to communities where the disease is prevalent. Residents then get a free chest X-ray, which can reveal if they have abnormal-looking lungs (even if they have no TB symptoms). If the X-ray is irregular, they are sent for a sputum test to confirm the diagnosis.

But while conducting the X-rays is simple enough, the next step is often where projects face a bottleneck. Dr Emily Wong, an infectious disease scientist at the African Health Research Institute , explains that “you have to interpret those chest X-rays, and usually that requires a doctor or even a radiologist, and (they) are very scarce in South Africa”.

In fact, the number of radiologists serving the public sector is currently a quarter of what’s required.

It’s here that AI comes in.

In 2021, a study published in The Lancet showed that a series of AI-based software applications were not only able to detect TB in X-ray images as accurately as experienced radiologists, but were outperforming them. When Wong and her colleagues tested one of these AI products in a TB screening project in KwaZulu-Natal, they found that the software was roughly as accurate as doctors.

Computer-aided detection

These AI-based tools, collectively known as computer-aided detection (CAD), typically work as follows: a digital X-ray image is captured on a computer. The CAD software analyses it and gives it an abnormality score ranging from zero to 100, where a higher number indicates an increased chance of TB.

Just as in the case of the radiologist, these scores aren’t definitive; a person with a low score might still have TB, there’s just a smaller chance that they do. Health workers decide on an appropriate threshold value (say 50) and anyone above that number is sent for a sputum test.

This threshold score is significant. If it’s set very low, say at five, then virtually everyone with TB will be sent for testing, but so will many other people with relatively normal, healthy lungs. This means expensive sputum tests and scarce laboratory capacity will get used up on people who didn’t need to be tested in the first place.

But if the threshold value is set too high – say at 95 – then more people with TB will be missed, since at more than 95, only the most extreme cases will result in testing.

In the 2021 study, it was found that at a threshold score of 60, the top-performing CAD tool, called qXR , captured 90% of TB cases, while 74% of TB-negative people were correctly categorised as negative (the remaining 26% were incorrectly identified as abnormal and sent for further testing).

By comparison, the human radiologists only captured about 89% of cases and classified 63% of the TB-negative people correctly (these values varied depending on the classifications used but they were always less accurate than the CAD).

Many of the CAD tools are based on deep learning, meaning they identify patterns in large amounts of data. For instance, CAD software is trained on thousands of chest X-ray images, each labelled as “indicating TB” or “healthy”.

As it’s fed more labelled data, the algorithm identifies various features associated with TB – for example, a more asymmetric chest X-ray image means a higher likelihood of the disease. It’s then tested on unlabelled data to see whether it can make accurate predictions.

Such models are quite different from large language models like ChatGPT – and while not perfect, they do not have the same problem with hallucinations.

How are these tools being used in South Africa?

In South Africa, CAD software is being used in various mobile chest X-ray programmes sponsored by international aid groups. Dr Jody Boffa, a scientist working at the TB Think Tank , which advises the Department of Health, said: “ Global Fund and USAid fund the machines, but then various implementing agencies (typically NGOs) are taking them out into the field.” In turn, the department “sets the rules” for how these programmes should operate.

Dr Elias Ramarumo, who works in the department monitoring these projects, said that 38 CAD software products had been procured by Global Fund, while eight were bought by USAid. Additionally, provincial Health Departments were “in a process of procuring digital X-ray units”, which would “come with CAD software”.

Currently, two CAD products are being bought by funders. One is CAD4TB, owned by Dutch company Delft , while the other is qXR by the Indian venture, Qure.AI . These products were the two top performers in the 2021 study, which tested five different tools.

Ramarumo said both companies are working with South African partners: Delft with Lomaen Medical and Qure.AI with Vertice MedTech .

Boffa said the products are being used in two kinds of screening programmes. In one, vans containing mobile X-ray devices are parked next to overburdened clinics, where people can have a CAD-assisted X-ray screening. In the second case, the vans are taken to “hotspot” communities and placed in areas “where people who are less likely to visit the clinic would be found”.

Before the vans arrive, project staff or community leaders “rally the area to let them know they’ll be coming”.

AI to help miners

While international funding agencies are the driving force behind AI-assisted screening in South Africa, the Department of Health says it’s also planning on using CAD software – not only for tackling TB but also for silicosis, the lung disease caused by breathing in silica, to which miners are often exposed. Unlike TB, there’s no lab test which confirms its presence – an analysis of a chest X-ray is final.

While there isn’t a cure for the disease, miners who are confirmed to have silicosis receive financial compensation from the Medical Bureau for Occupational Disease , run by the department.

It’s the bureau’s job to determine who deserves recompense. However, it hasn’t always been able to manage claims fast enough, says Professor Rodney Ehrlich, an occupational medicine specialist at UCT . “By about a decade ago, the completion backlog (of unpaid compensation claims) was more than 100 000, and all these paper files were piled up in back offices.”

Getting through claims requires enormous staffing capacity, he says, because a panel of doctors is required to analyse each X-ray image – the opinion of one doctor isn’t considered good enough.

It’s thus no surprise that the bureau is turning to AI, which has shown promise in this field, much like in TB screening. A 2022 study, published in the International Journal of Environmental Research , co-authored by Ehrlich analysed the ability of CAD software to detect silicosis and TB in chest X-ray images of North West gold miners.

Despite concerns that the AI would not be able to distinguish between the two diseases – which can have similar presentations in X-ray images – the CAD products were able to make similar classifications to those made by doctors.

The Health Department and its partners hosted a workshop in June which was designed to “forge a way towards harnessing AI” for silicosis and TB screening in “mining, peri mining and labour-sending communities of SA”, says Ramarumo.

The event included academics, CAD companies, the WHO as well as health departments from the Southern African Development Community.

Ramarumo says it was agreed that “the adoption of CAD systems for TB and silicosis in the mining sector is essential to enhance diagnostic accuracy, improve patient outcomes, enhance the compensation process and reduce the financial burden on the (mining) industry”.

The right data?

While researchers who spoke to Spotlight are excited about the capacity of AI to make our public health system more efficient, hosts of issues must be overcome with the tech. One is that the data used to train AI are not always appropriate for our current context.

For instance, these days, screening programmes in the country often try to find TB-positive people who do not yet have symptoms – as they are often already infectious and at risk of falling ill. But for a long time such “subclinical” TB didn’t accord with our traditional understanding of the disease.

Wong says that “the original paradigm… is that someone with TB is highly symptomatic – they have fevers, they’ve been coughing for weeks, lost a lot of weight, they’re sick – they’ve now come to seek care and they’ve been diagnosed with TB”.

The result? When CAD is trained on banks of chest X-rays, the images labelled “TB” will be from people who were highly symptomatic, says Wong. As such, the CAD software only learns to associate the disease with more extreme cases.

This can have practical consequences. When Wong and her colleagues used CAD for a screening programme in KwaZulu-Natal, they began by sending anyone with a CAD abnormality score above 60 for a test – in line with what had worked elsewhere.

Yet as the research continued, it became clear that many patients with subclinical TB were being missed because many had scores below that level. This forced them to use a much lower threshold to detect these cases, which as noted comes with trade-offs since many healthy people then get sent for testing.

It is likely that, as AI is rolled out in other healthcare contexts in South Africa, more of these nuances will emerge.

New regulations needed?

A related issue is that the data on which CAD is trained are often proprietary. Companies making the software aren’t obliged to share information about where their data come from or how their algorithms change when new versions come out.

In response, Wong and her colleagues released a statement in 2023 which called for “regulation to require CAD-developing companies to communicate changes between software versions”.

And this isn’t the only area where regulation appears to be lagging.

In this country, medical devices are technically regulated by the SA Health Products Regulatory Authority (Sahpra). But a 2022 journal article in SA Biotech Law argued that existing legislation is outdated for reviewing AI-based technologies.

In particular, the paper argues, is that the safety and efficacy of a device is supposed to be reviewed according to “predefined static specifications and standards”. For instance, a defibrillator might be assessed on how well it performs a specific function, and reviewers know that a given model would work in the same way over time.

However, the function of an AI-based chatbot is broader – it provides answers to different kinds of questions depending on what it’s asked – and its responses may change over time as it is fed more data. Assessing the technology thus becomes more difficult.

Asked about this problem, Sahpra’s communications officer, Nthabi Moloi, said the body “has not commenced with the registration of medical devices” so this is presumably not yet a problem (though Sahpra does sometimes use backdoor routes to review devices).

The way forward

Nevertheless, researchers say these are exciting times, and it appears that both international funders and the government are taking significant strides to use AI to address some of the country’s most devastating diseases.

Speaking about the recent workshop on the use of CAD tools for silicosis and TB screening, Zhi Zhen Qin, a digital health specialist at the United Nations Office for Project Service , says she was “impressed by the vision” of the conference organisers. By aiming to use AI to screen for both TB and silicosis at the same time – instead of viewing them as separate problems – “the South African government has been filling a much-needed leadership gap”.

In coming years, the role of AI in our health system might, of course, stretch far beyond TB and silicosis. But judging by our messy health data landscape, we are not ready for the transition.

While the Western Cape Department of Health & Wellness and the National Health Laboratory Service have done impressive work, our health data systems, generally, remain patchy and fragmented. This will make it more difficult to train and deploy locally appropriate AI solutions.

Whether new digital infrastructure being developed under the banner of NHI will solve the problem is debatable.

As with electronic data systems, building and deploying AI capacity in the public health system will not be easy. Patient data will have to be kept secure, systems will have to be interoperable, and rather than outsourcing everything to software vendors, the state will need to build at least some internal technical capacity – at the very least the government needs people with the technical expertise to know whether we are buying the right products.

In a country where hundreds of thousands of rands have been wasted on very simple websites, this can unfortunately not be taken for granted.

Large language models (LLMs)

Further afield, meanwhile, the European Medicines Agency (EMA) and the Heads of Medicines Agencies (HMA) have recently published high-level principles and recommendations for all staff across the European medicines regulatory network (EMRN) using large language models (LLMs) in their work.

LLMs are a category of generative AI, focusing on text generation. The applications can significantly support medicine regulators in their tasks and processes.

Whether they are used to query the extensive documentation regulators routinely receive, to automate knowledge/data mining processes, or as virtual AI assistants in everyday administrative tasks, LLMs have enormous transformative potential.

However, they also present challenges, e.g, variability in results, returning of irrelevant or inaccurate responses (so-called hallucinations), and potential data security risks.

The purpose of the guiding principles is to build understanding of the capabilities and limitations of these applications among staff at regulatory agencies across the EU so that they can harness the potential of LLMs effectively and avoid pitfalls.

The guiding principles cover various aspects of using LLMs, from ensuring safe input of data, to applying critical thinking and cross-checking outputs, to knowing whom to consult when concerns arise.

Additionally, the principles encourage regulatory agencies to support their staff in using LLMs. This includes defining governance on their use, specifying permitted use cases, providing training and monitoring risks.

The guiding principles are one of the deliverables of the multi-annual AI work-plan to 2028 by EMA and the HMA, and the living document will be regularly updated.

The Lancet article – Tuberculosis detection from chest x-rays for triaging in a high tuberculosis-burden setting: an evaluation of five artificial intelligence algorithms (Open access)

Int Journal of Environmental Research & Public Health article – Accuracy of Computer-Aided Detection of Occupational Lung Disease: Silicosis and Pulmonary Tuberculosis in Ex-Miners from the South African Gold Mines (Open access)

HHS article – Artificial intelligence in healthcare: Proposals for policy development in South Africa (Open access)

Spotlight article – InTheSpotlight — beyond the hype, what might AI actually mean for healthcare in SA? (Creative Commons Licence)

EMA article – Harnessing AI in medicines regulation: use of large language models (LLMs) (Open acess)

EMA Guiding Principales (Open access)

See more from MedicalBrief archives:

Ethical dilemmas as medicine intersects with AI chatbots

OECD: How artificial intelligence could change the future of health

WHO issues AI regulatory list

• African Health Research Institute
• artificial intelligence (AI)
• computer-aided detection (CAD)
• Department of Health
• Dr Elias Ramarumo
• Dr Emily Wong
• Dr Jody Boffa
• European Medicines Agency (EMA)
• European medicines regulatory network (EMRN)
• Global Fund
• Google DeepMind
• Heads of Medicines Agencies (HMA)
• large language models (LLMs)
• Lomaen Medical
• Medical Bureau for Occupational Disease
• National Health Laboratory Service (NHLS)
• Nthabi Moloi
• Professor Rodney Ehrlich
• radiologists
• SA Health Products Regulatory Authority (Sahpra)
• TB Think Tank
• United Nations Office for Project Service
• Vertice MedTech
• Western Cape Department of Health and Wellness
• Zhi Zhen Qin

RELATED ARTICLES

Major who review finds no link between phones and brain cancer, ai diagnosis based on tongue colour, minister targets dodgy lawyers as siu probes r30bn medico-legal claims, medicalbrief — our free weekly e-newsletter.

We'd appreciate as much information as possible, however only an email address is required.

Country South Africa United States of America Aaland Islands Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey (Channel Islands) Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of Kosovo Reunion Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa (Independent) San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Korea South Sudan Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay USA Minor Outlying Islands Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe

MedicalBrief is Africa’s authoritative weekly digest of medical matters, both on the continent and around the world. It brings you a succinct summary of the latest developments, both in news and research, with links to the original material. Contact us: [email protected]

QUICK LINKS

• Advertising
• Editorial Policy
• Terms and Conditions
• Privacy Policy

Privacy Overview