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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. 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. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

• 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.

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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

Google Scholar  

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

Article   CAS   PubMed   PubMed Central   Google Scholar  

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

Article   Google Scholar  

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

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

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

Article   PubMed   Google Scholar  

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

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

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

PubMed   PubMed Central   Google Scholar  

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

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

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

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

Article   PubMed Central   Google Scholar  

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

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

CAS   PubMed   PubMed Central   Google Scholar  

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

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

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

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

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

Mason J: Qualitative researching. 2002, London: Sage

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

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

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

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

Article   PubMed   PubMed Central   Google Scholar  

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

Article   CAS   PubMed   Google Scholar  

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

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

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

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

Book   Google Scholar  

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

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

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

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

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

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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

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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 investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

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• Published: November 2006

Case Studies: why are they important?

• Julie Solomon 1  

Nature Clinical Practice Cardiovascular Medicine volume  3 ,  page 579 ( 2006 ) Cite this article

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Nature Clinical Practice Cardiovascular Medicine is a journal designed to lighten the reading load for busy doctors; why, then, does it include Case Studies? Isn't the case study just a bit of light reading? It depends on what it is designed to do. So, what is the role of the Case Study?

Case Studies should act as instructive examples to people who might encounter similar problems. Ideally, in medicine, Case Studies should detail a particular medical case, describing the background of the patient and any clues the physician picked up (or should have, with hindsight). They should discuss investigations undertaken in order to determine a diagnosis or differentiate between possible diagnoses, and should indicate the course of treatment the patient underwent as a result. As a whole, then, Case Studies should be an informative and useful part of every physician's medical education, both during training and on a continuing basis.

It's debatable whether they always achieve this aim. Many journals publish what are often close to anecdotal reports (if they publish articles on individual cases at all), rather than detailed descriptions of a case; furthermore, the cases described are often esoteric or the conditions present on such an infrequent basis that a physician working outside a teaching-hospital environment would be hard-pressed to apply their new knowledge. It would be difficult, therefore, to say whether any conclusions could confidently be drawn by readers as a result of these reports. Most physicians would probably want to do some extra research—either in the literature or by canvassing opinions of colleagues.

By proposing, peer-reviewing and reading the Case Studies, you and your fellow physicians could gain a broader understanding of clinical diagnoses, treatments and outcomes.

In this light, then, Nature Clinical Practice Cardiovascular Medicine Case Studies have a specific aim: to help established physicians as well as trainees to improve patient care, without adding to their workload. Rather than being merely anecdotal, they include the etiology, diagnosis and management of a case. Importantly, they give an indication of the decision-making process, so that other physicians can apply lateral thinking to their own cases. Decisions on which of a range of treatment options to follow might involve input from the patient, or might be purely objective, but ideally a Case Study should outline why a particular course was followed. Readers should not have to resort to the Internet or to out-of-date textbooks to find basic background information explaining the reasons for approaching the case in that way; the reasons should be fully explained in the article itself.

Nature Clinical Practice Cardiovascular Medicine Case Studies represent an opportunity to spread the benefit of knowledge across the physical boundaries imposed by looking at one case, in one place, at one time. It's not so that fingers can be pointed at 'incorrect' treatment but instead so that geographical differences in practice can be highlighted, for example, or clearer descriptions be reached to explain a case more completely and accurately.

By proposing, peer-reviewing and reading the Case Studies, you and your fellow physicians could gain a broader understanding of clinical diagnoses, treatments and outcomes. So, we're inviting you to contribute to the further education of your colleagues. Will you meet the challenge?

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

Table of Contents

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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• Published: 15 May 2024

Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke

• Helena Teede 1 , 2   na1 ,
• Dominique A. Cadilhac 3 , 4   na1 ,
• Tara Purvis 3 ,
• Monique F. Kilkenny 3 , 4 ,
• Bruce C.V. Campbell 4 , 5 , 6 ,
• Coralie English 7 ,
• Alison Johnson 2 ,
• Emily Callander 1 ,
• Rohan S. Grimley 8 , 9 ,
• Christopher Levi 10 ,
• Sandy Middleton 11 , 12 ,
• Kelvin Hill 13 &
• Joanne Enticott   ORCID: orcid.org/0000-0002-4480-5690 1  

BMC Medicine volume  22 , Article number:  198 ( 2024 ) Cite this article

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In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit.

Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement.

Conclusions

The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.

Peer Review reports

Internationally, health systems are facing a crisis, driven by an ageing population, increasing complexity, multi-morbidity, rapidly advancing health technology and rising costs that threaten sustainability and mandate transformation and improvement [ 1 , 2 ]. Although research has generated solutions to healthcare challenges, and the advent of big data and digital health holds great promise, entrenched siloes and poor integration of knowledge generation, knowledge implementation and healthcare delivery between stakeholders, curtails momentum towards, and consistent attainment of, evidence-and value-based care [ 3 ]. This is compounded by the short supply of research and innovation leadership within the healthcare sector, and poorly integrated and often inaccessible health data systems, which have crippled the potential to deliver on digital-driven innovation [ 4 ]. Current approaches to healthcare improvement are also often isolated with limited sustainability, scale-up and impact [ 5 ].

Evidence suggests that integration and partnership across academic and healthcare delivery stakeholders are key to progress, including those with lived experience and their families (referred to here as consumers and community), diverse disciplines (both research and clinical), policy makers and funders. Utilization of evidence from research and evidence from practice including data from routine care, supported by implementation research, are key to sustainably embedding improvement and optimising health care and outcomes. A strategy to achieve this integration is through the Learning Health System (LHS) (Fig.  1 ) [ 2 , 6 , 7 , 8 ]. Although there are numerous publications on LHS approaches [ 9 , 10 , 11 , 12 ], many focus on research perspectives and data, most do not demonstrate tangible healthcare improvement or better health outcomes. [ 6 ]

Monash Learning Health System: The Learn Together for Better Health Framework developed by Monash Partners and Monash University (from Enticott et al. 2021 [ 7 ]). Four evidence quadrants: Q1 (orange) is evidence from stakeholders; Q2 (green) is evidence from research; Q3 (light blue) is evidence from data; and, Q4 (dark blue) is evidence from implementation and healthcare improvement

In developed nations, it has been estimated that 60% of care provided aligns with the evidence base, 30% is low value and 10% is potentially harmful [ 13 ]. In some areas, clinical advances have been rapid and research and evidence have paved the way for dramatic improvement in outcomes, mandating rapid implementation of evidence into healthcare (e.g. polio and COVID-19 vaccines). However, healthcare improvement is challenging and slow [ 5 ]. Health systems are highly complex in their design, networks and interacting components, and change is difficult to enact, sustain and scale up. [ 3 ] New effective strategies are needed to meet community needs and deliver evidence-based and value-based care, which reorients care from serving the provider, services and system, towards serving community needs, based on evidence and quality. It goes beyond cost to encompass patient and provider experience, quality care and outcomes, efficiency and sustainability [ 2 , 6 ].

The costs of stroke care are expected to rise rapidly in the next decades, unless improvements in stroke care to reduce the disabling effects of strokes can be successfully developed and implemented [ 14 ]. Here, we briefly describe the Monash LHS framework (Fig.  1 ) [ 2 , 6 , 7 ] and outline an exemplar case in order to demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare. The Australian LHS exemplar in stroke care has driven nationwide improvement in stroke care since 2007.

An evidence-based Learning Health System framework

In Australia, members of this author group (HT, AJ, JE) have rigorously co-developed an evidence-based LHS framework, known simply as the Monash LHS [ 7 ]. The Monash LHS was designed to support sustainable, iterative and continuous robust benefit of improved clinical outcomes. It was created with national engagement in order to be applicable to Australian settings. Through this rigorous approach, core LHS principles and components have been established (Fig.  1 ). Evidence shows that people/workforce, culture, standards, governance and resources were all key to an effective LHS [ 2 , 6 ]. Culture is vital including trust, transparency, partnership and co-design. Key processes include legally compliant data sharing, linkage and governance, resources, and infrastructure [ 4 ]. The Monash LHS integrates disparate and often siloed stakeholders, infrastructure and expertise to ‘Learn Together for Better Health’ [ 7 ] (Fig.  1 ). This integrates (i) evidence from community and stakeholders including priority areas and outcomes; (ii) evidence from research and guidelines; (iii) evidence from practice (from data) with advanced analytics and benchmarking; and (iv) evidence from implementation science and health economics. Importantly, it starts with the problem and priorities of key stakeholders including the community, health professionals and services and creates an iterative learning system to address these. The following case study was chosen as it is an exemplar of how a Monash LHS-aligned national stroke program has delivered clinical benefit.

Australian Stroke Learning Health System

Internationally, the application of LHS approaches in stroke has resulted in improved stroke care and outcomes [ 12 ]. For example, in Canada a sustained decrease in 30-day in-hospital mortality has been found commensurate with an increase in resources to establish the multifactorial stroke system intervention for stroke treatment and prevention [ 15 ]. Arguably, with rapid advances in evidence and in the context of an ageing population with high cost and care burden and substantive impacts on quality of life, stroke is an area with a need for rapid research translation into evidence-based and value-based healthcare improvement. However, a recent systematic review found that the existing literature had few comprehensive examples of LHS adoption [ 12 ]. Although healthcare improvement systems and approaches were described, less is known about patient-clinician and stakeholder engagement, governance and culture, or embedding of data informatics into everyday practice to inform and drive improvement [ 12 ]. For example, in a recent review of quality improvement collaborations, it was found that although clinical processes in stroke care are improved, their short-term nature means there is uncertainty about sustainability and impacts on patient outcomes [ 16 ]. Table  1 provides the main features of the Australian Stroke LHS based on the four core domains and eight elements of the Learning Together for Better Health Framework described in Fig.  1 . The features are further expanded on in the following sections.

Evidence from stakeholders (LHS quadrant 1, Fig.  1 )

Engagement, partners and priorities.

Within the stroke field, there have been various support mechanisms to facilitate an LHS approach including partnership and broad stakeholder engagement that includes clinical networks and policy makers from different jurisdictions. Since 2008, the Australian Stroke Coalition has been co-led by the Stroke Foundation, a charitable consumer advocacy organisation, and Stroke Society of Australasia a professional society with membership covering academics and multidisciplinary clinician networks, that are collectively working to improve stroke care ( https://australianstrokecoalition.org.au/ ). Surveys, focus groups and workshops have been used for identifying priorities from stakeholders. Recent agreed priorities have been to improve stroke care and strengthen the voice for stroke care at a national ( https://strokefoundation.org.au/ ) and international level ( https://www.world-stroke.org/news-and-blog/news/world-stroke-organization-tackle-gaps-in-access-to-quality-stroke-care ), as well as reduce duplication amongst stakeholders. This activity is built on a foundation and culture of research and innovation embedded within the stroke ‘community of practice’. Consumers, as people with lived experience of stroke are important members of the Australian Stroke Coalition, as well as representatives from different clinical colleges. Consumers also provide critical input to a range of LHS activities via the Stroke Foundation Consumer Council, Stroke Living Guidelines committees, and the Australian Stroke Clinical Registry (AuSCR) Steering Committee (described below).

Evidence from research (LHS quadrant 2, Fig.  1 )

Advancement of the evidence for stroke interventions and synthesis into clinical guidelines.

To implement best practice, it is crucial to distil the large volume of scientific and trial literature into actionable recommendations for clinicians to use in practice [ 24 ]. The first Australian clinical guidelines for acute stroke were produced in 2003 following the increasing evidence emerging for prevention interventions (e.g. carotid endarterectomy, blood pressure lowering), acute medical treatments (intravenous thrombolysis, aspirin within 48 h of ischemic stroke), and optimised hospital management (care in dedicated stroke units by a specialised and coordinated multidisciplinary team) [ 25 ]. Importantly, a number of the innovations were developed, researched and proven effective by key opinion leaders embedded in the Australian stroke care community. In 2005, the clinical guidelines for Stroke Rehabilitation and Recovery [ 26 ] were produced, with subsequent merged guidelines periodically updated. However, the traditional process of periodic guideline updates is challenging for end users when new research can render recommendations redundant and this lack of currency erodes stakeholder trust [ 27 ]. In response to this challenge the Stroke Foundation and Cochrane Australia entered a pioneering project to produce the first electronic ‘living’ guidelines globally [ 20 ]. Major shifts in the evidence for reperfusion therapies (e.g. extended time-window intravenous thrombolysis and endovascular clot retrieval), among other advances, were able to be converted into new recommendations, approved by the Australian National Health and Medical Research Council within a few months of publication. Feedback on this process confirmed the increased use and trust in the guidelines by clinicians. The process informed other living guidelines programs, including the successful COVID-19 clinical guidelines [ 28 ].

However, best practice clinical guideline recommendations are necessary but insufficient for healthcare improvement and nesting these within an LHS with stakeholder partnership, enables implementation via a range of proven methods, including audit and feedback strategies [ 29 ].

Evidence from data and practice (LHS quadrant 3, Fig.  1 )

Data systems and benchmarking : revealing the disparities in care between health services. A national system for standardized stroke data collection was established as the National Stroke Audit program in 2007 by the Stroke Foundation [ 30 ] following various state-level programs (e.g. New South Wales Audit) [ 31 ] to identify evidence-practice gaps and prioritise improvement efforts to increase access to stroke units and other acute treatments [ 32 ]. The Audit program alternates each year between acute (commencing in 2007) and rehabilitation in-patient services (commencing in 2008). The Audit program provides a ‘deep dive’ on the majority of recommendations in the clinical guidelines whereby participating hospitals provide audits of up to 40 consecutive patient medical records and respond to a survey about organizational resources to manage stroke. In 2009, the AuSCR was established to provide information on patients managed in acute hospitals based on a small subset of quality processes of care linked to benchmarked reports of performance (Fig.  2 ) [ 33 ]. In this way, the continuous collection of high-priority processes of stroke care could be regularly collected and reviewed to guide improvement to care [ 34 ]. Plus clinical quality registry programs within Australia have shown a meaningful return on investment attributed to enhanced survival, improvements in quality of life and avoided costs of treatment or hospital stay [ 35 ].

Example performance report from the Australian Stroke Clinical Registry: average door-to-needle time in providing intravenous thrombolysis by different hospitals in 2021 [ 36 ]. Each bar in the figure represents a single hospital

The Australian Stroke Coalition endorsed the creation of an integrated technological solution for collecting data through a single portal for multiple programs in 2013. In 2015, the Stroke Foundation, AuSCR consortium, and other relevant groups cooperated to design an integrated data management platform (the Australian Stroke Data Tool) to reduce duplication of effort for hospital staff in the collection of overlapping variables in the same patients [ 19 ]. Importantly, a national data dictionary then provided the common data definitions to facilitate standardized data capture. Another important feature of AuSCR is the collection of patient-reported outcome surveys between 90 and 180 days after stroke, and annual linkage with national death records to ascertain survival status [ 33 ]. To support a LHS approach, hospitals that participate in AuSCR have access to a range of real-time performance reports. In efforts to minimize the burden of data collection in the AuSCR, interoperability approaches to import data directly from hospital or state-level managed stroke databases have been established (Fig.  3 ); however, the application has been variable and 41% of hospitals still manually enter all their data.

Current status of automated data importing solutions in the Australian Stroke Clinical Registry, 2022, with ‘ n ’ representing the number of hospitals. AuSCR, Australian Stroke Clinical Registry; AuSDaT, Australian Stroke Data Tool; API, Application Programming Interface; ICD, International Classification of Diseases; RedCAP, Research Electronic Data Capture; eMR, electronic medical records

For acute stroke care, the Australian Commission on Quality and Safety in Health Care facilitated the co-design (clinicians, academics, consumers) and publication of the national Acute Stroke Clinical Care Standard in 2015 [ 17 ], and subsequent review [ 18 ]. The indicator set for the Acute Stroke Standard then informed the expansion of the minimum dataset for AuSCR so that hospitals could routinely track their performance. The national Audit program enabled hospitals not involved in the AuSCR to assess their performance every two years against the Acute Stroke Standard. Complementing these efforts, the Stroke Foundation, working with the sector, developed the Acute and Rehabilitation Stroke Services Frameworks to outline the principles, essential elements, models of care and staffing recommendations for stroke services ( https://informme.org.au/guidelines/national-stroke-services-frameworks ). The Frameworks are intended to guide where stroke services should be developed, and monitor their uptake with the organizational survey component of the Audit program.

Evidence from implementation and healthcare improvement (LHS quadrant 4, Fig.  1 )

Research to better utilize and augment data from registries through linkage [ 37 , 38 , 39 , 40 ] and to ensure presentation of hospital or service level data are understood by clinicians has ensured advancement in the field for the Australian Stroke LHS [ 41 ]. Importantly, greater insights into whole patient journeys, before and after a stroke, can now enable exploration of value-based care. The LHS and stroke data platform have enabled focused and time-limited projects to create a better understanding of the quality of care in acute or rehabilitation settings [ 22 , 42 , 43 ]. Within stroke, all the elements of an LHS culminate into the ready availability of benchmarked performance data and support for implementation of strategies to address gaps in care.

Implementation research to grow the evidence base for effective improvement interventions has also been a key pillar in the Australian context. These include multi-component implementation interventions to achieve behaviour change for particular aspects of stroke care, [ 22 , 23 , 44 , 45 ] and real-world approaches to augmenting access to hyperacute interventions in stroke through the use of technology and telehealth [ 46 , 47 , 48 , 49 ]. The evidence from these studies feeds into the living guidelines program and the data collection systems, such as the Audit program or AuSCR, which are then amended to ensure data aligns to recommended care. For example, the use of ‘hyperacute aspirin within the first 48 h of ischemic stroke’ was modified to be ‘hyperacute antiplatelet…’ to incorporate new evidence that other medications or combinations are appropriate to use. Additionally, new datasets have been developed to align with evidence such as the Fever, Sugar, and Swallow variables [ 42 ]. Evidence on improvements in access to best practice care from the acute Audit program [ 50 ] and AuSCR is emerging [ 36 ]. For example, between 2007 and 2017, the odds of receiving intravenous thrombolysis after ischemic stroke increased by 16% 9OR 1.06 95% CI 1.13–1.18) and being managed in a stroke unit by 18% (OR 1.18 95% CI 1.17–1.20). Over this period, the median length of hospital stay for all patients decreased from 6.3 days in 2007 to 5.0 days in 2017 [ 51 ]. When considering the number of additional patients who would receive treatment in 2017 in comparison to 2007 it was estimated that without this additional treatment, over 17,000 healthy years of life would be lost in 2017 (17,786 disability-adjusted life years) [ 51 ]. There is evidence on the cost-effectiveness of different system-focussed strategies to augment treatment access for acute ischemic stroke (e.g. Victorian Stroke Telemedicine program [ 52 ] and Melbourne Mobile Stroke Unit ambulance [ 53 ]). Reciprocally, evidence from the national Rehabilitation Audit, where the LHS approach has been less complete or embedded, has shown fewer areas of healthcare improvement over time [ 51 , 54 ].

Within the field of stroke in Australia, there is indirect evidence that the collective efforts that align to establishing the components of a LHS have had an impact. Overall, the age-standardised rate of stroke events has reduced by 27% between 2001 and 2020, from 169 to 124 events per 100,000 population. Substantial declines in mortality rates have been reported since 1980. Commensurate with national clinical guidelines being updated in 2007 and the first National Stroke Audit being undertaken in 2007, the mortality rates for men (37.4 deaths per 100,000) and women (36.1 deaths per 100,0000 has declined to 23.8 and 23.9 per 100,000, respectively in 2021 [ 55 ].

Underpinning the LHS with the integration of the four quadrants of evidence from stakeholders, research and guidelines, practice and implementation, and core LHS principles have been addressed. Leadership and governance have been important, and programs have been established to augment workforce training and capacity building in best practice professional development. Medical practitioners are able to undertake courses and mentoring through the Australasian Stroke Academy ( http://www.strokeacademy.com.au/ ) while nurses (and other health professionals) can access teaching modules in stroke care from the Acute Stroke Nurses Education Network ( https://asnen.org/ ). The Association of Neurovascular Clinicians offers distance-accessible education and certification to develop stroke expertise for interdisciplinary professionals, including advanced stroke co-ordinator certification ( www.anvc.org ). Consumer initiative interventions are also used in the design of the AuSCR Public Summary Annual reports (available at https://auscr.com.au/about/annual-reports/ ) and consumer-related resources related to the Living Guidelines ( https://enableme.org.au/resources ).

The important success factors and lessons from stroke as a national exemplar LHS in Australia include leadership, culture, workforce and resources integrated with (1) established and broad partnerships across the academic-clinical sector divide and stakeholder engagement; (2) the living guidelines program; (3) national data infrastructure, including a national data dictionary that provides the common data framework to support standardized data capture; (4) various implementation strategies including benchmarking and feedback as well as engagement strategies targeting different levels of the health system; and (5) implementation and improvement research to advance stroke systems of care and reduce unwarranted variation in practice (Fig.  1 ). Priority opportunities now include the advancement of interoperability with electronic medical records as an area all clinical quality registry’s programs needs to be addressed, as well as providing more dynamic and interactive data dashboards tailored to the need of clinicians and health service executives.

There is a clear mandate to optimise healthcare improvement with big data offering major opportunities for change. However, we have lacked the approaches to capture evidence from the community and stakeholders, to integrate evidence from research, to capture and leverage data or evidence from practice and to generate and build on evidence from implementation using iterative system-level improvement. The LHS provides this opportunity and is shown to deliver impact. Here, we have outlined the process applied to generate an evidence-based LHS and provide a leading exemplar in stroke care. This highlights the value of moving from single-focus isolated approaches/initiatives to healthcare improvement and the benefit of integration to deliver demonstrable outcomes for our funders and key stakeholders — our community. This work provides insight into strategies that can both apply evidence-based processes to healthcare improvement as well as implementing evidence-based practices into care, moving beyond research as an endpoint, to research as an enabler, underpinning delivery of better healthcare.

Availability of data and materials

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Abbreviations

Australian Stroke Clinical Registry

Confidence interval

• Learning Health System

World Health Organization. Delivering quality health services . OECD Publishing; 2018.

Enticott J, Braaf S, Johnson A, Jones A, Teede HJ. Leaders’ perspectives on learning health systems: A qualitative study. BMC Health Serv Res. 2020;20:1087.

Article   PubMed   PubMed Central   Google Scholar  

Melder A, Robinson T, McLoughlin I, Iedema R, Teede H. An overview of healthcare improvement: Unpacking the complexity for clinicians and managers in a learning health system. Intern Med J. 2020;50:1174–84.

Article   PubMed   Google Scholar  

Alberto IRI, Alberto NRI, Ghosh AK, Jain B, Jayakumar S, Martinez-Martin N, et al. The impact of commercial health datasets on medical research and health-care algorithms. Lancet Digit Health. 2023;5:e288–94.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Dixon-Woods M. How to improve healthcare improvement—an essay by Mary Dixon-Woods. BMJ. 2019;367: l5514.

Enticott J, Johnson A, Teede H. Learning health systems using data to drive healthcare improvement and impact: A systematic review. BMC Health Serv Res. 2021;21:200.

Enticott JC, Melder A, Johnson A, Jones A, Shaw T, Keech W, et al. A learning health system framework to operationalize health data to improve quality care: An Australian perspective. Front Med (Lausanne). 2021;8:730021.

Dammery G, Ellis LA, Churruca K, Mahadeva J, Lopez F, Carrigan A, et al. The journey to a learning health system in primary care: A qualitative case study utilising an embedded research approach. BMC Prim Care. 2023;24:22.

Foley T, Horwitz L, Zahran R. The learning healthcare project: Realising the potential of learning health systems. 2021. Available from https://learninghealthcareproject.org/wp-content/uploads/2021/05/LHS2021report.pdf . Accessed Jan 2024.

Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Washington: The National Academies Press; 2013.

Google Scholar  

Zurynski Y, Smith CL, Vedovi A, Ellis LA, Knaggs G, Meulenbroeks I, et al. Mapping the learning health system: A scoping review of current evidence - a white paper. 2020:63

Cadilhac DA, Bravata DM, Bettger J, Mikulik R, Norrving B, Uvere E, et al. Stroke learning health systems: A topical narrative review with case examples. Stroke. 2023;54:1148–59.

Braithwaite J, Glasziou P, Westbrook J. The three numbers you need to know about healthcare: The 60–30-10 challenge. BMC Med. 2020;18:1–8.

Article   Google Scholar  

King D, Wittenberg R, Patel A, Quayyum Z, Berdunov V, Knapp M. The future incidence, prevalence and costs of stroke in the UK. Age Ageing. 2020;49:277–82.

Ganesh A, Lindsay P, Fang J, Kapral MK, Cote R, Joiner I, et al. Integrated systems of stroke care and reduction in 30-day mortality: A retrospective analysis. Neurology. 2016;86:898–904.

Lowther HJ, Harrison J, Hill JE, Gaskins NJ, Lazo KC, Clegg AJ, et al. The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: A systematic review. Implement Sci. 2021;16:16.

Australian Commission on Safety and Quality in Health Care. Acute stroke clinical care standard. 2015. Available from https://www.safetyandquality.gov.au/our-work/clinical-care-standards/acute-stroke-clinical-care-standard . Accessed Jan 2024.

Australian Commission on Safety and Quality in Health Care. Acute stroke clinical care standard. Sydney: ACSQHC; 2019. Available from https://www.safetyandquality.gov.au/publications-and-resources/resource-library/acute-stroke-clinical-care-standard-evidence-sources . Accessed Jan 2024.

Ryan O, Ghuliani J, Grabsch B, Hill K, G CC, Breen S, et al. Development, implementation, and evaluation of the Australian Stroke Data Tool (AuSDaT): Comprehensive data capturing for multiple uses. Health Inf Manag. 2022:18333583221117184.

English C, Bayley M, Hill K, Langhorne P, Molag M, Ranta A, et al. Bringing stroke clinical guidelines to life. Int J Stroke. 2019;14:337–9.

English C, Hill K, Cadilhac DA, Hackett ML, Lannin NA, Middleton S, et al. Living clinical guidelines for stroke: Updates, challenges and opportunities. Med J Aust. 2022;216:510–4.

Cadilhac DA, Grimley R, Kilkenny MF, Andrew NE, Lannin NA, Hill K, et al. Multicenter, prospective, controlled, before-and-after, quality improvement study (Stroke123) of acute stroke care. Stroke. 2019;50:1525–30.

Cadilhac DA, Marion V, Andrew NE, Breen SJ, Grabsch B, Purvis T, et al. A stepped-wedge cluster-randomized trial to improve adherence to evidence-based practices for acute stroke management. Jt Comm J Qual Patient Saf. 2022.

Elliott J, Lawrence R, Minx JC, Oladapo OT, Ravaud P, Jeppesen BT, et al. Decision makers need constantly updated evidence synthesis. Nature. 2021;600:383–5.

Article   CAS   PubMed   Google Scholar  

National Stroke Foundation. National guidelines for acute stroke management. Melbourne: National Stroke Foundation; 2003.

National Stroke Foundation. Clinical guidelines for stroke rehabilitation and recovery. Melbourne: National Stroke Foundation; 2005.

Phan TG, Thrift A, Cadilhac D, Srikanth V. A plea for the use of systematic review methodology when writing guidelines and timely publication of guidelines. Intern Med J . 2012;42:1369–1371; author reply 1371–1362

Tendal B, Vogel JP, McDonald S, Norris S, Cumpston M, White H, et al. Weekly updates of national living evidence-based guidelines: Methods for the Australian living guidelines for care of people with COVID-19. J Clin Epidemiol. 2021;131:11–21.

Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7:50.

Harris D, Cadilhac D, Hankey GJ, Hillier S, Kilkenny M, Lalor E. National stroke audit: The Australian experience. Clin Audit. 2010;2:25–31.

Cadilhac DA, Purvis T, Kilkenny MF, Longworth M, Mohr K, Pollack M, et al. Evaluation of rural stroke services: Does implementation of coordinators and pathways improve care in rural hospitals? Stroke. 2013;44:2848–53.

Cadilhac DA, Moss KM, Price CJ, Lannin NA, Lim JY, Anderson CS. Pathways to enhancing the quality of stroke care through national data monitoring systems for hospitals. Med J Aust. 2013;199:650–1.

Cadilhac DA, Lannin NA, Anderson CS, Levi CR, Faux S, Price C, et al. Protocol and pilot data for establishing the Australian Stroke Clinical Registry. Int J Stroke. 2010;5:217–26.

Ivers N, Jamtvedt G, Flottorp S, Young J, Odgaard-Jensen J, French S, et al. Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev . 2012

Australian Commission on Safety and Quality in Health Care. Economic evaluation of clinical quality registries. Final report. . 2016:79

Cadilhac DA, Dalli LL, Morrison J, Lester M, Paice K, Moss K, et al. The Australian Stroke Clinical Registry annual report 2021. Melbourne; 2022. Available from https://auscr.com.au/about/annual-reports/ . Accessed 6 May 2024.

Kilkenny MF, Kim J, Andrew NE, Sundararajan V, Thrift AG, Katzenellenbogen JM, et al. Maximising data value and avoiding data waste: A validation study in stroke research. Med J Aust. 2019;210:27–31.

Eliakundu AL, Smith K, Kilkenny MF, Kim J, Bagot KL, Andrew E, et al. Linking data from the Australian Stroke Clinical Registry with ambulance and emergency administrative data in Victoria. Inquiry. 2022;59:469580221102200.

PubMed   Google Scholar  

Andrew NE, Kim J, Cadilhac DA, Sundararajan V, Thrift AG, Churilov L, et al. Protocol for evaluation of enhanced models of primary care in the management of stroke and other chronic disease (PRECISE): A data linkage healthcare evaluation study. Int J Popul Data Sci. 2019;4:1097.

CAS   PubMed   PubMed Central   Google Scholar  

Mosalski S, Shiner CT, Lannin NA, Cadilhac DA, Faux SG, Kim J, et al. Increased relative functional gain and improved stroke outcomes: A linked registry study of the impact of rehabilitation. J Stroke Cerebrovasc Dis. 2021;30: 106015.

Ryan OF, Hancock SL, Marion V, Kelly P, Kilkenny MF, Clissold B, et al. Feedback of aggregate patient-reported outcomes (PROs) data to clinicians and hospital end users: Findings from an Australian codesign workshop process. BMJ Open. 2022;12:e055999.

Grimley RS, Rosbergen IC, Gustafsson L, Horton E, Green T, Cadigan G, et al. Dose and setting of rehabilitation received after stroke in Queensland, Australia: A prospective cohort study. Clin Rehabil. 2020;34:812–23.

Purvis T, Middleton S, Craig LE, Kilkenny MF, Dale S, Hill K, et al. Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a national audit for acute stroke: Evidence of upscale and spread. Implement Sci. 2019;14:87.

Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D’Este C, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): A cluster randomised controlled trial. Lancet. 2011;378:1699–706.

Middleton S, Dale S, Cheung NW, Cadilhac DA, Grimshaw JM, Levi C, et al. Nurse-initiated acute stroke care in emergency departments. Stroke. 2019:STROKEAHA118020701.

Hood RJ, Maltby S, Keynes A, Kluge MG, Nalivaiko E, Ryan A, et al. Development and pilot implementation of TACTICS VR: A virtual reality-based stroke management workflow training application and training framework. Front Neurol. 2021;12:665808.

Bladin CF, Kim J, Bagot KL, Vu M, Moloczij N, Denisenko S, et al. Improving acute stroke care in regional hospitals: Clinical evaluation of the Victorian Stroke Telemedicine program. Med J Aust. 2020;212:371–7.

Bladin CF, Bagot KL, Vu M, Kim J, Bernard S, Smith K, et al. Real-world, feasibility study to investigate the use of a multidisciplinary app (Pulsara) to improve prehospital communication and timelines for acute stroke/STEMI care. BMJ Open. 2022;12:e052332.

Zhao H, Coote S, Easton D, Langenberg F, Stephenson M, Smith K, et al. Melbourne mobile stroke unit and reperfusion therapy: Greater clinical impact of thrombectomy than thrombolysis. Stroke. 2020;51:922–30.

Purvis T, Cadilhac DA, Hill K, Reyneke M, Olaiya MT, Dalli LL, et al. Twenty years of monitoring acute stroke care in Australia from the national stroke audit program (1999–2019): Achievements and areas of future focus. J Health Serv Res Policy. 2023.

Cadilhac DA, Purvis T, Reyneke M, Dalli LL, Kim J, Kilkenny MF. Evaluation of the national stroke audit program: 20-year report. Melbourne; 2019.

Kim J, Tan E, Gao L, Moodie M, Dewey HM, Bagot KL, et al. Cost-effectiveness of the Victorian Stroke Telemedicine program. Aust Health Rev. 2022;46:294–301.

Kim J, Easton D, Zhao H, Coote S, Sookram G, Smith K, et al. Economic evaluation of the Melbourne mobile stroke unit. Int J Stroke. 2021;16:466–75.

Stroke Foundation. National stroke audit – rehabilitation services report 2020. Melbourne; 2020.

Australian Institute of Health and Welfare. Heart, stroke and vascular disease: Australian facts. 2023. Webpage https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/hsvd-facts/contents/about (accessed Jan 2024).

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Acknowledgements

The following authors hold National Health and Medical Research Council Research Fellowships: HT (#2009326), DAC (#1154273), SM (#1196352), MFK Future Leader Research Fellowship (National Heart Foundation #105737). The Funders of this work did not have any direct role in the design of the study, its execution, analyses, interpretation of the data, or decision to submit results for publication.

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Helena Teede and Dominique A. Cadilhac contributed equally.

Authors and Affiliations

Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia

Helena Teede, Emily Callander & Joanne Enticott

Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia

Helena Teede & Alison Johnson

Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia

Dominique A. Cadilhac, Tara Purvis & Monique F. Kilkenny

Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia

Dominique A. Cadilhac, Monique F. Kilkenny & Bruce C.V. Campbell

Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia

Bruce C.V. Campbell

Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia

School of Health Sciences, Heart and Stroke Program, University of Newcastle, Hunter Medical Research Institute, University Drive, Callaghan, NSW, Australia

Coralie English

School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia

Rohan S. Grimley

Clinical Excellence Division, Queensland Health, Brisbane, Australia

John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Sydney, NSW, Australia

Christopher Levi

School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia

Sandy Middleton

Nursing Research Institute, St Vincent’s Health Network Sydney and and Australian Catholic University, Sydney, NSW, Australia

Stroke Foundation, Level 7, 461 Bourke St, Melbourne, VIC, Australia

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HT: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. DAC: conception, design and initial draft, provided essential literature and case study examples, approved the submitted version. TP: revised the manuscript critically for important intellectual content, approved the submitted version. MFK: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. BC: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. CE: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. AJ: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. EC: revised the manuscript critically for important intellectual content, approved the submitted version. RSG: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. CL: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. SM: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. KH: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. JE: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. All authors read and approved the final manuscript.

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Teede, H., Cadilhac, D.A., Purvis, T. et al. Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke. BMC Med 22 , 198 (2024). https://doi.org/10.1186/s12916-024-03416-w

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5 Benefits of Learning Through the Case Study Method

• 28 Nov 2023

While several factors make HBS Online unique —including a global Community and real-world outcomes —active learning through the case study method rises to the top.

In a 2023 City Square Associates survey, 74 percent of HBS Online learners who also took a course from another provider said HBS Online’s case method and real-world examples were better by comparison.

Here’s a primer on the case method, five benefits you could gain, and how to experience it for yourself.

Access your free e-book today.

What Is the Harvard Business School Case Study Method?

The case study method , or case method , is a learning technique in which you’re presented with a real-world business challenge and asked how you’d solve it. After working through it yourself and with peers, you’re told how the scenario played out.

HBS pioneered the case method in 1922. Shortly before, in 1921, the first case was written.

“How do you go into an ambiguous situation and get to the bottom of it?” says HBS Professor Jan Rivkin, former senior associate dean and chair of HBS's master of business administration (MBA) program, in a video about the case method . “That skill—the skill of figuring out a course of inquiry to choose a course of action—that skill is as relevant today as it was in 1921.”

Originally developed for the in-person MBA classroom, HBS Online adapted the case method into an engaging, interactive online learning experience in 2014.

In HBS Online courses , you learn about each case from the business professional who experienced it. After reviewing their videos, you’re prompted to take their perspective and explain how you’d handle their situation.

You then get to read peers’ responses, “star” them, and comment to further the discussion. Afterward, you learn how the professional handled it and their key takeaways.

HBS Online’s adaptation of the case method incorporates the famed HBS “cold call,” in which you’re called on at random to make a decision without time to prepare.

“Learning came to life!” said Sheneka Balogun , chief administration officer and chief of staff at LeMoyne-Owen College, of her experience taking the Credential of Readiness (CORe) program . “The videos from the professors, the interactive cold calls where you were randomly selected to participate, and the case studies that enhanced and often captured the essence of objectives and learning goals were all embedded in each module. This made learning fun, engaging, and student-friendly.”

If you’re considering taking a course that leverages the case study method, here are five benefits you could experience.

5 Benefits of Learning Through Case Studies

1. take new perspectives.

The case method prompts you to consider a scenario from another person’s perspective. To work through the situation and come up with a solution, you must consider their circumstances, limitations, risk tolerance, stakeholders, resources, and potential consequences to assess how to respond.

Taking on new perspectives not only can help you navigate your own challenges but also others’. Putting yourself in someone else’s situation to understand their motivations and needs can go a long way when collaborating with stakeholders.

2. Hone Your Decision-Making Skills

Another skill you can build is the ability to make decisions effectively . The case study method forces you to use limited information to decide how to handle a problem—just like in the real world.

Throughout your career, you’ll need to make difficult decisions with incomplete or imperfect information—and sometimes, you won’t feel qualified to do so. Learning through the case method allows you to practice this skill in a low-stakes environment. When facing a real challenge, you’ll be better prepared to think quickly, collaborate with others, and present and defend your solution.

3. Become More Open-Minded

As you collaborate with peers on responses, it becomes clear that not everyone solves problems the same way. Exposing yourself to various approaches and perspectives can help you become a more open-minded professional.

When you’re part of a diverse group of learners from around the world, your experiences, cultures, and backgrounds contribute to a range of opinions on each case.

On the HBS Online course platform, you’re prompted to view and comment on others’ responses, and discussion is encouraged. This practice of considering others’ perspectives can make you more receptive in your career.

“You’d be surprised at how much you can learn from your peers,” said Ratnaditya Jonnalagadda , a software engineer who took CORe.

In addition to interacting with peers in the course platform, Jonnalagadda was part of the HBS Online Community , where he networked with other professionals and continued discussions sparked by course content.

“You get to understand your peers better, and students share examples of businesses implementing a concept from a module you just learned,” Jonnalagadda said. “It’s a very good way to cement the concepts in one's mind.”

4. Enhance Your Curiosity

One byproduct of taking on different perspectives is that it enables you to picture yourself in various roles, industries, and business functions.

“Each case offers an opportunity for students to see what resonates with them, what excites them, what bores them, which role they could imagine inhabiting in their careers,” says former HBS Dean Nitin Nohria in the Harvard Business Review . “Cases stimulate curiosity about the range of opportunities in the world and the many ways that students can make a difference as leaders.”

Through the case method, you can “try on” roles you may not have considered and feel more prepared to change or advance your career .

5. Build Your Self-Confidence

Finally, learning through the case study method can build your confidence. Each time you assume a business leader’s perspective, aim to solve a new challenge, and express and defend your opinions and decisions to peers, you prepare to do the same in your career.

According to a 2022 City Square Associates survey , 84 percent of HBS Online learners report feeling more confident making business decisions after taking a course.

“Self-confidence is difficult to teach or coach, but the case study method seems to instill it in people,” Nohria says in the Harvard Business Review . “There may well be other ways of learning these meta-skills, such as the repeated experience gained through practice or guidance from a gifted coach. However, under the direction of a masterful teacher, the case method can engage students and help them develop powerful meta-skills like no other form of teaching.”

How to Experience the Case Study Method

If the case method seems like a good fit for your learning style, experience it for yourself by taking an HBS Online course. Offerings span seven subject areas, including:

• Business essentials
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• Business in society

No matter which course or credential program you choose, you’ll examine case studies from real business professionals, work through their challenges alongside peers, and gain valuable insights to apply to your career.

Are you interested in discovering how HBS Online can help advance your career? Explore our course catalog and download our free guide —complete with interactive workbook sections—to determine if online learning is right for you and which course to take.

About the Author

• Open access
• Published: 24 January 2023

Integrating case management for patients with complex needs in the ground practice: the importance of context in evaluative designs

• Catherine Hudon   ORCID: orcid.org/0000-0001-6140-9916 1 &
• Rodger Kessler 2  

Health Research Policy and Systems volume  21 , Article number:  9 ( 2023 ) Cite this article

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Responding to complex needs calls for integrating care across providers, settings and sectors. Among models to improve integrated care, case management demonstrates a good evidence base of facilitating the appropriate delivery of healthcare services. Since case management is a complex, multi component intervention, with its component parts interacting in a non-linear manner, effectiveness is largely influenced by the context in which the intervention is implemented. This paper discusses how to respond to implementation challenges to evaluating complex interventions for patients with complex needs. Building on the example of case management, we suggest that documenting innovation effectiveness remains important, but that evaluation needs to include theory-based and systems perspectives. We also suggest that implementation science needs to be part of intervention design while engaging stakeholders to define the most relevant research questions and implementation effectiveness, to optimize successful implementation and sustainability.

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Contributions to the literature

This paper suggests that evaluation of effectiveness by randomized controlled trials for complex interventions has structural limitations and discusses the pros and cons of such designs.

We propose examples of designs to evaluate the theory of the intervention, using the example of case management for people with complex needs.

It invites researchers and stakeholders to start implementation science early in intervention design to optimize adoption and sustainability.

Eighteen per cent of patients in primary healthcare face multiple interacting challenges among the physical, mental and social dimensions of health [ 1 ], having the most complex health needs (referred to, hereafter, as “complex needs”). These proportions increase with age, race, and ethnicity [ 2 ]. Per the inverse care law [ 3 ], with increased complexity of patient’s needs, comes decreased care availability and health equity, and thus decreased quality of life, and increased disability and mortality risk [ 4 ]. The COVID-19 pandemic has shone a light on the health inequities experienced by patients with complex needs [ 5 ]. Improving care and health equity for this population is a priority for healthcare systems worldwide [ 6 ].

Responding to complex needs calls for integrating care across providers, settings, and sectors. The World Health Organization suggests the following patient-led definition of integrated care: ‘My care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes’ [ 7 ]. Reviews demonstrated the impact of integrated care on access and quality of care, patient satisfaction, and reduction of hospitalization [ 8 ].

Among models to improve integrated care, evidence supported case management [ 9 , 10 , 11 ] facilitates the appropriate delivery of healthcare services for patients with complex needs [ 7 ]. Case management is a highly variable, collaborative approach used to assess, plan, facilitate, and coordinate care to meet patient and family healthcare needs, through communication and coordination of available resources across all levels of health care as well as sectors outside of the health system [ 12 ].

When focusing on the care of patients with multiple clinical, behavioral and social dimensions that impact on functioning and health, interventions involve many partners and are often complex [ 13 ]. This requires interacting and collaborating with underlying organizational systems and subsystems and adaptive learning for rapid cycle changes. Multiple contextual issues such as the setting of implementation, providers involved, and organizational culture, need to be considered as part of implementation and generate issues requiring operational and clinical adaptation. Since case management is a non linear complex multi component intervention [ 14 ], effectiveness is largely influenced by the context in which the intervention is implemented [ 15 ].

To support the development and evaluation of complex interventions, the United Kingdom Medical Research Council (MRC) proposed an adapted phased approach [ 13 , 16 ]. Their four phases Framework, building on qualitative and quantitative evidence and includes development, feasibility/piloting, evaluation, and implementation [ 16 ]. It was recently updated to incorporate developments in complex intervention research [ 17 ]. This revised Framework introduces more emphases on the importance of context and the need of understanding interventions as events in systems that produce effects through interactions including contextual factors associated with implementation.

Successful implementation of interventions that respond to complex care needs is critical to improving healthcare systems- and outcomes [ 17 ]. This paper discusses how to respond to implementation challenges to evaluating complex interventions for patients with complex needs, building on the example of case management.

Evaluation and implementation science

Intervention effectiveness remains important.

Pragmatic randomized controlled trials [ 18 ] (RCTs) remain indispensable to develop the foundation of evidence about a new intervention and are essential to document internal validity [ 18 ]. Reviews of RCTs on case management, for example, documented reduction of emergency department costs and improvement of social and clinical outcomes (e.g. alcohol or drug use and social problems) for patients who frequently used the healthcare services [ 9 , 10 , 11 ].

However, there are multiple challenges in conducting RCTs of complex multi-level interventions in the ground practices with patients having complex needs. RCT designs have mainly focused on internal validity minimizing inherent organizational and clinical contextual variation and restrict patient populations [ 19 , 20 ]. In addition, the time, expense and need for controlled research environments limit the generalizability and utility of findings and often do not respond to the immediate need of the providers [ 21 ]. Partially because of this disconnect, limited biobehavioural research makes its way into practice [ 22 ]. Many reviews of RCTs conclude that the inability to translate RCT data into clinical care may limit their utility [ 18 , 20 ], and therefore many authors have proposed alternative designs to traditional RCTs [ 23 ]. Cluster randomization [ 24 ] at the practice level, acknowledges organizational and contextual variation and tests whether there are effects across practices, despite variation. At the patient level, stepped wedge [ 25 ] designs allow patients to serve as their own controls over time, with changes after intervention serving as key outcome indicators. Rather than controlling variation, it is expected and documented when reporting results. Contextual variation also helps to understand why it is so difficult to conduct meta-analysis of complex interventions with patients with complex needs. These meta-analyses of RCTs, very supportive when available, are not always feasible and cannot be the unique strategy of evaluation.

Many good RCTs concluding that an intervention is not effective are a strong argument against this intervention which will have to be significantly improved and re-evaluated. On the other hand, having almost all RCT findings documenting effectiveness of complex interventions targeting patients with complex needs remain unlikely because of variations in key ingredients of the intervention, populations recruited in the study or local contexts. Researchers and decision-makers will often have to contend with a situation between those ends.

Should we conduct a new RCT in each new context?

Some might argue we should conduct a new RCT in each new context that interventions will be implemented. A more pressing question is whether RCTs always the best designs in multi level interventions of complex patients. We suggest that there must be a balance between the internal validity RCT focus and the crucial external validity necessary for data to be taken seriously on the ground, keeping in mind that evidence is usually not the main issue when translating research into practice [ 26 ]. Translation of research into practice is challenging if local context is not well considered in replication. In addition to evidence, in real world, many feasibility aspects have to be considered in implementation design, such as budget, human resources, work-flows for intervention and monitoring, and contextual adaptation. Given limited resources and limited uptake of RCT data, investing resources into additional RCTs should be questioned, and perhaps may be unethical, if RCTs demonstrated the effectiveness in controlled settings and populations but have limited practice uptake. In that case, alternative less expensive and resource consuming designs may be more suitable to better understand contextual facilitators to increase on the ground uptake [ 27 ].

But evaluation goes beyond effectiveness

The revised MRC Framework outlines the importance of considering strategies to maximise the usefulness of research results to inform decision-making [ 17 ], in contrast to focusing exclusively on obtaining unbiased estimates of effectiveness [ 28 ]. Research questions should be developed in partnership with stakeholders, utilizing study designs that rapidly answer questions of stakeholder interest and promote adoption of findings. Beyond effectiveness, evaluation should inform the theory-based and the systems perspectives [ 17 ].

Many designs may help identifying key ingredients of complex interventions [ 29 ]. For example, different kinds of synthesis were conducted for case management with frequent users of healthcare services. A mixed systematic review [ 30 ] identified characteristics of case management that yield positive outcomes among frequent users with chronic disease in primary care. Sufficient and necessary characteristics were identified using configurational comparative methods (CCM) [ 31 , 32 , 33 ]. This review documented that it is necessary to identify patients most likely to benefit from the intervention for case management to produce positive outcomes. By definition, patient complexity is heterogeneous in clinical presentation, effect on quality of life, and available support resources. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes.

The realist approaches offer an opportunity for complex interventions to be treated as complex systems [ 34 ]. Realist approaches focus not only on the outcomes, but also on the causal mechanisms that explain ‘how’ the outcomes were reached, and how context influenced outcomes [ 35 ]. Such a focus is particularly appropriate when seeking to better understand novel interventions with little information available on their effectiveness, those that have demonstrated mixed patterns and outcomes, and interventions that will be brought to broader scale [ 36 ]. For example, a realist synthesis [ 37 ] examined how and under what circumstances primary care case management improves outcomes among frequent users with chronic conditions [ 34 ]. This realist synthesis documented that the trusting relationship fostering patient and clinician engagement in the case management intervention was a key ingredient of the intervention [ 37 ].

Complex interventions are often embedded in changing organizations and systems including many parts interconnected that produce its own pattern of behavior over time [ 38 ]. ‘A systems perspective suggests that interventions can be better understood with an examination of the system(s) in which they are embedded or the systems that they set out to change’ [ 17 ]. Consideration of the relationships between the intervention and its multiple contextual factors is key [ 39 ]. Network analysis, for example, is an approach which can be used with other study designs to understand changing relationships among structures within a system of individuals or organizations [ 17 ]. Case management research for people with complex needs could benefit from this kind of analysis.

Implementation effectiveness starts with intervention design

An effective intervention needs to be designed to be useful, identifying important implementation considerations as the first phases of evaluation [ 17 ]. Identification of factors influencing implementation and effectiveness become a core element of research design [ 29 , 40 ]. Without being exhaustive, a few models can support research teams and stakeholders to consider implementation early in evaluation. The PRISM Practical, Robust Implementation and Sustainability Model—[ 41 ] proposes identifiable and measurable elements to assess context [ 42 ]. It evaluates how the healthcare program or intervention interacts with the recipients to influence program adoption, implementation, maintenance, reach, and effectiveness. Such application broadens identification of contextual factors and enriches our dynamic understanding of multi-layer interventions. Implementation questions should be asked concomitantly with effectiveness and other evaluation questions. Curran et al. [ 43 ] propose three hybrid designs to assess effectiveness and implementation: (1) testing effects of a clinical intervention on relevant outcomes while observing and gathering information on implementation; (2) dual testing of clinical and implementation interventions/strategies; and (3) testing of an implementation strategy while observing and gathering information on the clinical intervention’s impact on relevant outcomes [ 43 ]. Chambers et al. [ 44 ] propose the Dynamic Sustainability Framework involving continued learning and problem solving, and ongoing adaptation of complex interventions with a primary focus on fit between interventions and multi-level contexts, and expectations for ongoing improvement instead of implementation of fixed interventions at-risk of losing effectiveness over time [ 44 ]. A large part of implementation science research [ 45 ], therefore, ‘involves the development and evaluation of complex interventions to maximize effective implementation in practice and/or the policy of interventions that have already demonstrated effectiveness’ [ 17 ].

Barriers to and facilitators of effective implementation and contextual adaptation must be a core of evaluation strategy [ 17 ]. For example, a multiple embedded case study with a mixed-methods design identified characteristics and context of case management programs to help to improve patient self-management, experience of integrated care, and healthcare services use [ 46 ]. This study underscored the necessity of an experienced, knowledgeable and well-trained case manager with strong interpersonal skills to optimize case management programs implementation such that patients are more proactive in their care and their outcomes improve.

Early consideration of implementation implies involving stakeholders in all phases of development and evaluation of a complex intervention from the beginning, to ensure asking the most relevant research questions and increasing the potential an intervention be widely adopted [ 17 ]. Collaboration between researchers and knowledge users throughout a study or a research program is a strong predictor that findings will be used [ 47 ]. This collaboration may take different forms going from a consultation at certain phases of the study/research program to full engagement in all phases of the study [ 47 ].

Conclusions

RCTs remain indispensable to develop the foundation of evidence about a new intervention and are important to document effectiveness, but evaluation should go beyond effectiveness to include theory-based and systems perspectives, choosing the appropriate designs to answer research questions. Moreover, implementation effectiveness evaluation should start with intervention design. While conducting evaluation studies, engaging stakeholders to contribute defining the most relevant research questions and designs optimizes chances of adoption and sustainability.

Availability of data and materials

Not applicable.

Abbreviations

Randomized controlled trials

Coronavirus disease 2019

Medical Research Council

Configurational comparative methods

The Practical, Robust Implementation and Sustainability Model

de Oliveira CA, Weber B, Dos Santos JLF, et al. Health complexity assessment in primary care: a validity and feasibility study of the INTERMED tool. PLoS ONE. 2022;17: e0263702.

Article   CAS   Google Scholar  

Buttorff C, Ruder T, Bauman M. Multiple chronic conditions in the United States. Santa Monica, CA: Rand. 2017. https://www.rand.org/pubs/tools/TL221.html . Accessed 12 Dec 2022.

Marmot M. An inverse care law for our time. BMJ. 2018;362: k3216.

Article   Google Scholar  

Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Aff. 2011;30:2437–48.

Government of Canada. Reducing COVID-19 risk in community settings: A tool for operators. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/vulnerable-populations-covid-19.html . (2020). Accessed 30 May 2022.

Blumenthal D, Chernof B, Fulmer T, Lumpkin J, Selberg J. Caring for high-need, high-cost patients: an urgent priority. N Engl J Med. 2016;375:909–11.

World Health Organization. Integrated care models: an overview. https://www.euro.who.int/__data/assets/pdf_file/0005/322475/Integrated-care-models-overview.pdf . (2016). Accessed 30 May 2022.

Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. The effects of integrated care: a systematic review of UK and international evidence. BMC Health Serv Res. 2018;18:350.

Althaus F, Paroz S, Hugli O, et al. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review. Ann Emerg. 2011;58:41–52.

Kumar GS, Klein R. Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review. J Emerg Med. 2013;44:717–29.

Soril L, Legget L, Lorenzetti D, Noseworthy T. Reducing frequent visits to the emergency department: a systematic review of intervention. PLOS One. 2015;10.

What is a case manager? http://cmsa.org/who-we-are/what-is-a-case-manager/ . Accessed 30 May 2022.

Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321:694–6.

Nurjono M, Yoong J, Yap P, Wee SL, Vrijhoef HJM. Implementation of integrated care in Singapore: a complex adaptive system perspective. Int J Integr Care. 2018;18:4.

Dopson S, Fitzgerald L, Ferlie E. Understanding change and innovation in healthcare settings: reconceptualizing the active role of context. J Change Manag. 2008;8:213–31.

Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337: a1655.

Skivington K, Matthews L, Simpson SA, et al. Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update. HTA. 2021;25:1–132.

Google Scholar  

Ford I, Norrie J. Pragmatic trials. N Engl J Med. 2016;375:454–63.

Khorsan R, Crawford C. How to assess the external validity and model validity of therapeutic trials: a conceptual approach to systematic review methodology. Evid Based Complement Alternat Med. 2014;2014:694804.

Kessler R, Glasgow RE. A proposal to speed translation of healthcare research into practice: dramatic change is needed. Am J Prev Med. 2011;40:637–44.

Peek CJ, Glasgow RE, Stange KC, Klesges LM, Purcell EP, Kessler RS. The 5 R’s: an emerging bold standard for conducting relevant research in a changing world. Ann Fam Med. 2014;12:447–55.

Green LW. Making research relevant: if it is an evidence-based practice, where’s the practice-based evidence? Fam Pract. 2008;25(Suppl 1):i20–4.

Sanson-Fisher RW, Bonevski B, Green LW, D’Este C. Limitations of the randomized controlled trial in evaluating population-based health interventions. Am J Prev Med. 2007;33:155–61.

Dickinson LM, Beaty B, Fox C, et al. Pragmatic cluster randomized trials using covariate constrained randomization: a method for practice-based research networks (PBRNs). J Am Board Fam Med. 2015;28:663–72.

Hughes JP, Granston TS, Heagerty PJ. Current issues in the design and analysis of stepped wedge trials. Contemp Clin. 2015;45:55–60.

Umscheid CA, Williams K, Brennan PJ. Hospital-based comparative effectiveness centers: translating research into practice to improve the quality, safety and value of patient care. J Gen Intern. 2010;25:1352–5.

Hanley P, Chambers B, Haslam J. Reassessing RCTs as the ‘gold standard’: synergy not separatism in evaluation designs. Int J Res Method Educ. 2016;39:287–98.

Deaton A, Cartwright N. Understanding and misunderstanding randomized controlled trials. Soc Sci Med. 2018;210:2–21.

Petticrew M, Rehfuess E, Noyes J, et al. Synthesizing evidence on complex interventions: how meta-analytical, qualitative, and mixed-method approaches can contribute. J Clin Epidemiol. 2013;66:1230–43.

Hudon C, Chouinard MC, Pluye P, et al. Characteristics of case management in primary care associated with positive outcomes for frequent users of healthcare: a systematic review. Ann Fam Med. 2019;17:448–58.

Dy SM, Garg P, Nyberg D, et al. Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis. Health Serv Res. 2005;40:499–516.

Berg-Schlosser D, Meur G, le D, Rihoux B, Ragin CC. Configurational comparative methods: qualitative comparative analysis (QCA) and related techniques. Thousand Oaks, California: SAGE Publications, Inc. 2009. https://methods.sagepub.com/book/configurational-comparative-methods . Accessed 12 Dec 2022.

Hong QN, Pluye P, Bujold M, Wassef M. Convergent and sequential synthesis designs: implications for conducting and reporting systematic reviews of qualitative and quantitative evidence. Syst Rev. 2017;6:61.

Pawson R, Tilley N. Realistic evaluation. London: Sage; 1997.

Wong G, Westhorp G, Manzano A, Greenhalgh J, Jagosh J, Greenhalgh T. RAMESES II reporting standards for realist evaluations. BMC Med. 2016;14:96.

Wong G, Greenhalgh T, Westhorp G, Pawson R. Realist methods in medical education research: what are they and what can they contribute? Med Educ. 2012;46:89–96.

Hudon C, Chouinard MC, Aubrey-Bassler K, et al. Case management in primary care for frequent users of health care services: a realist synthesis. Ann Fam Med. 2020;18:218–26.

Meadows DH, Wright D, Wright D. Thinking in systems : a primer. White River Junction, Vermont: Chelsea Green Publishing; 2008.

Williams B. Prosaic or profound? The adoption of systems ideas by impact evaluation. Inst Develop Stud. 2015;46:7–16.

Hudon C, Chouinard M-C, Lambert M, Diadiou F, Bouliane D, Beaudin J. Key factors of case management interventions for frequent users of healthcare services: a thematic analysis review. BMJ Open. 2017;7: e017762.

Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34:228–43.

McCreight MS, Rabin BA, Glasgow RE, et al. Using the Practical, Robust Implementation and Sustainability Model (PRISM) to qualitatively assess multilevel contextual factors to help plan, implement, evaluate, and disseminate health services programs. Transl Behav Med. 2019;9:1002–11.

Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50:217–26.

Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013;8:117.

Eccles MP, Mittman BS. Welcome to implementation science. Implement Sci. 2006;1.

Hudon C, Chouinard MC, Bisson M, et al. Case management programs for improving integrated care for frequent users of healthcare services: an implementation analysis. Int J Integr Care. 2022;22:11.

Canadian Institutes of Health Research. Knowledge user engagement. http://www.cihr-irsc.gc.ca/e/49505.html . (2016). Accessed Dec 12 2022.

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Department of Family and Emergency Medicine, Université de Sherbrooke, Pavillon Z7-local 3007, 3001, 12eAvenue Nord, Sherbrooke, QC, J1H 5N4, Canada

Catherine Hudon

Department of Family Medicine, University of Colorado School of Medecine, Aurora, CO, United States of America

Rodger Kessler

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C.H. wrote a first draft of the manuscript which was reviewed and improved by R.K. All authors read and approved the final manuscript.

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Hudon, C., Kessler, R. Integrating case management for patients with complex needs in the ground practice: the importance of context in evaluative designs. Health Res Policy Sys 21 , 9 (2023). https://doi.org/10.1186/s12961-023-00960-4

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DOI : https://doi.org/10.1186/s12961-023-00960-4

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Healthcare Case Study

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The healthcare industry is growing at a very fast pace with global healthcare spending projected to touch USD 8.7 trillion in 2020. 1 The healthcare sector comprises the industries that specialize in products and services that provide health and medical care to patients. The sector can be broadly classified under four main subsectors displayed in Figure 5-1.

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An overview of the perspectives used in health economic evaluations

• Manit Sittimart 1 ,
• Waranya Rattanavipapong 1 ,
• Andrew J. Mirelman 2 ,
• Trinh Manh Hung 3 ,
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The term ‘perspective’ in the context of economic evaluations and costing studies in healthcare refers to the viewpoint that an analyst has adopted to define the types of costs and outcomes to consider in their studies. However, there are currently notable variations in terms of methodological recommendations, definitions, and applications of different perspectives, depending on the objective or intended user of the study. This can make it a complex area for stakeholders when interpreting these studies. Consequently, there is a need for a comprehensive overview regarding the different types of perspectives employed in such analyses, along with the corresponding implications of their use. This is particularly important, in the context of low-and-middle-income countries (LMICs), where practical guidelines may be less well-established and infrastructure for conducting economic evaluations may be more limited. This article addresses this gap by summarising the main types of perspectives commonly found in the literature to a broad audience (namely the patient, payer, health care providers, healthcare sector, health system, and societal perspectives), providing their most established definitions and outlining the corresponding implications of their uses in health economic studies, with examples particularly from LMIC settings. We then discuss important considerations when selecting the perspective and present key arguments to consider when deciding whether the societal perspective should be used. We conclude that there is no one-size-fits-all answer to what perspective should be used and the perspective chosen will be influenced by the context, policymakers'/stakeholders’ viewpoints, resource/data availability, and intended use of the analysis. Moving forward, considering the ongoing issues regarding the variation in terminology and practice in this area, we urge that more standardised definitions of the different perspectives and the boundaries between them are further developed to support future studies and guidelines, as well as to improve the interpretation and comparison of health economic evidence.

What is the perspective in health economic evaluations?

Health economic analyses, particularly economic evaluations and costing studies, have an important role in investigating the value-for-money of health interventions and supporting decision-making surrounding resource allocation within the health sector [ 1 , 2 , 3 ]. Such studies are a key element of Health Technology Assessment (HTA) processes and other priority-setting or decision-making processes [ 1 , 4 , 5 ]. When conducting an economic evaluation of a particular health intervention or technology, understanding the perspective, or the point of view from which the evaluation is conducted is important, as it determines the boundary of the study and which types of costs and consequences/outcomes are included within the analysis [ 6 ]. Note that cost is a general term that refers to the value of resources/inputs used to produce a good or service. As different perspectives include (or exclude) different costs and outcomes, they can substantially influence the results of health economic studies and the subsequent recommendations and policies informed by these studies [ 7 ]. Therefore, it is vital that the perspective is carefully considered when conducting, reviewing, or interpreting health economic analyses.

Different types of perspectives have been adopted in health economic studies. However, there is no universally accepted “right” answer regarding which perspective should be applied, and this decision will depend on the context, type of analysis, decision-maker and question that the evaluation aims to answer [ 7 ]. Due to contextual considerations, the perspective is one of the methodological areas that exhibits the largest variation within the currently available guidelines for health economic studies [ 8 , 9 , 10 ]. Therefore, this is a potentially challenging area for stakeholders when conducting and/or interpreting these studies. Consequently, there is a need for an overview outlining the key types of perspectives, along with the corresponding implications of using different perspectives in health economic analyses. This is particularly important in the context of low-and-middle-income countries (LMICs), where there are less well-established guidelines and infrastructure (including data) for conducting economic evaluations and subsequently the potential for more variation in methodology between studies. To date, the Guide to Economic Analysis and Research (GEAR) resource has only identified 14 national guidelines from LMICs related to conducting health economic evaluations [ 11 ].

This article aims to outline and introduce the main types of perspectives used in economic evaluations, as well as to discuss their implications on cost-effectiveness calculations. We also outline ongoing issues and considerations related to perspectives that are important to be aware of when comparing and interpreting economic evaluations. It is expected that greater awareness of these concepts will lead to better consistency in future health economic studies and improve the interpretation and comparison of health economic evidence.

What are the main types of perspectives?

Here we provide a breakdown of the most commonly used perspectives within health economic evaluations and costing studies. These are derived from a review of key texts [ 8 , 12 , 13 ], and recommendations from multiple international and national economic evaluation guidelines listed in the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Guide to Economic Analysis and Research (GEAR) websites [ 11 , 14 , 15 ]. That said, it is important to note that there is variation in terminology used within the field to describe perspectives as well as other terms for perspectives not included here. We have endeavoured to highlight what we consider to be the most established definitions.

The differences between these perspectives relate to what cost (and cost saving) items may be included within an analysis. Figure  1 provides an overview of the different perspectives and the variation of included costs. In the context of cost-effectiveness and cost-utility analysis, the inclusion of non-monetary health outcomes (such as disability-adjusted life year (DALY), quality-adjusted life year (QALY) or cases averted) in the denominator of the cost-effectiveness ratio calculations would not typically be influenced by these perspectives whereas the costs in the numerator would be directly influenced.

Overview of the different perspectives and the variation of included costs within economic evaluations. Y: Included; N: Not included; * The limited societal perspective excludes spillover impacts affecting sectors other than health care whereas the (non-limited) societal perspective includes the spillover impacts on at least one non-health care sector. Note that there is variation in terminology used within the field to describe these different perspectives as well as others not included here. Therefore, it is possible some studies would apply these perspectives differently to what we have outlined

Patient/household

The patient or household perspectives are used to describe the costs borne by individuals or their households, respectively. The patient perspective may be limited to the costs incurred by the patient whereas the household perspective also includes the costs incurred by other members of the household. This distinction is not always made as the terms are at times used interchangeably. Under the patient/household perspective, all costs that patients incur when facing a health issue could be included, such as direct medical costs that are not covered by the patient's health insurance (i.e., out-of-pocket costs, co-payments, and deductibles), direct non-medical costs (such as those from transport to health facilities), and potentially productivity costs—also known as indirect costs (i.e., monetised productivity losses resulting from lost paid and unpaid work due to an illness or an intervention). The extent to which these cost types are included depends on the type of study being conducted. Within the context of an economic evaluation of a health system intervention, all costs borne by the patient would be included. While the patient/household perspective is more likely to be used within cost-of-illness studies or analysis of patient health expenditure/analyses of financial risk protection [ 16 ], it is rarely applied within full economic evaluations. However, some have advocated for using this perspective in economic evaluations in the context of the increasing focus on patient-centred outcomes in health policy research [ 8 , 12 ].

Health care payer or payer

The health care payer perspective includes costs incurred by specific health care payer(s)—typically a third party, such as a specific health organisation, specific control programme or agency that manages an insurance programme [ 9 ]. This would include the costs incurred by a specific health care payer related to treatment, disease management or other health care services [ 9 , 16 ]. However, the costs that are not borne by this specific payer will not be considered (such as the out-of-pocket payments paid by patients). It is important to note that the payer perspective would only relate to the part of the organisation that the funds have been planned or budgeted for [ 17 ]. Therefore, it would capture the costs incurred by a specific control programme but not the costs incurred by the broader health care provider(s). It is noteworthy that in some settings there can be multiple relevant payers (such as multiple insurance programmes).

Health care provider(s)

The health care provider’s perspective will include all costs incurred by a given provider (or group of providers in the health system) in delivering care services to patients. Depending on the context, this can be the same as the health care payer perspective. However, the health care provider(s) perspective is usually broader in terms of its scope of costs included; as the payer perspective only relates to the specific part of the organisation that the funds have been planned/budgeted for [ 17 ]. The difference between the payer and provider perspectives will depend on the context of the study, but it is plausible that the provider’s perspective will give a more complete picture of total costs and hence is used more often in costing exercise [ 16 ].

Healthcare sector

The healthcare sector perspective is similar to the health care provider(s) perspective but broader and accounts for all the costs directly associated with the healthcare sector, regardless of who will bear such costs. This means that it not only includes the direct medical costs incurred by specific third-party payers (such as national health services), but it also includes the out-of-pocket payments for health care made by patients [ 9 ]. Costs that are not directly related to medical services/the health sector are considered outside of the scope of the healthcare sector perspective—such as costs related to the patients' travel or accommodation and productivity costs (indirect costs) [ 18 ]. The distinction between health care payer/provider and healthcare sector perspectives may be particularly important in LMIC settings where out-of-pocket payments by patients can be a significant source of health care expenditure [ 19 ].

Health system

The definition of the health system perspective is more variable within the literature [ 20 , 21 , 22 , 23 , 24 ]. The latest WHO-CHOICE guidelines [ 20 , 21 ] defined the health system perspective as including an ensemble of actions and actors whose primary intent is to improve human health. This therefore includes all direct, market-valued costs, whether public or private, that are required to deliver the intervention, regardless of payer. This would also cover the out-of-pocket payments for health care made by patients but would not account for the patients’ direct non-medical costs (such as travel-related costs), and productivity costs. This definition is subtly broader than the healthcare sector perspective (Fig.  1 ), as it can potentially include costs from other sectors when they are a direct component of the intervention intended to improve human health (e.g., the costs associated with developing health legislation and costs associated with regulation of health care and products) [ 20 ]. It is debatable how often these are included. Costs outside of the health system that are not primarily health oriented would not be included. It should be noted that in some cases, it is possible that the term health system perspective is being defined differently—such as to refer to the costs incurred by a particular publicly funded national healthcare provider. If this was the case, it could be more equivalent to the use of the health care provider(s) perspective as outlined above.

The societal perspective is the broadest and includes all healthcare-related costs, regardless of who is paying, including the patients'/caregivers’ costs for accessing an intervention (such as for travel and accommodation etc.) and their productivity costs [ 9 ]. This perspective can also potentially include other “relevant” non-health-related impacts in other sectors [ 25 ] such as those on social services, education, legal or criminal justice, environment, etc. In practice, there is variation in how far the societal perspective is taken and whether the impact on other sectors is included [ 13 ]. Kim et al. stratified the societal perspective by whether it is limited or not (Fig.  1 ) [ 9 ]. The limited societal perspective includes all healthcare-related costs (including the patients' costs) but excludes spillover impacts affecting sectors other than health care. In contrast, the (non-limited) societal perspective is broader and also includes the cost impacts on at least one non-healthcare sector [ 9 ]. In macroeconomic models, the societal perspective would also include the sectoral impact on other sectors due to changes in demand and supply in the economy [ 26 , 27 ].

It should be noted that there will be other types of perspectives not captured here that can fall in between these categories. For example, the National Institute for Health and Care Excellence (NICE) in the UK recommends “The perspective adopted on costs should be that of the NHS and personal social services.” [ 28 ]. This would be broader than the health system perspective as defined here as it includes the social care related costs, but not as broad as the societal perspective.

Some guidelines now recommend the use of a disaggregated societal perspective [ 29 , 30 ], where the costs and outcomes are disaggregated, either by sector of the economy or by who incurs them—and therefore it is possible to interest the results from a range of perspectives.

It should be noted that there are types of costs that may be excluded from the societal perspective [ 22 ]. For example, some interventions may result in transfer costs or payments; financial flows from one part of society to another, that do not consume resources but simply transfer the power to use resources from one person or sector to another (such as import tariffs as well as unemployment or sickness benefits) [ 31 ]. Transfer payments can be a cost to the paying government or control programme, but a financial gain to another sector or a patient. Therefore, because they do not use or create resources, transfer payments are typically not considered when estimating economic costs using a societal perspective [ 22 , 32 ], but can be included when using a narrower perspective (such as the health care payer perspective).

Implications on economic evaluations

There are several implications of the study perspective on health economic evaluations. The first is the scope of costs related to the intervention that are included. Generally, in terms of the cost of the intervention, the broader the perspective the higher the potential cost of the intervention (the impact will depend on the context). For example, when looking at the costs of providing a vaccine at a health clinic, the health care provider(s) perspective would only include the costs that are incurred by the government’s health service (such as those associated with the staff’s time, and the purchase of the vaccine etc.). However, under the societal perspective, the costs that are incurred by the patients in order to go to the clinic and get the vaccine would also be included (such as their travel costs and potentially their productivity costs associated with lost paid or unpaid work), increasing the overall cost of the intervention. Similarly, for cost-of-illness studies, the broader the perspective the wider the scope of costs included.

A related implication is that the choice of study perspective can have a significant impact on both the source of cost data and the method used for data collection. For example, this determines whether patient interviews may be needed. Having different sources of cost data and the way they are collected can contribute to the variation of cost values included in studies. For example, the costs for treating a patient at a hospital may be based on 'reimbursement rates’ under the payer perspective whereas the full cost of the resources utilised may be used under the health care provider perspective.

It is also important to note that, theoretically, the chosen perspective of an economic evaluation should not influence whether financial or economic costs should be adopted [ 33 ]. Nonetheless, the chosen perspective can influence how economic costs are valued and whether adjustments to market prices are required [ 33 ]. For example, if adopting the health care provider or payer perspective, it might be appropriate to use the market prices of a drug or vaccine that the provider has procured. However, if using the societal perspective, these prices may need to be adjusted to reflect their social opportunity costs (their value in their next best alternative use—only reflecting their short-run manufacturing and distribution costs), rather than their market price [ 22 , 34 ].

A further implication within economic evaluations is that the perspective will determine the consequences/outcomes that are included. A key example is that it affects if/what “cost savings” or cost offsets are included within the analysis. These “cost savings” are effectively deducted from the intervention cost within the cost-effectiveness ratios. These cost savings could include the costs associated with disease cases that are averted due to the intervention (for example in the case of measles vaccination, they would consider the cost savings associated with the averted measles cases that it prevents—such as the medical costs associated with hospitalised cases). The broader the perspective, the broader the types of costs included within these savings, and with the societal perspective, it can include prevented productivity costs that would have been associated with the morbidity and mortality of the cases and even costs outside the healthcare sector.

A further implication of the perspective is regarding the inclusion of future unrelated costs within these analyses [ 35 , 36 , 37 , 38 , 39 ]. Health interventions can increase the life expectancy of patients and consequently influence the consumption of both unrelated medical and non-medical resources during the additional lifetime they generate. These future unrelated costs are typically grouped into future medical costs (e.g., the costs of treating people with other future unrelated health conditions) and future non-medical costs (the costs related to consumption of non-medical resources, such as food, housing, utilities etc.). Which types of future unrelated costs that could be included within an economic evaluation, would be influenced by the perspective (with the societal perspective potentially including both future unrelated medical and non-medical costs). If these future costs are taken into account, adopting a broader perspective, could lead to a greater increase in the net cost of the intervention when it impacts the patient’s survival. This can therefore subsequently impact the estimated cost-effectiveness of the intervention. There is currently ongoing debate about the inclusion of these future unrelated costs in health economic analyses [ 35 , 36 , 37 , 38 , 39 ]. This debate and variation should be considered when interpreting different studies. The inclusion of future unrelated costs is still uncommon, and further guidance on this area is needed [ 35 ].

A particular area of debate is regarding the inclusion of future unrelated medical costs [ 35 ]. A key issue here is that the costs and outcomes of unrelated events in the future will depend on decisions not yet made and are therefore difficult to predict. This debate and variation should be considered when interpreting different studies.

Ultimately, although in some cases the use of different perspectives may only have a small impact on the cost-effectiveness ratios, it can also have a significant impact and could fundamentally change the conclusions of studies (Table  1 ). In some cases, broadening the perspective will not greatly change the estimated cost of the intervention, but could result in more cost-savings being included, resulting in the estimated cost-effectiveness ratio decreasing (Table  1 ). On the other hand, it is also possible that broadening the perspective would increase the cost of an intervention—potentially making its cost-effectiveness ratio increase (if this increase in the intervention cost outweighs any potential increase in the cost-savings). This relative impact and direction of the change on the cost-effectiveness ratio will depend on the context of the study and the intervention being investigated (Table  1 ). It should be noted that in some cases, health interventions may be estimated to be cost saving (i.e., have negative ICER values) even when using a more restricted perspective. For example, Owen et al. [ 40 ] found that among the cost-effectiveness analysis of public health interventions examined between 2005 to 2018 by the National Institute for Health and Care Excellence (NICE) in the UK, 21% were projected to generate cost savings even without using a societal perspective. In these cases, changing to a societal perspective would be unlikely to influence the results/policy recommendation. However, this will not always be the case and the perspective can have a significant impact (Table  1 ). This is particularly important to consider in countries in which the patients incur higher costs for assessing/receiving health care.

Due to this variation, if studies have used different perspectives, a direct comparison of results may be misleading. Of concern, even when the same perspective is reported to be used, the variation in the specific cost items included (Table  1 ) could still negatively impact the comparability of studies. A key driver in the variation of cost-effectiveness ratios between the use of the societal and other perspectives, is the specific types of costs being considered and if/what types of productivity costs are being included. Notably, there are issues surrounding the inclusion of productivity costs and potential double counting (outlined in Box 1). This highlights the importance of considering the perspective when comparing studies and the need to clearly report methodology regarding productivity costs.

Box 1: Issues surrounding productivity costs within economic evaluations (adapted from [ 46 ])

What is used in practice.

A review of the perspectives used in costing in cost-effectiveness analysis between 1974–2018 has been conducted by Kim et al. [ 9 ]. Interestingly, they found that studies often misspecified or did not clearly state the perspective used. After re-classification by registry reviewers, they found that a healthcare sector or payer perspective was the most common (74%) and that cost-effectiveness analysis rarely included impacts on non-healthcare sectors [ 9 ].

In terms of the available national economic evaluation guidelines (including from high income countries), a cross-country comparison by Sharma et al. [ 13 ] found that of the 31 guidelines they reviewed, 15 (48%) recommended using one of the non-societal perspectives (such as payer, health care provider health sector, health system etc.). However, the corresponding terminology used to describe these perspectives was variable. Three guidelines (10%) stated that any perspective relevant to the research question may be considered. Eight guidelines (26%) recommended using the societal perspective for the primary analysis, and 10 (26%) recommended using the societal perspective for additional analysis if required [ 13 ]. Yet, Sharma et al. also highlighted that even when the societal perspective was recommended, there was variation regarding the specific recommendations on the type of costs that should be included [ 13 ]. For example, the guidelines for Portugal recommended that intangible costs should also be included under the societal perspective [ 58 ], whereas the guidelines for Norway recommended using a societal perspective but the inclusion of productivity costs was optional [ 59 ]. In addition, while several guidelines recommended including all costs and outcomes within and outside the healthcare sector, others recommended for the more limited societal perspective excluding the impacts of the intervention on non-healthcare sectors [ 13 ]. This highlights the notable variation surrounding the societal perspective. A recent review of how the societal perspective is defined within guidelines by Avşar et al. also found substantial variation of the definition, including insufficient guidance on what to include under different perspectives [ 8 ]. Among 46 guidelines included in their review, the societal perspective featured in 30 guidelines, of which 21 (70%) explicitly considered this perspective (at times it was recommended within additional analysis). In several guidelines where productivity costs were allowed in additional analysis, this was usually referred to as a broader perspective (than healthcare), instead of explicitly defining it as a societal perspective. Interestingly, countries with multiple payers in the health systems were more likely to consider the societal perspective.

Table 2 highlights the recommendations regarding what perspective to use within key international/LMIC economic evaluation guidelines. The national economic evaluation guidelines were extracted from GEAR [ 11 ] (please note that some guidelines were not included as their text was not available in English). The focus on LMICs in Table  2 was chosen because literature providing contextual insights/case studies from LMICs are typically limited (despite the need for increased capacity in these settings). In terms of international guidelines, the WHO-CHOICE 2003 guidelines on cost-effectiveness analysis recommended using the societal perspective but excluding productivity costs [ 55 ]. The WHO-CHOICE's latest guidelines have now adopted a health system perspective [ 21 ]. In contrast, the International Decision Support Initiative (iDSI) reference case for economic evaluation recommended using a disaggregated societal perspective (where the costs and outcomes are disaggregated, either by sector of the economy or by who incurs them, making it possible to interpret the results from a range of perspectives) [ 29 , 30 ]. In terms of the available LMIC national economic evaluation guidelines, recommendations for the use of one of the non-societal perspectives were the most common. This could be because adopting these non-societal perspectives is relatively less complex and requires fewer data. That said, the societal perspective was recommended in several cases. In contrast, the perspective recommended for budget impact analysis is generally more consistent within guidelines, with the public payer or service purchaser perspectives typically recommended [ 60 ].

Selecting the perspective

In practice, it is important to note that there is no one-size-fits-all recommendation regarding what perspective should be used. The right perspective will depend on the research question, context, and goals of the decision-makers [ 7 , 34 , 71 ]. For example, if the goal is to understand the affordability of an intervention, the payer perspective may be the most appropriate.

When choosing the perspective, it is important to consider the role of patient out-of-pocket payments. Crucially, the payer and health care providers perspectives will not account for any costs paid by patients (including their out-of-pocket payments). They therefore may not be suitable for interventions that require co-payment by patients—as they will underestimate the cost of the intervention and potentially lead to inefficient policy recommendations. This is particularly important in a global heath context as patient out-of-pocket payments are one of the most critical healthcare funding sources in many LMICs [ 72 ]. In this context, at least the use of a healthcare sector perspective (if not a broader perspective) would be needed to account for these out-of-pocket payments (as outlined in Fig.  1 ).

Key considerations regarding navigating the use of societal perspective

In terms of selecting perspective, it should be noted that there is ongoing debate regarding the role of the societal perspective and when it should be used. The societal perspective is often referred to as the gold standard for economic evaluations [ 73 , 74 , 75 ] and recommended in several guidelines. The reasons for this relate to the fact that it considers a more complete picture of costs and consequences/outcomes. This has important advantages in the context of evaluating health interventions and promoting total welfare and the good of society. For example, since the societal perspective considers a full set of information regarding conceivable costs and outcomes, it has been argued that it offers a higher level of decision-supportive power and will be less dependent on the study commissioners, as well as the political and social character of the society that the study is intended for [ 73 , 74 , 76 , 77 , 78 ]. A focus solely on the health care payer/provider perspective could overlook interventions that demonstrate cost-effectiveness from a broader societal standpoint. Furthermore, excluding important costs and outcomes within an economic evaluation, as seen in more restricted perspectives, could lead to inefficient resource allocation decisions [ 78 ]. The societal perspective can identify cost-shifting between sectors and on to patients/their families [ 78 ] (e.g., if the costs to the health systems are decreased but the costs to patients are increased), which may not be accounted for with more restricted perspectives. Consequently, many have argued that the societal perspective is preferable to others [ 73 , 75 , 78 ].

However, there are important further considerations that need to be made when considering the societal perspective—particularly in a global health context [ 7 , 71 ]. Firstly, having an all-inclusive analysis from a societal perspective, where in theory all conceivable costs and outcomes are considered, may require more costs and effort in order to acquire the additional data and information. As such, there needs to be a balance between the costs of acquiring additional information needed to use the societal perspective and increasing the quality of the decision being made. In the context of having inadequate or inaccessible datasets (such as those related to epidemiology, resource uses, unit costs, baseline distribution of health outcomes and data to inform the cost-effectiveness threshold), there is a greater challenge to the adoption of a broader perspective [ 79 ]. This is the rationale why the proponents of adaptive HTA suggest that a more limited perspective can be used in more nascent systems [ 80 ]. Applying a narrower perspective, especially in the cases of limited data, may be more pragmatic, albeit presenting some degree of omitted variable bias.

Although the societal perspective has often been advocated for, less consideration has been given to what this should include and its practical implementation [ 74 , 81 ]. In practice, it is not always easy to define what the conceivable or relevant costs and outcomes to be captured are. Consequently, there can be uncertainty regarding which costs should be included, and the way the societal perspective is conceptualised and interpreted can vary [ 82 ]. Even studies that state they are using it can omit potentially relevant costs and outcomes, and the societal perspective is often less comprehensive than it could be [ 8 ]. This is notable as the choice of its conceptualisation can seriously affect the result of a health economic analysis and the variation in how it is implemented can make comparisons more challenging. More generally, it could be argued that the societal perspective increases the risk of gaming as methods are less standardised, and there are more prominent data gaps [ 7 ].

A further consideration surrounding the use of the societal perspective and the variation in its implementation relates to the ongoing debate regarding the inclusion of indirect non-health benefits within economic evaluations (i.e., averted productivity costs) [ 52 , 53 , 55 ]. From a broad utilitarian moral standpoint, including these benefits in economic evaluations is important to ensure the maximisation of the collective benefit to society from the allocation of healthcare resources. However, including productivity gains could lead to the prioritization of the treatment of one group of patients over another because one group generates greater non-health benefits, thereby failing to give equal moral concern and weight to each person’s health care needs. Consequently, there is also a potential moral argument for ignoring productivity gains, in line with Kant's moral theory and that the equitable distribution of healthcare resources should be based on individual health needs [ 83 ]. A further factor is that quantifying all relevant non-health outcomes and productivity gains could potentially be double-counting the effectiveness of interventions [ 53 ], and this is an area of debate within the field (outlined previously in Box 1). Due to these factors, even under the societal perspective, the inclusion of productivity costs (as well as types of productivity costs) is variable. It is also important to note that productivity costs are particularly sensitive to the methodology used to calculate them, and the different methods used can generate significantly different results (Box 1) [ 84 ]. It is vital to consider this variation regarding the types of productivity costs being considered and their calculation within economic evaluations when making comparisons between studies.

A further issue relates to what “society” should be considered under the societal perspective: does “society” refer to the entire world or the society of an individual country. This issue becomes more prominent when evaluating interventions with a limited supply or that involve cross-border issues [ 22 ]. Although this can influence to what degree societal costs will be included, it is not always clear what is the scope of the society of interest within studies.

Even if the societal perspective is being used correctly, it can be unclear how the information produced informs choices across different settings and decision-makers—particularly when decision-makers may have different judgements about what outcomes are relevant to their relative values [ 85 ]. This is an important limitation for which progress is being made: for example, Walker et al . [ 74 ] developed a framework for the economic evaluation of policies with the costs and outcomes falling on different sectors (e.g., health, criminal justice, education) and involving different decision makers.

To summarise, while the societal perspective offers some significant advantages, corresponding issues and challenges should also be acknowledged, particularly in LMIC settings. It is worth noting that the societal perspective will not always be required as, ultimately, economic evaluations must align with and serve the stated goals of the decision-maker. In the United Kingdom, the primary focus of the decision-maker is to enhance health outcomes efficiently within a fixed health budget [ 28 , 85 ]. Therefore, in this context, adopting a health care provider perspective is typically considered more justifiable than a societal perspective. In contrast, this perspective could be misleading in settings where co-payments by the patients are notable, when the goal is to enhance the health system’s efficiency as a whole. Consequently, the choice of the perspective will depend on the purpose of the analysis, who needs to know/use the results and policymakers'/stakeholders’ viewpoints. It is also important to consider that the adoption of the societal perspective can involve notable additional data needs and the corresponding resource needs for collecting this data. This is not to discourage adoption of the societal perspective but rather to highlight that it is not a universal gold standard and the aforementioned factors/challenges are a consideration regarding its adoption.

Recommendations for policy and research

The terminology used to describe perspectives is variable within the literature. We have endeavoured to use the most established definitions, but it is possible that studies have interpreted and used them differently as well as potentially referred to terminology not included here. We recommend that the global health economic field set more standard definitions of the different perspectives and boundaries between these terms. This is to prevent confusion and misunderstanding not only among researchers but also policymakers and the public as a whole.

A related issue is that broader perspectives consider a wider range of costs, and therefore are likely to capture greater potential cost savings resulting from health interventions. If the healthcare budget is fixed, then this would imply that the cost-effectiveness threshold should be lower for a broader perspective, i.e. that different perspectives should be accompanied by different thresholds. However, the implications go beyond simply lowering the threshold. Some of these cost savings may extend beyond the designated budget holder (e.g. the health care provider), and the presence of budget constraints and trade-offs with other sectors need to be considered. For example, switching from the health care provider perspective to the societal perspective would mean that the provider (e.g. Department of Health) is effectively subsidising other sectors and without increasing the budget, the change could effectively decrease the amount of health being generated. Hence, we recommend that future studies further explore how to more accurately account for the interaction between the chosen perspective and appropriate cost-effectiveness threshold, considering the corresponding impact of budget constraints and trade-offs with other sectors [ 85 ]. In addition, not accounting for the impact of the use of different perspectives could potentially lead to biases in decision making, with interventions that have been evaluated with the societal perspective (including more cost savings) more likely to be favoured compared to those that have been evaluated with a narrower perspective.

A factor that needs to be further investigated on the implications of the chosen perspectives is the presence and impact of budget constraints as well as the desired time scale of investment returns.

A key issue to consider when evaluating and interpreting health economic studies is the potential inclusion of productivity costs when using the societal perspective. Estimates of productivity costs are highly sensitive to the method used [ 56 ], and it is important to be aware of the potential variation in methodology when comparing studies. In addition, the types of productivity costs included can vary—even when using the societal perspective. We recommend that this is an area that should have more comprehensive and consistent reporting in future studies. Having more standardised productivity cost estimates (potentially within country specific economic evaluation reference cases/guidelines) could be helpful to ensure increased consistency between studies for a particular country setting.

In this paper, we focused on the implications of the perspectives used in economic evaluations such as cost-effectiveness and cost-utility analysis. However, it is also important for future work to consider how the perspective interacts with other health economics methods and frameworks used within public health [ 86 , 87 , 88 , 89 ].

When conducting an economic evaluation of a particular intervention, or health technology, the concept of perspective is paramount. There are different types of perspectives which are used in economic evaluations with corresponding differences in the types of costs that are considered, as well as what outcomes are included (for example it can affect if/what “cost savings” are included). The choice of perspective can have a significant impact on the results of economic evaluations. Its relative impact on the results will depend on the context of the study and the intervention being investigated.

When choosing the perspective, it is important to consider the role of patient out-of-pocket payments. Crucially, the payer and health care provider(s) perspectives will not account for any costs paid by patients (including other out-of-pocket payments). They therefore may not be suitable for interventions that require co-payments by patients, as they could underestimate the cost of interventions and potentially lead to inefficient policy recommendations. This is particularly an important consideration in LMIC settings where out-of-pocket payments can be a significant source of health care expenditure [ 19 ].

Concerningly, the terminology used to describe the different perspectives is variable within the literature. We have endeavoured to highlight what we consider to be the most established definitions. We recommend that the global health economic field set more standard definitions of the different perspectives and boundaries between these terms.

Finally, it is important to note that despite the advantages of the societal perspective, its adoption does involve additional data needs and there is notable variation in how it is implemented, particularly surrounding what types of productivity costs are considered. Ultimately, there is no universal gold standard regarding what perspective should be used as it depends on the context (including policymakers'/stakeholders’ viewpoints and data/resource availability) as well as the question that the evaluation aims to provide an answer to [ 7 ].

Availability of data and materials

The authors confirm that the data supporting the findings of this study are available within the article.

Kristensen FB, Husereau D, Huić M, Drummond M, Berger ML, Bond K, et al. Identifying the need for good practices in health technology assessment: summary of the ISPOR HTA Council Working Group Report on Good Practices in HTA. Value Health. 2019;22(1):13–20.

Article   PubMed   Google Scholar  

Nemzoff C, Ruiz F, Chalkidou K, Mehndiratta A, Guinness L, Cluzeau F, et al. Adaptive health technology assessment to facilitate priority setting in low-and middle-income countries. BMJ Glob Health. 2021;6(4): e004549.

Article   PubMed   PubMed Central   Google Scholar  

World Health Organization. SEA/RC66/R4-Health intervention and technology assessment in support of universal health coverage. WHO Regional Office for South-East Asia; 2013.

Oortwijn W, Jansen M, Baltussen R. Evidence-informed deliberative processes for health benefit package design—part II: a practical guide. Int J Health Policy Manage. 2022;11(10):2327–36.

Google Scholar  

Baltussen R, Jansen M, Oortwijn W. Evidence-informed deliberative processes for legitimate health benefit package design—part I: conceptual framework. Int J Health Policy Manage. 2022;11(10):2319–26.

York Health Economics Consortium (YHEC). Perspective. 2016. Available from: https://yhec.co.uk/glossary/perspective/ .

Chalkidou K, Culyer AJ, Nemzoff C. Perspective in economic evaluations of health care interventions in low-and middle-income countries—one size does not fit all. CGD Policy Paper. 2018.

Avşar TS, Yang X, Lorgelly P. How is the societal perspective defined in health technology assessment? Guidelines from Around the Globe. Pharmacoeconomics. 2023;41(2):123–38.

Kim DD, Silver MC, Kunst N, Cohen JT, Ollendorf DA, Neumann PJ. Perspective and costing in cost-effectiveness analysis, 1974–2018. Pharmacoeconomics. 2020;38(10):1135–45.

Culyer A, Chalkidou K, Teerawattananon Y, Santatiwongchai B. Rival perspectives in health technology assessment and other economic evaluations for investing in global and national health. Who decides? Who pays? F1000 Res. 2018;7:72.

Article   Google Scholar  

GEAR. Guidelines Comparison. Available from: http://www.gear4health.com/gear/health-economic-evaluation-guidelines .

Tai BB, Bae YH, Le QA. A systematic review of health economic evaluation studies using the patient’s perspective. Value Health. 2016;19(6):903–8.

Sharma D, Aggarwal AK, Downey LE, Prinja S. National healthcare economic evaluation guidelines: a cross-country comparison. Pharmacoecon Open. 2021;5(3):349–64.

ISPOR. Pharmacoeconomic Guidelines: Russian Federation 2018. Available from: https://www.ispor.org/heor-resources/more-heor-resources/pharmacoeconomic-guidelines/pe-guideline-detail/russian-federation .

ISPOR. Pharmacoeconomic Guidelines: Brazil. 2014. Available from: https://www.ispor.org/heor-resources/more-heor-resources/pharmacoeconomic-guidelines/pe-guideline-detail/brazil .

Özaltın A, Cashin C. Costing of health services for provider payment: a practical manual based on country costing challenges, trade-offs, and solutions. Washington, DC: Joint Learning Network for Universal Health Coverage; 2014.

Vassall A, Sweeney S, Kahn J, Gomez Guillen G, Bollinger L, Marseille E, et al. Reference case for estimating the costs of global health services and interventions. 2017. Available from: https://ghcosting.org/pages/standards/reference_case .

Neumann PJ, Sanders GD, Russell LB, Siegel JE, Ganiats TG. Cost-effectiveness in health and medicine. Oxford: Oxford University Press; 2016.

Book   Google Scholar  

World Health Organization. Public spending on health: a closer look at global trends. World Health Organization; 2018. Report No.: 9240040331.

Bertram MY, Stenberg K, Brindley C, Li J, Serje J, Watts R, et al. Disease control programme support costs: an update of WHO-CHOICE methodology, price databases and quantity assumptions. Cost Effect Resour Allocat. 2017;15:21.

Bertram MY, Lauer JA, Stenberg K, Edejer TTT. Methods for the economic evaluation of health care interventions for priority setting in the health system: an update from WHO CHOICE. Int J Health Policy Manag. 2021;10(11):673–7.

PubMed   PubMed Central   Google Scholar  

Garrison LP Jr, Mansley EC, Abbott TA III, Bresnahan BW, Hay JW, Smeeding J. Good research practices for measuring drug costs in cost-effectiveness analyses: a societal perspective: the ispor drug cost task force report—Part II. Value in Health. 2010;13(1):8–13.

Henrikson NB, Skelly AC. Economic studies part I: basics and terms. Evid Based Spine Care. 2012;3(4):7–11.

Abbott JH, Wilson R, Pryymachenko Y, Sharma S, Pathak A, Chua JYY. Economic evaluation: a reader’s guide to studies of cost-effectiveness. Arch Physiother. 2022;12(1):28.

Garrison LP Jr, Pauly MV, Willke RJ, Neumann PJ. An overview of value, perspective, and decision context—a health economics approach: an ISPOR Special Task Force Report [2]. Value Health. 2018;21(2):124–30.

Smith KM, Machalaba CC, Seifman R, Feferholtz Y, Karesh WB. Infectious disease and economics: the case for considering multi-sectoral impacts. One Health. 2019;7: 100080.

Nicola M, Alsafi Z, Sohrabi C, Kerwan A, Al-Jabir A, Iosifidis C, et al. The socio-economic implications of the coronavirus pandemic (COVID-19): a review. Int J Surg. 2020;78:185–93.

National Institute for Health and Care Excellence (NICE). NICE health technology evaluations: the manual. 2022. Available from: https://www.nice.org.uk/process/pmg36/chapter/introduction-to-health-technology-evaluation .

Wilkinson T, Sculpher MJ, Claxton K, Revill P, Briggs A, Cairns JA, et al. The international decision support initiative reference case for economic evaluation: an aid to thought. Value Health. 2016;19(8):921–8.

Claxton KP, Revill P, Sculpher M, Wilkinson T, Cairns J, Briggs A. The gates reference case for economic evaluation: the Bill and Melinda Gates Foundation; 2014.

Hutton G, Baltussen R. Cost valuation in resource-poor settings. Health Policy Plan. 2005;20(4):252–9.

Hay JW, Smeeding J, Carroll NV, Drummond M, Garrison LP, Mansley EC, et al. Good research practices for measuring drug costs in cost effectiveness analyses: issues and recommendations: the ISPOR Drug Cost Task Force Report—Part I. Value Health. 2010;13(1):3–7.

Turner HC, Sandmann FG, Downey LE, Orangi S, Teerawattananon Y, Vassall A, et al. What are economic costs and when should they be used in health economic studies? Cost Effect Resour Allocat. 2023;21(1):31.

Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. 4th ed. Oxford: Oxford University Press; 2015.

De Vries LM, Van Baal PHM, Brouwer WBF. Future costs in cost-effectiveness analyses: past, present. Future Pharmacoecon. 2019;37(2):119–30.

Garber AM, Phelps CE. Future costs and the future of cost-effectiveness analysis. J Health Econ. 2008;27(4):819–21.

Meltzer D. Accounting for future costs in medical cost-effectiveness analysis. J Health Econ. 1997;16(1):33–64.

Article   CAS   PubMed   Google Scholar  

Kellerborg K, Wouterse B, Brouwer W, van Baal P. Estimating the costs of non-medical consumption in life-years gained for economic evaluations. Soc Sci Med. 2021;289: 114414.

Morton A, Adler AI, Bell D, Briggs A, Brouwer W, Claxton K, et al. Unrelated future costs and unrelated future benefits: reflections on NICE guide to the methods of technology appraisal. Health Econ. 2016;25(8):933–8.

Owen L, Fischer A. The cost-effectiveness of public health interventions examined by the National Institute for Health and Care Excellence from 2005 to 2018. Public Health. 2019;169:151–62.

Turner HC, Quyen DL, Dias R, Huong PT, Simmons CP, Anders KL. An economic evaluation of Wolbachia deployments for dengue control in Vietnam. PLoS Negl Trop Dis. 2023;17(5): e0011356.

Kim SY, Goldie SJ, Salomon JA. Cost-effectiveness of rotavirus vaccination in Vietnam. BMC Public Health. 2009;9:29.

Le P, Griffiths UK, Anh DD, Franzini L, Chan W, Swint JM. Cost-effectiveness of Haemophilus influenzae type b vaccine in Vietnam. Vaccine. 2015;33(36):4639–46.

Turner HC, Lauer JA, Tran BX, Teerawattananon Y, Jit M. Adjusting for inflation and currency changes within health economic studies. Value Health. 2019;22(9):1026–32.

World Bank. GDP deflator (base year varies by country). Available from: https://data.worldbank.org/indicator/NY.GDP.DEFL.ZS .

Turner HC, Archer RA, Downey LE, Isaranuwatchai W, Chalkidou K, Jit M, et al. An introduction to the main types of economic evaluations used for informing priority setting and resource allocation in healthcare: key features, uses, and limitations. Front Public Health. 2021;9: 722927.

Brouwer WB, Koopmanschap MA, Rutten FF. Productivity costs measurement through quality of life? A response to the recommendation of the Washington Panel. Health Econ. 1997;6(3):253–9.

Brouwer WB, Koopmanschap MA, Rutten FF. Productivity costs in cost-effectiveness analysis: numerator or denominator: a further discussion. Health Econ. 1997;6(5):511–4.

Sculpher M. The role and estimation of productivity costs in economic evaluation. In: Drummond M, McGuire A, editors. Economic evaluation in health care: merging theory with practice. Oxford University Press: Oxford; 2001. p. 94–112.

Chapter   Google Scholar  

Olsen JA, Richardson J. Production gains from health care: what should be included in cost-effectiveness analyses? Soc Sci Med. 1999;49(1):17–26.

Liljas B. How to calculate indirect costs in economic evaluations. Pharmacoeconomics. 1998;13(1):1–7.

Pritchard C, Sculpher M. Productivity costs: principles and practice in economic evaluation. Office of Health Economics; 2000.

Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness in health and medicine. New York: Oxford University Press; 1996.

Neumann PJ, Thorat T, Zhong Y, Anderson J, Farquhar M, Salem M, et al. A systematic review of cost-effectiveness studies reporting cost-per-DALY averted. PLoS ONE. 2016;11(12): e0168512.

World Health Organization. Making choice in health: WHO guide to cost effectiveness analysis. Geneva: WHO; 2003.

Krol M, Brouwer W, Rutten F. Productivity costs in economic evaluations: past, present, future. Pharmacoeconomics. 2013;31(7):537–49.

Hung TM, Shepard DS, Bettis AA, Nguyen HA, McBride A, Clapham HE, et al. Productivity costs from a dengue episode in Asia: a systematic literature review. BMC Infect Dis. 2020;20(1):1–18.

Da Silva EA, Pinto CG, Sampaio C, Pereira J, Drummond M, Trindade R. Guidelines for economic drug evaluation studies. Lisbon, Portugal: Infarmed. 1998.

Agency NM. Guidelines for the submission of documentation for single technology assessment (STA) of pharmaceuticals. Norwegian Medicines Agency Oslo (Norway); 2018.

Chugh Y, De Francesco M, Prinja S. Systematic literature review of guidelines on budget impact analysis for health technology assessment. Appl Health Econ Health Policy. 2021;19(6):825–38.

ISPOR. Pharmacoeconomic Guidelines: Thailand 2019: Available from: https://www.ispor.org/heor-resources/more-heor-resources/pharmacoeconomic-guidelines/pe-guideline-detail/thailand .

Department of Health Research, Ministry of Health & Family Welfare, Government of India. Health Technology Assessment in India: A Manual. New Delhi: Department of Health Research; 2018.

Elsisi GH, Kaló Z, Eldessouki R, Elmahdawy MD, Saad A, Ragab S, et al. Recommendations for reporting pharmacoeconomic evaluations in Egypt. Value Health Reg Issues. 2013;2(2):319–27.

Health Technology Assessment Unit, Department of Health—Philippines. P Philippine HTA Methods Guide, Health Technology Assessment Unit Department of Health - Philippines: Department of Health; 2020.

Indonesian Health Technology Assessment Committee (InaHTAC). Health technology assessment (HTA) guideline. Jakarta: Pusat Pembiayaan dan Jaminan Kesehatan Kementerian Kesehatan RI. 2017;143.

Ministry of Health Malaysia. Pharmacoeconomic Guideline for Malaysia (2nd Edition). Pharmaceutical Services Programme; 2020.

Moreno Viscaya M, Mejía Mejía A, Castro Jaramillo HE. Manual para la elaboración de evaluaciones económicas en salud. Bogotá: Instituto de Evaluación Tecnológica en Salud. 2014.

Yue X, Li Y, Wu J, Guo J. Current development and practice of pharmacoeconomic evaluation guidelines for universal health coverage in China. Value Health Reg Issues. 2021;24:1–5.

Consejo de Salubridad General. Guía para la conducción de estudios de evaluación económica para la actualización del cuadro básico y catálogo de insumos del sector salud en México. México, DF: CSG. 2017.

Cuba Ministry of Health. Methodological Guidelines for Health Economic Evaluation. 2003.

Culyer AJ. “Perspectives” in health technology assessment. AMA J Ethics. 2021;23(8):619–23.

World Health Organization. Public spending on health: a closer look at global trends. World Health Organization; 2018.

Johannesson M, Jönsson B, Jönsson L, Kobelt G, Zethreaus N. Why should economic evaluations of medical technologies have a societal perspective. OHE Briefing Paper London: Office of Health Economics. 2009.

Walker S, Griffin S, Asaria M, Tsuchiya A, Sculpher M. Striving for a societal perspective: a framework for economic evaluations when costs and effects fall on multiple sectors and decision makers. Appl Health Econ Health Policy. 2019;17(5):577–90.

Gold M. Panel on cost-effectiveness in health and medicine. Medical Care. 1996:DS197–DS9.

Drost RMWA, Paulus ATG, Evers SMAA. Five pillars for societal perspective. Int J Technol Assess Health Care. 2020;36(2):72–4.

Byford S, Raftery J. Perspectives in economic evaluation. BMJ. 1998;316(7143):1529–30.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Jöonsson B. Ten arguments for a societal perspective in the economic evaluation of medical innovations. Eur J Health Econ. 2009;10:357–9.

Chalkidou K. A Global Burden of Disease Data Plus Model to Inform Domestic Decision-Making: In Search of Super-local Data. Blog post of the Center for Global Development. 2017. Available from: https://www.cgdev.org/blog/global-burden-disease-data-plus-model-inform-domestic-decision-making-search-super-local-data .

Nemzoff C, Ruiz F, Chalkidou K, Mehndiratta A, Guinness L, Cluzeau F, et al. Adaptive health technology assessment to facilitate priority setting in low- and middle-income countries. BMJ Glob Health. 2021;6(4): e004549.

Evers SM, Hiligsmann M, Adarkwah CC. Risk of bias in trial-based economic evaluations: identification of sources and bias-reducing strategies. Psychol Health Econ Rev. 2015;30(1):52–71.

Drost RM, Van der Putten IM, Ruwaard D, Evers SM, Paulus AT. Conceptualizations of the societal perspective within economic evaluations: a systematic review. Int J Technol Assess Health Care. 2017;33(2):251–60.

Sullivan RJ. Immanuel Kant’s moral theory. Cambridge: Cambridge University Press; 1989.

Van den Hout W. The value of productivity: human-capital versus friction-cost method. Ann Rheum Dis. 2010;69(Suppl 1):i89–91.

Claxton K, Walker S, Palmer S, Sculpher M. Appropriate perspectives for health care decisions. Centre for Health Economics, University of York, Working Papers. 2010.

Fischer AJ, Ghelardi G. The precautionary principle, evidence-based medicine, and decision theory in public health evaluation. Front Public Health. 2016;4:107.

Ryan M, Gerard K. Using discrete choice experiments to value health care programmes: current practice and future research reflections. Appl Health Econ Health Policy. 2003;2(1):55–64.

PubMed   Google Scholar  

Baltussen R, Marsh K, Thokala P, Diaby V, Castro H, Cleemput I, et al. Multicriteria decision analysis to support health technology assessment agencies: benefits, limitations, and the way forward. Value Health. 2019;22(11):1283–8.

Coast J, Kinghorn P, Mitchell P. The development of capability measures in health economics: opportunities, challenges and progress. Patient. 2015;8(2):119–26.

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Acknowledgements

The authors alone are responsible for the views expressed, which do not necessarily represent the views, decisions or policies of the institutions with which the authors are affiliated.

HCT acknowledges funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/X020258/1), funded by the UK Medical Research Council (MRC). This UK funded award is carried out in the frame of the Global Health EDCTP3 Joint Undertaking. The Health Intervention and Technology Assessment Program (HITAP) is a semi-autonomous research unit in the Ministry of Public Health, Thailand, and supports evidence-informed priority-setting and decision-making for healthcare. HITAP is funded by national and international public funding agencies. HITAP is also supported by the Health Systems Research Institute (HSRI), the Thai Health Promotion Foundation (ThaiHealth), the World Health Organization (WHO), the Access and Delivery Partnership, which is hosted by the United Nations Development Programme and funded by the Government of Japan, among others. The findings, interpretations and conclusions expressed in this article do not necessarily reflect the views of the funding agencies. MJ was supported by the NIHR Health Protection Research Unit in Modelling and Health Economics (grant code HPRU-2019-NIHR200908). MJ was also supported by the NIHR Health Protection Research Unit in Immunisation (HPRU-2019-NIHR200929). The views expressed are those of the authors and not necessarily those of the United Kingdom (UK) Department of Health and Social Care, the National Health Service, the National Institute for Health Research (NIHR), or the UK Health Security Agency. For the purpose of open access, the author has applied a ‘Creative Commons Attribution’ (CC BY) licence to any Author Accepted Manuscript version arising from this submission.

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Manit Sittimart, Waranya Rattanavipapong, Saudamini Dabak & Yot Teerawattananon

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Laura E. Downey

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Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK

School of Public Health, University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China

Saw Swee Hock School of Public Health, National University of Singapore (NUS), Singapore, Singapore

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MS and HCT wrote the original draft. WR, AJM, TMH, SD, LED, MJ and YT contributed to the writing, reviewing and editing of the draft. All authors read and approved the final draft.

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Sittimart, M., Rattanavipapong, W., Mirelman, A.J. et al. An overview of the perspectives used in health economic evaluations. Cost Eff Resour Alloc 22 , 41 (2024). https://doi.org/10.1186/s12962-024-00552-1

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Lung cancer study offers further evidence on importance of screening

by University of Liverpool

Researchers from the University of Liverpool and Queen Mary University of London have published the first study in the UK to demonstrate the benefits of lung cancer screening across socioeconomic groups. Evidence in the new study illustrates the value and importance of screening, especially for those who live in areas of economic deprivation.

Lung cancer affects the lives of about 40,000 people a year in the UK and previous studies from Liverpool researchers illustrate the unequivocal benefit of lung cancer screening in identified high risk groups.

In a newly published paper in The Lancet Regional Health Europe , lung cancer researchers further demonstrate the benefits of low-dose CT lung cancer screening. The latest study illustrates lung cancer outcomes are comparable across all socioeconomic groups .

Significantly, it also demonstrates that screening may provide additional health benefits for other smoking-related diseases. The analysis showed that conditions COPD and emphysema, both of which disproportionately affect lower socioeconomic groups, were less often the cause of death when subjects received a low-dose CT scan.

Researchers examined long-term outcomes of recruited participants from across the socioeconomic spectrum. This allowed assessment of the impact of socioeconomic status on a variety of aspects, including initial recruitment, selection for screening, lung cancer detection, and long-term mortality benefit from lung cancer and other diseases.

It is shown that those from a lower socioeconomic group benefited from low-dose-CT screening in terms of lung cancer survival to the same extent as those from more affluent groups. However, they were more likely to benefit in terms of death from COPD and emphysema.

Professor John Field, Professor of Molecular Oncology, University of Liverpool and lead author on the paper said, "The impact of low-dose CT lung cancer screening has been previously demonstrated in a number of international clinical trials, including the UKLS study here in the UK.

"However, this is the first time that the long-term impact of risk-stratified lung cancer screening has been compared across different socioeconomic groups, demonstrating that those disadvantaged groups at the greatest risk of developing the disease benefit as much as those in less deprived areas."

Dr. Chris Warburton, Respiratory Consultant at Liverpool University Hospitals NHS Foundation Trust and Clinical Lead for the Targeted Lung Health Check Program for the NHS Cheshire and Merseyside Cancer Alliance said, "This is excellent data which demonstrates that lung cancer screening of high risk populations not only delivers benefits in lung cancer outcomes for the most deprived in our society, but it could also have wider beneficial effects on other smoking related diseases such as COPD and cardiovascular disease.

"The Cancer Alliance would encourage anyone offered a Lung Health Check to attend this important appointment which might just help to prolong their life."

Professor Field worked with Dr. Michael Davies, from the University of Liverpool's Institute of Systems, Molecular & Integrative Biology, and Daniel Vulkan, Professor Rhian Gabe, and Professor Stephen Duffy, from the Wolfson Institute of Preventive Medicine, Queen Mary University of London.

Professor Duffy said, "These results indicate the potential for lung cancer screening to address some serious inequalities in health. As the targeted program is rolled out nationally, we need to make an effort to deliver the service to those deprived populations who need it most."

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Research finds step-count and time are equally valid in reducing health risks

Kira Sampson

BWH Communications

A new study suggests that both step-count and time-based exercise goals are equally effective in reducing risks of heart disease and early death.

Researchers from Harvard-affiliated Brigham and Women’s Hospital reviewed data on healthy women age 62+, who used wearable devices to record their physical activity, and then tracked their health outcomes. After a median follow-up of nine years, the researchers found higher levels of physical activity, whether in time of exercise or step counts, were associated with large risk reductions in mortality and cardiovascular disease. The most active quarter of women in the study had a 30 to 40 percent reduced risk compared to the least active quarter.

Results of the study are published in JAMA Internal Medicine . 

“We recognized that existing physical activity guidelines focus primarily on activity duration and intensity but lack step-based recommendations,” said lead author Rikuta Hamaya, a researcher in the  Division of Preventive Medicine  at BWH. “With more people using smartwatches to measure their steps and overall health, we saw the importance of ascertaining how step-based measurements compare to time-based targets in their association with health outcomes — is one better than the other?” 

“Movement looks different for everyone, and nearly all forms of movement are beneficial to our health.”  Rikuta Hamaya

The current  U.S. guidelines , last updated in 2018, recommend that adults engage in at least 150 minutes of moderate to vigorous physical activity (e.g., brisk walking) or 75 minutes of vigorous activity (e.g., jogging) per week. At that time, most of the existing evidence on health benefits came from studies where participants self-reported their physical activity. Few data points existed on the relationship between steps and health. Fast-forward to the present — with wearables being ubiquitous, step counts are now a popular metric among many fitness-tracking platforms. How do time-based goals stack up against step-based ones? Investigators sought to answer this question. 

For this study, investigators collected data from 14,399 women who participated in the Women’s Health Study, and were healthy (free from cardiovascular disease and cancer). Between 2011 and 2015, participants aged 62 years and older were asked to wear research-grade wearables for seven consecutive days to record their physical activity levels, only removing the devices for sleep or water-related activities. Throughout the study period, annual questionnaires were administered to ascertain health outcomes of interest, in particular, death from any cause and cardiovascular disease. Investigators followed up with participants through the end of 2022. 

At the time of device wear, researchers found that participants engaged in a median of 62 minutes of moderate-to-vigorous intensity physical activity per week and accumulated a median of 5,183 steps per day. During a median follow-up of nine years, approximately 9 percent of participants had passed and roughly 4 percent developed cardiovascular disease.

Higher levels of physical activity (whether assessed as step counts or time in moderate to vigorous activity) were associated with large risk reductions in death or cardiovascular disease — the most active quarter of women reduced their risk by 30-40 percent compared with the least-active quarter. Individuals in the top three quartiles of physical activity outlived those in the bottom quartile by an average of 2.22 and 2.36 months respectively, based on time and step-based measurements, at nine years of follow-up. This survival advantage persisted regardless of differences in body mass index (BMI). 

While both metrics are useful in portraying health status, Hamaya explained that each has its advantages and downsides. For one, step counts may not account for differences in fitness levels. For example, if a 20-year-old and 80-year-old both walk for 30 minutes at moderate intensity, their step counts may differ significantly. Conversely, steps are straightforward to measure and less subject to interpretation compared to exercise intensity. Additionally, steps capture even sporadic movements of everyday life, not just exercise, and these kinds of daily life activities likely are those carried out by older individuals. 

“For some, especially for younger individuals, exercise may involve activities like tennis, soccer, walking, or jogging, all of which can be easily tracked with steps. However, for others, it may consist of bike rides or swimming, where monitoring the duration of exercise is simpler,” said Hamaya. “That’s why it’s important for physical-activity guidelines to offer multiple ways to reach goals. Movement looks different for everyone, and nearly all forms of movement are beneficial to our health.” 

The authors note that this study incorporates only a single assessment of time and step-based physical activity metrics. Further, most women included in the study were white and of higher socioeconomic status. Finally, this study was observational, and thus causal relations cannot be proven. In the future, Hamaya aims to collect more data via a randomized controlled trial to better understand the relationship between time and step-based exercise metrics and health. 

“The next federal physical activity guidelines are planned for 2028,” said senior author I-Min Lee, an epidemiologist in the Division of Preventive Medicine at BWH. “Our findings further establish the importance of adding step-based targets, in order to accommodate flexibility of goals that work for individuals with differing preferences, abilities and lifestyles.”  

Disclosures : Hamaya reported receiving consulting fees from DeSC Healthcare, Inc., outside of the submitted work. Co-authors Christopher Moore, Julie Buring, Kelly Evenson, and Lee reported receiving institutional support from the National Institutes of Health during the conduct of the study.

This research was supported in part by the National Institutes of Health (CA154647, CA047988, CA182913, HL043851, HL080467, and HL09935), the National Cancer Institute (5R01CA227122), Office of the Director, Office of Disease Prevention, and Office of Behavioral and Social Sciences Research; and by the extramural research program at the National Heart, Lung, and Blood Institute. 

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The Healthcare Hub

Healthcare Provider and Supplier Collaboration: Unlocking Better Care

Collaboration between healthcare providers and suppliers can unlock untapped opportunities to increase supply chain efficiency and lower the cost of doing business while supporting the overall goal of patient care. Keep reading to find out how an aligned vision, collaborative decision-making and shared best practices can benefit all parties involved, and discover real-world success stories of provider-supplier collaboration in action.

Table of contents

• The importance of collaboration in healthcare
• The benefits of strong provider-supplier partnerships
• Overcoming challenges in healthcare collaboration
• Strategies for building and enhancing collaborative relationships
• Provider-supplier collaboration case studies

The Importance of Collaboration in Healthcare

In the healthcare industry, collaborative relationships between providers and suppliers is essential to ensuring that the right supplies get to where they are needed in an efficient, accurate and cost effective manner.

Historically, the relationship between providers and their suppliers was largely transactional and conversations based on product price. As Jimmy Chung, M.D., CMO of Advantus Health Partners, stated recently in Healthcare Purchasing News :

"Centered around group purchasing organizations (GPOs), the practice of keeping many suppliers on contract, with pricing tiers only revisited every two to three years, creates unstable environments that do not support the challenges today’s healthcare organizations face, nor do they align with the goals of value-based care."

Collaborative relationship-building between a healthcare system and their suppliers requires changing mindsets and breaking down traditional barriers that prevent stakeholders from working toward common goals. It supports the parties in engaging in mutually beneficial activities, including strategic planning to match supply with demand and eliminating waste in the supply chain.

A supportive environment, where hospitals and suppliers promote collaboration, results in efficiency gains and savings, especially when stakeholders share knowledge and systems to address challenges and opportunities.

For instance, a shared vision and understanding that manual handling of consignment or “ bill-only implant orders " increases complexity, errors and costs on both sides of the trading partner relationship, has prompted healthcare partnership models aimed at addressing the issue.

The Benefits of Strong Provider-Supplier Partnerships

Strong relationships between providers and suppliers promote collaboration with is essential for leaders seeking to drive supply chain efficiencies and for streamlining healthcare operations.

• Timely Access to Supplies: Closer partnerships can ensure that healthcare providers have timely access to the necessary medical supplies and equipment, reducing the risk of treatment delays or interruptions for patients.
• Cost Efficiency: Efficient supply chain management and collaborative partnerships can help reduce costs associated with procurement and inventory management, allowing healthcare providers to allocate resources more effectively toward patient care.
• Mitigate the impact of supply disruptions: When a health system has close ties with their suppliers, they can better anticipate and manage potential disruptions in the supply chain, by working together to develop contingency plans, secure alternative sources of supply, or collaborate with suppliers to address challenges swiftly, ensuring that patient care remains uninterrupted.
• Innovative Solutions: By fostering innovation and collaboration, provider-supplier relationships and the sharing of medical knowledge can support the development and continuous improvement of technology, treatments, practices and solutions that ultimately benefit patients.

Overcoming Challenges in Healthcare Collaboration

Healthcare trading partners have made tremendous progress in the development of collaborative relationships and effective communication channels to tackle mutual challenges, but the work isn't over. Let's look at some of the obstacles hospitals and suppliers face in their ability to work collaboratively.

According to a 2024 roundtable facilitated by the Healthcare Distribution Alliance (HDA), in partnership with the U.S. Chamber of Commerce Foundation, here are some of the key issues facing these relationships today.

Raw materials and prioritization challenges

There have been significant disruptions to global supply chains amid rising international conflicts and geopolitical tensions, the Red Sea shipping crisis , drought affecting the Panama Canal and concerns over an economic slowdown in China. This is of particular concern due to the globalization of US medical product supply chain , which is reliant on distant nations countries such as China and India.

In addition, information sharing on the status of raw materials used in medical/surgical supplies among trading partners can help them develop strategies for mitigating the impacts of shortages. Looking beyond product pricing and conducting a thorough analysis of the components and other aspects that influence the availability of medical supplies may provide an effective strategy to understand risks facing healthcare services.

Access to data, data and information sharing

Research conducted by Deloitte found more than two-thirds of healthcare supply chain leaders interviewed experienced data-related challenges such as data availability, data quality and data integration.

As AHRMM points out , "Supply chain plays a central role when it comes to leveraging data to advance health care excellence.  In today's data-driven and analytics environment, it is imperative that supply chain professionals understand data management, flow, and utilization."

Uneven adoption of blockchain, machine learning and AI

A 2023 study described several barriers to adoption of these advanced technologies in healthcare as "ethical, technological, liability and regulatory, workforce, social, and patient safety".

However, when it comes to AI, there are some important benefits for supply chain partners an uncertain global climate. For example, generative AI has the ability to model supply and demand scenarios , and see how sudden and extreme events (e.g., natural disasters) could affect the supply chain.

Communication barriers among healthcare supply chain stakeholders

A 2021 study investigating the buyer-supplier relationships in healthcare described four themes underpinning distrust trust between both parties: "lack of information sharing, opportunistic pricing behavior, changing regulations, and physician-supplier alliances."

To learn more about strategies to build trust, communication and common goals, scroll to the next section .

Inequitable hoarding of healthcare supplies...

... And anticipation of global crises. A clinician's main priority is their patient; therefore, it comes as no surprise that healthcare professionals turn to supply hoarding in times of supply chain uncertainty to ensure they have what they need for patient care. But the problems of hoarding are numerous - excessive inventories, items outside of the vision or control of supply chain teams, items expiring on shelves, expired items being use on patients, etc.

In addition to educating physicians and clinicians on the dangers of hoarding and training them on responsible inventory practices, cloud solutions that facilitate real-time communication among hospital and supplier supply chain team members can both strengthen resiliency and help clinicians trust that supplies will be available when needed.

Strategies for Building and Enhancing Collaborative Relationships

"Supply chain collaboration is often deemed as a critical strategy for ensuring that all independent firms work cooperatively to create a cohesive, singularly competitive supply network capable of improving overall performance."

Palgrave Handbook of Supply Chain Management , Springer (2022)

Here are key strategies for building collaborative relationships among healthcare supply chain stakeholders. From building trust between partners to invoicing and payment automation and order automation to streamline supply chain operations for providers and suppliers alike.

Establishing Trust and Transparency Between Partners

"Before health care stakeholders can become more transparent about their operations, they must first build trust with one another."

Cost, Quality and Outcomes White Pape r, AHRMM (2020)

Trust and transparency between partners is vital for effective collaborative relationships in healthcare. Trust facilitates open communication and mutual respect, while transparency provides clarity on expectations and processes.

In healthcare, where patient care is paramount, these qualities create a strong foundation for collaboration. They enable providers and suppliers to work seamlessly, make informed decisions, and deliver optimal care. Here are six steps to successful supply chain collaboration according to McKinsey :

• Collaborate in areas where you are successful.
• Find the right benefit-sharing model.
• Choose partners according on capability, strategic goals and value potential. .
• Invest in the right infrastructure and people.
• Establish a joint performance-management system.
• Collaborate for the long term.

Using Technology and Data to Improve Communication

The digital transformation of healthcare supply chain management (SCM) among providers and suppliers alike is breaking down communication barriers, facilitating secure data sharing and enabling the use of advanced analytics empowered by AI.

Cloud ERP, EHR and SCM solutions are playing a key role in system integration, shared tools and capabilities, and the capture and sharing of real-time, complete and accurate digital data. According to a  July 2023 Cloud Market Survey from GHX, nearly half (45%) of hospitals and health systems have already transitioned to cloud technologies for supply chain management, and many more will do so over the next 24 months.

The integration of data and application of AI driven analytics is helping trading partners work collaboratively and more proactively to address issues as they arise - or in the case of predictive analytics, predict and address potential problems before they even happen.

"GenAI can be queried to produce risk assessments, scenario simulations and mitigation strategies on demand — in response to shortages or widespread calamities, such as another pandemic — to help planners manage and mitigate the risks proactively ," stated EY analysts in a recent article on GenAi in healthcare supply chain optimization.

Extending P2P Process Automation in the Healthcare Supply Chain

"When orders go out and invoices come in, they match and go straight through processing to greatly reduce end-to-end transaction time through to payments.”

Amy Platis , Northwestern Medicine Program Director of Finance for Accounts Payable

From order to invoice, automation streamlines processes, removes cumbersome manual touchpoints, increases data accuracy, provides greater visibility and improves overall supply chain performance.

Automating procure-to-pay (P2P) processes generates value for providers and suppliers alike. Trading partners on the GHX Exchange can transact and collaborate on a single platform where they have access to the same information (e.g., PO status, discrepancies holding up orders, backorders, etc.) and can work in partnership to overcome issues in real-time.

While most trading partners have made progress in automating POs, POAs, ASNs, invoice and payment automation has historically lagged behind. Healthcare supply chain leaders are focusing on automating processes to enhance efficiency and optimize limited working capital. A key trend is collaboration between trading partners to extend automation from procurement to invoicing and payments.

Provider-Supplier Collaboration Case Studies

From the provider's perspective.

Northwestern Medicine recently turned its AP department from cost center to a profit center by automating these processes with GHX ePay . The results were substantial:

• 98% of payments made through a digital workstream
• 133% increase in annual payment program rebates
• Strengthened supplier relationship and communication

Program Director of Finance for Accounts Payable (AP), Amy Platis, commented on the mutual benefits her organization and its suppliers have achieved through payment automation:

“A big selling point for GHX ePay was that it would deliver value to not just Northwestern Medicine but our suppliers as well. GHX was a huge help in achieving alignment. They worked with us and our suppliers to make sure data was ‘apples to apples’ on both sides in terms of contracts, pricing, unit of measure, quantities and minimum orders."

Read the case study .

From the Supplier's Perspective

Axogen, a supplier and leading developer of surgical solutions, implemented GHX ePay and GHX Exchange to tackle inefficient and manual order and payment processes and achieved significant benefits:

• Double-digit business growth without adding any new FTEs
• 50% reduction in administrative work
• 90% reduction in fees
• 12-15% average decrease in DSO

“Managing transactions via EDI is far less time-consuming than before. Our Customer Care unit can focus on reviewing orders as they’re being placed instead of placing the orders themselves. A process that took half a day now takes a quarter of the day or less,” said Axogen Manager, Treasury & Financial Services Ralph Engle.

Q: Why is collaboration between healthcare providers and suppliers important?

A: Collaboration between healthcare providers and suppliers is crucial because it ensures that both sides are aligned in efficiently delivering necessary supplies for patient care. This optimizes the supply chain, matching demand with supply and reducing resource waste, ultimately benefiting patient outcomes.

Q: What benefits can be achieved through effective collaboration?

A: Effective collaboration between healthcare providers and suppliers leads to streamlined operations and reduced costs by aligning procurement processes, ensuring accurate transactions, and minimizing administrative expenses through automation.

Q: What are some common challenges in establishing these partnerships and how can they be overcome?

A: Common challenges in establishing partnerships between healthcare providers and suppliers include difficulties with data access and sharing, uneven adoption of advanced technologies like blockchain and AI, and communication barriers among supply chain stakeholders.

Q: How is the landscape of healthcare collaboration expected to evolve in the coming years?

A: The landscape of healthcare collaboration is expected to evolve as providers and suppliers increasingly utilize advanced analytics, including AI-driven predictive analytics, to strengthen resilience against potential disruptions in the supply chain.

Building Toward Healthcare Supply Chain Resilience, U.S. Chamber of Commerce Foundation, January 2024,  https://chamber-foundation.files.svdcdn.com/production/documents/23-12438_USCCF_2023_HDA-Report_Digital.pdf?dm=1705601598

Where is Supply Chain Transformation Headed? 3 Insights, Healthcare Purchasing News, October 2023,  https://www.hpnonline.com/sourcing-logistics/article/53076717/where-is-supply-chain-transformation-headed-3-insights

Operating Room Efficiency 2023 Research Report, Owens & Minor,  https://www.owens-minor.com/wp-content/uploads/2023/03/20230324_OM-Research-Report.pdf

A Step-by-Step Guide for Consignment Implant Order Automation with GHX and Infor, GHX, https://gateway.on24.com/wcc/eh/2552798/lp/4206329/a-step-by-step-guide-for-consignment-implant-order-automation-with-ghx-and-infor

AHRMM Recommended Initiatives for the Health Care Supply Chain, AHRMM, https://www.ahrmm.org/ahrmm-recommended-initiatives-health-care-supply-chain

5 Supply Chain Insights From Innovative Healthcare Leaders, Workday, November 9, 2023, https://blog.workday.com/en-us/2023/5-supply-chain-insights-innovative-healthcare-leaders.html#weigh-supply-chain-resiliency-and-supplier-transparency-alongside-price

Three Healthcare Supply Chain Benchmarking Lessons for 2024, Gartner, April 9, 2024, https://www.gartner.com/en/supply-chain/insights/power-of-the-profession-blog/three-healthcare-supply-chain-benchmarking-lessons-for-2024

The gold standard for new product evaluation, GHX, https://www.ghx.com/value-analysis-providers/product-introduction-management/

Key determinants for resilient health care supply chains, Deloitte, April 25, 2022, https://www2.deloitte.com/us/en/insights/industry/health-care/healthcare-supply-chain.html

Ahmed MI, Spooner B, Isherwood J, Lane M, Orrock E, Dennison A. A Systematic Review of the Barriers to the Implementation of Artificial Intelligence in Healthcare. Cureus. 2023 Oct 4;15(10):e46454. doi: 10.7759/cureus.46454. PMID: 37927664; PMCID: PMC10623210., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10623210/

Abdulsalam YJ, Schneller ES. Of barriers and bridges: Buyer-supplier relationships in health care. Health Care Manage Rev. 2021 Oct-Dec 01;46(4):358-366. doi: 10.1097/HMR.0000000000000278. PMID: 32167964, https://pubmed.ncbi.nlm.nih.gov/32167964/

Osei, V., Asante-Darko, D. (2023). Collaboration Within the Supply Chain. In: Sarkis, J. (eds) The Palgrave Handbook of Supply Chain Management. Palgrave Macmillan, Cham. https://link.springer.com/referenceworkentry/10.1007/978-3-030-89822-9_56-1

AHRMM20+ Cost, Quality and Outcomes Summit White Paper: CQO: Building a More Resilient Health Care Supply Chain, AHRMM, https://www.ahrmm.org/ahrmm20-cqo-summit-white-paper

Six steps to successful supply chain collaboration, McKinsey & Company, 2012, https://www.mckinsey.com/capabilities/operations/our-insights/six-steps-to-successful-supply-chain-collaboration#/

Healthcare 2024: How AI and Collaboration Will Drive Supply Chain Transformation, Supply Chain Brain, February 7, 2024, https://www.supplychainbrain.com/blogs/1-think-tank/post/38942-healthcare-2024-how-ai-and-collaboration-will-drive-supply-chain-transformation

Northwestern Medicine’s Procure-to-Pay Workstream Goes Digital With Big Payoff, GHX, https://www.ghx.com/resources/customer-stories/northwestern-medicine-s-procure-to-pay-workstream-goes-digital-with-big-payoff/

Axogen Boosts Financial Health and Customer Relationships, GHX, https://www.ghx.com/resources/customer-stories/axogen-implements-payment-and-order-automation/

Kara L. Nadeau

Healthcare industry contributor.

Kara L. Nadeau has more than 20 years of experience as a writer for the healthcare industry, working for clients in fields including medical device/supply manufacturers and distributors; software, solution and service providers; hospitals and health systems; and industry associations.

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Why writing by hand beats typing for thinking and learning

Jonathan Lambert

If you're like many digitally savvy Americans, it has likely been a while since you've spent much time writing by hand.

The laborious process of tracing out our thoughts, letter by letter, on the page is becoming a relic of the past in our screen-dominated world, where text messages and thumb-typed grocery lists have replaced handwritten letters and sticky notes. Electronic keyboards offer obvious efficiency benefits that have undoubtedly boosted our productivity — imagine having to write all your emails longhand.

To keep up, many schools are introducing computers as early as preschool, meaning some kids may learn the basics of typing before writing by hand.

But giving up this slower, more tactile way of expressing ourselves may come at a significant cost, according to a growing body of research that's uncovering the surprising cognitive benefits of taking pen to paper, or even stylus to iPad — for both children and adults.

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In kids, studies show that tracing out ABCs, as opposed to typing them, leads to better and longer-lasting recognition and understanding of letters. Writing by hand also improves memory and recall of words, laying down the foundations of literacy and learning. In adults, taking notes by hand during a lecture, instead of typing, can lead to better conceptual understanding of material.

"There's actually some very important things going on during the embodied experience of writing by hand," says Ramesh Balasubramaniam , a neuroscientist at the University of California, Merced. "It has important cognitive benefits."

While those benefits have long been recognized by some (for instance, many authors, including Jennifer Egan and Neil Gaiman , draft their stories by hand to stoke creativity), scientists have only recently started investigating why writing by hand has these effects.

A slew of recent brain imaging research suggests handwriting's power stems from the relative complexity of the process and how it forces different brain systems to work together to reproduce the shapes of letters in our heads onto the page.

Your brain on handwriting

Both handwriting and typing involve moving our hands and fingers to create words on a page. But handwriting, it turns out, requires a lot more fine-tuned coordination between the motor and visual systems. This seems to more deeply engage the brain in ways that support learning.

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"Handwriting is probably among the most complex motor skills that the brain is capable of," says Marieke Longcamp , a cognitive neuroscientist at Aix-Marseille Université.

Gripping a pen nimbly enough to write is a complicated task, as it requires your brain to continuously monitor the pressure that each finger exerts on the pen. Then, your motor system has to delicately modify that pressure to re-create each letter of the words in your head on the page.

"Your fingers have to each do something different to produce a recognizable letter," says Sophia Vinci-Booher , an educational neuroscientist at Vanderbilt University. Adding to the complexity, your visual system must continuously process that letter as it's formed. With each stroke, your brain compares the unfolding script with mental models of the letters and words, making adjustments to fingers in real time to create the letters' shapes, says Vinci-Booher.

That's not true for typing.

To type "tap" your fingers don't have to trace out the form of the letters — they just make three relatively simple and uniform movements. In comparison, it takes a lot more brainpower, as well as cross-talk between brain areas, to write than type.

Recent brain imaging studies bolster this idea. A study published in January found that when students write by hand, brain areas involved in motor and visual information processing " sync up " with areas crucial to memory formation, firing at frequencies associated with learning.

"We don't see that [synchronized activity] in typewriting at all," says Audrey van der Meer , a psychologist and study co-author at the Norwegian University of Science and Technology. She suggests that writing by hand is a neurobiologically richer process and that this richness may confer some cognitive benefits.

Other experts agree. "There seems to be something fundamental about engaging your body to produce these shapes," says Robert Wiley , a cognitive psychologist at the University of North Carolina, Greensboro. "It lets you make associations between your body and what you're seeing and hearing," he says, which might give the mind more footholds for accessing a given concept or idea.

Those extra footholds are especially important for learning in kids, but they may give adults a leg up too. Wiley and others worry that ditching handwriting for typing could have serious consequences for how we all learn and think.

What might be lost as handwriting wanes

The clearest consequence of screens and keyboards replacing pen and paper might be on kids' ability to learn the building blocks of literacy — letters.

"Letter recognition in early childhood is actually one of the best predictors of later reading and math attainment," says Vinci-Booher. Her work suggests the process of learning to write letters by hand is crucial for learning to read them.

"When kids write letters, they're just messy," she says. As kids practice writing "A," each iteration is different, and that variability helps solidify their conceptual understanding of the letter.

Research suggests kids learn to recognize letters better when seeing variable handwritten examples, compared with uniform typed examples.

This helps develop areas of the brain used during reading in older children and adults, Vinci-Booher found.

"This could be one of the ways that early experiences actually translate to long-term life outcomes," she says. "These visually demanding, fine motor actions bake in neural communication patterns that are really important for learning later on."

Ditching handwriting instruction could mean that those skills don't get developed as well, which could impair kids' ability to learn down the road.

"If young children are not receiving any handwriting training, which is very good brain stimulation, then their brains simply won't reach their full potential," says van der Meer. "It's scary to think of the potential consequences."

Many states are trying to avoid these risks by mandating cursive instruction. This year, California started requiring elementary school students to learn cursive , and similar bills are moving through state legislatures in several states, including Indiana, Kentucky, South Carolina and Wisconsin. (So far, evidence suggests that it's the writing by hand that matters, not whether it's print or cursive.)

Slowing down and processing information

For adults, one of the main benefits of writing by hand is that it simply forces us to slow down.

During a meeting or lecture, it's possible to type what you're hearing verbatim. But often, "you're not actually processing that information — you're just typing in the blind," says van der Meer. "If you take notes by hand, you can't write everything down," she says.

The relative slowness of the medium forces you to process the information, writing key words or phrases and using drawing or arrows to work through ideas, she says. "You make the information your own," she says, which helps it stick in the brain.

Such connections and integration are still possible when typing, but they need to be made more intentionally. And sometimes, efficiency wins out. "When you're writing a long essay, it's obviously much more practical to use a keyboard," says van der Meer.

Still, given our long history of using our hands to mark meaning in the world, some scientists worry about the more diffuse consequences of offloading our thinking to computers.

"We're foisting a lot of our knowledge, extending our cognition, to other devices, so it's only natural that we've started using these other agents to do our writing for us," says Balasubramaniam.

It's possible that this might free up our minds to do other kinds of hard thinking, he says. Or we might be sacrificing a fundamental process that's crucial for the kinds of immersive cognitive experiences that enable us to learn and think at our full potential.

Balasubramaniam stresses, however, that we don't have to ditch digital tools to harness the power of handwriting. So far, research suggests that scribbling with a stylus on a screen activates the same brain pathways as etching ink on paper. It's the movement that counts, he says, not its final form.

Jonathan Lambert is a Washington, D.C.-based freelance journalist who covers science, health and policy.

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Social media health 'cures' are not what the doctor ordered

Many people are flocking to social media for healthcare guidance from online quacks and laypersons, research shows. a recent university of chicago study on tiktok videos regarding sinus infections is a case in point..

University of Chicago researchers found that nearly 60% of certain TikTok videos they analyzed on sinus infection contained inaccurate or misleading information. That compares to nonfactual information in 15% of videos from medical professionals.

Michael Dwyer/AP

Medicine is an imperfect science and doctors, being human, can make mistakes. But that doesn’t mean a physicians’ advice and expertise can be replaced with the musings of a social media influencer with the latest iPhone and selfie light.

Health misinformation proliferated during the height of the COVID-19 pandemic, leading to deadly consequences for some Americans who flouted scientists by opting to go maskless and not get vaccinated.

Chucking the doctor’s orders appears to be an infectious disease in itself, as more people are flocking to social media to seek guidance for ailments from online quacks and laypeople.

Case in point: TikTok videos on sinusitis, or sinus infections, created by nonmedical influencers, or those who didn’t identify themselves as medical professionals were more popular than clips posted by health experts, a recent study by two University of Chicago researched found.

Not all the content generated by medical professionals that was analyzed in a 24-hour period was perfect. Fifteen percent of their videos had nonfactual components. But nearly 60% of the more visible recordings made by people who never went to medical school contained inaccurate or misleading information, as Sun-Times reporter Mary Norkol noted.

• Garlic in your nostrils? Potatoes in your socks? Health misinformation is rampant on TikTok, Chicago researchers find

Tips like shoving garlic in a nostril to combat sinus problems and placing potatoes in a pair of socks overnight to “draw out toxins” may just elicit laughs from most viewers. And maybe the risks to people who attempt these hacks are mostly going to be smelling like they’re trying to ward off a vampire,having a bulbous plant stuck in their nose, or starchy feet. But straying away from expert medical assistance can be a slippery slope and cause serious harm if science-deniers are dealing with a serious or potentially life-threatening disease.

The statistics on the reliance on social media for health care are nothing to sneeze at.

Nearly 1 in 5 Americans trust health influencers more than medical professionals and nearly 1 in 5 Americans flock to TikTok before their doctors when seeking treatment for a health condition, a 2022 survey commissioned by discount pharmacy service CharityRx revealed.

It is OK to glance at the internet for some answers when you’re under the weather, as there is evidence-based information online. But in most cases, “there’s no substitute for seeing the doctor,” said Dr. Christopher Roxbury, one of the researchers who conducted the University of Chicago TikTok study.

Still skeptical over what the doctor suggests? There’s always a second opinion, or third, from other medical experts.

It’s not rocket science: There’s an easy cure for health misinformation, if we use common sense.

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