Abstract
The January issue of this journal focused on quality improvement. We received a large number of submissions in response to that Call for Papers, too many to publish in one issue. Consequently, this issue includes the remainder of those articles. The reader may have noted that case studies were included in both of these issues. This editorial elaborates on the organizational case study as a genre in the rhetoric of inquiry in primary care and community health research. The case study is relevant for reporting quality improvement studies (as defined in the editorial to the January issue 1 ) and also for reports about other types of practice innovations.
In addition to original research articles and pilot studies, this journal publishes case studies of community health programs, primary care services, and practice innovations in primary care organizations. Authors sometimes struggle with how to present evidence about their programs. This much is obvious: Reports should be convincing to reviewers and objective rather than biased in favor of the program studied.
Additional guidance would be helpful to both authors and reviewers. It is not my intention to present a rigid formula for how to write a case study for this journal. Our authors are scholar-practitioners. Their focus should be on what actually happened in their programs and forcing them to use methods designed by organizational psychologists for National Institutes of Health–funded studies would not be appropriate. At the same time, valid measurement and use of the reasonable designs are important.
Case studies can be quantitative, qualitative, or mixed-methods research, meaning that quantitative measures are employed but some qualitative evidence also is reviewed. Each program has objectives and those objectives can be used to measure performance. Let me offer some hypothetical examples.
An outreach program using community health workers. The authors might focus on efforts to improve nutrition. The research question is this: is the program effective in improving diets using brief advice in the context of an outreach visit? The workers are surveyed to assess whether they are offering nutritional advice and whether they think it is helpful. Discussion of the value of this activity within this type of program constitutes a contribution to general knowledge. Reviewers will consider whether the survey methods are sufficient for answering the research question. Note that the objective is to improve diets, an outcome measure not directly assessed by asking workers if they believe diets are improved. However, assessing provider judgments might be reasonable first step toward a solid analysis of actual dietary change.
A primary care clinic integrates mental health services into its practice. “Integrated behavioral health” has been suggested for many years. However, implementation has not always been successful. Possible research questions might include the followings: did integration of mental health services reduce referrals to psychiatry? Did it reduce emergency visits? Did it reduce primary care visits? Did it expedite reduction in psychiatric symptoms? Were patients satisfied with the service? A single case study probably could not address all of these questions but could be the beginning of a research program. Most of the questions could be answered by analyzing trend data extracted from medical records. As always, at least one comparison group is helpful. Trend data from the same clinic during an equivalent period prior to implementation might serve this purpose. Line charts would be ideal to show the impact of the program on performance indicators.
A retail clinic staffed by nurse practitioners is opened in a grocery store. No pretest information is possible in this situation. Let us assume that the purpose of the study is to assess the quality of care. A sample of medical records can be reviewed to measure adherence to clinical protocols for tracer conditions. Rates of adherence should be compared to benchmarks or, better yet, data obtained from standard clinics using the same data collection methods.
Authors may wonder whether studies such as those described above would not fit just as well into the original research or pilot study categories as they do in the case study category. Clearly, some studies might fit into more than one category. However, original research studies usually have larger samples. They often address more basic questions than whether a program is effective. Statistical methods employed can reach a higher level of sophistication because of the design and large sample. Findings might be more generalizable.
Case studies might be published as pilot studies. However, if the authors want to expand the description of the program and discussion of the impact of the program, then the case study category would be more appropriate. I should point out that neither of these categories is appropriate for an article that describes a new program but offers no evidence about its performance. Our reviewers and our readers want to know if the program worked and if so how well it worked.
Community health programs and clinical services in primary care require continued monitoring to assess performance and sometimes the case study format is ideal for this purpose. For a good example, see Kaboli et al’s assessment of care quality for patients who are managed both by Veterans Administration providers and private providers. 2 Kaboli et al combined retrospective analysis of medical records with information from a patient survey. The result was a convincing report that dual management did not reduce the quality of care for veterans.
Case studies may be ideal for reports about new programs and practice innovations, which always are adventures. You never know how they will turn out. Surprises are to be expected. Unexpected benefits and unanticipated problems will arise. These characteristics make case studies an interesting genre within the field of health services research. Unfortunately, few case studies of this type are published. We hope more authors will take the time to write case study reports and submit them to our journal.