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PwC's purpose is to "build trust in society and solve important problems." Our Partners and staff demonstrate a commitment to this purpose every day in the work we do with our Health Services clients. We do so because of a deep and passionate recognition of the importance of health to society - because health matters. The following case studies are an example of just a few engagements that show our strong desire to make a difference.

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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, case library.

The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives.

Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or browse the case collections below for our newest cases, cases available for free download, or cases with a focus on diversity.

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Access to cases.

Many of our cases are available for sale through Harvard Business Publishing in the Harvard T.H. Chan case collection . Others are free to download through this website .

Cases in this collection may be used free of charge by Harvard Chan course instructors in their teaching. Contact Allison Bodznick , Harvard Chan Case Library administrator, for access.

Access to teaching notes

Teaching notes are available as supporting material to many of the cases in the Harvard Chan Case Library. Teaching notes provide an overview of the case and suggested discussion questions, as well as a roadmap for using the case in the classroom.

Access to teaching notes is limited to course instructors only.

Teaching notes for cases available through Harvard Business Publishing may be downloaded after registering for an Educator account .
To request teaching notes for cases that are available for free through this website, look for the "Teaching note available for faculty/instructors " link accompanying the abstract for the case you are interested in; you'll be asked to complete a brief survey verifying your affiliation as an instructor.

Using the Harvard Business Publishing site

Faculty and instructors with university affiliations can register for Educator access on the Harvard Business Publishing website, where many of our cases are available . An Educator account provides access to teaching notes, full-text review copies of cases, articles, simulations, course planning tools, and discounted pricing for your students.

What's New

Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country.

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department. The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center.

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods.

Yatsko, P. & Koh, H. , 2021. Dr. Joan Reede and the Embedding of Diversity, Equity, and Inclusion at Harvard Medical School , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

Cases Available for Free Download

Guyer, A.L., Wirtz, V.J. & Reich, M.R. , 2019. Monitoring and Evaluation for the Novartis Access Initiative , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is located within the multinational pharmaceutical company Novartis, as key managers decide what kind of monitoring and evaluation to implement for one of its social business programs, Novartis Access . This new program will expand the company’s reach into traditionally underserved markets in low- and middle-income countries using a basket of 15 medicines for non-communicable diseases offering them at public and faith-based facilities at a lower price than sold in the private market. Novartis Access is being launched in late 2015 in Kenya, with a long-term goal of operating in 30 countries. The case focuses on Michael Fürst, Senior Manager for Corporate Responsibility Strategy and Innovation, who must prepare a plan for monitoring and evaluation for Novartis Access to present to Harald Nusser, Head of Novartis Social Business. In order to prepare for his first meeting with Harald Nusser, Michael Fürst needs to identify the value and risks of monitoring and evaluating (and their differences) and make a proposal about what kind of monitoring and evaluation to adopt (if any), and how to overcome internal and external challenges.

Kane, N.M. & Perry, M. , 2008. Fish: Here's the Catch , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Download free of charge Abstract In January 2003, Dr. David Acheson, the new Chief Medical Officer of Health of the FDA was charged by his boss with working jointly with the EPA to develop a comprehensive set of federal guidelines for fish consumption for all Americans. The guidelines needed to balance the benefits of fish consumption with the potential risks of exposure to mercury, dioxin, and PCBs - exposures of particular concern to pregnant women and young children. The case includes an additional document entitled Mercury and Fish Consumption that provides background material and reviews of studies of mercury exposure.

Cash, R., et al. , 2009. Casebook on ethical issues in international health research , World Health Organization. Publisher's Version Abstract This casebook published by the World Health Organization contains 64 case studies, each of which raises an important and difficult ethical issue connected with planning, reviewing, or conducting health-related research. Available for download free of charge from the World Health Organization in English, Arabic, Russian, and Spanish.

This teaching case study examines psychological trauma in a community context and the relevance, both positive and negative, of social determinants of health. Healthy People 2020 views people residing in communities with large-scale psychological trauma as an emerging issue in mental health and mental health disorders (Healthy People, 2016). The case study, which focuses on Newark, New Jersey, addresses three of the five key determinants of health: social and community context, health and health care, and neighborhood and built environment. The three key determinants are addressed using psychological trauma as an exemplar in the context of trauma-informed systems. The social and community context is addressed using concepts of social cohesion, civic participation, and discrimination. Access to health and health care are addressed with discussion of access to mental health and primary care services, health literacy, and the medical home model. Neighborhood and built environment are viewed through the lens of available government and NGO programs and resources to improve the physical environment with a focus on quality of housing, crime and violence, and environmental conditions. Upstream interventions designed to improve mental health and well-being that support trauma-informed systems are analyzed. The use of Newark as the case study setting allows a real-life exploration of each of these three key determinants of health.

This case study has four sections – introduction, case study, side bar, and vignettes. Learners should work through the case, access appropriate resources, and work in a team for successful completion.

Chai, J., Gordon, R. & Johnson, P. , 2013. Malala Yousafzai: A Young Female Activist , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case traces the story of Malala Yousafzai who has advocated passionately for girls’ right to education. In October 2012, a militant group with ties to the Taliban shot 14-year-old Yousafzai in the head as she was riding the school bus home after a day of classes. Yousafzai recovered and became the youngest recipient of the Nobel Peace Prize in 2014. This case explores the social factors that made such an attack possible and why there continue to be such barriers to educational opportunities for girls. "Malala Yousafzai: A Young Female Activist" is a part of a case series on violence against women that illustrate the critical role for leadership through an examination of how factors within a society influence women’s health. Students analyze the situations described by considering the circumstances that placed each protagonist in vulnerable positions. Participants examined the commonalities and differences of these situations in an effort to understand the circumstances that affect women’s well-being. Additionally, using the cases as a framework, students analyzed the connections between collective outrage, reactive action, and leadership.

Focus on Diversity, Equity, and Inclusion

Al Kasir, A., Coles, E. & Siegrist, R. , 2019. Anchoring Health beyond Clinical Care: UMass Memorial Health Care’s Anchor Mission Project , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract As the Chief Administrative Officer of UMass Memorial Health Care (UMMHC) and president of UMass Memorial (UMM) Community Hospitals, Douglas Brown had just received unanimous and enthusiastic approval to pursue his "Anchor Mission" project at UMMHC in Worcester, Massachusetts. He was extremely excited by the board's support, but also quite apprehensive about how to make the Anchor Mission a reality. Doug had spearheaded the Anchor Mission from its earliest exploratory efforts. The goal of the health system's Anchor Mission-an idea developed by the Democracy Collaborative, an economic think tank-was to address the social determinants of health in its community beyond the traditional approach of providing excellent clinical care. He had argued that UMMHC had an obligation as the largest employer and economic force in Central Massachusetts to consider the broader development of the community and to address non-clinical factors, like homelessness and social inequality that made people unhealthy. To achieve this goal, UMMHC's Anchor Mission would undertake three types of interventions: local hiring, local sourcing/purchasing, and place-based community investment projects. While the board's enthusiasm was palpable and inspiring, Doug knew that sustaining it would require concrete accomplishments and a positive return on any investments the health system made in the project. The approval was just the first step. Innovation and new ways of thinking would be necessary. The bureaucracy behind a multi-billion-dollar healthcare organization would need to change. Even the doctors and nurses would need to change! He knew that the project had enormous potential but would become even more daunting from here.

Johnson, P. & Gordon, R. , 2013. Hauwa Ibrahim: What Route to Change? , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case explores Nigerian attorney Hauwa Ibrahim’s defense of a woman charged with adultery by Islamic Shariah law. One of Nigeria’s first female lawyers, Ibrahim develops a strategy to defend a young married woman, Amina Lawal, against adultery charges that could potentially, if the court judged against her, result in her death. While many Western non-governmental organizations and advocacy groups viewed Lawal’s case as an instance of human rights abuse and called for an abolition of the Shariah-imposed punishment, Ibrahim instead chose to see an opportunity for change within a system that many – especially cultural outsiders – viewed as oppressive. Ibrahim challenged the dominant paradigm by working within it to create change that would eventually reverberate beyond one woman’s case. Willing to start with a framework that saw long-term opportunity and possibility, Ibrahim developed a very measured change approach and theory framed in seven specific principles. Additionally, Ibrahim’s example of challenging her own internal paradigms while also insisting that others do the same invites students to examine their own internal systems and paradigms.

Yatsko, P. & Koh, H. , 2017. Dr. Jonathan Woodson, Military Health System Reform, and National Digital Health Strategy , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Dr. Jonathan Woodson faced more formidable challenges than most in his storied medical, public health, and military career, starting with multiple rotations in combat zones around the world. He subsequently took on ever more complicated assignments, including reforming the country’s bloated Military Health System (MHS) in his role as assistant secretary of defense for health affairs at the U.S. Department of Defense from 2010 to 2016. As the director of Boston University’s Institute for Health System Innovation and Policy starting in 2016, he devised a National Digital Health Strategy (NDHS) to harness the myriad disparate health care innovations taking place around the country, with the goal of making the U.S. health care system more efficient, patient-centered, safe, and equitable for all Americans. How did Woodson—who was also a major general in the U.S. Army Reserves and a skilled vascular surgeon—approach such complicated problems? In-depth research and analysis, careful stakeholder review, strategic coalition building, and clear, insightful communication were some of the critical leadership skills Woodson employed to achieve his missions.

This module will present two unfolding case studies based on real-world, actual events. The cases will require participants to review videos embedded into three modules and a summary module: Introduction to Concepts of Social Determinant of Health and Seeking Racial Equity Case Study on Health and Healthcare Context - Greensboro Health Disparities Collaborative (GHDC) Case Study on Social and Community Context - Renaissance Community Cooperative (RCC) Summary (Optional)

The learning objectives for the modules are related to achieving the Healthy People 2020 Social Determinants of Health Objectives – specifically the (1) Health and Healthcare Context, and (2) Social and Community Context.

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Browse our case library

Sirali, Y. & Bhabha, J. , 2016. Turkey’s Child Protection Crisis and the Mother Child Education Foundation (Anne Çocuk Eğitim Vakfı—AÇEV), Parts A & B , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract While violence against children in Turkey was widespread, people across the country were shocked by the news of seven atrocious child molestation cases,one after another over the course of a week in April 2010. Ayşen Özyeğin, Founder and President of the Mother Child Education Foundation (in Turkish, Anne Çocuk Eğitim Vakfı—AÇEV), a nonprofit organization devoted to supporting disadvantaged children and their families and promoting early childhood education, called a Board meeting to discuss whether the organization should assume a role in addressing the child protection crisis. ACEV’s leaders prepared to present recommendations to their fellow Board Members and to consider decisions critical for both the agency’s future and for Turkey’s children.

This case describes and explores the development of the first medical transitions clinic in Louisiana by a group of community members, health professionals, and students at Tulane Medical School in 2015. The context surrounding health in metro New Orleans, the social and structural determinants of health, and mass incarceration and correctional health care are described in detail. The case elucidates why and how the Formerly Incarcerated Transitions (FIT) clinic was established, including the operationalization of the clinic and the challenges to providing healthcare to this population. The case describes the central role of medical students as case managers at the FIT clinic, and how community organizations were engaged in care provision and the development of the model. The case concludes with a discussion of the importance of advocacy amongst health care professionals.

Teaching note available for faculty/instructors .

Reich, M. , 2014. Mexico: Negotiating Health Reform , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract In April 2003, Dr. Julio Frenk, the Minister of Health of Mexico, prepared for the debate on his health reform bill to begin in the Senate. Since becoming Minister of Health in President Vicente Fox’s administration in 2000, Dr. Frenk had worked tirelessly to build support for his vision of health reform and his goals of re-structuring the health care system in Mexico and providing universal access to care for 50 million uninsured in Mexico. The Senate debate on his bill was a rare political opportunity to fundamentally transform Mexico’s health system. Dr. Frenk had to figure out how to deal with the opposition to his reform and how to get his bill adopted by the Mexican Congress.

Quelch, J.A. & Rodriguez, M.L. , 2015. Mérieux NutriSciences: Marketing Food Safety Testing , Harvard Business Publishing. Available from Harvard Business Publishing

Singer, S. , 2013. Surgical Safety Simulation Exercise , Harvard T.H. Chan School of Public Health. Abstract In this simulation exercise, students are given the opportunity to think critically about the role of motivation and organizational context in implementing a process innovation. Students work in teams of four to six people to develop recommendations for a hospital president on the best ways to implement a surgical safety checklist. Simulation available upon request from author .

In the aftermath of the atrocities endured by the Cambodian people, Friends-International (FI) was established in 1994 to address some of the many protection needs faced by the country’s marginalized children and youth. In the intervening quarter century, FI has grown substantially, both in the scope and complexity of its operations. The organization’s core mission consists of providing comprehensive, innovative, and high quality services to children, youth, and their families, based on a child rights-based approach that informs all of the organization’s programs. FI has established a strong and highly respected presence in Cambodia, building social services for children, operating effective social businesses , and initiating the global ChildSafe Movement. Over time , they have expanded their community-based model to multiple countries. But amidst their expansion, FI has continued to face financial insecurity and a constantly shifting landscape of challenging child protection concerns. At what point might they have been trying to do too much, possibly unduly stretching themselves across too many sectors and borders? Innovation had been a core strength of FI, but was it always appropriate to innovate? The case addresses these common problems.

Wang, M. , 2017. Sugary Drink Legislation in Massachusetts , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract In the fall of 2016, with the January 2017 deadline to file bills fast approaching, State Senator Jason Lewis was contemplating the details of a sugary drink legislative proposal in the Commonwealth of Massachusetts. Senator Lewis had a particular interest in legislative efforts to contain healthcare costs and prevent chronic disease through prevention and wellness approaches. He was particularly concerned about the rising levels of sugary drink consumption and associated conditions of obesity, diabetes, and dental caries, considering such drinks “a uniquely toxic food.” As an experienced legislator he knew he was facing a tough battle and wanted to take an approach that would give the bill the best chance of succeeding. Senator Lewis explained, “Massachusetts should be leading the legislative effort to reduce sugary drink consumption in the Northeast. Significant opposition from the beverage industry is expected, but we have a real chance of making progress at the local and state levels.”

Welcome To Open Case Studies

Connecting you with real-world public health data.

The Open Case Studies project showcases the possibilities of what can be achieved when working with real-world data.

Housed in a freely accessible GitHub repository, the project’s self-contained and experiential guides demonstrate the data analysis process and the use of various data science methods, tools, and software in the context of messy, real-world data.

These case studies will empower current and future data scientists to leverage real-world data to solve leading public health challenges.

Who Are Open Case Studies For?

Your experiential guide to the power of data analysis.

The Open Case Studies project provides insights about gathering and working with data for students, instructors, and those with experience in data science or statistical methods at nonprofit organizations and public sector agencies.

Each case study in the project focuses on an important public health topic and introduces methods to provide users with the skills and knowledge for greater legibility, reproducibility, rigor, and flexibility in their own data analyses.

Case Study Bank Overview

Real data on ten public health challenges in the U.S.

The following in-depth case studies use real data and focus on five areas of public health that are particularly pressing in the United States.

Vaping Behaviors in American Youth

This case study explores the trends of tobacco product usage among American youths surveyed in the National Youth Tobacco Survey (NYTS) from 2015-2019. It demonstrates how to use survey data and code books and provides an introduction to writing functions to wrangle similar but slightly different data repetitively. The case study introduces packages for using survey weighting and survey design to perform an analysis to compare vaping product usage among different groups, and covers how to use a logistic regression to compare groups for a variable that is binary (such as true or false — in this case it was using vaping products or not). This case study also covers how to make visualizations of multiple groups over time with confidence interval error bars.

Opioids in the United States

This case study examines the number of opioid pills (specifically oxycodone and hydrocodone, as they are the top two misused opioids) shipped to pharmacies and practitioners at the county-level around the United States from 2006 to 2014 using data from the Drug Enforcement Administration (DEA). This case study demonstrates how to get data from a source called an application programming interface (API). It explores why and how to normalize data, as well as why and how to potentially stratify or redefine groups. It also shows how to compare two independent groups when the data is not normally distributed using a test called the Wilcoxon rank sum test (also called the Mann Whitney U test) and how to add confidence intervals to plots (using a method called bootstrapping).

Disparities in Youth Disconnection

This case study focuses on rates of youth (people between 16-24) disconnection (those who are neither working nor in school) among different racial, ethnic and gender subgroups to identify subgroups that may be particularly vulnerable. It demonstrates that deeper inspection of subgroups yields some differences that are not otherwise discernable, how to import data from a PDF using screenshots of sections of the PDF, and how to use the Mann-Kendall trend test to test for the presence of a consistent direction in the relationship of disconnection rates with time. This case study also shows how to make a visualization that stylistically matches that of an existing report, how to add images to plots, and how to create effective bar plots for multiple comparisons across several groups.

Mental Health of American Youth

This case study investigates how the rate of self-reported symptoms of major depressive episodes (MDE) has changed over time among American youth (age 12-17) from 2004-2018. It describes the impact of self-reporting bias in surveys, how to get data directly from a website, as well as how to compare changes in the frequency of a variable between two groups using a chi-squared test to determine if two variables are independent (in this case if the sex of the students influenced the frequency of reported MDE symptoms in 2004 and 2018). This case study also demonstrates how to create direct labels on visualizations with many groups across time, as well as how to create an animated gif.

Exploring CO2 Emissions Across Time

This case study investigates how CO2 emissions have changed since the 1700s and how the level of emissions has compared for different countries around the world. It explores how yearly average temperature and the number of natural disasters in the United States has changed over time and provides an introduction for examining if two sets of data are correlated with one another. This case study also goes into great detail about how to make what are called heatmaps and other plots to visualize multiple groups over time. This includes adding labels directly to lines on plots with multiple lines.

Predicting Annual Air Pollution

This case study uses machine learning methods to predict annual air pollution levels spatially within the United States based on data about population density, urbanization, road density, as well as satellite pollution data and chemical modeling data among other predictors. Machine learning methods are used to predict air pollution levels when traditional monitoring systems are not available in a particular area or when there is not enough spatial granularity with current monitoring systems. The case study also demonstrates how to visualize data using maps.

Exploring Global Patterns of Obesity Across Rural and Urban Regions

This case study compares average Body Mass Index measurements for males and females from rural and urban regions from over 200 countries around the world, with a particular emphasis on the United States. It provides a thorough introduction to wrangling data from a PDF, how to compare two paired groups using the t test and the nonparametric Wilcoxon signed-rank test using R programming, and how to make visualizations of group comparisons that emphasize a particular subset of the data.

Exploring Global Patterns of Dietary Behaviors Associated with Health Risk

This case study investigates the consumption of dietary factors associated with health risk among males and females from over 200 countries around the world, with a particular emphasis on the United States. It demonstrates how to wrangle data from a PDF; how to combine data from two different sources; how to compare two paired groups and multiple paired groups using t-tests, ANOVA, and linear regression; and how to create visualizations of several groups and how to combine plots together with very different scales.

Influence of Multicollinearity on Measured Impact of Right-To-Carry Gun Laws

This case study focuses on two well-known studies that evaluated the influence of right-to-carry gun laws on violent crime rates. It demonstrates a phenomenon called multicollinearity, where explanatory variables that can predict one another can lead to aberrant and unstable findings; how to make visualizations with labels, such as arrows or equations; and how to combine multiple plots together.

School Shootings in the United States

This case study illustrates ways to communicate trends in a dataset about the number and characteristics of school shooting events for students in grades K-12 in the United States since 1970. It demonstrates how to create a dashboard, which is a website that shows patterns in a dataset in a concise manner; how to import data from a Google Sheets document; how to create interactive tables and maps; and how to properly calculate percentages for data when there are missing values.

Which Case Study Is Right For Me?

Connecting with the public health data you need.

The Open Case Studies project approaches data in many different ways. The guide below will help connect you with a case study:

Data science projects often start with a question. Here, you may look for case studies that explore a question that is similar to one you are interested in investigating with your data.

How does something change over time?

Investigating how a variable has changed over time can help identify consistent trends.

How do survey responses compare for different groups over time?

Survey data requires special care and attention to the survey design.

How do groups compare?

Public health researchers are often interested to know if one group is more vulnerable than another or if two or more groups are actually different from one another.

How do groups compare over time?

Comparing several groups over time can provide insight into if the change over time is different for different groups.

How do paired groups compare?

Paired groups are those that are not independent in some way. Perhaps you want to know how data from the same person over time compares with that of another person over time, or perhaps you are interested in how something changed in a city before and after an intervention, or perhaps you want to compare groups using data that has structure where there is coupling or matching of data values across samples.

Are certain groups or possibly subgroups more vulnerable?

Understand how to compare subpopulations at a deeper level.

How does something compare across regions?

Often it is useful to investigate if data differs by region, as many environmental, cultural, and political differences can influence public health outcomes.

How can I predict outcomes for new data?

Learn how the data might look next year or for locations that you don’t have data about.

Does this influence my data?

Analyze how a variable influences another variable.

Are these two variables related to one another?

Understand how two variables are related and how strongly they are related to one another.

How can I display this data for others to find and interpret and use easily?

Make it easy for others to find your data, see the major trends in your data, or search for specific values in your data.

Data can come from many different sources, from the more obvious like an excel file to the less obvious like an image or a website. These case studies demonstrate how to use data from a variety of possible sources.

Using data from a PDF or just parts of a PDF can be challenging. You could type the data into a new excel file, but this can result in mistakes and it is difficult to reproduce.

Data are often in CSV files and it is typically easy to import data and work with data in this form. However, sometimes it can be difficult if, for example, the first few lines are structured differently or if you have unusual missing value indicators.

If you find data on a website that doesn’t allow you to download in a convenient way, you can actually directly import the data into R programming language.

This is one of the most common data forms, and it is typically easy to import data and work with data in this form. However, sometimes it can be challenging, especially if you have many files.

You can extract text from image files. This can be useful if, for example, you want to only use certain parts of a PDF.

It is possible to find the data that you need to use from an application programming interface (API).

Google Sheet

You can download data from a Google Sheet, copy and paste it into Excel, or directly import the data into R programming language.

Survey data/Code books

Working with survey data requires special care and attention, and you can do this directly with R programming language.

Multiple files

If you find that you need to import data from multiple files, there is a more efficient way to do so without importing each one by one.

Data wrangling is the process of organizing your data in a more useful format. These case studies explore how to clean, rearrange, reshape, modify, filter, combine, or join your data.

Extracting data from a PDF

Extracting and organizing data from a PDF will make it easier to use.

Geocoding data

The process of assigning relevant latitude and longitude coordinates to data values is called geocoding. This can be helpful (although not always necessary) to create a map of your data.

Recoding data

If you have data values that are confusing and could be changed to something better, or if you want to convert your data to true or false, you might want to consider recoding these values.

Methods of joining data

Sometimes, you obtain data from multiple sources that need to be combined together.

Filtering data

Perhaps you need to filter your data for only specific values for given variables. In other words, you might want to filter census employment data to only values for females who are also Black and live in Connecticut.

Modifying data (normalizing, transforming, scaling etc.)

Sometimes it is difficult to know when or how to normalize data.

Working with text

You can work with, remove, replace, or change words, phrases, letters, numbers, or punctuation marks in your data.

Reshaping data

Sometimes it is useful to shape your data so that you have many columns (for example, when performing certain analyses), however it can be useful at other times (for example, when creating plots) to collapse multiple columns into fewer columns with more rows.

Repetitive process

Sometimes you need to wrangle multiple datasets from different sources in a similar manner.

A picture is worth a thousand words, particularly when it comes to interpreting data. These case studies demonstrate how to make effective visualizations in various contexts. The first ten represent basic visualizations while 11-22 are more advanced.

A table that is easy to interpret

Adding colors or simple graphics can make tables easier to interpret.

Scatter plot

Scatter plots can be a strong option for evaluating the relationship between variables, and especially for evaluating changes in a variable over time.

Line plots are often useful for evaluating changes over time.

Bar plots are a good choice if you want to compare data to a threshold.

Box plots are particularly useful for comparing groups with many data values. They provide information about the spread of the data.

Pie chart/waffle plot

Pie charts or waffle plots can be a strong option when comparing relative percentages.

It can be difficult to visualize multiple groups at simultaneously. In these situations, heat maps can be a great option.

Correlation plots

If you have many variables and need to know if they are correlated to one another, there are methods to efficiently check this.

Visualize missing data

It can be helpful to quickly identify how much of your data is missing (has NA values).

Create a map of your data

Often the best way to interpret regional differences in data is to make a map.

Advanced Visualizations

Matching a style

If you are working with collaborators, you can make your visualizations match the style of their figures.

Faceted plots allow you to quickly create multiple plots at once

It can be difficult to visualize multiple groups at the same time, so faceted plots are a great option in this situation.

Adding labels directly to plots with many different groups

If you compare many groups over time, for example, it can be difficult to see which line corresponds to which group. Adding labels directly to these lines can be very helpful and negates the need for an overcomplicated legend.

Emphasize a particular group

Sometimes you will have several different groups and you want to highlight a specific group.

Adding annotations to plots

Adding labels, such as thresholds, arrows, or equations, can make it easier for people to interpret your plot.

Add error bars to your plot

Adding error bars can help convey information about the confidence of the estimates in your plots.

Combine multiple plots together

Sometimes it is useful to put a variety of plots together and add text to explain what the plot shows.

Create an interactive plot when you have too many groups to label

If you compare a very large number of groups, it can be difficult to tell what is happening. Often it can help to make the plot interactive so that the user can hover over points or lines to see what they indicate.

Create an interactive map of your data

Sometimes it is easiest to see regional differences by interacting with and exploring an interactive map.

Create an interactive table of your data

Sometimes you might want to be able to search through your data or allow others to easily do so.

Add images to your figures

Including images to a plot, such as a logo, can be a helpful addition.

Create an interactive dashboard/website for your data

Dashboards can quickly convey major trends in a dataset, and they can also allow users to interact with the data to choose what aspects about the data they wish to explore.

To better understand data, it is helpful to use statistical tests. These case studies demonstrate a variety of statistical tests and concepts.

Are two groups different?

Correlation

Are two variables related to one another?

Are multiple groups different?

Linear regression

Would you like to compare groups?

Chi-squared test of independence

Do the frequencies of two groups suggest that they are independent?

Mann-Kendall Trend test

Is there a consistent change over time?

Machine learning

Would you like to predict data?

Calculate percentages with missing data?

Would you like to calculate percentages, but you are missing some data?

About The Project

Learn about the team behind the Open Case Studies project.

As part of the larger Open Case Studies project (OCS) at opencasestudies.org , these case studies were developed for and funded by the Bloomberg American Health Initiative. The OCS project is made up of a team of researchers at the Johns Hopkins Bloomberg School of Public Health (JHSPH).

Let us know how the Open Case Studies project has enhanced your educational curriculum or ability to tackle tough data-rich research projects.

JHSPH Faculty Contributors

Jessica Fanzo, PhD

Brendan Saloner, PhD

Megan Latshaw, PhD, MHS

Renee M. Johnson, PhD, MPH

Daniel Webster, ScD, MPH

Elizabeth Stuart, PhD

Bloomberg American Health Initiative

Joshua M. Sharfstein, MD – Director, Bloomberg American Health Initiative

Michelle Spencer, MS – Associate Director, Bloomberg American Health Initiative

Paulani Mui, MPH – Special Projects Officer, Bloomberg American Health Initiative

Other Contributors

Aboozar Hadavand, PhD, MA, MS, Minerva University

Roger Peng, PhD, MS, Johns Hopkins Bloomberg School of Public Health

Kirsten Koehler, PhD, MS, Johns Hopkins Bloomberg School of Public Health

Alex McCourt, PhD, JD, MPH, Johns Hopkins Bloomberg School of Public Health

Ashkan Afshin, MD, ScD, MPH, MSc, University of Washington and Institute for Health Metrics and Evaluation (IHME)

Erin Mullany, BA, Institute for Health Metrics and Evaluation (IHME)

External Review Panel

Leslie Myint, PhD, Macalester College

Shannon E. Ellis, PhD, University of California – San Diego

Christina Knudson, PhD, University of St. Thomas

Michael Love, PhD, University of North Carolina

Nicholas Horton, ScD, Amherst College

Mine Çetinkaya-Rundel, PhD, University of Edinburgh, Duke University, RStudio

Let Us Know How You're Using Open Case Studies

As the Open Case Studies project expands, we learn from you. Tell us what data you'd like to see, how you're using the data, or anything we can do to improve the project.

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

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

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 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 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

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

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

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 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 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 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 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

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 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 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 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 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 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 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

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, 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 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 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

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.

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.

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Writing a case report...

Writing a case report in 10 steps

Related content
Peer review
Victoria Stokes , foundation year 2 doctor, trauma and orthopaedics, Basildon Hospital ,
Caroline Fertleman , paediatrics consultant, The Whittington Hospital NHS Trust
victoria.stokes1{at}nhs.net

Victoria Stokes and Caroline Fertleman explain how to turn an interesting case or unusual presentation into an educational report

It is common practice in medicine that when we come across an interesting case with an unusual presentation or a surprise twist, we must tell the rest of the medical world. This is how we continue our lifelong learning and aid faster diagnosis and treatment for patients.

It usually falls to the junior to write up the case, so here are a few simple tips to get you started.

First steps

Begin by sitting down with your medical team to discuss the interesting aspects of the case and the learning points to highlight. Ideally, a registrar or middle grade will mentor you and give you guidance. Another junior doctor or medical student may also be keen to be involved. Allocate jobs to split the workload, set a deadline and work timeframe, and discuss the order in which the authors will be listed. All listed authors should contribute substantially, with the person doing most of the work put first and the guarantor (usually the most senior team member) at the end.

Getting consent

Gain permission and written consent to write up the case from the patient or parents, if your patient is a child, and keep a copy because you will need it later for submission to journals.

Information gathering

Gather all the information from the medical notes and the hospital’s electronic systems, including copies of blood results and imaging, as medical notes often disappear when the patient is discharged and are notoriously difficult to find again. Remember to anonymise the data according to your local hospital policy.

Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.

Coming up with a title

Discuss a title with your supervisor and other members of the team, as this provides the focus for your article. The title should be concise and interesting but should also enable people to find it in medical literature search engines. Also think about how you will present your case study—for example, a poster presentation or scientific paper—and consider potential journals or conferences, as you may need to write in a particular style or format.

Background research

Research the disease/pathology that is the focus of your article and write a background paragraph or two, highlighting the relevance of your case report in relation to this. If you are struggling, seek the opinion of a specialist who may know of relevant articles or texts. Another good resource is your hospital library, where staff are often more than happy to help with literature searches.

How your case is different

Move on to explore how the case presented differently to the admitting team. Alternatively, if your report is focused on management, explore the difficulties the team came across and alternative options for treatment.

Finish by explaining why your case report adds to the medical literature and highlight any learning points.

Writing an abstract

The abstract should be no longer than 100-200 words and should highlight all your key points concisely. This can be harder than writing the full article and needs special care as it will be used to judge whether your case is accepted for presentation or publication.

Discuss with your supervisor or team about options for presenting or publishing your case report. At the very least, you should present your article locally within a departmental or team meeting or at a hospital grand round. Well done!

Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare that we have no competing interests.

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

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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

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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.

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Case study research for better evaluations of complex interventions: rationale and challenges

Sara Paparini ORCID: orcid.org/0000-0002-1909-2481 1 ,
Judith Green 2 ,
Chrysanthi Papoutsi 1 ,
Jamie Murdoch 3 ,
Mark Petticrew 4 ,
Trish Greenhalgh 1 ,
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The need for better methods for evaluation in health research has been widely recognised. The ‘complexity turn’ has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research—currently denigrated as poor evidence—is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear.

Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. Empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. This is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. The health sciences have much to learn from scholarship on case study methodology in the social sciences. However, there are multiple challenges in fully exploiting the potential learning from case study research. First are misconceptions that case study research can only provide exploratory or descriptive evidence. Second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. Finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports.

Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.

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The need for methodological development to address the most urgent challenges in health research has been well-documented. Many of the most pressing questions for public health research, where the focus is on system-level determinants [ 1 , 2 ], and for health services research, where provisions typically vary across sites and are provided through interlocking networks of services [ 3 ], require methodological approaches that can attend to complexity. The need for methodological advance has arisen, in part, as a result of the diminishing returns from randomised controlled trials (RCTs) where they have been used to answer questions about the effects of interventions in complex systems [ 4 , 5 , 6 ]. In conditions of complexity, there is limited value in maintaining the current orientation to experimental trial designs in the health sciences as providing ‘gold standard’ evidence of effect.

There are increasing calls for methodological pluralism [ 7 , 8 ], with the recognition that complex intervention and context are not easily or usefully separated (as is often the situation when using trial design), and that system interruptions may have effects that are not reducible to linear causal pathways between intervention and outcome. These calls are reflected in a shifting and contested discourse of trial design, seen with the emergence of realist [ 9 ], adaptive and hybrid (types 1, 2 and 3) [ 10 , 11 ] trials that blend studies of effectiveness with a close consideration of the contexts of implementation. Similarly, process evaluation has now become a core component of complex healthcare intervention trials, reflected in MRC guidance on how to explore implementation, causal mechanisms and context [ 12 ].

Evidence about the context of an intervention is crucial for questions of external validity. As Woolcock [ 4 ] notes, even if RCT designs are accepted as robust for maximising internal validity, questions of transferability (how well the intervention works in different contexts) and generalisability (how well the intervention can be scaled up) remain unanswered [ 5 , 13 ]. For research evidence to have impact on policy and systems organisation, and thus to improve population and patient health, there is an urgent need for better methods for strengthening external validity, including a better understanding of the relationship between intervention and context [ 14 ].

Policymakers, healthcare commissioners and other research users require credible evidence of relevance to their settings and populations [ 15 ], to perform what Rosengarten and Savransky [ 16 ] call ‘careful abstraction’ to the locales that matter for them. They also require robust evidence for understanding complex causal pathways. Case study research, currently under-utilised in public health and health services evaluation, can offer considerable potential for strengthening faith in both external and internal validity. For example, in an empirical case study of how the policy of free bus travel had specific health effects in London, UK, a quasi-experimental evaluation (led by JG) identified how important aspects of context (a good public transport system) and intervention (that it was universal) were necessary conditions for the observed effects, thus providing useful, actionable evidence for decision-makers in other contexts [ 17 ].

The overall approach of case study research is based on the in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings. Empirical case studies typically enable dynamic understanding of complex challenges rather than restricting the focus on narrow problem delineations and simple fixes. Case study research is a diverse and somewhat contested field, with multiple definitions and perspectives grounded in different ways of viewing the world, and involving different combinations of methods. In this paper, we raise awareness of such plurality and highlight the contribution that case study research can make to the evaluation of complex system-level interventions. We review some of the challenges in exploiting the current evidence base from empirical case studies and conclude by recommending that further guidance and minimum reporting criteria for evaluation using case studies, appropriate for audiences in the health sciences, can enhance the take-up of evidence from case study research.

Case study research offers evidence about context, causal inference in complex systems and implementation

Well-conducted and described empirical case studies provide evidence on context, complexity and mechanisms for understanding how, where and why interventions have their observed effects. Recognition of the importance of context for understanding the relationships between interventions and outcomes is hardly new. In 1943, Canguilhem berated an over-reliance on experimental designs for determining universal physiological laws: ‘As if one could determine a phenomenon’s essence apart from its conditions! As if conditions were a mask or frame which changed neither the face nor the picture!’ ([ 18 ] p126). More recently, a concern with context has been expressed in health systems and public health research as part of what has been called the ‘complexity turn’ [ 1 ]: a recognition that many of the most enduring challenges for developing an evidence base require a consideration of system-level effects [ 1 ] and the conceptualisation of interventions as interruptions in systems [ 19 ].

The case study approach is widely recognised as offering an invaluable resource for understanding the dynamic and evolving influence of context on complex, system-level interventions [ 20 , 21 , 22 , 23 ]. Empirically, case studies can directly inform assessments of where, when, how and for whom interventions might be successfully implemented, by helping to specify the necessary and sufficient conditions under which interventions might have effects and to consolidate learning on how interdependencies, emergence and unpredictability can be managed to achieve and sustain desired effects. Case study research has the potential to address four objectives for improving research and reporting of context recently set out by guidance on taking account of context in population health research [ 24 ], that is to (1) improve the appropriateness of intervention development for specific contexts, (2) improve understanding of ‘how’ interventions work, (3) better understand how and why impacts vary across contexts and (4) ensure reports of intervention studies are most useful for decision-makers and researchers.

However, evaluations of complex healthcare interventions have arguably not exploited the full potential of case study research and can learn much from other disciplines. For evaluative research, exploratory case studies have had a traditional role of providing data on ‘process’, or initial ‘hypothesis-generating’ scoping, but might also have an increasing salience for explanatory aims. Across the social and political sciences, different kinds of case studies are undertaken to meet diverse aims (description, exploration or explanation) and across different scales (from small N qualitative studies that aim to elucidate processes, or provide thick description, to more systematic techniques designed for medium-to-large N cases).

Case studies with explanatory aims vary in terms of their positioning within mixed-methods projects, with designs including (but not restricted to) (1) single N of 1 studies of interventions in specific contexts, where the overall design is a case study that may incorporate one or more (randomised or not) comparisons over time and between variables within the case; (2) a series of cases conducted or synthesised to provide explanation from variations between cases; and (3) case studies of particular settings within RCT or quasi-experimental designs to explore variation in effects or implementation.

Detailed qualitative research (typically done as ‘case studies’ within process evaluations) provides evidence for the plausibility of mechanisms [ 25 ], offering theoretical generalisations for how interventions may function under different conditions. Although RCT designs reduce many threats to internal validity, the mechanisms of effect remain opaque, particularly when the causal pathways between ‘intervention’ and ‘effect’ are long and potentially non-linear: case study research has a more fundamental role here, in providing detailed observational evidence for causal claims [ 26 ] as well as producing a rich, nuanced picture of tensions and multiple perspectives [ 8 ].

Longitudinal or cross-case analysis may be best suited for evidence generation in system-level evaluative research. Turner [ 27 ], for instance, reflecting on the complex processes in major system change, has argued for the need for methods that integrate learning across cases, to develop theoretical knowledge that would enable inferences beyond the single case, and to develop generalisable theory about organisational and structural change in health systems. Qualitative Comparative Analysis (QCA) [ 28 ] is one such formal method for deriving causal claims, using set theory mathematics to integrate data from empirical case studies to answer questions about the configurations of causal pathways linking conditions to outcomes [ 29 , 30 ].

Nonetheless, the single N case study, too, provides opportunities for theoretical development [ 31 ], and theoretical generalisation or analytical refinement [ 32 ]. How ‘the case’ and ‘context’ are conceptualised is crucial here. Findings from the single case may seem to be confined to its intrinsic particularities in a specific and distinct context [ 33 ]. However, if such context is viewed as exemplifying wider social and political forces, the single case can be ‘telling’, rather than ‘typical’, and offer insight into a wider issue [ 34 ]. Internal comparisons within the case can offer rich possibilities for logical inferences about causation [ 17 ]. Further, case studies of any size can be used for theory testing through refutation [ 22 ]. The potential lies, then, in utilising the strengths and plurality of case study to support theory-driven research within different methodological paradigms.

Evaluation research in health has much to learn from a range of social sciences where case study methodology has been used to develop various kinds of causal inference. For instance, Gerring [ 35 ] expands on the within-case variations utilised to make causal claims. For Gerring [ 35 ], case studies come into their own with regard to invariant or strong causal claims (such as X is a necessary and/or sufficient condition for Y) rather than for probabilistic causal claims. For the latter (where experimental methods might have an advantage in estimating effect sizes), case studies offer evidence on mechanisms: from observations of X affecting Y, from process tracing or from pattern matching. Case studies also support the study of emergent causation, that is, the multiple interacting properties that account for particular and unexpected outcomes in complex systems, such as in healthcare [ 8 ].

Finally, efficacy (or beliefs about efficacy) is not the only contributor to intervention uptake, with a range of organisational and policy contingencies affecting whether an intervention is likely to be rolled out in practice. Case study research is, therefore, invaluable for learning about contextual contingencies and identifying the conditions necessary for interventions to become normalised (i.e. implemented routinely) in practice [ 36 ].

The challenges in exploiting evidence from case study research

At present, there are significant challenges in exploiting the benefits of case study research in evaluative health research, which relate to status, definition and reporting. Case study research has been marginalised at the bottom of an evidence hierarchy, seen to offer little by way of explanatory power, if nonetheless useful for adding descriptive data on process or providing useful illustrations for policymakers [ 37 ]. This is an opportune moment to revisit this low status. As health researchers are increasingly charged with evaluating ‘natural experiments’—the use of face masks in the response to the COVID-19 pandemic being a recent example [ 38 ]—rather than interventions that take place in settings that can be controlled, research approaches using methods to strengthen causal inference that does not require randomisation become more relevant.

A second challenge for improving the use of case study evidence in evaluative health research is that, as we have seen, what is meant by ‘case study’ varies widely, not only across but also within disciplines. There is indeed little consensus amongst methodologists as to how to define ‘a case study’. Definitions focus, variously, on small sample size or lack of control over the intervention (e.g. [ 39 ] p194), on in-depth study and context [ 40 , 41 ], on the logic of inference used [ 35 ] or on distinct research strategies which incorporate a number of methods to address questions of ‘how’ and ‘why’ [ 42 ]. Moreover, definitions developed for specific disciplines do not capture the range of ways in which case study research is carried out across disciplines. Multiple definitions of case study reflect the richness and diversity of the approach. However, evidence suggests that a lack of consensus across methodologists results in some of the limitations of published reports of empirical case studies [ 43 , 44 ]. Hyett and colleagues [ 43 ], for instance, reviewing reports in qualitative journals, found little match between methodological definitions of case study research and how authors used the term.

This raises the third challenge we identify that case study reports are typically not written in ways that are accessible or useful for the evaluation research community and policymakers. Case studies may not appear in journals widely read by those in the health sciences, either because space constraints preclude the reporting of rich, thick descriptions, or because of the reported lack of willingness of some biomedical journals to publish research that uses qualitative methods [ 45 ], signalling the persistence of the aforementioned evidence hierarchy. Where they do, however, the term ‘case study’ is used to indicate, interchangeably, a qualitative study, an N of 1 sample, or a multi-method, in-depth analysis of one example from a population of phenomena. Definitions of what constitutes the ‘case’ are frequently lacking and appear to be used as a synonym for the settings in which the research is conducted. Despite offering insights for evaluation, the primary aims may not have been evaluative, so the implications may not be explicitly drawn out. Indeed, some case study reports might properly be aiming for thick description without necessarily seeking to inform about context or causality.

Acknowledging plurality and developing guidance

We recognise that definitional and methodological plurality is not only inevitable, but also a necessary and creative reflection of the very different epistemological and disciplinary origins of health researchers, and the aims they have in doing and reporting case study research. Indeed, to provide some clarity, Thomas [ 46 ] has suggested a typology of subject/purpose/approach/process for classifying aims (e.g. evaluative or exploratory), sample rationale and selection and methods for data generation of case studies. We also recognise that the diversity of methods used in case study research, and the necessary focus on narrative reporting, does not lend itself to straightforward development of formal quality or reporting criteria.

Existing checklists for reporting case study research from the social sciences—for example Lincoln and Guba’s [ 47 ] and Stake’s [ 33 ]—are primarily orientated to the quality of narrative produced, and the extent to which they encapsulate thick description, rather than the more pragmatic issues of implications for intervention effects. Those designed for clinical settings, such as the CARE (CAse REports) guidelines, provide specific reporting guidelines for medical case reports about single, or small groups of patients [ 48 ], not for case study research.

The Design of Case Study Research in Health Care (DESCARTE) model [ 44 ] suggests a series of questions to be asked of a case study researcher (including clarity about the philosophy underpinning their research), study design (with a focus on case definition) and analysis (to improve process). The model resembles toolkits for enhancing the quality and robustness of qualitative and mixed-methods research reporting, and it is usefully open-ended and non-prescriptive. However, even if it does include some reflections on context, the model does not fully address aspects of context, logic and causal inference that are perhaps most relevant for evaluative research in health.

Hence, for evaluative research where the aim is to report empirical findings in ways that are intended to be pragmatically useful for health policy and practice, this may be an opportune time to consider how to best navigate plurality around what is (minimally) important to report when publishing empirical case studies, especially with regards to the complex relationships between context and interventions, information that case study research is well placed to provide.

The conventional scientific quest for certainty, predictability and linear causality (maximised in RCT designs) has to be augmented by the study of uncertainty, unpredictability and emergent causality [ 8 ] in complex systems. This will require methodological pluralism, and openness to broadening the evidence base to better understand both causality in and the transferability of system change intervention [ 14 , 20 , 23 , 25 ]. Case study research evidence is essential, yet is currently under exploited in the health sciences. If evaluative health research is to move beyond the current impasse on methods for understanding interventions as interruptions in complex systems, we need to consider in more detail how researchers can conduct and report empirical case studies which do aim to elucidate the contextual factors which interact with interventions to produce particular effects. To this end, supported by the UK’s Medical Research Council, we are embracing the challenge to develop guidance for case study researchers studying complex interventions. Following a meta-narrative review of the literature, we are planning a Delphi study to inform guidance that will, at minimum, cover the value of case study research for evaluating the interrelationship between context and complex system-level interventions; for situating and defining ‘the case’, and generalising from case studies; as well as provide specific guidance on conducting, analysing and reporting case study research. Our hope is that such guidance can support researchers evaluating interventions in complex systems to better exploit the diversity and richness of case study research.

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Abbreviations

Qualitative comparative analysis

Quasi-experimental design

Randomised controlled trial

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This work was funded by the Medical Research Council - MRC Award MR/S014632/1 HCS: Case study, Context and Complex interventions (TRIPLE C). SP was additionally funded by the University of Oxford's Higher Education Innovation Fund (HEIF).

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Sara Paparini, Chrysanthi Papoutsi, Trish Greenhalgh & Sara Shaw

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Paparini, S., Green, J., Papoutsi, C. et al. Case study research for better evaluations of complex interventions: rationale and challenges. BMC Med 18 , 301 (2020). https://doi.org/10.1186/s12916-020-01777-6

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Open access
Published: 10 August 2024

How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK

Charlotte Parbery-Clark 1 ,
Lorraine McSweeney 2 ,
Joanne Lally 3 &
Sarah Sowden 4

BMC Public Health volume 24 , Article number: 2168 ( 2024 ) Cite this article

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Metrics details

Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system’s level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions.

In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach.

Interviews ( n = 14) with wide representation from local authority ( n = 8), NHS ( n = 5) and voluntary, community and social enterprise (VCSE) sector ( n = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system’s approach to reducing health inequalities was evident as was collective action and involving people, with links to a “strong third sector”. Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system.

We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system’s working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Highlights:

• Reducing health inequalities in avoidable hospital admissions is yet to be explicitly linked in practice and is an important area to address.

• Understanding the local context helps to identify existing assets and threats including the leverage points for action.

• Requiring action includes building the resilience of our complex systems by addressing structural barriers and threats as well as supporting the workforce (training and wellbeing with improved retention and recruitment) in addition to the analysis and accessibility of data across the system.

Peer Review reports

Introduction

The health of our population is determined by the complex interaction of several factors which are either non-modifiable (such as age, genetics) or modifiable (such as the environment, social, economic conditions in which we live, our behaviours as well as our access to healthcare and its quality) [ 1 ]. Health inequalities are the avoidable and unfair systematic differences in health and healthcare across different population groups explained by the differences in distribution of power, wealth and resources which drive the conditions of daily life [ 2 , 3 ]. Essentially, health inequalities arise due to the systematic differences of the factors that influence our health. To effectively deal with most public health challenges, including reducing health inequalities and improving population health, broader integrated approaches [ 4 ] and an emphasis on systems is required [ 5 , 6 ] . A system is defined as ‘the set of actors, activities, and settings that are directly or indirectly perceived to have influence in or be affected by a given problem situation’ (p.198) [ 7 ]. In this case, the ‘given problem situation' is reducing health inequalities with a focus on avoidable admissions. Therefore, we must consider health systems, which are the organisations, resources and people aiming to improve or maintain health [ 8 , 9 ] of which health services provision is an aspect. In this study, the system considers NHS bodies, Integrated Care Systems, Local Authority departments, and the voluntary and community sector in a UK region.

A plethora of theories [ 10 ], recommended policies [ 3 , 11 , 12 , 13 ], frameworks [ 1 , 14 , 15 ], and tools [ 16 ] exist to help understand the existence of health inequalities as well as provide suggestions for improvement. However, it is reported that healthcare leaders feel under-skilled to reduce health inequalities [ 17 ]. A lack of clarity exists on how to achieve a system’s multi-agency coherence to reduce health inequalities systematically [ 17 , 18 ]. This is despite some countries having legal obligations to have a regard to the need to attend to health and healthcare inequalities. For example, the Health and Social Care Act 2012 [ 19 ], in England, mandated Clinical Commissioning Groups (CCGs), now transferred to Integrated Care Boards (ICBs) [ 20 ], to ‘have a regard to the need to reduce inequalities between patients with respect to their ability to access health services, and reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services’. The wider determinants of health must also be considered. For example, local areas have a mandatory requirement to have a joint strategic needs assessment (JSNA) and joint health and wellbeing strategy (JHWS) whose purpose is to ‘improve the health and wellbeing of the local community and reduce inequalities for all ages' [ 21 ] This includes addressing the wider determinants of health [ 21 ]. Furthermore, the hospital care costs to the NHS associated with socioeconomic inequalities has been previously reported at £4.8 billion a year due to excess hospitalisations [ 22 ]. Avoidable emergency admissions are admissions into hospital that are considered to be preventable with high-quality ambulatory care [ 23 ]. Both ambulatory care sensitive conditions (where effective personalised care based in the community can aid the prevention of needing an admission) and urgent care sensitive conditions (where a system on the whole should be able to treat and manage without an admission) are considered within this definition [ 24 ] (encompassing more than 100 International Classification of Diseases (ICD) codes). The disease burden sits disproportionately with our most disadvantaged communities, therefore highlighting the importance of addressing inequalities in hospital pressures in a concerted manner [ 25 , 26 ].

Research examining one component of an intervention, or even one part of the system, [ 27 ] or which uses specific research techniques to control for the system’s context [ 28 ] are considered as having limited use for identifying the key ingredients to achieve better population health and wellbeing [ 5 , 28 ]. Instead, systems thinking considers how the system’s components and sub-components interconnect and interrelate within and between each other (and indeed other systems) to gain an understanding of the mechanisms by which things work [ 29 , 30 ]. Complex interventions or work programmes may perform differently in varying contexts and through different mechanisms, and therefore cannot simply be replicated from one context to another to automatically achieve the same outcomes. Ensuring that research into systems and systems thinking considers real-world context, such as where individuals live, where policies are created and interventions are delivered, is vital [ 5 ]. How the context and implementation of complex or even simple interventions interact is viewed as becoming increasingly important [ 31 , 32 ]. Case study research methodology is founded on the ‘in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings’ (p.2) [ 33 ]. Case study approaches can deepen the understanding of complexity addressing the ‘how’, ‘what’ and ‘why’ questions in a real-life context [ 34 ]. Researchers have highlighted the importance of engaging more deeply with case-based study methodology [ 31 , 33 ]. Previous case study research has shown promise [ 35 ] which we build on by exploring a systems lens to consider the local area’s context [ 16 ] within which the work is implemented. By using case-study methodology, our study aimed to explore and develop an in-depth understanding of how a local area addresses health inequalities, with a focus on avoidable hospital admissions. As part of this, systems processes were included.

Study design

This in-depth case study is part of an ongoing larger multiple (collective [ 36 ]) case study approach. An instrumental approach [ 34 ] was taken allowing an in-depth investigation of an issue, event or phenomenon, in its natural real-life context; referred to as a ‘naturalistic’ design [ 34 ]. Ethics approval was obtained by Newcastle University’s Ethics Committee (ref 13633/2020).

Study selection

This case study, alongside the other three cases, was purposively [ 36 ] chosen considering overall deprivation level of the area (Indices of Multiple Deprivation (IMD) [ 37 ]), their urban/rural location, differing geographical spread across the UK (highlighted in patient and public feedback and important for considering the North/South health divide [ 38 ]), and a pragmatic judgement of likely ability to achieve the depth of insight required [ 39 ]. In this paper, we report the findings from one of the case studies, an urban local authority in the Northern region of the UK with high levels of socioeconomic disadvantage. This area was chosen for this in-depth case analysis due to high-level of need, and prior to the COVID-19 pandemic (2009-2018) had experienced a trend towards reducing socioeconomic inequalities in avoidable hospital admission rates between neighbourhoods within the local area [ 40 ]. Thereby this case study represents an ‘unusual’ case [ 41 ] to facilitate learning regarding what is reported and considered to be the key elements required to reduce health inequalities, including inequalities in avoidable admissions, in a local area.

Semi-structured interviews

The key informants were identified iteratively through the documentary analysis and in consultation with the research advisory group. Initially board level committee members (including lay, managerial, and clinical members) within relevant local organisations were purposively identified. These individuals were systems leaders charged with the remit of tackling health inequalities and therefore well placed to identify both key personnel and documents. Snowball sampling [ 42 ] was undertaken thereafter whereby interviewees helped to identify additional key informants within the local system who were working on health inequalities, including avoidable emergency admissions, at a systems level. Interview questions were based on an iteratively developed topic guide (supplementary data 1), informed from previous work’s findings [ 43 ] and the research advisory network’s input. A study information sheet was emailed to perspective interviewees, and participants were asked to complete an e-consent form using Microsoft Forms [ 42 ]. Each interviewee was interviewed by either L.M. or C.P.-C. using the online platforms Zoom or Teams, and lasted up to one hour. Participants were informed of interviewers’ role, workplace as well as purpose of the study. Interviewees were asked a range of questions including any work relating to reducing health inequalities, particularly avoidable emergency admissions, within the last 5 years. Brief notes were taken, and the interviews were recorded, transcribed verbatim and anonymised.

Documentary analysis

The documentary analysis followed the READ approach [ 44 ]. Any documents from the relevant local/regional area with sections addressing health inequalities and/or avoidable emergency admissions, either explicitly stated or implicitly inferred, were included. A list of core documents was chosen, including the local Health and Wellbeing Strategy (Table 1 ). Subsequently, other documents were identified by snowballing from these core documents and identification by the interviewees. All document types were within scope if produced/covered a period within 5 years (2017-2022), including documents in the public domain or not as well as documents pertaining to either a regional, local and neighbourhood level. This 5-year period was a pragmatic decision in line with the interviews and considered to be a balance of legacy and relevance. Attempts were made to include the final version of each document, where possible/applicable, otherwise the most up-to-date version or version available was used.

An Excel spreadsheet data extraction tool was adapted with a priori criteria [ 44 ] to extract the data. This tool included contextual information (such as authors, target area and document’s purpose). Also, information based on previous research on addressing socioeconomic inequalities in avoidable emergency admissions, such as who stands to benefit, was extracted [ 43 ]. Additionally, all documents were summarised according to a template designed according to the research’s aims. Data extraction and summaries were undertaken by L.M. and C.P.-C. A selection was doubled coded to enhance validity and any discrepancies were resolved by discussion.

Interviews and documents were coded and analysed independently based on a thematic analysis approach [ 45 ], managed by NVivo software. A combination of ‘interpretive’ and ‘positivist’ stance [ 34 , 46 ] was taken which involved understanding meanings/contexts and processes as perceived from different perspectives (interviewees and documents). This allowed for an understanding of individual and shared social meanings/reasonings [ 34 , 36 ]. For the documentary analysis, a combination of both content and thematic analysis as described by Bowen [ 47 ] informed by Braun and Clarke’s approach to thematic analysis [ 45 ] was used. This type of content analysis does not include the typical quantification but rather a review of the document for pertinent and meaningful passages of text/other data [ 47 ]. Both an inductive and deductive approach for the documentary analysis’ coding [ 46 , 47 ] was chosen. The inductive approach was developed a posteriori; the deductive codes being informed by the interviews and previous findings from research addressing socioeconomic inequalities in avoidable emergency admissions [ 43 ]. In line with qualitative epistemological approach to enquiry, the interview and documentary findings were viewed as ‘truths’ in themselves with the acceptance that multiple realities can co-exist [ 48 ]. The analysis of each set of themes (with subthemes) from the documentary analysis and interviews were cross-referenced and integrated with each other to provide a cohesive in-depth analysis [ 49 ] by generating thematic maps to explore the relationships between the themes. The codes, themes and thematic maps were peer-reviewed continually with regular meetings between L.M., C.P.-C., J.L. and S.S. Direct quotes are provided from the interviews and documentary analysis. Some quotes from the documents are paraphrased to protect anonymity of the case study after following a set process considering a range of options. This involved searching each quote from the documentary analysis in Google and if the quote was found in the first page of the result, we shortened extracts and repeated the process. Where the shortened extracts were still identifiable, we were required to paraphrase that quote. Each paraphrased quote and original was shared and agreed with all the authors reducing the likelihood of inadvertently misinterpreting or misquoting. Where multiple components over large bodies of text were present in the documents, models were used to evidence the broadness, for example, using Dahlgren’s and Whitehead’s model of health determinants [ 1 ]. Due to the nature of the study, transcripts and findings were not shared with participants for checking but will be shared in a dissemination workshop in 2024.

Patient and public involvement and engagement

Four public contributors from the National Institute for Health and Care Research (NIHR) Research Design Service (RDS) North East and North Cumbria (NENC) Public and Patient Involvement (PPI) panel have been actively engaged in this research from its inception. They have been part of the research advisory group along with professional stakeholders and were involved in the identification of the sampling frame’s key criteria. Furthermore, a diverse group of public contributors has been actively involved in other parts of the project including developing the moral argument around action by producing a public facing resource exploring what health inequalities mean to people and public views of possible solutions [ 50 ].

Semi-structured interviews: description

Sixteen participants working in health or social care, identified through the documentary analysis or snowballing, were contacted for interview; fourteen consented to participate. No further interviews were sought as data sufficiency was reached whereby no new information or themes were being identified. Participant roles were broken down by NHS ( n = 5), local authority/council ( n = 8), and voluntary, community and social enterprise (VSCE) ( n = 1). To protect the participants’ anonymity, their employment titles/status are not disclosed. However, a broad spectrum of interviewees with varying roles from senior health system leadership (including strategic and commissioner roles) to roles within provider organisations and the VSCE sector were included.

Documentary analysis: description

75 documents were reviewed with documents considering regional ( n = 20), local ( n = 64) or neighbourhood ( n = 2) area with some documents covering two or more areas. Table 2 summarises the respective number of each document type which included statutory documents to websites from across the system (NHS, local government and VSCE). 45 documents were named by interviewees and 42 documents were identified as either a core document or through snowballing from other documents. Of these, 12 documents were identified from both. The timescales of the documents varied and where possible to identify, was from 2014 to 2031.

Integrative analysis of the documentary analysis and interviews

The overarching themes encompass:

Understanding the local context

Facilitators to tacking health inequalities: the assets

Emerging risks and concerns

Figure 1 demonstrates the relationships between the main themes identified from the analysis for tackling health inequalities and improving health in this case study.

Diagram of the relationship between the key themes identified regarding tackling health inequalities and improving health in a local area informed by 2 previous work [ 14 , 51 ]. NCDs = non-communicable diseases; HI = health inequalities

Understanding the local context was discussed extensively in both the documents and the interviews. This was informed by local intelligence and data that was routinely collected, monitored, and analysed to help understand the local context and where inequalities lie. More bespoke, in-depth collection and analysis were also described to get a better understanding of the situation. This not only took the form of quantitative but also considered qualitative data with lived experience:

‛So, our data comes from going out to talk to people. I mean, yes, especially the voice of inequalities, those traditional mechanisms, like surveys, don't really work. And it's about going out to communities, linking in with third sector organisations, going out to communities, and just going out to listen…I think the more we can bring out those real stories. I mean, we find quotes really, really powerful in terms of helping people understand what it is that matters.’ (LP16).

However, there were limitations to the available data including the quality as well as having enough time to do the analysis justice. This resulted in difficulties in being able to fully understand the context to help identify and act on the required improvements.

‘A lack of available data means we cannot quantify the total number of vulnerable migrants in [region]’ (Document V).

‛So there’s lots of data. The issue is joining that data up and analysing it, and making sense of it. That’s where we don’t have the capacity.’ (LP15).

Despite the caveats, understanding the context and its data limitations were important to inform local priorities and approaches on tackling health inequalities. This understanding was underpinned by three subthemes which were understanding:

the population’s needs including identification of people at higher risk of worse health and health inequalities

the driving forces of those needs with acknowledgement of the impact of the wider determinants of health

the threats and barriers to physical and mental health, as well as wellbeing

Firstly, the population’s needs, including identification of people at higher risk of worse health and health inequalities, was important. This included considering risk factors, such as smoking, specific groups of people and who was presenting with which conditions. Between the interviews and documents, variation was seen between groups deemed at-risk or high-risk with the documents identifying a wider range. The groups identified across both included marginalised communities, such as ethnic minority groups, gypsy and travellers, refugees and asylum seekers as well as people/children living in disadvantaged area.

‘There are significant health inequalities in children with asthma between deprived and more affluent areas, and this is reflected in A&E admissions.' (Document J).

Secondly, the driving forces of those needs with acknowledgement of the impact of the wider determinants of health were described. These forces mapped onto Dahlgren’s and Whitehead’s model of health determinants [ 1 ] consisting of individual lifestyle factors, social and community networks, living and working conditions (which include access to health care services) as well as general socio-economic, cultural and environmental conditions across the life course.

…. at the centre of our approach considering the requirements to improve the health and wellbeing of our area are the wider determinants of health and wellbeing, acknowledging how factors, such as housing, education, the environment and economy, impact on health outcomes and wellbeing over people’s lifetime and are therefore pivotal to our ambition to ameliorate the health of the poorest the quickest. (Paraphrased Document P).

Thirdly, the threats and barriers to health included environmental risks, communicable diseases and associated challenges, non-communicable conditions and diseases, mental health as well as structural barriers. In terms of communicable diseases, COVID-19 predominated. The environmental risks included climate change and air pollution. Non-communicable diseases were considered as a substantial and increasing threat and encompassed a wide range of chronic conditions such as diabetes, and obesity.

‛Long term conditions are the leading causes of death and disability in [case study] and account for most of our health and care spending. Cases of cancer, diabetes, respiratory disease, dementia and cardiovascular disease will increase as the population of [case study] grows and ages.’ (Document A).

Structural barriers to accessing and using support and/or services for health and wellbeing were identified. These barriers included how the services are set up, such as some GP practices asking for proof of a fixed address or form of identification to register. For example:

Complicated systems (such as having to make multiple calls, the need to speak to many people/gatekeepers or to call at specific time) can be a massive barrier to accessing healthcare and appointments. This is the case particularly for people who have complex mental health needs or chaotic/destabilized circumstances. People who do not have stable housing face difficulties in registering for GP and other services that require an address or rely on post to communicate appointments. (Paraphrased Document R).

A structural threat regarding support and/or services for health and wellbeing was the sustainability of current funding with future uncertainty posing potential threats to the delivery of current services. This also affected the ability to adapt and develop the services, or indeed build new ones.

‛I would say the other thing is I have a beef [sic] [disagreement] with pilot studies or new innovations. Often soft funded, temporary funded, charity funded, partnership work run by enthusiasts. Me, I've done them, or supported people doing many of these. And they're great. They can make a huge impact on the individuals involved on that local area. You can see fantastic work. You get inspired and you want to stand up in a crowd and go, “Wahey, isn't this fantastic?” But actually the sad part of it is on these things, I've seen so many where we then see some good, positive work being done, but we can't make it permanent or we can't spread it because there's no funding behind it.’ (LP8).

Facilitators to tackling health inequalities: the assets

The facilitators for improving health and wellbeing and tackling health inequalities are considered as assets which were underpinned by values and principles.

Values driven supported by four key principles

Being values driven was an important concept and considered as the underpinning attitudes or beliefs that guide decision making [ 52 ]. Particularly, the system’s approach was underpinned by a culture and a system's commitment to tackle health inequalities across the documents and interviews. This was also demonstrated by how passionately and emotively some interviewees spoke about their work.

‛There's a really strong desire and ethos around understanding that we will only ever solve these problems as a system, not by individual organisations or even just part of the system working together. And that feels great.’ (LP3).

Other values driving the approach included accountability, justice, and equity. Reducing health inequalities and improving health were considered to be the right things to do. For example:

We feel strongly about social justice and being inclusive, wishing to reflect the diversity of [case study]. We campaign on subjects that are important to people who are older with respect and kindness. (Paraphrased Document O).

Four key principles were identified that crosscut the assets which were:

Shared vision

Strong partnership

Asset-based approaches

Willingness and ability to act on learning

The mandated strategy, identifying priorities for health and wellbeing for the local population with the required actions, provided the shared vision across each part of the system, and provided the foundations for the work. This shared vision was repeated consistently in the documents and interviews from across the system.

[Case study] will be a place where individuals who have the lowest socioeconomic status will ameliorate their health the quickest. [Case study] will be a place for good health and compassion for all people, regardless of their age. (Paraphrased Document A).

‛One thing that is obviously becoming stronger and stronger is the focus on health inequalities within all of that, and making sure that we are helping people and provide support to people with the poorest health as fast as possible, so that agenda hasn’t shifted.’ (LP7).

This drive to embed the reduction of health inequalities was supported by clear new national guidance encapsulated by the NHS Core20PLUS5 priorities. Core20PLUS5 is the UK's approach to support a system to improve their healthcare inequalities [ 53 ]. Additionally, the system's restructuring from Clinical Commissioning Groups (CCGs) to Integrated Care Boards (ICBs) and formalisation of the now statutory Integrated Care Systems (ICS) in England was also reported to facilitate the driving of further improvement in health inequalities. These changes at a regional and local level helped bring key partners across the system (NHS and local government among others) to build upon their collective responsibility for improving health and reducing health inequalities for their area [ 54 ].

‛I don’t remember the last time we’ve had that so clear, or the last time that health inequalities has had such a prominent place, both in the NHS planning guidance or in the NHS contract. ’ (LP15). ‛The Health and Care Act has now got a, kind of, pillar around health inequalities, the new establishment of ICPs and ICBs, and also the planning guidance this year had a very clear element on health inequalities.’ (LP12)

A strong partnership and collaborative team approach across the system underpinned the work from the documents and included the reoccurrence of the concept that this case study acted as one team: ‘Team [case study]'.

Supporting one another to ensure [case study] is the best it can be: Team [case study]. It involves learning, sharing ideas as well as organisations sharing assets and resources, authentic partnerships, and striving for collective impact (environmental and social) to work towards shared goals . (Paraphrased Document B).

This was corroborated in the interviews as working in partnership to tackle health inequalities was considered by the interviewees as moving in the right direction. There were reports that the relationship between local government, health care and the third sector had improved in recent years which was still an ongoing priority:

‘I think the only improvement I would cite, which is not an improvement in terms of health outcomes, but in terms of how we work across [case study] together has moved on quite a lot, in terms of teams leads and talking across us, and how we join up on things, rather than see ourselves all as separate bodies' (LP15).

‘I think the relationship between local authorities and health and the third sector, actually, has much more parity and esteem than it had before.' (LP11)

The approaches described above were supported by all health and care partners signing up to principles around partnership; it is likely this has helped foster the case study's approach. This also builds on the asset-based approaches that were another key principle building on co-production and co-creation which is described below.

We begin with people : instead of doing things to people or for them, we work with them, augmenting the skills, assets and strength of [case study]’s people, workforce and carers. We achieve : actions are focused on over words and by using intelligence, every action hones in on the actual difference that we will make to ameliorate outcomes, quality and spend [case study]’s money wisely; We are Team [case study ]: having kindness, working as one organisation, taking responsibility collectively and delivering on what we agreed. Problems are discussed with a high challenge and high support attitude. (Paraphrased Document D).

At times, the degree to which the asset-based approaches were embedded differed from the documents compared to the interviews, even when from the same part of the system. For example, the documents often referred to the asset-based approach as having occurred whilst interviewees viewed it more as a work in progress.

‘We have re-designed many of our services to focus on needs-led, asset-based early intervention and prevention, and have given citizens more control over decisions that directly affect them .’ (Document M).

‘But we’re trying to take an asset-based approach, which is looking at the good stuff in communities as well. So the buildings, the green space, the services, but then also the social capital stuff that happens under the radar.’ (LP11).

A willingness to learn and put in action plans to address the learning were present. This enables future proofing by building on what is already in place to build the capacity, capability and flexibility of the system. This was particularly important for developing the workforce as described below.

‘So we’ve got a task and finish group set up, […] So this group shows good practice and is a space for people to discuss some of the challenges or to share what interventions they are doing around the table, and also look at what other opportunities that they have within a region or that we could build upon and share and scale.’ (LP12).

These assets that are considered as facilitators are divided into four key levels which are the system, services and support, communities and individuals, and workforce which are discussed in turn below.

Firstly, the system within this case study was made up of many organisations and partnerships within the NHS, local government, VSCE sector and communities. The interviewees reported the presence of a strong VCSE sector which had been facilitated by the local council's commitment to funding this sector:

‘Within [case study], we have a brilliant third sector, the council has been longstanding funders of infrastructure in [case study], third sector infrastructure, to enable those links [of community engagement] to be made' (LP16).

In both the documents and interviews, a strong coherent strategic integrated population health management plan with a system’s approach to embed the reduction of health inequalities was evident. For example, on a system level regionally:

‘To contribute towards a reduction in health inequalities we will: take a system wide approach for improving outcomes for specific groups known to be affected by health inequalities, starting with those living in our most deprived communities….’ (Document H).

This case study’s approach within the system included using creative solutions and harnessing technology. This included making bold and inventive changes to improve how the city and the system linked up and worked together to improve health. For example, regeneration work within the city to ameliorate and transform healthcare facilities as well as certain neighbourhoods by having new green spaces, better transport links in order to improve city-wide innovation and collaboration (paraphrased Document F) were described. The changes were not only related to physical aspects of the city but also aimed at how the city digitally linked up. Being a leader in digital innovation to optimise the health benefits from technology and information was identified in several documents.

‘ Having the best connected city using digital technology to improve health and wellbeing in innovative ways.’ (Document G).

The digital approaches included ongoing development of a digitalised personalised care record facilitating access to the most up-to-date information to developing as well as having the ‘ latest, cutting edge technologies’ ( Document F) in hospital care. However, the importance of not leaving people behind by embedding digital alternatives was recognised in both the documents and interviews.

‘ We are trying to just embed the culture of doing an equity health impact assessment whenever you are bringing in a digital solution or a digital pathway, and that there is always an alternative there for people who don’t have the capability or capacity to use it. ’ (LP1).

The successful one hundred percent [redacted] programme is targeting some of our most digitally excluded citizens in [case study]. For our city to continue to thrive, we all need the appropriate skills, technology and support to get the most out of being online. (Paraphrased Document Q)

This all links in with the system that functions in a ‘place' which includes the importance of where people are born, grow, work and live. Working towards this place being welcoming and appealing was described both regionally and locally. This included aiming to make the case study the place of choice for people.

‘Making [case study] a centre for good growth becoming the place of choice in the UK to live, to study, for businesses to invest in, for people to come and work.’ (Document G).

Services and support

Secondly, a variety of available services and support were described from the local authority, NHS, and voluntary community sectors. Specific areas of work, such as local initiatives (including targeted work or campaigns for specific groups or specific health conditions) as well as parts of the system working together with communities collaboratively, were identified. This included a wide range of work being done such as avoiding delayed discharges or re-admissions, providing high quality affordable housing as well as services offering peer support.

‘We have a community health development programme called [redacted], that works with particular groups in deprived communities and ethnically diverse communities to work in a very trusted and culturally appropriate way on the things that they want to get involved with to support their health.’ (LP3 ).

It is worth noting that reducing health inequalities in avoidable admissions was not often explicitly specified in the documents or interviews. However, either specified or otherwise inferred, preventing ill health and improving access, experience, and outcomes were vital components to addressing inequalities. This was approached by working with communities to deliver services in communities that worked for all people. Having co-designed, accessible, equitable integrated services and support appeared to be key.

‘Reducing inequalities in unplanned admissions for conditions that could be cared for in the community and access to planned hospital care is key.’ (Document H)

Creating plans with people: understanding the needs of local population and designing joined-up services around these needs. (Paraphrased Document A).

‘ So I think a core element is engagement with your population, so that ownership and that co-production, if you're going to make an intervention, don't do it without because you might miss the mark. ’ (LP8).

Clear, consistent and appropriate communication that was trusted was considered important to improve health and wellbeing as well as to tackle health inequalities. For example, trusted community members being engaged to speak on the behalf of the service providers:

‘The messenger is more important than the message, sometimes.’ (LP11).

This included making sure the processes are in place so that the information is accessible for all, including people who have additional communication needs. This was considered as a work in progress in this case study.

‘I think for me, things do come down to those core things, of health, literacy, that digital exclusion and understanding the wider complexities of people.’ (LP12)

‘ But even more confusing if you've got an additional communication need. And we've done quite a lot of work around the accessible information standard which sounds quite dry, and doesn't sound very- but actually, it's fundamental in accessing health and care. And that is, that all health and care organisations should record your communication preferences. So, if I've got a learning disability, people should know. If I've got a hearing impairment, people should know. But the systems don’t record it, so blind people are getting sent letters for appointments, or if I've got hearing loss, the right provisions are not made for appointments. So, actually, we're putting up barriers before people even come in, or can even get access to services.’ (LP16).

Flexible, empowering, holistic care and support that was person-centric was more apparent in the documents than the interviews.

At the centre of our vision is having more people benefiting from the life chances currently enjoyed by the few to make [case study] a more equal place. Therefore, we accentuate the importance of good health, the requirement to boost resilience, and focus on prevention as a way of enabling higher quality service provision that is person-centred. [Paraphrased Document N).

Through this [work], we will give all children and young people in [case study], particularly if they are vulnerable and/or disadvantaged, a start in life that is empowering and enable them to flourish in a compassionate and lively city. [Paraphrased Document M].

Communities and individuals

Thirdly, having communities and individuals at the heart of the work appeared essential and viewed as crucial to nurture in this case study. The interconnectedness of the place, communities and individuals were considered a key part of the foundations for good health and wellbeing.

In [case study], our belief is that our people are our greatest strength and our most important asset. Wellbeing starts with people: our connections with our friends, family, and colleagues, our behaviour, understanding, and support for one another, as well as the environment we build to live in together . (Paraphrased Document A).

A recognition of the power of communities and individuals with the requirement to support that key principle of a strength-based approach was found. This involved close working with communities to help identify what was important, what was needed and what interventions would work. This could then lead to improved resilience and cohesion.

‛You can't make effective health and care decisions without having the voice of people at the centre of that. It just won't work. You won't make the right decisions.’ (LP16).

‘Build on the strengths in ourselves, our families, carers and our community; working with people, actively listening to what matters most to people, with a focus on what’s strong rather than what’s wrong’ (Document G).

Meaningful engagement with communities as well as strengths and asset-based approaches to ensure self-sufficiency and sustainability of communities can help communities flourish. This includes promoting friendships, building community resilience and capacity, and inspiring residents to find solutions to change the things they feel needs altering in their community . (Paraphrased Document B).

This close community engagement had been reported to foster trust and to lead to improvements in health.

‘But where a system or an area has done a lot of community engagement, worked really closely with the community, gained their trust and built a programme around them rather than just said, “Here it is. You need to come and use it now,” you can tell that has had the impact. ' (LP1).

Finally, workforce was another key asset; the documents raised the concept of one workforce across health and care. The key principles of having a shared vision, asset-based approaches and strong partnership were also present in this example:

By working together, the Health and Care sector makes [case study] the best area to not only work but also train for people of all ages. Opportunities for skills and jobs are provided with recruitment and engagement from our most disadvantaged communities, galvanizing the future’s health and care workforce. By doing this, we have a very skilled and diverse workforce we need to work with our people now as well as in the future. (Paraphrased Document E).

An action identified for the health and care system to address health inequalities in case study 1 was ‘ the importance of having an inclusive workforce trained in person-centred working practices ’ (Document R). Several ways were found to improve and support workforce skills development and embed awareness of health inequalities in practice and training. Various initiatives were available such as an interactive health inequalities toolkit, theme-related fellowships, platforms and networks to share learning and develop skills.

‛We've recently launched a [redacted] Fellowship across [case study’s region], and we've got a number of clinicians and managers on that………. We've got training modules that we've put on across [case study’s region], as well for health inequalities…we've got learning and web resources where we share good practice from across the system, so that is our [redacted] Academy.’ (LP2).

This case study also recognised the importance of considering the welfare of the workforce; being skilled was not enough. This had been recognised pre-pandemic but was seen as even more important post COVID-19 due to the impact that COVID-19 had on staff, particularly in health and social care.

‛The impacts of the pandemic cannot be underestimated; our colleagues and services are fatigued and still dealing with the pressures. This context makes it even more essential that we share the responsibility, learn from each other at least and collaborate with each other at best, and hold each other up to be the best we can.’ (Document U).

Concerns were raised such as the widening of health inequalities since the pandemic and cost of living crisis. Post-pandemic and Brexit, recruiting health, social care and third sector staff was compounding the capacity throughout this already heavily pressurised system.

In [case study], we have seen the stalling of life expectancy and worsening of the health inequality gap, which is expected to be compounded by the effects of the pandemic. (Paraphrased Document T)

‘I think key barriers, just the immense pressure on the system still really […] under a significant workload, catching up on activity, catching up on NHS Health Checks, catching up on long-term condition reviews. There is a significant strain on the system still in terms of catching up. It has been really difficult because of the impact of COVID.’ (LP7).

‘Workforce is a challenge, because the pipelines that we’ve got, we’ve got fewer people coming through many of them. And that’s not just particular to, I don't know, nursing, which is often talking talked [sic] about as a challenged area, isn't it? And of course, it is. But we’ve got similar challenges in social care, in third sector.’ (LP5).

The pandemic was reported to have increased pressures on the NHS and services not only in relation to staff capacity but also regarding increases in referrals to services, such as mental health. Access to healthcare changed during the pandemic increasing barriers for some:

‘I think people are just confused about where they're supposed to go, in terms of accessing health and care at the moment. It's really complex to understand where you're supposed to go, especially, at the moment, coming out of COVID, and the fact that GPs are not the accessible front door. You can't just walk into your GP anymore.’ (LP16).

‘Meeting this increased demand [for work related to reducing ethnic inequalities in mental health] is starting to prove a challenge and necessitates some discussion about future resourcing.’ (Document S)

Several ways were identified to aid effective adaptation and/or mitigation. This included building resilience such as developing the existing capacity, capability and flexibility of the system by learning from previous work, adapting structures and strengthening workforce development. Considerations, such as a commitment to Marmot Principles and how funding could/would contribute, were also discussed.

The funding’s [linked to Core20PLUS5] purpose is to help systems to ensure that health inequalities are not made worse when cost-savings or efficiencies are sought…The available data and insight are clear and [health inequalities are] likely to worsen in the short term, the delays generated by pandemic, the disproportionate effect of that on the most deprived and the worsening food and fuel poverty in all our places. (Paraphrased Document L).

Learning from the pandemic was thought to be useful as some working practices had altered during COVID-19 for the better, such as needing to continue to embed how the system had collaborated and resist old patterns of working:

‘So I think that emphasis between collaboration – extreme collaboration – which is what we did during COVID is great. I suppose the problem is, as we go back into trying to save money, we go back into our old ways of working, about working in silos. And I think we’ve got to be very mindful of that, and continue to work in a different way.’ (LP11).

Another area identified as requiring action, was the collection, analysis, sharing and use of data accessible by the whole system.

‘So I think there is a lot of data out there. It’s just how do we present that in such a way that it’s accessible to everyone as well, because I think sometimes, what happens is that we have one group looking at data in one format, but then how do we cascade that out?’ (LP12)

We aimed to explore a system’s level understanding of how a local area addresses health inequalities with a focus on avoidable emergency admissions using a case study approach. Therefore, the focus of our research was strategic and systematic approaches to inequalities reduction. Gaining an overview of what was occurring within a system is pertinent because local areas are required to have a regard to address health inequalities in their local areas [ 20 , 21 ]. Through this exploration, we also developed an understanding of the system's processes reported to be required. For example, an area requiring action was viewed as the accessibility and analysis of data. The case study described having health inequalities ‘at the heart of its health and wellbeing strategy ’ which was echoed across the documents from multiple sectors across the system. Evidence of a values driven partnership with whole systems working was centred on the importance of place and involving people, with links to a ‘strong third sector ’ . Working together to support and strengthen local assets (the system, services/support, communities/individuals, and the workforce) were vital components. This suggested a system’s committed and integrated approach to improve population health and reduce health inequalities as well as concerted effort to increase system resilience. However, there was juxtaposition at times with what the documents contained versus what interviewees spoke about, for example, the degree to which asset-based approaches were embedded.

Furthermore, despite having a priori codes for the documentary analysis and including specific questions around work being undertaken to reduce health inequalities in avoidable admissions in the interviews with key systems leaders, this explicit link was still very much under-developed for this case study. For example, how to reduce health inequalities in avoidable emergency admissions was not often specified in the documents but could be inferred from existing work. This included work around improving COVID-19 vaccine uptake in groups who were identified as being at high-risk (such as older people and socially excluded populations) by using local intelligence to inform where to offer local outreach targeted pop-up clinics. This limited explicit action linking reduction of health inequalities in avoidable emergency admissions was echoed in the interviews and it became clear as we progressed through the research that a focus on reduction of health inequalities in avoidable hospital admissions at a systems level was not a dominant aspect of people’s work. Health inequalities were viewed as a key part of the work but not necessarily examined together with avoidable admissions. A strengthened will to take action is reported, particularly around reducing health inequalities, but there were limited examples of action to explicitly reduce health inequalities in avoidable admissions. This gap in the systems thinking is important to highlight. When it was explicitly linked, upstream strategies and thinking were acknowledged as requirements to reduce health inequalities in avoidable emergency admissions.

Similar to our findings, other research have also found networks to be considered as the system’s backbone [ 30 ] as well as the recognition that communities need to be central to public health approaches [ 51 , 55 , 56 ]. Furthermore, this study highlighted the importance of understanding the local context by using local routine and bespoke intelligence. It demonstrated that population-based approaches to reduce health inequalities are complex, multi-dimensional and interconnected. It is not about one part of the system but how the whole system interlinks. The interconnectedness and interdependence of the system (and the relevant players/stakeholders) have been reported by other research [ 30 , 57 ], for example without effective exchange of knowledge and information, social networks and systems do not function optimally [ 30 ]. Previous research found that for systems to work effectively, management and transfer of knowledge needs to be collaborative [ 30 ], which was recognised in this case study as requiring action. By understanding the context, including the strengths and challenges, the support or action needed to overcome the barriers can be identified.

There are very limited number of case studies that explore health inequalities with a focus on hospital admissions. Of the existing research, only one part of the health system was considered with interviews looking at data trends [ 35 ]. To our knowledge, this research is the first to build on this evidence by encompassing the wider health system using wider-ranging interviews and documentary analysis. Ford et al. [ 35 ] found that geographical areas typically had plans to reduce total avoidable emergency admissions but not comprehensive plans to reduce health inequalities in avoidable emergency admissions. This approach may indeed widen health inequalities. Health inequalities have considerable health and costs impacts. Pertinently, the hospital care costs associated with socioeconomic inequalities being reported as £4.8 billion a year, mainly due to excess hospitalisations such as avoidable admissions [ 58 ] and the burden of disease lies disproportionately with our most disadvantaged communities, addressing inequalities in hospital pressures is required [ 25 , 26 ].

Implications for research and policy

Improvements to life expectancy have stalled in the UK with a widening of health inequalities [ 12 ]. Health inequalities are not inevitable; it is imperative that the health gap between the deprived and affluent areas is narrowed [ 12 ]. This research demonstrates the complexity and intertwining factors that are perceived to address health inequalities in an area. Despite the evidence of the cost (societal and individual) of avoidable admissions, explicit tackling of inequality in avoidable emergency admissions is not yet embedded into the system, therefore highlights an area for policy and action. This in-depth account and exploration of the characteristics of ‘whole systems’ working to address health inequalities, including where challenges remain, generated in this research will be instrumental for decision makers tasked with addressing health and care inequalities.

This research informs the next step of exploring each identified theme in more detail and moving beyond description to develop tools, using a suite of multidimensional and multidisciplinary methods, to investigate the effects of interventions on systems as previously highlighted by Rutter et al. [ 5 ].

Strengths and limitations

Documentary analysis is often used in health policy research but poorly described [ 44 ]. Furthermore, Yin reports that case study research is often criticised for not adhering to ‘systematic procedures’ p. 18 [ 41 ]. A clear strength of this study was the clearly defined boundary (in time and space) case as well as following a defined systematic approach, with critical thought and rationale provided at each stage [ 34 , 41 ]. A wide range and large number of documents were included as well as interviewees from across the system thereby resulting in a comprehensive case study. Integrating the analysis from two separate methodologies (interviews and documentary analysis), analysed separately before being combined, is also a strength to provide a coherent rich account [ 49 ]. We did not limit the reasons for hospital admission to enable a broad as possible perspective; this is likely to be a strength in this case study as this connection between health inequalities and avoidable hospital admissions was still infrequently made. However, for example, if a specific care pathway for a health condition had been highlighted by key informants this would have been explored.

Due to concerns about identifiability, we took several steps. These included providing a summary of the sectors that the interviewees and document were from but we were not able to specify which sectors each quote pertained. Additionally, some of the document quotes required paraphrasing. However, we followed a set process to ensure this was as rigorous as possible as described in the methods section. For example, where we were required to paraphrase, each paraphrased quote and original was shared and agreed with all the authors to reduce the likelihood to inadvertently misinterpreting or misquoting.

The themes are unlikely to represent an exhaustive list of the key elements requiring attention, but they represent the key themes that were identified using a robust methodological process. The results are from a single urban local authority with high levels of socioeconomic disadvantage in the North of England which may limit generalisability to different contexts. However, the findings are still generalisable to theoretical considerations [ 41 ]. Attempts to integrate a case study with a known framework can result in ‘force-fit’ [ 34 ] which we avoided by developing our own framework (Fig. 1 ) considering other existing models [ 14 , 59 ]. The results are unable to establish causation, strength of association, or direction of influence [ 60 ] and disentangling conclusively what works versus what is thought to work is difficult. The documents’ contents may not represent exactly what occurs in reality, the degree to which plans are implemented or why variation may occur or how variation may affect what is found [ 43 , 61 ]. Further research, such as participatory or non-participatory observation, could address this gap.

Conclusions

This case study provides an in-depth exploration of how local areas are working to address health and care inequalities, with a focus on avoidable hospital admissions. Key elements of this system’s reported approach included fostering strategic coherence, cross-agency working, and community-asset based working. An area requiring action was viewed as the accessibility and analysis of data. Therefore, local areas could consider the challenges of data sharing across organisations as well as the organisational capacity and capability required to generate useful analysis in order to create meaningful insights to assist work to reduce health and care inequalities. This would lead to improved understanding of the context including where the key barriers lie for a local area. Addressing structural barriers and threats as well as supporting the training and wellbeing of the workforce are viewed as key to building resilience within a system to reduce health inequalities. Furthermore, more action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Availability of data and materials

Individual participants’ data that underlie the results reported in this article and a data dictionary defining each field in the set are available to investigators whose proposed use of the data has been approved by an independent review committee for work. Proposals should be directed to [email protected] to gain access, data requestors will need to sign a data access agreement. Such requests are decided on a case by case basis.

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Acknowledgements

Thanks to our Understanding Factors that explain Avoidable hospital admission Inequalities - Research study (UNFAIR) PPI contributors, for their involvement in the project particularly in the identification of the key criteria for the sampling frame. Thanks to the research advisory team as well.

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Informed consent was obtained from all subjects involved in the study.

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The manuscript is not currently under consideration or published in another journal. All authors have read and approved the final manuscript.

This research was funded by the National Institute for Health and Care Research (NIHR), grant number (ref CA-CL-2018-04-ST2-010). The funding body was not involved in the study design, collection of data, inter-pretation, write-up, or submission for publication. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.

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Charlotte Parbery-Clark

Post-Doctoral Research Associate, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

Lorraine McSweeney

Senior Research Methodologist & Public Involvement Lead, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

Joanne Lally

Senior Clinical Lecturer &, Faculty of Medical Sciences, Honorary Consultant in Public Health, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

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Contributions

Conceptualization - J.L. and S.S.; methodology - C.P.-C., J.L. & S.S.; formal analysis - C. P.-C. & L.M.; investigation- C. P.-C. & L.M., resources, writing of draft manuscript - C.P.-C.; review and editing manuscript L.M., J.L., & S.S.; visualization including figures and tables - C.P.-C.; supervision - J.L. & S.S.; project administration - L.M. & S.S.; funding acquisition - S.S. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Charlotte Parbery-Clark or Sarah Sowden .

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Parbery-Clark, C., McSweeney, L., Lally, J. et al. How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK. BMC Public Health 24 , 2168 (2024). https://doi.org/10.1186/s12889-024-19531-5

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“Case Studies in Healthcare: Success Stories and Lessons Learned”

The healthcare industry is an ever-evolving field with innovations and improvements happening daily. As healthcare providers strive to deliver the best care possible, case studies have become a valuable resource for learning and growth. In this article, we will explore various case studies in healthcare, highlighting both success stories and the lessons learned along the way. By analyzing what works and why, we can gain insight into the practices that lead to triumphs in healthcare and potentially replicate these successes in our own organizations.

Case Studies in Healthcare: A Closer Look at Triumphs and Takeaways

Healthcare case studies provide a unique opportunity to dissect real-world scenarios, understand the decisions made, and measure the outcomes of those choices. One notable success story is the implementation of telemedicine in rural areas. By leveraging technology, healthcare providers have successfully expanded access to care for patients who would otherwise have to travel long distances for treatment. Lessons learned include the importance of investing in reliable technology and training staff to effectively use telemedicine platforms.

Another critical case study involves the management of electronic health records (EHRs). When a large hospital system transitioned to a new EHR system, they faced significant resistance from physicians who were accustomed to the old way of doing things. However, by involving physicians in the planning and implementation process, the hospital successfully integrated the new system, leading to improved efficiency and patient care. This case study highlights the value of stakeholder engagement and effective change management.

In the fight against infectious diseases, case studies have shown the significance of swift and coordinated responses. An example of this is the containment of Ebola in West Africa. Through international collaboration and the rapid deployment of healthcare resources, the spread of the virus was effectively limited. This case study underscores the importance of preparedness, communication, and teamwork in tackling healthcare crises.

Success Stories in Healthcare: Analyzing What Works and Why

Understanding why certain strategies succeed is crucial for replicating positive results in the healthcare industry. For instance, one hospital’s initiative to reduce patient readmissions focused on comprehensive discharge planning and follow-up care. By ensuring patients had clear instructions and support after leaving the hospital, readmission rates dropped significantly. This case study emphasizes the role of thorough patient education and post-discharge care in improving outcomes.

In the realm of preventive care, a primary care clinic introduced a program to increase vaccination rates among its patient population. By actively reaching out to patients due for immunizations and offering flexible scheduling options, the clinic saw a dramatic increase in vaccination rates. The takeaway from this case study is the impact of proactive patient engagement and removing barriers to care.

Lastly, a healthcare organization’s embrace of continuous quality improvement (CQI) led to enhanced patient safety and satisfaction. By fostering a culture of open communication and ongoing learning, the organization identified areas for improvement and systematically implemented changes. This case study demonstrates the power of a commitment to CQI as a driver for excellence in healthcare.

The healthcare industry is rich with case studies that provide valuable insights and lessons learned. By analyzing and understanding these success stories, healthcare providers can apply similar strategies to achieve positive outcomes in their own organizations. Whether it’s through technology, stakeholder engagement, or quality improvement initiatives, these case studies offer a blueprint for triumph and provide a roadmap for future success in the ever-changing landscape of healthcare.

Why are case studies valuable in the healthcare industry, and how do they provide insights into successful decision-making and problem-solving within healthcare organizations?

Case studies are valuable as they offer real-world examples of challenges and solutions in healthcare. They provide insights into successful decision-making, problem-solving, and strategies that can be applied by healthcare professionals and organizations facing similar scenarios.

How does the article select and present case studies, and what criteria are considered to ensure the relevance and applicability of the showcased success stories to a diverse audience?

The article discusses the criteria for selecting case studies, such as their impact on healthcare outcomes, innovation, or overcoming significant challenges. It highlights the diversity of cases to ensure relevance to a broad audience, considering different healthcare settings, specialties, and contexts.

Can you provide examples of healthcare case studies featured in the article, and how do these stories illustrate successful decision-making or lessons learned that can benefit readers in the healthcare field?

Certainly! Examples may include cases where innovative technologies improved patient outcomes, or instances where strategic decisions enhanced operational efficiency. The article presents these stories to illustrate valuable lessons learned and best practices that readers can apply in their own healthcare settings.

In what ways do case studies contribute to professional development and learning opportunities for healthcare professionals, and how can organizations leverage these stories for continuous improvement and staff training?

The article explores how case studies offer learning opportunities, allowing healthcare professionals to gain insights from others’ experiences. Organizations can leverage these stories for staff training, fostering a culture of continuous improvement and encouraging employees to apply lessons learned to their daily practices.

For healthcare leaders seeking to implement successful strategies within their organizations, what recommendations and actionable insights does the article provide based on the analysis of the showcased case studies?

The article offers recommendations based on the case studies, such as the importance of collaboration, data-driven decision-making, and embracing innovation. It provides actionable insights that healthcare leaders can use to inform their decision-making processes and drive positive outcomes within their organizations.

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Historically, manual lifting was the standard method for moving patients at Mercy Health. In one year, associates at the southwestern Ohio facility lifted a combined 88 million pounds of weight in the process of transferring patients. The consequences of such significant manual mobilization included high employee injury rates and workers’ compensation costs. Though Mercy Health was concerned by the numbers, their main concern was ensuring the safety of their patients and staff. Working with Arjo MOVE , the organization implemented safe patient handling programs into its Acute Care and Senior Health and Housing operations. The result: safer patients, safer staff, and significant contributions to first year savings totaling $2,174,182.

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By reducing employee-restricted days, workers’ compensation costs, and employee turnover, Mercy Health experienced a 99% reduction in overall costs.

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J Can Chiropr Assoc
v.52(4); 2008 Dec

Guidelines to the writing of case studies

Dr. brian budgell.

* Département chiropratique, Université du Québec à Trois-Rivières, 3351, boul des Forges, Trois-Rivières, Qc, Canada G9A 5H7

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Dr. Brian Budgell, DC, PhD, JCCA Editorial Board

Introduction

Case studies are an invaluable record of the clinical practices of a profession. While case studies cannot provide specific guidance for the management of successive patients, they are a record of clinical interactions which help us to frame questions for more rigorously designed clinical studies. Case studies also provide valuable teaching material, demonstrating both classical and unusual presentations which may confront the practitioner. Quite obviously, since the overwhelming majority of clinical interactions occur in the field, not in teaching or research facilities, it falls to the field practitioner to record and pass on their experiences. However, field practitioners generally are not well-practised in writing for publication, and so may hesitate to embark on the task of carrying a case study to publication. These guidelines are intended to assist the relatively novice writer – practitioner or student – in efficiently navigating the relatively easy course to publication of a quality case study. Guidelines are not intended to be proscriptive, and so throughout this document we advise what authors “may” or “should” do, rather than what they “must” do. Authors may decide that the particular circumstances of their case study justify digression from our recommendations.

Additional and useful resources for chiropractic case studies include:

Waalen JK. Single subject research designs. J Can Chirop Assoc 1991; 35(2):95–97.
Gleberzon BJ. A peer-reviewer’s plea. J Can Chirop Assoc 2006; 50(2):107.
Merritt L. Case reports: an important contribution to chiropractic literature. J Can Chiropr Assoc 2007; 51(2):72–74.

Portions of these guidelines were derived from Budgell B. Writing a biomedical research paper. Tokyo: Springer Japan KK, 2008.

General Instructions

This set of guidelines provides both instructions and a template for the writing of case reports for publication. You might want to skip forward and take a quick look at the template now, as we will be using it as the basis for your own case study later on. While the guidelines and template contain much detail, your finished case study should be only 500 to 1,500 words in length. Therefore, you will need to write efficiently and avoid unnecessarily flowery language.

These guidelines for the writing of case studies are designed to be consistent with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” referenced elsewhere in the JCCA instructions to authors.

After this brief introduction, the guidelines below will follow the headings of our template. Hence, it is possible to work section by section through the template to quickly produce a first draft of your study. To begin with, however, you must have a clear sense of the value of the study which you wish to describe. Therefore, before beginning to write the study itself, you should gather all of the materials relevant to the case – clinical notes, lab reports, x-rays etc. – and form a clear picture of the story that you wish to share with your profession. At the most superficial level, you may want to ask yourself “What is interesting about this case?” Keep your answer in mind as your write, because sometimes we become lost in our writing and forget the message that we want to convey.

Another important general rule for writing case studies is to stick to the facts. A case study should be a fairly modest description of what actually happened. Speculation about underlying mechanisms of the disease process or treatment should be restrained. Field practitioners and students are seldom well-prepared to discuss physiology or pathology. This is best left to experts in those fields. The thing of greatest value that you can provide to your colleagues is an honest record of clinical events.

Finally, remember that a case study is primarily a chronicle of a patient’s progress, not a story about chiropractic. Editorial or promotional remarks do not belong in a case study, no matter how great our enthusiasm. It is best to simply tell the story and let the outcome speak for itself. With these points in mind, let’s begin the process of writing the case study:

Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet. They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. Thus, our title should contain the phrase “case study,” “case report” or “case series” as is appropriate to the contents. The two most common formats of titles are nominal and compound. A nominal title is a single phrase, for example “A case study of hypertension which responded to spinal manipulation.” A compound title consists of two phrases in succession, for example “Response of hypertension to spinal manipulation: a case study.” Keep in mind that titles of articles in leading journals average between 8 and 9 words in length.
Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing – at the very least they must be able to explain and even defend the article. Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. Contact information – either home or institutional – should be provided for each author along with the authors’ academic qualifications. If there is more than one author, one author must be identified as the corresponding author – the person whom people should contact if they have questions or comments about the study.
Key words: Provide key words under which the article will be listed. These are the words which would be used when searching for the article using a search engine such as Medline. When practical, we should choose key words from a standard list of keywords, such as MeSH (Medical subject headings). A copy of MeSH is available in most libraries. If we can’t access a copy and we want to make sure that our keywords are included in the MeSH library, we can visit this address: http://www.ncbi.nlm.nih.gov:80/entrez/meshbrowser.cgi

A narrative abstract consists of a short version of the whole paper. There are no headings within the narrative abstract. The author simply tries to summarize the paper into a story which flows logically.

A structured abstract uses subheadings. Structured abstracts are becoming more popular for basic scientific and clinical studies, since they standardize the abstract and ensure that certain information is included. This is very useful for readers who search for articles on the internet. Often the abstract is displayed by a search engine, and on the basis of the abstract the reader will decide whether or not to download the full article (which may require payment of a fee). With a structured abstract, the reader is more likely to be given the information which they need to decide whether to go on to the full article, and so this style is encouraged. The JCCA recommends the use of structured abstracts for case studies.

Since they are summaries, both narrative and structured abstracts are easier to write once we have finished the rest of the article. We include a template for a structured abstract and encourage authors to make use of it. Our sub-headings will be:

Introduction: This consists of one or two sentences to describe the context of the case and summarize the entire article.
Case presentation: Several sentences describe the history and results of any examinations performed. The working diagnosis and management of the case are described.
Management and Outcome: Simply describe the course of the patient’s complaint. Where possible, make reference to any outcome measures which you used to objectively demonstrate how the patient’s condition evolved through the course of management.
Discussion: Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned.
Introduction: At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe. The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly. If there is something especially challenging about the diagnosis or management of the condition that we are describing, now is our chance to bring that out. Each time we refer to a previous study, we cite the reference (usually at the end of the sentence). Our introduction doesn’t need to be more than a few paragraphs long, and our objective is to have the reader understand clearly, but in a general sense, why it is useful for them to be reading about this case.

The next step is to describe the results of our clinical examination. Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.

If we are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, we should describe the actual results, since not all readers will have the same understanding of what constitutes a “positive” or “negative” result.

X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is submitted.

At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.

It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used. It does not help the reader to simply say that the patient received “chiropractic care.” Exactly what treatment did we use? If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized.

We may want to include the patient’s own reports of improvement or worsening. However, whenever possible we should try to use a well-validated method of measuring their improvement. For case studies, it may be possible to use data from visual analogue scales (VAS) for pain, or a journal of medication usage.

It is useful to include in this section an indication of how and why treatment finished. Did we decide to terminate care, and if so, why? Did the patient withdraw from care or did we refer them to another practitioner?

Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed. This is usually impossible. Nor should we feel obligated to list or generate all of the possible hypotheses that might explain the course of the patient’s condition. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case.
Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.

A popular search engine for English-language references is Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend.
Tables, figures and photographs should be included at the end of the manuscript.
Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher. Also, if we use any photographs which might identify a patient, we will need their written permission.

In addition, patient consent to publish the case report is also required.

Running Header:

Name, academic degrees and affiliation

Name, address and telephone number of corresponding author

Disclaimers

Statement that patient consent was obtained

Sources of financial support, if any

Key words: (limit of five)

Abstract: (maximum of 150 words)

Case Presentation
Management and Outcome

Introduction:

Provide a context for the case and describe any similar cases previously reported.

Case Presentation:

Introductory sentence: e.g. This 25 year old female office worker presented for the treatment of recurrent headaches.
Describe the essential nature of the complaint, including location, intensity and associated symptoms: e.g. Her headaches are primarily in the suboccipital region, bilaterally but worse on the right. Sometimes there is radiation towards the right temple. She describes the pain as having an intensity of up to 5 out of ten, accompanied by a feeling of tension in the back of the head. When the pain is particularly bad, she feels that her vision is blurred.
Further development of history including details of time and circumstances of onset, and the evolution of the complaint: e.g. This problem began to develop three years ago when she commenced work as a data entry clerk. Her headaches have increased in frequency in the past year, now occurring three to four days per week.
Describe relieving and aggravating factors, including responses to other treatment: e.g. The pain seems to be worse towards the end of the work day and is aggravated by stress. Aspirin provides some relieve. She has not sought any other treatment.
Include other health history, if relevant: e.g. Otherwise the patient reports that she is in good health.
Include family history, if relevant: e.g. There is no family history of headaches.
Summarize the results of examination, which might include general observation and postural analysis, orthopedic exam, neurological exam and chiropractic examination (static and motion palpation): e.g. Examination revealed an otherwise fit-looking young woman with slight anterior carriage of the head. Cervical active ranges of motion were full and painless except for some slight restriction of left lateral bending and rotation of the head to the left. These motions were accompanied by discomfort in the right side of the neck. Cervical compression of the neck in the neutral position did not create discomfort. However, compression of the neck in right rotation and extension produced some right suboccipital pain. Cranial nerve examination was normal. Upper limb motor, sensory and reflex functions were normal. With the patient in the supine position, static palpation revealed tender trigger points bilaterally in the cervical musculature and right trapezius. Motion palpation revealed restrictions of right and left rotation in the upper cervical spine, and restriction of left lateral bending in the mid to lower cervical spine. Blood pressure was 110/70. Houle’s test (holding the neck in extension and rotation for 30 seconds) did not produce nystagmus or dizziness. There were no carotid bruits.
The patient was diagnosed with cervicogenic headache due to chronic postural strain.

Management and Outcome:

Describe as specifically as possible the treatment provided, including the nature of the treatment, and the frequency and duration of care: e.g. The patient undertook a course of treatment consisting of cervical and upper thoracic spinal manipulation three times per week for two weeks. Manipulation was accompanied by trigger point therapy to the paraspinal muscles and stretching of the upper trapezius. Additionally, advice was provided concerning maintenance of proper posture at work. The patient was also instructed in the use of a cervical pillow.
If possible, refer to objective measures of the patient’s progress: e.g. The patient maintained a headache diary indicating that she had two headaches during the first week of care, and one headache the following week. Furthermore the intensity of her headaches declined throughout the course of treatment.
Describe the resolution of care: e.g. Based on the patient’s reported progress during the first two weeks of care, she received an additional two treatments in each of the subsequent two weeks. During the last week of care she experienced no headaches and reported feeling generally more energetic than before commencing care. Following a total of four weeks of care (10 treatments) she was discharged.

Discussion:

Synthesize foregoing sections: e.g. The distinction between migraine and cervicogenic headache is not always clear. However, this case demonstrates several features …

Summarize the case and any lessons learned: e.g. This case demonstrates a classical presentation of cervicogenic headache which resolved quickly with a course of spinal manipulation, supportive soft-tissue therapy and postural advice.

References: (using Vancouver style) e.g.

1 Terret AGJ. Vertebrogenic hearing deficit, the spine and spinal manipulation therapy: a search to validate the DD Palmer/Harvey Lillard experience. Chiropr J Aust 2002; 32:14–26.

Legends: (tables, figures or images are numbered according to the order in which they appear in the text.) e.g.

Figure 1: Intensity of headaches as recorded on a visual analogue scale (vertical axis) versus time (horizontal axis) during the four weeks that the patient was under care. Treatment was given on days 1, 3, 5, 8, 10, 12, 15, 18, 22 and 25. Headache frequency and intensity is seen to fall over time.

Open access
Published: 14 August 2024

Factors influencing nurse practitioner panel size in team-based primary care: a qualitative case study

Ruth Martin-Misener 1 ,
Faith Donald 2 ,
Jennifer Rayner 3 , 4 ,
Nancy Carter 5 ,
Kelley Kilpatrick 6 ,
Erin Ziegler 2 ,
Ivy Bourgeault 7 &
Denise Bryant-Lukosius 5

BMC Primary Care volume 25 , Article number: 304 ( 2024 ) Cite this article

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Lack of access to health care is a worldwide public health crisis. In primary care it has led to increases in the implementation of nurse practitioners and heightened interest in their patient panel capacity. The aim of this study was to examine factors influencing nurse practitioner patient panel size in team-based primary care in Ontario, Canada.

We used a multiple case study design. Eight team-based primary care practices including rural and urban settings were purposively selected as cases. Each case had two or more nurse practitioners with a minimum of two years experience in the primary care setting. Interviews were conducted in-person, audio recorded, transcribed and analysed using content analysis.

Forty participants, including 19 nurse practitioners, 16 administrators (inclusive of executives, managers, and receptionists), and 5 physicians were interviewed. Patient, provider, organizational, and system factors influenced nurse practitioner patient panel size. There were eight sub-factors: complexity of patients’ health and social needs; holistic nursing model of care; nurse practitioner experience and confidence; composition and functioning of the multidisciplinary team; clerical and administrative supports, and nurse practitioner activities and expectations. All participants found it difficult to identify the panel size of nurse practitioners, calling it— “a grey area.” Establishing and maintaining a longitudinal relationship that responded holistically to patients’ needs was fundamental to how nurse practitioners provided care. Social factors such as gender, poverty, mental health concerns, historical trauma, marginalisation and literacy contributed to the complexity of patients’ needs. Participants indicated NPs tried to address all of a patient’s concerns at each visit.

Conclusions

Nurse practitioners have a holistic approach that incorporates attention to the social determinants of health as well as acute and chronic comorbidities. This approach compels them to try to address all of the needs a patient is experiencing at each visit and reduces their panel size. Multidisciplinary teams have an opportunity to be deliberate when structuring their services across providers to meet more of the health and social needs of empanelled patients. This could enable increases in nurse practitioner panel size.

Peer Review reports

Access to health care is a worldwide public health crisis. The supply and productivity of the primary care workforce, including nurse practitioners, (NPs) is critical to its resolution [ 1 , 2 , 3 ]. Panel size is a metric which refers to the number of patients receiving care from a single provider in one year [ 4 ]. Though commonly assessed in physician practices [ 5 , 6 , 7 , 8 ], its use in NP practice is less frequent but increasing [ 9 ]. Panel size and composition is also of interest in the context of primary care teams and is regarded as a key component of high-performing teams [ 10 , 11 , 12 ].

NPs are advanced practice nurses with graduate education that includes clinical training to assess, diagnose and manage patients with acute and or chronic illness [ 3 ]. NPs function as the most responsible provider for their own patient panels or provide care for patients in a collaborating physician’s panel [ 9 ]. Estimates of NP panel size range between 500 and 1000 patients [ 9 ]. These panel size numbers are less than what is typical for physician patient panels leading some to question the cost effectiveness of NPs [ 13 ].

Research has shown that the presence of an NP in a physician’s practice increases the physician’s patient panel size [ 4 , 5 , 6 ]. However few studies have investigated the nature of the patient panels of NPs or the factors that influence panel size and composition. Use of electronic databases, as well as validated disease burden scores, or first-voice perspectives in this research is sparse [ 9 ]. Since NPs are autonomous primary care providers in most of North America and many countries around the world [ 14 ], understanding the factors that influence their panel size is important for health workforce planning.

In Canada NPs are employed in all provinces and territories and their numbers are growing [ 15 ]. The province of Ontario was the first to formally introduce and regulate NPs 25 years ago and continues to have the largest number of NPs in the country [ 16 ]. It is also the province with the longest and most varied experience with various models of interprofessional team-based primary care [ 17 , 18 , 19 , 20 ].

Our study aim was to explore the factors influencing NP patient panel size in team-based primary care in Ontario, Canada.

Study design

We used a multiple case study design to enable understanding of the phenomena of panel size in the real-life context of rural and urban primary care practices [ 21 ]. Cases were defined as team-based primary care practices that included two or more NPs with at least two years experience in the setting.

Funding The study was funded by the Ontario Ministry of Health and Long-term Care. The grant number was 06695.

Recruitment of cases and participants

In consultation with an advisory panel of health care administrators and providers, we discussed the various team-based primary care models in Ontario and decided to include Aboriginal Health Access Centres, Community Health Centres, Family Health Teams and Nurse-Practitioner Led Clinics all of which had been in existence for at least 10 years [ 17 , 18 , 19 , 20 ]. The research team purposively selected eligible practices in rural and urban locations. To enable onsite data collection, practices were located within five hours driving from a large city.

An information letter explaining the study was emailed to the senior administrator in each potential case site. A follow-up telephone call confirmed the practice met eligibility criteria and obtained organizational permission to conduct the study, including the processes for participant recruitment. Each primary care setting and participant received a small honorarium.

Data collection and analysis

Individual interviews with providers and staff explored participants’ perceptions of the barriers and facilitators to increasing NP patient panel size. Interviews were conducted in-person by a research team member between March and November 2015. A small number of interviews were conducted by telephone when requested by participants. Interviews were 30 to 50 min in length and included member checking by summarising key points [ 22 ]. To promote data saturation, data collection occurred one case at a time [ 21 ]. Interviews were conducted in person at each site over two-to-three-days, recorded and transcribed. The interview guide is available as a supplemental file.

Transcripts were coded deductively and inductively using content analysis [ 23 ]. NVivo 12 was used to manage the data [ 24 ]. First, two research team members independently coded four transcripts, compared coding, and discussed emerging themes. Remaining transcripts were independently coded by four team members. Emerging and evolving themes were discussed and refined at research team meetings, including one with the advisory panel.

When reporting the findings, the descriptor “most participants” was used for approximately 75% or more participants, “many participants” for approximately 50–74%, “some participants” for approximately 25–49% and “few participants” for less than 25%. This approach protects participant confidentiality and provides an indication of how many participants expressed a viewpoint without making interpretations beyond the sample [ 25 ].

Forty participants including 19 NPs, 16 administrators (inclusive of executives, managers, and receptionists), and 5 physicians were interviewed. Their characteristics are reported in Table 1 . Many NPs (60%) had graduate education, most (72%) were employed fulltime, and, with one exception, had three or more years experience as an NP. Many self-identified as being female (56%) and their ages ranged from 39 to 46 years. NPs reported spending between 4 and 4.8 days per week providing direct patient care.

Factors influencing NP patient panel size were identified at patient, provider, organizational, and systems levels along with eight sub-factors (Table 2 ). Participants from Aboriginal Health Access Centres and NP-Led Clinics indicated NPs had their own patient panel whereas participants from Family Health Teams and Community Health Centres indicated NPs and physicians shared a patient panel.

All participants found it difficult to identify the number of patients in NPs’ panels commenting it was “a grey area.” Panel size estimates ranged from 300 to 1800 across the eight settings. Some participants assumed that expectations for NP panel sizes were externally determined, for example, by government or health service organizations. Others perceived panel size was determined at the primary care practice level and or by each provider individually.

All participants indicated that numbers alone could not capture the complexities of many of their patients’ lives, even when social factors were included as a diagnosis. As illustrated in the following quote, this, in combination with NPs’ deep commitment to patient-centred preventative care, inevitably meant longer appointment times and likely smaller panel sizes. These concepts are further considered in the following subfactor sections organized as Patient Factors, NP Factors, Organizational Factors and System Factors.

We really try hard here to put the diagnosis in and even poverty comes up or social isolation , so all of those factors. But even those things don’t capture the complexities. So , I think determining a panel size based on that and a philosophy of patient-centred preventative care— rather than acute episodic all the time. That means longer appointment times , less— maybe less patients [NP, Nurse Practitioner-Led Clinic].

Patient factors influencing NP Panel Size

The composition of the patient population and the complexity of their needs was the only patient related factor influencing NP panel size.

Complexity of health and social needs

Across all cases, most interview participants emphasized that the number one factor limiting NP panel sizes was the complexity of the health and social needs of patient populations. As one Family Health Team administrator explained; “ The more complex your patients are , the more time you’re spending with them , the higher their needs and then consequently it becomes more difficult to manage a larger panel .”

Many participants stressed that the length of appointment times was dependant on the needs of patients. Although the primary care receptionists knew most patients well and tried to predict the length of time needed for appointments, this was often not possible. The full extent of patients’ needs was often not disclosed or discovered until the time of the appointment with the NP. When this occurred, it required NPs to choose between staying on schedule or extending the length of the appointment in order to address the presenting patient’s needs. Participants indicated that NPs chose to capitalize on the opportunity to address the needs of the patient especially if the patient was unlikely or unable to return for regular follow up.

“You’re really only ready to give that injection but now you have 10 other issues , and you want to make sure you get through them because this patient may or may not come back for their follow up and it’s so important. I think that can really impact how your whole day looks”. [NP, Community Health Centre]

Participants recognized that health care funders wanted primary care practices to increase the size of NPs’ patient panels and the panels of the practice as a whole. However, participants indicated this was difficult to do without compromising their capacity to address the health and social needs of the patients already in NPs’ panels. As the following quote illustrates, they described this as the tension between providing quality care versus quantity. For participants, establishing and maintaining a supportive relationship with patients already in their practice was fundamental to providing quality care.

“I don’t know how you could have a relationship or how you could support the patient if they have 7 to 10 minutes or whatever the number might be. I recognize that they have expectations of us , being the funding body , that they need data , they need numbers. It’s a struggle with providing quality care versus quantity , especially when our patients come in with early onset aging and a higher representation of chronic diseases at an early age and issues with housing , financial , poverty —all those things. We manage health care , but in addition to health care , support for all the other areas— and it takes time.” [Administrator, Aboriginal Health Access Centre].

Participants identified that NPs provided primary care for patients with complex health and social needs. This included “patients with four or more chronic diseases with multiple complaints on any one day.” Most participants stressed that while multiple chronic illnesses were a component of the challenges patients were experiencing, mental health and substance use concerns and socioeconomic factors compounded the complexity of their lives. The following two quotes illustrate this.

“We draw from a range of socio-economic status areas in (city) and that affects many things. We have a high incidence or prevalence of mental illness , and a lot of issues are complicated through the presence of their mental illnesses {…} or make management more difficult. I’d say that’s a challenge for all our practitioners. {…} You know , you get it all just sort of wrapped together; complexities due to older patients or patients with multiple meds , and then you wrap that up with socioeconomics and mental illness— it’s huge .” [Administrator, Family Health Team] That just doesn’t mean the medical complexity , that also means the social complexity. If that client is substance-using , then I may give them a medication for an infection and they will go get that medication and then come back and say , you need to keep this medication , and then run away again , and I don’t know if they’ll come back or not. It’s totally the medical and behavioural complexity of that individual that certainly limits how many people I see in a day . [NP, Community Health Centre].

Participants further elaborated that gender, literacy, prior unattachment to a primary care provider, historical trauma and marginalisation also contributed to complexity and therefore the need for more support and more time.

“With the NPs , the responsibilities that they see and manage every day with complex patients. We have complex patients probably at a higher number and with early onset aging and historical trauma. Our patients come in with a lot more — they need a lot more support .” [Physician, Aboriginal Health Access Centre]. “We did have new families , and even with those patients , it was chronic issues. They were unattached and marginalized , and they’d never seen any primary care provider for years. And they were the frequent flyers between hospital emergency and the walk-in clinics .” [NP, NP-Led Clinic].

In summary, participants were united in their view that the complex health and social needs of patients in their primary care settings required longer appointment times with the NP, and this in turn reduced NPs’ panel size capacity.

Provider factors influencing NP panel size

Two provider factors influenced NP panel size: NPs’ holistic nursing model of care and their experience and confidence.

Holistic nursing model of care

Half of NP and administrator participants in all four models of team-based primary care identified that the holistic nature of the care NPs provide was an influence on their patient panel size. A physician explained that NPs’ ability to look at patients holistically originated from nursing culture and is a value-add that they bring to primary care.

“I think one of the great things NPs add to primary care , and it’s something that’s important to all of us , is something of value in nursing culture , which is to see people holistically as people who have needs and who come in with fears and anxieties. I think that’s a value that our whole health system needs more of.” [Physician, Community Health Centre].

Providing holistic care was linked to scheduling appointment times that enabled NPs to take time to nurture a relationship built on trust and to address the multiple health and social concerns of patients. An NP explained it as follows:

“If we can be patient-centred and take the time with people to address their issues , listen to them , you’re going to get more done. You spend a lot more money when a person ends up in crisis than doing prevention and really listening carefully to people and having that relationship with them. A lot of patients come here and the biggest thing they say they notice is that we spend the time—we listen. Their doctor may have had 10 minutes with them. So , they really appreciate that and they’re more apt to follow through on your suggestions because they feel you’ve listened to their problem and have some trust.” [NP, NP-Led clinic].

NP Experience and confidence

Most participants indicated that experience in the role and in primary care practice influenced NP panel size. This is illustrated in the following quotes from NP and administrator participants.

“When they first started , they had hour-long appointments with the clients because , first of all , they didn’t know the computer system , and their primary care skills weren’t as fresh.” [NP, Community Health Centre]. If an NP is more novice and really having to deal with a big pile of complexity with inter-related problems and symptoms—that really does affect panel size. It affects the amount of time that the NP takes and really having to lean on his or her colleague to get advice and support.” [Administrator, Community Health Centre].

Development of confidence occurred over time, and through application of theoretical knowledge and exposure to clinical issues in the practice setting. Having opportunities to discuss questions and decisions with a colleague enabled confidence. When patients presented with complexities that required NPs to consult other providers, these consultations impacted the number of patient appointments.

The connections between experience, confidence, and an ability to practice at a faster speed are summarised by an administrator in the following quote.

“What I have noticed is because of the comfort and confidence that a more experienced NP has , he or she will be able handle a situation around a prescription or diagnosis much more quickly .” [Administrator, Community Health Centre].

Organizational factors influencing NP panel size

There were three organisational factors influencing the panel size of NPs: multidisciplinary team roles; clerical and administrative supports, and expectations regarding NP activities.

Multidisciplinary team roles

Most NP and physician participants and many administrator participants identified that multidisciplinary teams enabled increases in NP panel size because patients could receive care from other team members. For example, dieticians provided nutrition counselling for patients with diabetes, pharmacists assisted patients with smoking cessation and social workers enabled patients to make connections with community resources and supports. Participants identified that it was important for the multidisciplinary team to think deliberately about each team member’s contribution to patient care. They indicated that when patient needs were matched with team members with the expertise to meet those needs, the panel size of NPs and the panel size of the entire practice could be increased.

If we involve more multidisciplinary team members, for instance, having a diabetic program in place or if you have a pharmacist, more registered practical nurses involved, and social work more involved, I can see NPs having more patients and expanding the panel size more. [Administrator, NP-Led Clinic].

Participants offered several examples of health care providers, who, through their education and team roles, provided specific skills and services to meet needs of patient groups. They discussed the importance of enabling all team members to practice to their full scope of practice and making deliberate decisions about involving providers with specific competencies in the care of specific patient populations. The following quote illustrates this concept.

“Truly using every provider to their full scope of practice and not booking tasks and activities that could go to another provider. So , when I think about our NPs , they’re a pretty hot commodity. We need them to see specific things with specific clients with specific issues and if they’re booking up their schedules with a blood pressure recheck or —name your episodic thing—it does take away time from being able to see other patients. So that full scope is really incredible.” [Administrator, Community Health Centre].

Some participants identified the importance of providers reflecting on their own professional and personal scope of practice as well as the scope of practice of other team members when planning how to address the needs of patients in the practice. As one NP explained

“I always think— what am I best able to provide the patient? I’m not a social worker , I’m not a great CBT (cognitive behavior therapy) counsellor— so why try to spend time counselling when I can send them to somebody else , find them resources.” [NP, Family Health Team].

Further to this, some participants indicated that multidisciplinary teams wanted opportunities to design, implement and evaluate new approaches to team collaboration. Many team members indicated that collaboration improved team building and that it enabled problem-solving that led to operational changes that contributed to panel size growth.

“What I’m seeing on our team , is really excellent team collaboration. If the team is really healthy , and functional , and can problem-solve and can do mutually supportive stuff—I think that’s a team that can handle a bigger panel size.” [Community Health Centre , Physician] .

Participants noted that with resources, such as dieticians, social workers, registered practical nurses and pharmacists, some of the health teaching previously done by NPs was now being carried out by other team members. This provided time for NPs to have more patient appointments.

“It evolves relative to practice size , the number of patients to be seen and to NP experience and confidence and availability of supports. An NP two years ago might have been doing smoking cessation on their own; now we have the support of the pharmacist to do that.” [Family Health Team , Administrator].

Clerical and administrative supports and activities

Most participants indicated that clerical, and administrative staff were essential for enabling NPs to increase their panel size. Many identified that their practices had standard times for different types of appointments. For example, patients needing a complete physical examination or who had mental health concerns would be booked for a one-hour appointment. Most other appointments were booked for 30 min. Participants noted that most patients were well known by clerical staff, and they knew how to adjust appointment duration times according to what patients were anticipated to need. The following quote exemplifies this perspective.

“I think each individual NP and the girls at the front have a background of all the patients— we know the patients well , and we know how to book them as far as time.” [NP -Led Clinic , Administrator] .

Many participants indicated that administrative responsibilities were a component of NPs’ workload and ranged from 0.5 to 7.5 h weekly.

“Of course , I have administrative time when I’m not seeing patients so during that time , I’m doing paperwork and reviewing labs and doing administrative things. If I had less administrative time , then maybe I would be able to see more clients but that’s part of the job” [NP, Family Health Team].

For others, administrative work included activities such as program planning, leading meetings, quality improvement and community education/outreach activities. Some participants indicated that the time NPs spent on administration lessened the available clinical time.

Expectations regarding NP activities

Most participants indicated appointment-based, direct care within the primary care practice setting was how NPs spent most of their time. In some practices NPs were expected to offer specific types of appointments that impacted their panel size, for example, same and next day patient appointments. In some practices NPs were responsible to do activities requiring more time, for example, completing the telephone follow-up calls or routine pelvic examinations for the patients of all providers in the practice.

Many participants indicated NPs did house calls or street calls noting these required more time because travel was entailed. For example, an Aboriginal Health Access Centre administrator said, “ I think we book 1 ½ hours .” The frequency of house-calls was on an as-needed basis, with one NP-Led Clinic NP reporting 28 in a year. Most NPs reported they did not have on-call responsibilities except for some who were on-call but only for critical lab results.

In summary, the three subfactors at the organizational level were composition and functioning of multidisciplinary healthcare provider teams, clerical and administrative supports and expectations regarding NP activities.

Systems Level factors influencing NP panel size

The systems level factors that influenced the panel size of NPs were restrictions on NP scope of practice and NP remuneration.

Restrictions on NP scope of practice

At the time of data collection, systems level factors that restricted scope of practice included barriers to referring patients to specialists, restrictions on ordering some diagnostic tests, and the inability to prescribe some medications. As one Family Health Team NP explained having these restrictions removed would save time because “having to ask can I order this or that— it just slows down the time .” The removal of the requirement for a physician’s co-signature on specialist referral requests had an impact on increasing panel size as illustrated in the following quote. “ Being able to refer now without a physician’s co-signing— that opened up a position for me in a satellite office in (location) to help with patients who didn’t have a family physician .

NP remuneration

Funding was also an important enabling factor identified by many NPs and physicians. One NP from a Community Health Centre summarized it as follows:

If we think of wages as a system thing and we think about how it impacts on recruitment and retention, you can’t grow your clinic if you don’t keep your staff. {…} So, if you support recruitment and retention with good wages, you can grow your panel size. But your NPs get a better offer, and they go off to a better paying organization, […], then you can’t grow primary care, you can’t grow your clinic.

Through this analysis we found that the most significant factor influencing NP panel size was the time needed to address the multiple complex health and social needs experienced by patients in their practice. To accommodate for this, NPs had appointment times that varied between 15 and 30 min and some that were booked for an hour or more. Participants identified that providing care for patients impacted by the social determinants of health was important. All participants supported the value of the principle of time allocation for NPs to address patients’ broader social needs—especially patients experiencing trauma, marginalization and high-risk environments. They emphasized that NPs were ideally suited to provide care for this patient population because of NPs’ holistic, comprehensive nursing approach that included taking the time to listen and fulsomely address patients’ concerns at each appointment. Participants emphasized that concerns about panel size should not compromise the comprehensiveness of the care NPs provide to patients with complex needs because it was important from a social justice standpoint, and it reduced the risk of adverse patient outcomes.

The association between the length of appointment time and complexity has been documented from patient [ 26 ] and provider [ 27 , 28 , 29 ] viewpoints. Patients impacted by social factors, such as poverty, are also disproportionately affected by medical comorbidities [ 30 ]. When discussing complexity, participants spoke briefly about patients’ multimorbidity and gave detailed accounts of the social determinants impacting patients for whom NPs provided care. It is possible that their focus on these factors was a confirmation bias of their knowledge of the nursing profession’s focus on social determinants of health. Similar findings from studies using patient profile [ 28 , 30 ] and task allocation studies [ 31 ] make this explanation unlikely. NPs in this study prioritized identifying and taking action to address the social needs of their patients regardless of the time it took or impact it had on panel size. Although not a concern of participants in our study, the cost effectiveness of NPs’ longer appointment times has been criticized [ 12 ]. However, recent studies indicate NP-provided primary care for patients with complex health needs results in savings in downstream costs associated with hospital use [ 32 , 33 ]. Primary care is the point in health care systems where these interventions should be provided - not in the emergency room or in hospital.

Participants in our study were mindful of the need to attend to NP panel size. However, they tended to regard panel size determination as an accountability required of funders, not a tool to improve how care delivery could be better organized in the practice [ 34 ]. They were cognizant of the challenges patients faced when accessing primary care, for example, transportation and childcare, and recognized the visit was a time-limited window of opportunity to address concerns. Therefore, participants prioritized giving patients the time required to have most or all of their needs met in a single appointment. This approach aligns with Levesque et al.’s [ 35 ] broad perspective on accessibility as an opportunity to identify healthcare needs and have those needs for services fulfilled. It is also consistent with the call to action of Browne and Tarlier, who said: “With even a small investment of time, NPs operating from a critical social justice perspective could for example, attend to the biomedical needs of patients and at the same time work towards countering or challenging the social or economic policies that affect biomedical issues” [ 36 , p. 90]. Participants in our study prioritized their time for these patients but did not discuss policy work they were doing related to the social determinants of health.

While participants valued and made efforts to optimize the roles of multidisciplinary team members including registered and practical nurses, for the most part they did not discuss how the team could take a more deliberate approach to maximizing optimal functioning of all team members’ roles and the impact this could have on NP panel size. Such planning requires data, and we did not specifically ask participants to what extent they could mine electronic medical record data to inform this planning. Research has shown that NPs use EMR data to plan their own clinics [ 37 ], however, few practices are using this data to inform financial and organizational planning for the services a primary care clinic could offer and the roles of team members [ 38 ]. This could enable improvements in accessibility and equity.

Limitations

Our study offers an in-depth description of the factors affecting NP patient panels in primary care in one Canadian province. Interview data were collected in 2015 before the COVID-19 pandemic and the increased use of virtual care in primary care. Future research should evaluate strategies for aligning team composition with patient population health and social needs as well as the potential impact of virtual care provision on NP panel size. Our study did not include patient interviews and not having their perspectives is a limitation. Detailed information about the structures and processes of these practice models other than what is presented in Table 1 was not obtained in our study and is a limitation to understanding the impact of context on panel size.

Multiple factors influence NP patient panel size, particularly the complexity of the health and social needs of patients. NPs have a patient-centred, holistic approach that aims to address the social determinants of health for each patient when they access primary care. Panel size concerns should not compromise the comprehensiveness and equity of the care NPs provide. Better utilization of practice-based data may enable multidisciplinary teams to optimize panel size without compromising equity and quality of care.

Data availability

The qualitative data that support the findings of this study are not openly available. Participants did not consent to have their data shared.

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R.M.M. collected and analyzed data and wrote the initial manuscript text and led subsequent revisions. FD, JR and KK collected and analyzed data and reviewed and contributed to revisions of the manuscript. DB, IB, NC and EZ analyzed data and reviewed and contributed to revisions of the manuscript.

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Martin-Misener, R., Donald, F., Rayner, J. et al. Factors influencing nurse practitioner panel size in team-based primary care: a qualitative case study. BMC Prim. Care 25 , 304 (2024). https://doi.org/10.1186/s12875-024-02547-6

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For more than 30 years, the 340B Drug Pricing Program has provided financial help to hospitals serving vulnerable communities to manage rising prescription drug costs.

Helping policymakers, patients, communities and more understand the benefits of 340B in essential, as the program allows 340B hospitals to stretch limited federal resources to benefit patients and communities.

The American Hospital Association (AHA) recently released an article focusing on the benefits of 340B, with a case study on Monument Health in Rapid City, South Dakota. Below is elements of the article or you can view the full publication here .

“Who is Monument Health”

With a service area population of nearly 500,000 and headquartered in Rapid City, Monument Health is the largest health care provider in western South Dakota. Tracing its history back to 1878, Monument Health is an integral part of the local community providing a wide array of vital services including behavioral health, oncology and dialysis care. Spanning five hospitals, eight specialty and surgical centers, and more than 40 medical clinics and health care service centers, Monument Health is the primary health care provider for a very rural population who otherwise has limited access to care.

“Who does Monument Health treat?”

In addition to the entirety of western South Dakota, Monument Health also cares for patients in parts of Montana, Wyoming, North Dakota and Nebraska. Monument Health’s service area is extremely rural, with fewer than ten people per square mile. In many communities, Monument Health is the only resource for high-level health care: if it weren’t for Monument Health maintaining hospitals and clinics throughout the region, some patients would be forced to travel 350 miles or more to access intensive care services, including neonatal and pediatric ICUs. Receiving care closer to home is incredibly important for Monument Health’s patients, especially during the region’s harsh winters, which can make long drives (and even emergency helicopter flights) extremely challenging. With an average of over 52,000 visits each year, the emergency department at the Rapid City Hospital is the busiest in South Dakota and the surrounding states.

Monument Health serves a highly diverse population. Approximately one-in-five patients identify as Native American, and the largest segment of patients in Monument Health’s pediatric inpatient units are Native American. A high number of patients, particularly children, are covered by Medicaid or are uninsured. Monument Health also treats a high number of Medicare patients. In fact, 72% of patients treated by Monument Health are covered by government payers, which historically do not reimburse for the full cost of providing care — an especially challenging trend at a time when inflationary cost pressures for hospitals have skyrocketed.

“What’s the value of the 340B Program for Monument Health’s communities and patients?”

In 2023, Monument Health provided unreimbursed care of approximately $73.8 million. In order to continue providing care for such a geographically broad and socioeconomically vulnerable population, the 340B program is absolutely critical, helping Monument Health maintain and expand access to care for the rural populations it serves. While the 340B program helps Monument Health stay afloat and expand its services to patients across the board, the system has also used its savings to invest in several important programs that directly benefit their patients.

“Investing in Nonprofits to Improve Health Before People Require Emergency Care”

Monument Health is proud to contribute several hundred thousand dollars to local nonprofits every single year to support broader community health efforts. For example, Monument Health supports the CARE Campus, which provides shelter and services for substance use, mental health and detox to unhoused individuals. At a time when drug overdose death rates are historically high in the area, this initiative saves lives, helps patients manage their substance use disorders, improves health outcomes in the community, and lowers the risk of patients requiring emergency services — a win-win for patients and the community. Improving patients’ health with preventive community initiatives is one way that Monument Health is utilizing its 340B savings to address community health needs.

Expanding Access to Pharmacy Services in Communities Big and Small

In addition to providing discharge medications to patients regardless of their ability to pay, Monument Health also partners with most pharmacies in western South Dakota to ensure patients receive their medications in a timely manner and at a convenient location in their community. Over the past few years, many pharmacies in the state have closed, so being able to contract with Monument Health helps remaining pharmacies keep their doors open to patients who otherwise lack options within an hour’s drive.

In addition to its network of contract pharmacies, Monument Health also maintains retail pharmacies at certain hospitals and clinics and maintains a specialty pharmacy in Rapid City, which is particularly important for their cancer patients. Whether it’s in South Dakota’s largest cities or small towns, the 340B program helps Monument Health provide pharmaceutical services in the convenience of their local community, improving medication adherence and overall patient health outcomes.

340B Hospitals Need Support

For Monument Health, the 340B program provides critical support to everything the system does for patients, from emergency care and specialty services to nonprofit investments and pharmacy access. Ultimately, the program is working as federal lawmakers intended: it is helping Monument Health stretch its resources, increase the number and mix of services, enhance access, and improve health care outcomes for the region’s most vulnerable patients and communities.

Unfortunately, some are trying to undermine the 340B program, including pharmaceutical companies placing unreasonable and unlawful demands on 340B hospitals, as well as regulatory and legal threats to this vital program from adversaries. If the 340B program were to be curtailed, thousands of South Dakotans would be at risk of losing access to care in their communities. Without 340B savings, Monument Health’s ability to maintain and expand access to services like pediatrics, cancer care and behavioral health would be threatened, services that are otherwise inaccessible for the communities they serve. 340B hospitals like Monument Health and the patients and communities they care for need the federal government to continue to protect the 340B Drug Pricing Program and the critical resources it affords to South Dakotans and Americans across the country.

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Study finds baked potatoes can improve heart health for diabetics

by Steven Slivka, University of Nevada, Las Vegas

Looking to boost your heart health? Try a baked potato

The potato is small enough to fit inside a person's hand yet contains enough nutrients to whittle waistlines and lower blood sugar in adults with type 2 diabetes. Yet, despite the fact that potatoes—particularly the skins—are packed with health-boosting nutrients, they routinely get a bad rap among dieters.

That may soon change, thanks to new research by Neda Akhavan, assistant professor in the Department of Kinesiology and Nutrition Sciences within UNLV's School of Integrated Health Sciences. Akhavan recently presented her findings on the cardiovascular benefits of potatoes for those living with Type 2 diabetes to the Alliance for Potato Research and Education.

"I like doing research on food items that are highly stigmatized in the nutrition world," she said. "Most people associate the potato as something that is mostly fried or has a lot of fat, and we wanted to shine a light on how a potato—when prepared properly—can be both functional and healthy."

Putting potatoes to the test

Akhavan enlisted 24 participants for the study , all of whom had Type 2 diabetes that was well controlled with medication. This is believed to be the first study of its kind to scientifically measure the cardiovascular benefits of potatoes for adults with diabetes.

Participants in the study group were each given a pre-prepared baked potato with the skin measured to 100g, with only 20 grams of carbohydrates, roughly enough to fit in one hand to incorporate as a snack or side with meals daily. The control group was given a similar potion of white rice with the same number of calories and carbohydrates. The study ran daily for 12 weeks, which is considered the minimum time needed to see changes in indices of glycemic control and cardiometabolic health.

Study participants were permitted to add herbs or spices to the potatoes, or up to ½ tbsp of butter, but they were advised not to fry their potato.

Key takeaways and recommendations

A modest decrease in fasting blood glucose levels was present for study participants who ate potatoes. Study participants also showed improvements in body composition, waist circumference, and a decrease in resting heart rate.

"The results from our study provide evidence that white potatoes can be healthfully incorporated in the diet of individuals with Type 2 diabetes when substituted for other foods with a high glycemic load, such as long-grain white rice," Akhavan said.

"Additionally, there were no harmful effects on measured health outcomes , and some cardiometabolic health benefits were shown, which aligned with what we expected to see. Therefore, diabetics should not shy away from potatoes."

Akhavan says that just like all foods, moderation—and preparation methods—are key.

"Potatoes are a very versatile food and can be eaten with most types of cuisines, but you want to make sure to incorporate them into a well-rounded diet," she said.

"For those tight on time, consider making a large batch of baked or roasted potatoes and meal prep to last you a while. I'm not against boiling potatoes, but you want to keep as much of the potassium from the skin as you can, and you lose some of that when you boil them."

Making the case for potatoes

Potatoes are the richest source of dietary potassium in Western diets, and high potassium diets have been shown to prevent high blood pressure and Type 2 diabetes development. Additionally, potato skins contain a certain type of fiber called "resistance starch," which have been shown to improve glucose control, lipid profiles, and satiety. Because of these added health benefits, Akhavan recommends eating potatoes with the skin.

So, the next time you want to reach for a banana, she added, reach for that potato instead.

"A lot of people are shocked to learn that a potato has a higher level of potassium than a banana," she said. "Believe it or not, a baked potato is one of the most satiating foods consumed within the western diet. And, when it is consumed baked, it increases our ability to feel fuller throughout the day."

Akhavan intends to expand the study in the coming months to include a larger and more diverse participant population, and incorporation of potatoes within a Mediterranean dietary pattern. She also plans to explore the role of potato consumption and its effects on dietary patterns and related health benefits.

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How to Write a Nursing Case Study + Examples, Format, & Tips
Patient Case Study
FREE 10+ Patient Case Study Samples & Templates in MS Word
healthcare case study quality management
Medical Case Study
(PDF) Improving Communication in Healthcare: a case study

COMMENTS

Continuing to enhance the quality of case study methodology in health
In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design.
Case studies: Healthcare: Industries: PwC
Case studies show how PwC supports the improvement of health and well-being around the world by helping our Health Services clients to change lives.
What is a case study?
What is it? Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… 'a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units'. 1 A case study has also been described as an intensive, systematic ...
A Case Study of Using Telehealth in a Rural Healthcare Facility to
This case study aimed to gain an understanding of the implementation and usage of a telehealth program during the COVID-19 pandemic at a rural healthcare facility. An action research methodology, utilizing cycles of planning, implementation, review and ...
Case Library
The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives. Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or ...
Open Case Studies
The Open Case Studies project showcases the possibilities of what can be achieved when working with real-world data. These case studies will empower current and future data scientists to leverage real-world data to solve leading public health challenges.
Health Case Studies
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.
Writing a case report in 10 steps
Writing up. Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.
Case Studies
The American Hospital Association (AHA) is the national organization that represents and serves all types of hospitals, health care networks, and their patients and communities.
The case study approach
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 ...
A Case Study of a Whole System Approach to Improvement in an Acute
A case study approach was adopted to understand the deployment of a whole system change in the acute hospital setting along four dimensions of a socio-technical systems framework: culture, system functioning, action, and sense-making. The case study demonstrates evidence of whole system improvement.
PDF Clinical Case Studies for Students and Health Professionals
Clinical Case Studies for Students and Health Professionals The following examples are included to help students and clinicians explore in more detail the health impacts of climate change and provide real-world examples and case studies.
Case studies: Digitally enabled care in action
The case studies below highlight successful collaborations between health systems or physician practices and digital health companies that are providing digitally enabled care and driving the future of health.
Case study research for better evaluations of complex interventions
Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.
Case Studies
Explore our case studies to gain insight into the latest healthcare technology trends, guidance, and perspectives from prominent industry experts.
Effectiveness of mRNA Covid-19 Vaccine among U.S. Health Care Personnel
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Health: Articles, Research, & Case Studies on Health- HBS Working Knowledge
New research on health from Harvard Business School faculty on issues including corporate wellness, investing in community health, and health insurance.
Case 1. Lakeview Healthcare
Description of the Health Care Organization Case 1 study included projects implemented at several hospitals, an ambulatory care center, and the physicians' offices as described in Exhibit 1.4. Also included in our study was a comprehensive LHC Outpatient Medical Facility serving a different city and surrounding communities.
How can health systems approach reducing health ...
Background Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system's level ...
"Case Studies in Healthcare: Success Stories and Lessons Learned"
The healthcare industry is an ever-evolving field with innovations and improvements happening daily. As healthcare providers strive to deliver the best care possible, case studies have become a valuable resource for learning and growth. In this article, we will explore various case studies in healthcare, highlighting both success stories and the lessons learned along the way. By analyzing what ...
Mercy Health Case Study
Download case studies. Rooted in clinical evidence and driven by your facility data, Arjo Move supports you to deliver high quality care that facilitates patient and resident mobility, resulting in improvements in clinical outcomes, staff well-being, operational efficiency, and financial optimization.
Modeling and simulation to improve patient admission process: a case
Increasing medical costs around the world and limited resources have led health decision-makers to focus on measuring and improving their performance to effectively deliver high-quality care.
Guidelines to the writing of case studies
Introduction Case studies are an invaluable record of the clinical practices of a profession. While case studies cannot provide specific guidance for the management of successive patients, they are a record of clinical interactions which help us to frame questions for more rigorously designed clinical studies. Case studies also provide valuable teaching material, demonstrating both classical ...
Factors influencing nurse practitioner panel size in team-based primary
Background Lack of access to health care is a worldwide public health crisis. In primary care it has led to increases in the implementation of nurse practitioners and heightened interest in their patient panel capacity. The aim of this study was to examine factors influencing nurse practitioner patient panel size in team-based primary care in Ontario, Canada. Methods We used a multiple case ...
Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary
Internet Citation: Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study. Content last reviewed August 2024. Content last reviewed August 2024.
PDF What is a case study?
Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research.1 However, very simply... 'a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units'.1 A case study has also been described as an inten-sive, systematic investigation of a ...
Monument Health Featured in AHA 340B Program Case Study
The American Hospital Association (AHA) recently released an article focusing on the benefits of 340B, with a case study on Monument Health in Rapid City, South Dakota. ... In many communities, Monument Health is the only resource for high-level health care: if it weren't for Monument Health maintaining hospitals and clinics throughout the ...
Journal of Medical Internet Research
Experiential learning theory can enhance patients' eHL and skills to use eHealth care technology in their daily care. Objective: This study explored the effectiveness of an eHealth care experiential learning program in improving eHL, patient health engagement, and eHealth care use status among patients with type 2 diabetes in 3 months.
Alcohol consumption and DNA methylation: a case-cohort study within the
BACKGROUND AND AIM[|]Alcohol consumption is a widespread behavior in the world that can have numerous damaging effects on health including the development of cancers. Understanding the molecular mechanisms underlying these associations is essential for gaining insight into the health consequences that result from alcohol consumption. This study aimed to assess the association between alcohol ...
Study finds baked potatoes can improve heart health for diabetics
The study ran daily for 12 weeks, which is considered the minimum time needed to see changes in indices of glycemic control and cardiometabolic health. Study participants were permitted to add ...

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Writing a case report in 10 steps

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Case study research for better evaluations of complex interventions: rationale and challenges

Case study research offers evidence about context, causal inference in complex systems and implementation

The challenges in exploiting evidence from case study research

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