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

  • Sara Paparini   ORCID: orcid.org/0000-0002-1909-2481 1 ,
  • Judith Green 2 ,
  • Chrysanthi Papoutsi 1 ,
  • Jamie Murdoch 3 ,
  • Mark Petticrew 4 ,
  • Trish Greenhalgh 1 ,
  • Benjamin Hanckel 5 &
  • Sara Shaw 1  

BMC Medicine volume  18 , Article number:  301 ( 2020 ) Cite this article

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The need for better methods for evaluation in health research has been widely recognised. The ‘complexity turn’ has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research—currently denigrated as poor evidence—is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The challenges in exploiting evidence from case study research

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

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

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

Acknowledging plurality and developing guidance

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

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

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

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

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

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Abbreviations

Qualitative comparative analysis

Quasi-experimental design

Randomised controlled trial

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

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

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This chapter reviews the strengths and limitations of case study as a research method in social sciences. It provides an account of an evidence base to justify why a case study is best suitable for some research questions and why not for some other research questions. Case study designing around the research context, defining the structure and modality, conducting the study, collecting the data through triangulation mode, analysing the data, and interpreting the data and theory building at the end give a holistic view of it. In addition, the chapter also focuses on the types of case study and when and where to use case study as a research method in social science research.

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Case Control Studies

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A case-control study is a type of observational study commonly used to look at factors associated with diseases or outcomes. The case-control study starts with a group of cases, which are the individuals who have the outcome of interest. The researcher then tries to construct a second group of individuals called the controls, who are similar to the case individuals but do not have the outcome of interest. The researcher then looks at historical factors to identify if some exposure(s) is/are found more commonly in the cases than the controls. If the exposure is found more commonly in the cases than in the controls, the researcher can hypothesize that the exposure may be linked to the outcome of interest.

For example, a researcher may want to look at the rare cancer Kaposi's sarcoma. The researcher would find a group of individuals with Kaposi's sarcoma (the cases) and compare them to a group of patients who are similar to the cases in most ways but do not have Kaposi's sarcoma (controls). The researcher could then ask about various exposures to see if any exposure is more common in those with Kaposi's sarcoma (the cases) than those without Kaposi's sarcoma (the controls). The researcher might find that those with Kaposi's sarcoma are more likely to have HIV, and thus conclude that HIV may be a risk factor for the development of Kaposi's sarcoma.

There are many advantages to case-control studies. First, the case-control approach allows for the study of rare diseases. If a disease occurs very infrequently, one would have to follow a large group of people for a long period of time to accrue enough incident cases to study. Such use of resources may be impractical, so a case-control study can be useful for identifying current cases and evaluating historical associated factors. For example, if a disease developed in 1 in 1000 people per year (0.001/year) then in ten years one would expect about 10 cases of a disease to exist in a group of 1000 people. If the disease is much rarer, say 1 in 1,000,0000 per year (0.0000001/year) this would require either having to follow 1,000,0000 people for ten years or 1000 people for 1000 years to accrue ten total cases. As it may be impractical to follow 1,000,000 for ten years or to wait 1000 years for recruitment, a case-control study allows for a more feasible approach.

Second, the case-control study design makes it possible to look at multiple risk factors at once. In the example above about Kaposi's sarcoma, the researcher could ask both the cases and controls about exposures to HIV, asbestos, smoking, lead, sunburns, aniline dye, alcohol, herpes, human papillomavirus, or any number of possible exposures to identify those most likely associated with Kaposi's sarcoma.

Case-control studies can also be very helpful when disease outbreaks occur, and potential links and exposures need to be identified. This study mechanism can be commonly seen in food-related disease outbreaks associated with contaminated products, or when rare diseases start to increase in frequency, as has been seen with measles in recent years.

Because of these advantages, case-control studies are commonly used as one of the first studies to build evidence of an association between exposure and an event or disease.

In a case-control study, the investigator can include unequal numbers of cases with controls such as 2:1 or 4:1 to increase the power of the study.

Disadvantages and Limitations

The most commonly cited disadvantage in case-control studies is the potential for recall bias. Recall bias in a case-control study is the increased likelihood that those with the outcome will recall and report exposures compared to those without the outcome. In other words, even if both groups had exactly the same exposures, the participants in the cases group may report the exposure more often than the controls do. Recall bias may lead to concluding that there are associations between exposure and disease that do not, in fact, exist. It is due to subjects' imperfect memories of past exposures. If people with Kaposi's sarcoma are asked about exposure and history (e.g., HIV, asbestos, smoking, lead, sunburn, aniline dye, alcohol, herpes, human papillomavirus), the individuals with the disease are more likely to think harder about these exposures and recall having some of the exposures that the healthy controls.

Case-control studies, due to their typically retrospective nature, can be used to establish a correlation between exposures and outcomes, but cannot establish causation . These studies simply attempt to find correlations between past events and the current state.

When designing a case-control study, the researcher must find an appropriate control group. Ideally, the case group (those with the outcome) and the control group (those without the outcome) will have almost the same characteristics, such as age, gender, overall health status, and other factors. The two groups should have similar histories and live in similar environments. If, for example, our cases of Kaposi's sarcoma came from across the country but our controls were only chosen from a small community in northern latitudes where people rarely go outside or get sunburns, asking about sunburn may not be a valid exposure to investigate. Similarly, if all of the cases of Kaposi's sarcoma were found to come from a small community outside a battery factory with high levels of lead in the environment, then controls from across the country with minimal lead exposure would not provide an appropriate control group. The investigator must put a great deal of effort into creating a proper control group to bolster the strength of the case-control study as well as enhance their ability to find true and valid potential correlations between exposures and disease states.

Similarly, the researcher must recognize the potential for failing to identify confounding variables or exposures, introducing the possibility of confounding bias, which occurs when a variable that is not being accounted for that has a relationship with both the exposure and outcome. This can cause us to accidentally be studying something we are not accounting for but that may be systematically different between the groups.

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The case study approach

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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.

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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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Sarah Crowe & Anthony Avery

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

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

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99 million people included in largest global vaccine safety study

19 February 2024

Health and medicine , Faculty of Medical and Health Sciences

The Global Vaccine Data Network, hosted at the University of Auckland, utilises vast data sets to detect potential vaccine safety signals

Global Vaccine Data Network co-director Dr Helen Petousis-Harris: Latest study uses vast data sets to ensure vaccine safety.

The Global Vaccine Data Network (GVDN) assessed 13 neurological, blood, and heart related medical conditions to see if there was a greater risk of them occurring after receiving a Covid-19 vaccine in the latest of eight studies in the Global COVID Vaccine Safety (GCoVS) Project.

Recently published in the journal Vaccine , this observed versus expected rates study included 99 million people (over 23 million person-years of follow-up) from 10 collaborator sites across eight countries. The study identified the pre-established safety signals for myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the thin sac covering the heart) after mRNA vaccines, and Guillain-Barré syndrome (muscle weakness and changed sensation (feeling)), and cerebral venous sinus thrombosis (type of blood clot in the brain) after viral vector vaccines.

Possible safety signals for transverse myelitis (inflammation of part of the spinal cord) after viral vector vaccines and acute disseminated encephalomyelitis (inflammation and swelling in the brain and spinal cord) after viral vector and mRNA vaccines were identified.

So far, these findings were further investigated by the GVDN site in Victoria, Australia. Their study and results are described in the accompanying paper. Results are available for public review on GVDN’s interactive data dashboards .

Observed versus expected analyses are used to detect potential vaccine safety signals. These studies look at all people who received a vaccine and examine if there is a greater risk for developing a medical condition in various time periods after getting a vaccine compared with a period before the vaccine became available.

Lead author Kristýna Faksová of the Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark, remarked that use of a common protocol and aggregation of the data through the GVDN makes studies like this possible. “The size of the population in this study increased the possibility of identifying rare potential vaccine safety signals,” she explains. “Single sites or regions are unlikely to have a large enough population to detect very rare signals.”

By making the data dashboards publicly available, we are able to support greater transparency, and stronger communications to the health sector and public.

Associate Professor Helen Petousis-Harris Co-Director, Global Vaccine Data Network hosted at University of Auckland

GVDN Co-Director Dr Steven Black said, “GVDN supports a coordinated global effort to assess vaccine safety and effectiveness so that vaccine questions can be addressed in a more rapid, efficient, and cost-effective manner. We have a number of studies underway to build upon our understanding of vaccines and how we understand vaccine safety using big data.”

GVDN Co-Director Dr. Helen Petousis-Harris said, “By making the data dashboards publicly available, we are able to support greater transparency, and stronger communications to the health sector and public.”

The GCoVS Project was made possible with support by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) to allow the comparison of the safety of vaccines across diverse global populations.

About the Global Data Vaccine Network

Established in 2019 and with data sourced from millions of individuals across six continents, the GVDN collaborates with renowned research institutions, policy makers, and vaccine related organisations to establish a harmonised and evidence-based approach to vaccine safety and effectiveness.

The GVDN is supported by the Global Coordinating Centre based at Auckland UniServices Ltd, a not-for-profit, stand-alone company that provides support to researchers and is wholly owned by the University of Auckland. Aiming to gain a comprehensive understanding of vaccine safety and effectiveness profiles, the GVDN strives to create a safer immunisation landscape that empowers decision making for the global community. For further information, visit globalvaccinedatanetwork.org.

Disclaimer: This news release summarises the key findings of the GVDN observed versus expected study. To view the full publication in Vaccine, visit doi.org/10.1016/j.vaccine.2024.01.100.

This project is supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totalling US$10,108,491 with 100 percent funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS, or the U.S. Government. For more information, please visit cdc.gov

Media enquiries: gvdn@auckland.ac.nz and communications@uniservices.co.nz

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The effectiveness of geothermal systems in cooling residential buildings: a case study of a residential building in Alexandria, Egypt

  • Heba Fouad   ORCID: orcid.org/0009-0006-6903-2379 1 , 2 ,
  • Ayman H. Mahmoud 1 &
  • Rania Rushdy Moussa 3  

Journal of Engineering and Applied Science volume  71 , Article number:  45 ( 2024 ) Cite this article

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The urbanization of cities, the corroding of green areas, and the increasing demand for electric energy lead to the formation of heat islands in cities and the appearance of the global climate change phenomenon.

Therefore, it was necessary to resort to the use of renewable energy sources, such as geothermal energy, to be used in different applications, as it can be used to cool buildings in cities during the summer.

This research deals with the benefits of using geothermal energy systems, their different types, and the possibility of their application in Egypt. Also discussing the effectiveness of the vertical closed geothermal system in residential buildings in Alexandria Governorate in Egypt to reach an answer to a question.

The effectiveness of the geothermal energy system in residential buildings is to reduce the problem of rising temperatures, energy consumption for cooling, and carbon emissions and thus reduce the problem of the formation of heat islands in cities and the appearance of the global climate change phenomenon and reaching a sustainable, environmentally friendly building that achieves thermal comfort for humans through the use of a simulation program called TRNSYS-17, through which the current situation of the building was compared and the addition of a vertical closed geothermal system was assumed, the extent of its effectiveness was compared in the whole building, and the cost of a vertical closed geothermal system and a traditional air conditioning system (HVAC) in a building was compared (case study).

Hence, the efficiency of the vertical closed geothermal system appeared to reduce electric energy consumption and carbon emissions in the whole building at Alexandria in Egypt, especially the ground floor, which reached thermal comfort for humans and worked to reduce electricity consumption and carbon emissions by up to 22.93% in the building as a whole.

Introduction

Most countries around the world are targeting “renewable sources” as a future governmental initiative, especially developed countries, to reduce energy consumption and carbon emissions to limit the increase in global temperatures caused by the intensity of human activity, the absence of vegetation, the abundance of impermeable surfaces in cities, and increased energy consumption for cooling and heating [ 1 ], which causes an increase in the effects of both urban heat islands in cities (UHI), global warming, and global climate change. Therefore, climate change and energy supply are considered the two biggest challenges facing the world today [ 2 ].

Since one of the main reasons for the increase in energy consumption in Middle Eastern countries is cooling buildings due to population growth, industrialization, and the hot climate, more than a third of the energy consumed in buildings is spent on cooling systems [ 3 ]. So, it was necessary to turn to renewable energy sources such as solar energy, wind energy, and geothermal energy to provide energy without depleting traditional energy sources and without any negative impact on the environment at the lowest costs.

Geothermal systems in buildings are especially characterized by their many long-term environmental and economic benefits compared to other renewable energy sources, so the use of geothermal energy systems to heat and cool buildings has been evaluated and applied in many countries, such as the USA, the UK, the Kingdom of Saudi Arabia, and India, without testing it widely in countries with tropical and subtropical climates, Middle Eastern countries, and Egypt.

Although these countries are facing many problems related to energy efficiency, there is an increasing demand for it, and there is an increase in carbon and heat gas emissions. For example, in Egypt, we notice an increase in the rate of electrical energy consumption to cool buildings, which is responsible for 26% of the total consumption of electrical energy in buildings and 62% of the total consumption of electricity in cities [ 4 ].

However, renewable energy sources have not been sufficiently exploited, and only a few researchers have been interested in exploiting it in cooling buildings in this country.

Also, the use of geothermal energy in heating commercial buildings was investigated, and the environmental and economic efficiency of it was studied, but no attention was paid to residential buildings, although it is considered the second most important human need and is considered one of the most energy-consuming and carbon-emitting sectors in cities [ 5 ]. They also contribute to forming the largest part of the city’s area. The amount of carbon emissions resulting from it is large compared to the rest of the sectors.

Hence, the research aims to study the effectiveness of applying thermal energy systems to cool residential buildings in Egypt, evaluate it environmentally and economically, and propose it as a practical solution. It contributes to solving environmental problems resulting from climate change, heat islands, and increasing energy consumption for cooling in residential buildings by evaluating the effectiveness of the vertical closed geothermal system and determining its impact on reducing electrical energy consumption, reducing carbon emissions, and achieving thermal comfort for humans to ensure its efficiency in reducing the island effect and thermal insulation in residential buildings in Egypt.

This is done by selecting an existing residential building in Egypt, analyzing its current situation using the simulation program TRNSYS-17 and comparing the current situation with the assumption of adding a vertical closed geothermal system to the building in order to determine which is more efficient in reducing electric energy consumption, reducing carbon emissions, and accessing the thermal comfort of the person in the building and to determine if this system is useful and economical for its use in Egypt or if it is necessary to resort to other better solutions. Then, it evaluates its role in reducing the negative effects of heat islands and climate change on the Egyptian residential environment.

Geothermal systems in buildings

There are many geothermal systems that can be applied to heat and cool buildings, which differ from each other in design, implementation method, drilling method, pipe thickness, etc., so they can be divided into two different categories: surface geothermal systems with open loops and surface geothermal systems with closed loops (vertical, horizontal, submerged in a pond or lake, with geothermal substrates) [ 6 ], which is considered the most common system because it is the easiest and cheapest ground loop to install [ 6 ]. There is a new system that was issued recently, and it is a combination of renewable energy and geothermal energy and is considered one of the most efficient systems [ 7 ], as shown in Table  1 .

Benefits of using surface geothermal systems in buildings

According to previous studies, the use of geothermal systems in buildings provides many benefits at all environmental, economic, health, psychological, social, and esthetic levels that accrue to the user, the city, and thus the world as a whole [ 8 ]. It saves energy and reduces pollution. In Table  2 , there is a brief explanation of those benefits and their impact on all levels [ 9 ].

Therefore, the research will study the effectiveness of this system and its application in Egypt to benefit from these environmental, health, and economic benefits by identifying the potential of geothermal energy in Egypt and applying one of its systems there.

The potential of geothermal energy in Egypt

As a result of many studies and analyses that were carried out in Egypt by many researchers, the various geothermal energy resources in it were evaluated through the analysis based on geographic information systems for many places and the analysis of the geothermal characteristics of the Bahariya Oasis, the Western Desert, and the study of geothermal energy around the Red Sea. In addition, the Gulf of Suez uses magnetic methods [ 6 ].

Egypt appeared to have a relatively low estimated content of about 251 billion US dollars, consisting of 15 hot springs and 52 thermal wells located along the Gulf of Suez, the Red Sea, and the Western Desert, which differ from each other in surface temperatures ranging between 23 and 71 °C in hot springs and 35 and 50 °C in thermal wells, as shown in Fig.  1 .

figure 1

Heat content classification of geothermal energy resources in Egypt. Source: A discussion on the potential use of shallow geothermal energy for cooling in Egypt, 2019

Volumetric estimates through the HYDROTHERM model showed that the reservoir with a temperature of 170 °C and a depth of more than 1 km could generate 28.34 MW of electrical energy.

The entire Sinai over a period of 35 years [ 15 ] and temperature distributions of 90–180 °C were determined at a depth of 2–3 km with a preference for the use of open system or closed system submerged geothermal energy along the Gulf of Suez and the Red Sea [ 16 ].

This indicates the possibility of exploiting it for energy generation. For example, in the Bath of Pharaoh (Gulf of Suez), the deep temperature in it can be exploited in energy generation (over approximately 30 years of production) based on the results that indicate that the temperature in a thermal reservoir with a depth of 500 m is 130 °C; then, it can be classified, as shown in Fig.  1 .

Hence, the geothermal energy resources in Egypt can be classified as shown in Table  3 .

A study of the possibility of exploiting geothermal energy in buildings in Egypt

Average ground temperatures in Egypt range from 15° to 25° at a depth ranging between 20 and 50 m, and they can be used either for direct cooling or to reduce the use of electric air conditioning units used in commercial and domestic buildings [ 18 ].

Recently, a new trend has appeared at the governmental and commercial levels to use geothermal energy to solve the growing problem of air conditioning in buildings in cities because of the following:

Reduces electricity consumption for air conditioners as it consumes approximately 100 MWh per 1 °C when the atmosphere temperature rises above 35 °C [ 19 ]

It limits the heat waves in the summer, especially the long ones, such as those in Alexandria, where millions of people need air conditioning, thus forming a large urban heat island in it [ 17 ]

Reduces pollution and improves air quality in the heat islands, where geothermal air conditioning can provide electricity better and more efficiently in Alexandria while reducing the burning of fossil fuels

Since Egypt is the most populated country in the Middle East and has relatively low reserves of oil and gas, it provides an opportunity to invest in renewable energy, especially in the production of geothermal energy, and since the majority of the country’s energy is consumed by industries (47%) and buildings (20%).

Therefore, geothermal energy is an alternative energy option for Egypt. Moreover, there is a large land area (94% of desert land).

Some countries will explore geothermal energy resources as an alternative source of energy in the future, so we must think in an innovative way to develop an environmentally friendly building that reduces energy consumption, reduces heat islands, faces global warming and climate change, and limits the depletion of non-renewable energy sources by using geothermal energy in buildings. This is in order to reach a sustainable building that achieves thermal comfort for humans, through many data sets, studies, and analyses, as shown in Fig.  2 .

figure 2

Shows the data, studies and analyzes that must be considered to achieve the maximum benefit from geothermal energy systems to achieve thermal comfort in buildings

These applications still require qualified people and technologies in the fields of geothermal energy investigation, design of power generation, cooling and heating systems in buildings, management of geothermal energy projects, monitoring systems that will be allocated to the Egyptian market, raising awareness in society, and decision-making about geothermal resources.

The population density in Egypt is concentrated on the banks of the Nile, especially in Cairo and the Delta, which makes these areas more energy-consuming and carbon-emitting.

Therefore, it is preferable to use a vertical closed geothermal system due to the lack of sufficient spaces to establish horizontal thermal energy systems and the lack of energy reservoirs in all regions. So, I will choose a vertical closed-loop geothermal system on the North Coast for application in this study.

The methodology is a simulation tool to study the effectiveness of applying thermal energy systems to cool residential buildings in Egypt, with the purpose of evaluating it environmentally and economically and determining its effect on reducing electrical energy consumption, reducing carbon emissions, and achieving human thermal comfort and, at the lowest cost, ensure its efficiency in reducing the island effect in Alexandria, Egypt.

The methodology used in this research was explained and clarified, and the stages that the research went through were identified, as shown in Table  4 , and in it, the vertical closed geothermal system was chosen to be used in this study because it is considered the most effective and cheapest system among all geothermal systems, as shown in Fig.  3 . It consists of a traditional distribution system inside the building, a ground heat pump, and vertical closed ground loops, as shown in Fig.  4 , and the TRNSYS-17 software as a simulation was chosen to be used in this study to measure the thermal loads and electricity consumption inside the case study.

figure 3

The geothermal system add to building. Source: SKETCH UP-2014 program

figure 4

The type of geothermal system chosen. Source: SKETCH UP-2014 program

The first stage (experimental stage)

In this study, the study area was selected, the building geometry of the current situation was determined, and the building (study case) was drawn on a program SKETCH UP-2014 program. What happened at this stage can be explained by the following points.

Choose a case study area

According to previous studies and analyses in terms of population [ 20 ] and energy consumption [ 21 ] for each governorate, as shown in Figs.  5 and 6 , Alexandria, Egypt, was chosen as a study area because it is considered one of the most populous governorates in Egypt with population density and electricity consumption, and it has a relatively low percentage of green spaces and is more attractive to the population at the level of the rest of the governorates.

figure 5

Shows the population of each governorate of the Arab Republic of Egypt. Source: The Central Agency for Public Mobilization and Statistics in Egypt, 2023

figure 6

Shows the consumption of electricity kilowatt-hours/mon Building geometry. Source: Ministry of Electricity and Energy website, calculate consumption in February 2021

Therefore, it is one of the most appropriate governorates to determine the impact of geothermal energy systems on the formation of heat islands in cities and human thermal comfort.

The building geometry of the current situation was determined

A traditional, two-story residential building located in the fifth settlement in Cairo, Egypt, was chosen randomly to be simulated in this research as shown in Fig.  7 . The design of the building is shown in Fig.  8 .

figure 7

The case study design

figure 8

The case study design and components

The building consists of a ground floor, a first floor, and a roof. It accommodates a large family consisting of six members and two workers, as shown in Fig.  6 and described in Table  5 . This building, like most of the buildings located in Cairo, has an HVAC system used to cool the building during the hot seasons, which almost takes place between March and October.

The second stage (monitoring stage)

At this stage, data and information about the case study are collected, the modeling parameters for the current situation and the VCGS system are determined, and they are set in the program TRNSYS-17, to determine and analyze the current status of the building and when adding a geothermal system to each floor in terms of a thermal analysis of the current situation and its thermal loads.

Case study simulation

The TRNSYS-17 software was used as a simulation tool in this research to measure the cooling load inside the building before and after using the vertical closed geothermal system. A series of simulations were conducted to capture the effect of the vertical closed geothermal system on the building’s heat, energy consumption, and carbon emissions reduction during the year, especially during the peak period.

A 3D model for the case study was built as a primary stage using the Sketch Up software, as shown in Fig.  9 . This model was imported into the TRNSYS software for simulation.

figure 9

The case study modeling on Sketch Up software

Modeling parameters

There were some parameters taken into consideration during the modeling process that affected the simulation results. All the modeling parameters were summarized and presented in Tables  6 , 7 and 8 .

There are many factors affecting the internal thermal loads of the building, such as users, indoor lighting, and the heat gain from operating equipment and devices; these factors contributed to the increases in the thermal loads inside the indoor spaces. According to the ASHRAE Guide [ 22 ], which is presented in Table  9 , the thermal loads were calculated in terms of occupancy, lighting features, and electronic devices.

Taking into consideration the thermostat set point for the HVAC system, it is assumed to be 24 °C for optimal cooling, with an acceptable range of 23–26 °C.

The parameters set for VCGS system

The piping of a vertical closed geothermal system has been excavated and designed, as shown in Table  10 .

Calculation model

Temperatures and thermal loads in the current situation in the building were calculated using the TRNSYS-17 software, as shown in Figs. 10 and 11 .

figure 10

Thermal loads in the current situation in the building

figure 11

Climatic analysis of the building

The third stage (analysis stage)

At this stage, study the results and analyze the difference between the current situation and when adding the vertical closed geothermal system in terms of temperature difference, electricity consumption, carbon emissions, and the cost of purchasing and installing the closed geothermal system. This is to know the efficiency of the system and the possibility of implementation.

The results presented in this study were divided into four stages. It can be presented in the following ways:

The first stage presents the amount of heat loss after installing the vertical closed geothermal system in a residential building located in a hot, arid environment

The second stage measures the amount of energy loss from using the vertical closed geothermal system in Alexandria, Egypt

The third stage is to calculate the amount of carbon emission reduction from using the proposed system

Final stage: calculate the difference in economics when purchasing and installing each system

The first stage: the difference in temperatures between the current situation and after installing a vertical closed geothermal system

The research found that the temperature decreased by 36.5 °C in the current situation and became 31.7 °C when adding a vertical closed geothermal system during the peak period.

The temperature decreased by 3.6 °C in September, 4.2 °C in August, 4.6 °C in July, and 4.6 °C in May, as shown in Fig.  12 .

figure 12

The difference in temperatures before and after installing a vertical closed geothermal system in the building

The second stage: the difference of electrical energy consumption for cooling of floors between the current situation and when adding a vertical closed geothermal system

The research found that electrical energy consumption decreased by 7136.13 kwh in the current situation and became 5739.12 kwh when adding a vertical closed geothermal system during the peak period (summer), as shown in Fig.  13 .

figure 13

The difference between the current situation and when adding a vertical closed geothermal system in terms of electrical energy consumption

Then, we concluded that a vertical closed geothermal system helped reduce the electrical energy consumption for cooling by 22.93% during the peak period, as shown in Fig.  14 .

figure 14

The total percentage decrease in the electrical energy consumption for cooling the building during the peak period when a vertical closed geothermal system is added

The third stage is the difference between the current situation and adding a vertical closed geothermal system in terms of carbon emissions in floors

The research found that carbon emissions decreased by 5308.6 kg in the current situation and became 4269.3 kg when adding a vertical closed geothermal system during the peak period (summer), as shown in Fig.  15 .

figure 15

The difference between the current situation and when adding a vertical closed geothermal system in terms of carbon emissions

Then, we concluded that a vertical closed geothermal system helped reduce the carbon emissions for cooling by 22.93% during the peak period, as shown in Fig.  16 .

figure 16

Total building carbon emissions reduction during peak period when a closed vertical geothermal loop system is added

Final stage: the difference between the cost of a vertical closed geothermal system and a traditional air conditioning system (HVAC) in a building (case study)

Costs of establishing the traditional HVAC system in the residential building were calculated. In this case study, a comparison was made between the cost of a vertical closed geothermal system, as shown in Table  11 , and a traditional air conditioning system (HVAC), as shown in Table  12 , in a building (case study).

By calculating the cost of establishing a vertical closed geothermal system, which amounted to 159,879.758 EGP, and comparing it with the cost of establishing a traditional air conditioning system (HVAC) in a building (case study), which amounted to 190,230 EGP, as shown in Table 11 , it can be concluded that the cost of purchasing and implementing a vertical closed-loop geothermal system is relatively less expensive than the cost of a traditional cooling system.

The study costs were estimated according to the capacity of adaptations required on each floor of the building, as shown in Table  13 , so that the total costs of purchase and installation are 190,230 EGP, by calculating the cost of establishing a vertical closed geothermal system, which amounted to 159,879.758 EGP, and comparing it with the cost of establishing a traditional air conditioning system (HVAC) in a building (case study), which amounted to 190,230 EGP.

The process of construction and operation consumes a lot of energy, causing the depletion of fossil fuels and increasing the percentage of carbon emissions and greenhouse gasses. Consequently, the general characteristics of local climate change and heat islands are formed that cause the emergence of the phenomenon of global climate change, which negatively affects the environment and achieves thermal comfort for humans. Thus, there is a constant need for energy consumption to absorb the negative effects resulting from climate change and heat islands, so we must resort to using renewable energies such as solar energy, geothermal energy, and wind energy to reduce the burden on the state in terms of environmental pollution and achieve comfort in providing thermal energy for humans as well as rationalizing electricity consumption in buildings.

Geothermal systems can be divided into an open system in which the main cooling loop either adds or extracts heat, and the secondary loop transports natural water from another source to the heat exchanger to supply thermal energy. There must be sufficient distance between the supply pipes for the discharged water to regain efficiency thermally [ 25 ] and a closed system that can be horizontal, vertical, pond, or lake [ 26 ].

Geothermal cooling and heating are environmentally friendly and significantly reduce CO 2 emissions [ 27 ]. The integrated system can reduce CO 2 emissions by more than 7 kg per square meter. Therefore, the integrated system can make full use of shallow geothermal energy to build an energy-efficient HVAC system [ 28 ].

Replacing a conventional electric cooling system with a geothermal system achieves a 26% energy reduction in an apartment building in Memphis, Tennessee, by combining the microscopic properties of the earth [ 27 ].

The greatest focus by researchers on the subject of geothermal energy and its systems was on utilizing it in heating buildings, and there were a few researchers who were interested in using it in cooling buildings, so its benefits must remain applicable in other locations. If knowledge of geothermal systems spreads to the extent of solar panels, many will benefit on a small scale. There are hybrid systems used for heating and cooling that are more efficient than traditional geothermal systems, although geothermal energy does not suffer from any problems when operating compared to other renewable sources.

A study was conducted on the role of geothermal energy in heating commercial buildings and a study of its environmental and economic efficiency, but no attention was given to residential buildings, even though it is considered the second most important human need and is considered one of the sectors that consume the most energy in cities at a rate of 74%, as it accounts for nearly half of electrical energy consumption. In Egypt [ 6 ], it is also the sector with the most carbon emissions in cities at 50% because it contributes to forming the largest part of the city’s area [ 29 ], so the amount of carbon emissions resulting from it is large compared to the rest of the sectors that emit large amounts of carbon. Geothermal energy systems were also evaluated in the USA, Britain, Saudi Arabia, and India, but not Egypt.

Therefore, this research worked to study the effectiveness of geothermal energy systems in cooling residential buildings in Egypt, to complete the study on the role of geothermal energy and its systems in cooling residential buildings in Egypt, to evaluate its role environmentally and economically, and to propose it as a practical solution that contributes to containing environmental problems resulting from climate change and heat islands and increasing energy consumption for cooling in residential buildings.

As the research found that geothermal systems in buildings work to reduce temperatures, electrical energy consumption for cooling, and carbon emissions, which brings the user to thermal comfort inside the residential building at the lowest costs, then it can be proven that the closed vertical geothermal loop system is considered more efficient than traditional HVAC systems in terms of initial costs, and it also works to reduce the electrical energy used for cooling when operating and the temperature of the building.

Therefore, it is considered an effective and clean system that must be circulated in Egypt to benefit from its environmental and economic benefits.

So, if geothermal energy is exploited to cool residential buildings, we will take a step forward in reducing the burden on the state in terms of improving air quality, reducing greenhouse gas emissions, reducing energy demand globally, and knowing whether this system is beneficial for use in Egypt or not. Other, better solutions must be resorted to.

Conclusions

According to the above statements, we note the effect of a vertical closed geothermal system on reducing the temperature of the ground floor significantly, which led to reaching thermal comfort for humans in that floor, but in the first floor, because of the exposure of a large part of its surface to the sun and external heat, the percentage was lower, as well as the floor of the roof due to the exposure of all its surface to the sun and external heat, so the difference was small, but it is less than the traditional cooling system, and this resulted in a decrease in the amount of electrical energy consumption for cooling at a noticeable rate in the ground and first floors and thus led to a reduction in carbon emissions, which works to reduce the effect of heat island and thus reduce the effect of global warming and climate change.

Hence, the vertical closed geothermal system can be concluded as one of the effective solutions that works to reduce the effect of heat islands in residential buildings in Alex, Egypt, and contributes to reducing environmental problems (global warming and climate change).

The main objective of this research is to shed light on and raise awareness in Egyptian society and decision-making circles about the need to apply renewable energy systems, especially geothermal energy systems, to take advantage of Its environmental and economic benefits and exploit them in cooling by thinking in an innovative way by limiting consumption of fossil fuels and rising energy prices and consumption, rising temperatures, and carbon emissions, especially in the summer, in order to limit the formation of heat islands in cities and thus limit global climate change by applying geothermal energy systems in general and the vertical closed geothermal system in particular because they are safe, clean systems on the environment with installation and maintenance costs with a long life span.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Heating, ventilation, and air conditioning

  • Vertical closed geothermal system

Urban heat islands

  • Climate change
  • Global warming
  • Renewable energy

Kilowatt-hours/month

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All authors contributed to the study conception and design [Eng. Heba, Prof. Ayman, and Associate Prof. R.R.Moussa]. Data collection, simulation process, and analysis were performed by Eng. Heba. The first draft of the manuscript was written by Eng. Heba and Associate Prof. R.R.Moussa, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Fouad, H., Mahmoud, A.H. & Moussa, R.R. The effectiveness of geothermal systems in cooling residential buildings: a case study of a residential building in Alexandria, Egypt. J. Eng. Appl. Sci. 71 , 45 (2024). https://doi.org/10.1186/s44147-024-00378-x

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Larry A Broussard, Commentary on Calcium Kidney Stone Patient with Normocalcemia, The Journal of Applied Laboratory Medicine , 2024;, jfad136, https://doi.org/10.1093/jalm/jfad136

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This case study describes the workup, diagnosis, and successful treatment of a patient with a calcium kidney stone and a serum calcium concentration within the reference range. The investigation of the origin of the calcium stone included endocrine testing with the combination of low serum 25-OH vitamin D and elevated parathyroid hormone (PTH) levels indicating secondary hyperparathyroidism. After treatment with 25-OH vitamin D3, the 25-OH vitamin D levels increased but remained below the reference range lower limit and the PTH remained elevated. The calcium level now indicated hypercalcemia and the patient’s test results now matched the criteria for primary hyperparathyroidism (PHPT). The masking of the hypercalcemia by the secondary hyperparathyroidism complicated the initial diagnosis. Hyperparathyroidism was confirmed by scintigraphic confirmation of enlargement of the upper left parathyroid and surgical removal of this gland resulted in normal PTH and calcium concentrations.

Normocalcemic PHPT as seen in this case was first formally recognized in 2008 and the lack of consistency in diagnostic criteria still exists. In general, the diagnosis can be made with the combination of multiple occasions (at least 3 months apart) of elevated PTH levels with consistently normal total and ionized serum calcium. As mentioned in the case study and in an excellent review by Cusano and Cetani ( 1 ), the diagnosis of normocalcemic PHPT is a diagnosis of exclusion once secondary causes have been eliminated. The disease is relatively rare with an apparent prevalence of less than 1% but more epidemiological studies are needed to determine an accurate occurrence rate.

This case serves to remind us of the complexity of interpreting laboratory results when there is a possibility of multiple conditions. The systematic investigation of the cause of the kidney stone illustrates the role of the laboratory as part of the healthcare team.

Author Contributions:   The corresponding author takes full responsibility that all authors on this publication have met the following required criteria of eligibility for authorship: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; (c) final approval of the published article; and (d) agreement to be accountable for all aspects of the article thus ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved. Nobody who qualifies for authorship has been omitted from the list.

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Research Funding: None declared.

Disclosures: L.A. Broussard is Associate Editor for The Journal of Applied Laboratory Medicine .

Cusano   NE , Cetani   F . Normocalcemic primary hyperparathyroidism . Arch Endocrinol Metab   2022 ; 66 : 666 – 77 .

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A key study in the case against the FDA’s abortion pill approval at the Supreme Court has been retracted from an academic journal and its authors say the move is an "unprovoked and partisan assault" on scientific research.  

On March 26, the Supreme Court will hear arguments in a case challenging access to the abortion pill and the U.S. Food and Drug Administration’s regulatory approval process. The FDA made several moves, intending to make it easier to access and use the mifepristone pill in the wake of the overturning of Roe v. Wade last year. 

Legal arguments against FDA’s push have cited a study published in 2021 which found that the rate of abortion-related emergency room visits following a chemical abortion increased over 500% from 2002 through 2015, according to an analysis of Medicaid claims data. That study was published by Sage Publishing, an academic publishing company. 

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The author of the emergency room study, Dr. Jim Studnicki, is the vice president of data analytics for the Charlotte Lozier Institute (CLI), who was trained at Johns Hopkins University. He has a 50-year career conducting scientific research and has 70 peer-reviewed studies indexed in PubMed.

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CLI is a non-profit research arm of the Susan B. Anthony Pro Life America group – one of the most successful pro-life advocacy groups in the country. CLI says they are a network of over 70 associate scholars who are "credentialed experts in medicine, statistical analysis, sociology, science, bioethics, public health, law, and social services for women and families." 

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CLI also said that "the affiliations of all authors are documented in the paper. In addition, a bio sketch for each author is included with the paper. Funding support for the research from CLI is also disclosed."

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CLI notes in its response that part of the COPE [Committee on Publication Ethics] definition of conflict of interest describes "those which may not be fully apparent, and which may influence the judgment of author, reviewers, and editors" and "which, when revealed later, would make a reasonable reader feel misled or deceived."

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"Most importantly, it is excellent science, and the methods and findings are unchallenged. We respectfully ask that you not allow ideologically motivated and unsubstantiated ‘concerns’ to damage the reputation of this work and its authors," they said.

Four months later, with very little communication in the meantime, Sage notified CLI they were retracting the three studies.

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But lawyers representing CLI told the publishing firm that "the allegations raised in support of retraction are not only procedurally flawed but meritless, and Sage’s actions are unlawful."

MISSOURI ATTORNEY GENERAL SUES BIDEN ADMIN FOR APPROVING THE SHIPMENT OF CHEMICAL ABORTION PILLS IN THE MAIL

"Your decision also reflects a regrettable pattern of using scientific publications as a sword against unpopular findings—regardless of their objectivity. This further undermines the public’s confidence in scientific bodies and does a disservice to your mission to ‘advance knowledge,’" CLI’s lawyer David A. Shaneyfelt wrote in a letter to Sage in November. 

"Our clients have spent their careers building credibility and engaging in objective scientific discovery. Your decision to retract their articles, your recurring breach of confidentiality, and your blatant breach of contract have already done palpable damage to their reputation," Shaneyfelt wrote. 

He also alleged that the timing of the retraction was "concerning," considering the studies’ connection to the Supreme Court case Alliance for Hippocratic Medicine v. FDA.

Dr. Studnicki said in a statement to Fox News Digital, "I think Dobbs really accelerated this, there’s a sense of desperation among those in the abortion industry. They’ve always had the literature to themselves. All of the major health associations are pro-abortion, most of the journals are pro-abortion, all the academic departments in the universities are pro-abortion." 

"It’s profoundly sad to me what is going on in science today. I’m at a point in my life, at 80 years old, where they won’t damage me," he said. "But what if I was a mid-career faculty member or someone aiming for tenure or trying to raise a family? Right now, the science industry’s message appears to be - ‘if we can do this to Dr. Studnicki, who’s had a 50-year career without blemish, imagine what we can do to you.’" 

Tessa Longbons, a senior research associate for CLI, said, "this incident points to a larger, newer phenomenon, which is that many of our scientific institutions and publications no longer stand in defense of open inquiry."

"Rather, we’re seeing a biased elite faction across the medical community with all the power attempting to suppress any research that cuts against their approved, pro-abortion narrative," she said. 

"Scientific research and publication should be grounded in science, not driven by ideology," she added. 

The authors of the study told Fox News Digital they will be taking appropriate legal action. 

Original article source: Key study in FDA abortion pill case at the Supreme Court was retracted in 'partisan assault' authors say

Mifepristone, also known as RU-486, is a medication typically used in combination with misoprostol to bring about a medical abortion during pregnancy and manage early miscarriage. Getty Images

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A Case Study of Using Telehealth in a Rural Healthcare Facility to Expand Services and Protect the Health and Safety of Patients and Staff

This case study aimed to gain an understanding of the implementation and usage of a telehealth program during the COVID-19 pandemic at a rural healthcare facility. An action research methodology, utilizing cycles of planning, implementation, review and adaptation was adopted to improve use of telehealth as COVID-19 cases continued to increase. Data was collected from literature review, examination of existing documents, review of gap and SWOT analysis, and examination of staffing plans. This helped in ensuring that adequate resources were in place to start and continue usage of telehealth. Additionally, review of the entire process was conducted as the program advanced through various phases of implementation. By conducting rigorous analysis and reflection, these data informed cycles of improvement in the telehealth program. Challenges surrounding the continuation and usage of telehealth have also been described. Because there is a paucity of research on the use of telehealth programs in rural healthcare facilities, especially during the pandemic, this study can provide practical tips to leaders and healthcare managers.

1. Introduction

Telehealth includes a broad array of services that facilitate delivery of medical consultation, patient education, health information services, and other related services via use of digital technologies. Technologies utilized in telehealth include but are not limited to video conferencing, health apps, mobile health, and other methods that promote patient monitoring from remote locations if needed. It is noteworthy that telehealth allows patients in rural settings to gain access to medical providers at larger facilities. These services can be used to address issues associated with physician shortages and access to specialty care in rural and remote locations [ 1 ]. A recent study suggested that 95% of patients who received medical consultation via telehealth were highly satisfied with the quality of care, ease of access, timeliness, and ability to integrate technology in their plan of care [ 2 ].

The COVID-19 Public Health Emergency was declared on 13 March 2020. For many healthcare facilities this meant limiting face-to-face services to protect the health and safety of patients, caregivers, and staff. According to the Center for Disease Control and Prevention [ 3 ], one major benefit of telehealth is maintaining continuity of care while avoiding the negative consequences of delayed preventive, chronic, or routine care. It has been reported that people living in rural areas are at increased risk of premature deaths due to chronic illness, stroke, and unintentional injury. Telehealth can serve as an effective method for providing care especially when medical professionals are able to monitor a patients’ condition, such as lung disease, from remote locations. This can lead to reductions in hospital admissions and even deaths in some cases [ 3 ]. Evidence suggests that there is a rise in the demand for telehealth services after COVID-19 hit. Compared to previous years, the usage in the month of October 2021 increased by 3.060% [ 4 ]. However, there is an increasing recognition that lack of adequate infrastructure, minimal or no training of health professionals, and restrictions on payment to many healthcare facilities for such services proved problematic. These barriers could lead to discontinuation of active telehealth programs. With the rise in COVID-19 cases around the world, it is important to examine new and on-going telehealth programs in rural facilities especially in areas where there are limited resources to address an outbreak. This action research project presents a case of a rural health facility located in northern Minnesota, where telehealth was implemented to provide care to patients during the pandemic. When the public health emergency was declared, the facility limited services to urgent and emergent care only and moved pharmacy dispensing outdoors. It was quickly realized that this model of care would not be sustainable for an extended period of time. Every discussion pointed to a telehealth program. Several factors surrounding implementation and continuation of the program have been discussed.

Background and Rationale

Telemedicine refers to remote clinical services including clinical care, administrative services and ongoing/continuing medical education via use of technology. Telehealth can be defined as use of technology and electronic information to provide and enhance provision of health services, education, patient care, and health administration [ 5 ]. With an aging population, issues related to mobility and transportation can create obstacles for in-person hospital visits. Usage of telemedicine and advanced technologies including information processing, sensing, and artificial intelligence can help in providing support to individuals in their homes [ 6 ]. Additionally, timely access to information needed to make medical decisions, evidence based medicine and use of digital technologies and big data analytics can be help in managing health conditions of patients who suffer from two or more diseases and chronic health conditions [ 7 ].

Evidence suggests that telemedicine and telehealth programs can enhance patients’ access to care, help administrators manage scarce resources, support continuation in care and thereby reduce risk of transmission of coronavirus. Given rapid increases in the number of cases, many health centers have expanded telehealth visits. Approximately 95% of health centers reported that such visits were conducted during the pandemic [ 8 ]. A recent study conducted by Panicacci et al. (2021) presented a case of existing telemedicine system that was updated with new features to monitor and provide care to high risk COVID patients in their homes. This approach was extremely successful and led to a reduction in (or no) hospitalization, deaths, and positive feedback from patients and practitioners [ 9 ].

Utilizing telehealth during the pandemic can lead to long-term benefits for individuals who live in rural areas. This includes subspecialty services for patients who could not travel to urban locations to receive treatment. Research also suggests that usage of telemedicine enables effective management of care. Further, expansion of such services may have significant benefits for patients who seek mental health services. This in turn could benefit rural communities in cases such as deaths due to suicide, alcohol and drugs [ 10 ].

Data reported by the Center for Disease Control (CDC) and Health Resources and Services Administration (HRSA) clearly indicates a rapid decline in the usage of telehealth across health centers. For instance, during the week ending 26 June 2020, these visits declined to 35.8%. Further, a decrease of approximately 25% was reported when usage reports were examined in November 2020. It is important to note that health centers in the south and in rural areas reported the lowest usage of telehealth services over the period of 20 weeks when compared to urban areas. As COVID cases continue to increase, it is imperative to expand these services to limit exposure to the virus [ 8 ]. Telehealth programs can be successfully implemented in rural and remote locations, however, appropriate infrastructure issues such as reimbursement methods, access to internet, and licensure requirements still need attention [ 10 ]. Using action research methodology, this case study aimed to gain an understanding of the implementation and utilization of a telehealth program at a rural facility. By examining a variety of data sources, this project helps in building a greater understanding of the real world implementation of a telehealth program and challenges faced by leaders as they work on adoption of new processes/approaches in a rural health facility.

Due to the benefits associated with telehealth in rural locations, efforts must be made to examine implementation, usage, and reasons behind the increase in or declining use of telehealth in healthcare facilities. Dissemination of the findings from this research could help management and senior leaders as they work on implementing and/or expanding these services at their facilities.

2. Materials and Methods

This project was conducted using action research and action learning methods. Action learning is a method where individuals charged with real tasks work collaboratively to complete those activities in real conditions. Together, the entire team is exposed to challenges as they carry out real responsibilities. Once, an element of data collection and monitoring is added to the process, action research takes place. It is important to note that this monitoring aids in enhancing overall understanding of the process and generation of new knowledge, which is applicable in real life scenarios. Both action research and action learning build confidence in the new knowledge that is being generated and the outcomes of real world projects [ 11 , 12 ].

2.1. Study Site

This project was completed at White Earth Health Center (WEHC), an Indian Health Service (IHS) facility located in rural northern Minnesota in the United States of America. The facility provides ambulatory care services to approximately 10,000 American Indians and Alaska Natives annually. Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing health services to roughly 2.6 million American Indians and Alaska Natives who are part of 574 federally recognized Tribes [ 13 ].

2.2. Phases of Project/Research

This action research project was completed in three phases (highlighted below):

2.2.1. Phase I—Strengths Weaknesses Opportunities Threats (SWOT) Analysis

Phase I of this project involved a thorough SWOT analysis by the organizational leaders. A SWOT analysis examines and evaluates internal strengths and weaknesses and external opportunities and threats in an organization’s environment. This analysis allows stakeholders to identify and understand means/assets, competencies and skill set, advantages the organization has, and how organizational leaders could utilize these resources to enhance competitiveness of its’ services. On the other hand, thorough analysis of external threats and opportunities allows organizational leaders to plan and expand their operations strategically based on market needs [ 14 ]. Organizational leaders utilized SWOT analysis to understand opportunities and strengths of telehealth as they worked with clinicians to prepare for challenges posed by rising COVID-19 cases.

2.2.2. Phase II—Gap Analysis and Creation of Staffing Plan and Implementation Plan

Organizational leaders conducted a gap analysis to assess the current state of telehealth utilization and how clinicians utilized telehealth to conduct patients’ visits. For the purpose of this project, gaps were defined as those occurrences in which WEHC resources, support mechanisms and procedures confirmed a difference when compared to the national evidence base [ 15 ]. This approach allowed WEHC to develop an efficient and integrated approach to delivering care that increases value for the patient population.

2.2.3. Phase III—Ongoing Examination of Telemedicine Usage

To enhance participation and maintain the momentum for usage of telehealth services, it is extremely important to continuously examine the current process and develop change ideas that may be implemented in the care delivery process. This was also carried out at WEHC, and helped organizational leaders see the reasons behind declining usage when comparing the current state of usage against national trends seen throughout the US.

3.1. Results of Phase I

The SWOT analysis that follows was created to identify areas within the telehealth program that could be addressed to improve utilization. The literature has made it clear that the primary strength of telehealth is safety for both the patients and providers. A telehealth program would also allow for continuity of care and expanded services. There are also a number of opportunities to grow the program, however, weaknesses and threats can prevent the program from being successful (see Table 1 ; see Figure 1 ).

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SWOT Analysis.

Reflection on these findings suggested that it was important to address lack of training and buy in from staff needed to conduct telemedicine visits. Telehealth can be a great mitigation strategy for COVID-19. However, more efforts were needed to direct staff to convert visits suitable for telehealth to telehealth and implement scheduled telework/telehealth on a regular basis (see Figure 1 ).

Once CMS issued 1135 waivers allowing IHS to collect revenue from telehealth visits a number of trainings were released to bring providers up to speed with offering the service. During this time frame, the medical staff were seeing very few patients so they were able to dedicate time to learning about telehealth services. The clinical applications coordinator built electronic health record (EHR) templates for the providers to use for their visits and also provided training on telehealth visit requirements. The physician lead for the telehealth program found a great continuing education piece from the American College of Physicians on incorporating telehealth into practice. Once the staff received more training on this piece, they were able to make clinical decisions without physically examining patients. Once the medical staff became more confident in the telehealth visits an audio visual component was incorporated using Cisco meeting. This service also required some staff training, demonstrations on use, and collaboration with nursing to connect patients to their provider through this service. The nursing staff played a vital role in sending patients connection information and directions to join Cisco meeting. They also made the initial call to patients for the meeting to perform screening prior to the provider joining the call.

Many of the staff were reluctant to provide telehealth on site as it seemed like more of an inconvenience for patients and themselves. When a staff member traveled internationally and had to quarantine upon return they provided telehealth from home. Their positive experiences providing telehealth from home created buy in with the other medical staff, bringing them on board with providing telehealth services. Having the option to work from home also gained provider buy in. The ability to work from home allowed many of the providers an alternate work schedule as they no longer had lengthy drives to the clinic.

Telehealth provided WEHC with opportunities to offer services in new ways. The CMS 1135 waivers allowed health care facilities to provide the service across state lines. This was beneficial because many of the consultative services WEHC patients received were located in North Dakota (ND). When patients needed services outside of what WEHC could offer they had to travel to urban locations in the state of ND. These patients were now able to receive these consultations for specialty services on site. This was essential to patients who needed cardiology or oncology consults, but were unable to easily get to urban locations.

Audio visual visits were the preferred method of telehealth for revenue generation purposes, but it was quickly realized that the internet connectivity on the reservation could not maintain connections for these visits. The CMS 1135 waivers allowed payment for services offered by phone, so telephone visits quickly became the preferred method of telehealth. To ensure medical staff privacy, google voice was used as opposed to using their actual phone numbers. If patients needed to share photos of something they could do so through text if they felt comfortable. If this method wasn’t reasonable the providers would either complete a home visit, or coordinate any in-person needs through the Tribal Home Health Nursing program.

The most significant threat to WEHC’s telehealth program is the potential discontinuation of the CMS 1135 waivers. The waivers are temporary and end no later than the termination of the pandemic, or 60 days from the date the waiver or modification is made unless the health and human services secretary extends it for periods of up to 60 days until the end of the pandemic [ 16 ]. By the end of May 2020, Medicare was reviewing their waivers and the data associated with them to consider making some of them permanent. The extension of expanded telehealth benefits under Medicare would please many providers, who have increased their use during the pandemic. Telehealth has provided another avenue for patients to receive medical services. While telehealth cannot replace in-person visits completely, it is a good alternative to meet patient needs. No longer offering the service could be detrimental to some patients and services.

3.2. Results of Phase II

To better identify gaps in the current telehealth program, the team focused on two goals/objectives. Overall, the identified gap is that telehealth services were available and could be expanded, but they were not being utilized to the fullest extent possible (see Figure 2 ).

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3.2.1. Gap Analysis and Creation of Implementation Plan

This project intended to provide 25 percent of total primary care visits via telehealth by 1 November 2020. Several pieces of literature that were reviewed discussed how telehealth can provide access to care and continuity of care while keeping both the patients and healthcare providers safe. White Earth Health Center did not have a telehealth program prior to the pandemic due to limitations imposed by CMS. When the program was implemented at the end of March 2020, it slowly gained use. By early April, WEHC had developed and adopted a telehealth policy, developed and implemented EHR templates, and trained all medical staff on telehealth requirements. The telehealth program was launched. It slowly gained speed as it helped WEHC meet patient needs without coming to the clinic. By August, it was not uncommon to see 10 percent or less of primary care visits being completed using telehealth. The gap identified was the lack of telehealth visits taking place. The actions taken to close this gap were to direct staff to move visits that could be completed via telehealth to telehealth and develop a provider schedule that is more conducive to telehealth activity (see Table 2 ).

Gap Analysis.

3.2.2. Review of Staffing Plan

Another primary objective of this project was to develop a schedule where 2–4 providers worked from home providing telehealth on a rotating basis. At the time, all providers were working on site, including those that provide telehealth. Some healthcare providers had moved to providing telehealth from home as a result of needing to quarantine [ 17 ]. While providers were in quarantine in mid-September, there was a notable increase in telehealth visits that had not been seen before (see Figure 3 ). This generated the idea of trialing a weekly rotating telework schedule to improve telehealth utilization. If the provider was not on site, there was no way for them to do anything other than telehealth. This also gave the healthcare facility the ability to place quarantined providers on telework if they were otherwise well.

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Telehealth Utilization.

3.3. Results of Phase III

Ongoing review of medical visits indicated that in the early months of the pandemic, WEHC limited all services to urgent and emergent care only. The facility was seeing very few patients as people were afraid to come in unless they absolutely had to. Collections plummeted. WEHC did not have a telehealth program prior to the pandemic as Medicaid only paid IHS for face-to-face encounters. Medicaid is the largest portion of WEHC’s payer mix, so it was not fiscally responsible to offer a service WEHC could not be reimbursed for. IHS is prohibited from billing patients for services. Continuous review of literature and existing processes at WEHC revealed that when CMS announced the 1135 waivers, IHS was able to collect the face-to-face encounter rate by phone and other telehealth options, the race was on to rapidly implement a telehealth program. As the months passed, it was found that COVID was having very little impact on the area. There was feedback from the staff that many patients were becoming concerned about the lack of well-care taking place. Many patients were overdue for lab work, mammograms, and physicals. Area hospitals had resumed surgeries, which required pre-operative clearance for many WEHC patients. The limitations on services were decreased while continuing to offer telehealth as a primary option. By the end of summer, little to no telehealth visits were taking place (see Figure 3 ). This phenomenon also aligned with what was found during the literature review. There was a spike in telehealth in the spring and by fall the numbers decreased. Despite many discussions and other communications to staff, telehealth was not being used. WEHC leadership agreed that allowing the medical providers to telework would only give them the option to provide telehealth. This would also help maintain staff in the case there was a COVID outbreak in the clinic. The staff on telework would be well and able to come to work (see Figure 4 ). The telework schedule for medical staff was implemented during the week of 1 October 2020.

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4. Discussion and Important Considerations

Prior to the COVID-19 Public Health Emergency, WEHC did not have a telehealth program. This was due to Medicaid restrictions that only allow IHS to bill for outpatient encounters when they are face-to-face visits. An encounter for an IHS facility, as defined by Minnesota Department of Health (MDH), is a face-to-face visit between a member eligible for Medical Assistance (MA) and any health professional at an IHS facility within a 24-h period ending at midnight. Since Medicaid comprises approximately 40 percent of WEHC’s third party payer mix, it was not fiscally responsible to limit collections by providing telehealth services regardless of reimbursement. WEHC receives only 27 percent of their funding through federal appropriations and the remainder of the funding comes by way of third party collections. All outpatient services at IHS facilities are at no cost to the patient. Effective 19 March 2020 for the Indian Health Service, telemedicine services, including telephonic, were included for the purpose of the face-to-face encounter payment methodology [ 17 ]. This meant that the Minnesota Department of Health (MDH) would reimburse IHS for telemedicine services of all types, which is vital to telehealth sustainability at WEHC [ 18 ].

The state of Minnesota was able to change their payment methodology due to the issuance of 1135 waivers. According to CMS (2017), when the president declares a disaster or emergency and the secretary of Health and Human Services (HHS) declares a public health emergency, the HHS secretary is authorized to temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements to ensure sufficient health care items and services meet the needs of those affected by the emergency. Many of the waivers fall under section 1135 of the Social Security Act giving these waivers their name. CMS added equal coverage of audio only telehealth visits and 135 other allowable services as a result of these waivers. This more than doubled the number of services beneficiaries could receive via telehealth [ 19 ]. These flexibilities and allowances led to a surge in the number of beneficiaries getting telemedicine services. Before the public health emergency, approximately 13,000 beneficiaries received telemedicine in a week. As of April, nearly 1.7 million beneficiaries received telehealth services, and in total, over 9 million beneficiaries have received a telehealth service during the public health emergency [ 19 ]. Other changes made by Medicare include offering telehealth services to patients located in their homes and outside of designated rural areas, and reimbursement of telehealth visits in lieu of many in-person appointments. Furthermore, ability to communicate with patients across state lines, opportunity to see both new and established patients, and being able to conduct telephone visits helped in enhancing telemedicine services [ 20 ].

Payment for telehealth services was not the only barrier WEHC was facing. The facility is also in a very rural location and is considered an isolated hardship area due to its proximity to major hospitals. People who live in rural areas are more likely than urban residents to die prematurely from the five leading causes of death: heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke. Telehealth is just one approach to reduce barriers to care for those living rurally. Strategies that use cell phones have shown to be more helpful in providing services to these patients as more than 90 percent of rural residents own cell phones [ 3 ]. Unfortunately, telehealth options that rely on high-speed internet connections are not as helpful. Only about 60 percent of residents living in rural or Tribal areas have high-speed internet access, compared to over 95 percent of urban residents [ 3 ]. High-speed internet is commonly needed for audio video services.

Medicare beneficiaries represent a significant portion of the patient population at WEHC that experience disparities in digital access. More than 41 percent of Medicare patients lack access to a computer with high-speed internet connection at home, almost 41 percent do not have a smartphone with a wireless data plan, and more than 26 percent do not have access to either [ 21 ]. Evidence of telehealth un-readiness and inequities showed that those who were over 85, widowed, had a high school education or less, were Black or Hispanic, received Medicaid, or had a disability had even less digital access than other beneficiaries [ 21 ]. It was evident that federal telemedicine policy has focused on reimbursement and clinician ability to deliver care remotely and very little on disparities in digital access in order for patients to receive that care. The authors recommended expanding programs that provide reduced-cost phones or internet service to families with incomes 135 percent or more below the federal poverty level [ 21 ].

To summarize, WEHC quickly adopted a telehealth program near the end of March 2020 with utilization peaking by the end of April 2020. Due to the rural location of the health center, cases of COVID-19 remained low and telehealth usage declined starting in May and throughout the summer. An all-time low of 3% was experienced by the end of August with many patients returning on site for face-to-face visits. Literature from The Commonwealth Fund showed that the changes WEHC was experiencing were happening across the nation. By early April, in-person visits to ambulatory care practices had declined by nearly 60 percent. By mid-May, there was a rebound in the number of visits, but they were still about one-third lower than what was seen before the pandemic [ 22 ]. They also determined that as in-person visits dropped, telehealth visits increased rapidly before plateauing [ 22 ].

5. Facilitators and Challenges—Lessons for Healthcare Leaders

Leaders at WEHC adopted several strategies for increasing telehealth uptake. These include promoting and optimizing the use of telehealth services for safety purposes, communicating with payers to understand covered services, using tele-triage methods for assessing and caring for patients to decrease the number of people seeking in-person services, and providing outreach to patients with limited technology and connectivity. While WEHC was doing these things, there was still a decline in telehealth utilization. The medical staff were providing telehealth from the clinic, as opposed to their homes. As a result of healthcare staff needing to quarantine, WEHC noted an increase in telehealth visits. This led to the idea of incorporating regular telework into the staffing schedule to increase telehealth utilization. The section below highlights various facilitators and barriers that could help in adoption of telehealth programs.

5.1. Creating Buy-In

One of the key steps in implementing and continuing a telehealth program was to gain the buy-in of the medical staff early on for a rotating telework schedule to provide telehealth. Administrators in this project, as evident by documents, were able to develop and implement a 30 min telehealth appointment schedule and assign one provider to telework/telehealth on a rotating weekly basis. This grew to two providers as infection rates were on the rise. One objective was to accomplish the goal for two to four providers on telework at a time by hiring up to three contract physicians. This has been a difficult process compounded by COVID-19 and the northern Minnesota climate. Additional efforts for contracting physicians and clinical staff are needed to meet demands and increase utilization.

5.2. Communication

Communication with the team members, patients, and caregivers is important to enhance adoption of telehealth services. Similar to change initiatives, communication is central for ongoing usage of services. This communication needs to be between physicians, administrators, and amongst staff of various departments. Research suggests that if one fails to listen to others in an organization or in a different department, they will be limited in adoption of new practices [ 23 , 24 ]. This was illustrated in this study where open communication regarding telehealth programs helped in safe and effective patient care process. However, as time passed, the facility returned to usual in-person appointments for patients.

5.3. Financial Considerations

Financial considerations are extremely important so leaders and facilities can invest in additional telehealth equipment to facilitate connection with the specialists at specialty/subspecialty healthcare facilities located in urban areas. For the overall telehealth program, the CMS 1135 waiver that added equal coverage of audio only telehealth visits and subsequent adoption of the same by Minnesota Medicaid made it possible for WEHC to be reimbursed for nontraditional telehealth services. Had this change not been made, there would have been significant financial impacts to third party reimbursement for the organization. Inability to get reimbursed for audio only visits from both Medicaid and Medicare prior to the CMS 1135 waivers has proved detrimental for the success of telehealth programs. Due to poor internet connectivity in remote areas of the reservation, audio only visits became the most feasible form of telehealth. Before telehealth utilization started, WEHC was averaging about 10 primary care visits a day among 12 providers. Now, the facility has 60 to 70 primary care visits a day among 8 providers.

5.4. Evaluation

Leaders need to continuously monitor telehealth utilization rates to ensure there is on-going usage and no changes are needed. Change in utilization rate is a common evaluation method that was used for this project and will continue to be used in the future. For instance, key individuals leading the project communicated to staff about improving the utilization of telehealth. Daily monitoring of schedules allowed leaders to see if these visits were increasing or declining. When little to no change was noted a directive came from the top leadership that telehealth utilization must be a primary consideration. Ongoing monitoring and continuous communication helped in achieving the desired goal for the visits. Further, as next steps, leaders need to explore reasons behind low adoption of telehealth and then work on creating a plan to enhance participation in such programs.

5.5. Challenges for Leaders

There are significant concerns in the healthcare community about the state of telehealth once the pandemic ends. The 1135 waivers are only valid during the public health emergency. How do we take something away when the community has become used to having more options? There are already groups advocating to adopt the 1135 waivers moving forward. The value of telehealth must be communicated to the state, CMS, and Congress to ensure the 1135 waivers are adopted. Recruiting and maintaining the workforce is another big challenge in rural and tribal healthcare facilities. For instance, due to high turnover of physicians and clinical staff, administrators were faced with additional challenges in recruitment due to the COVID-19 pandemic. From April to December 2020, WEHC had three physicians and one nurse practitioner leave the organization for new positions. Failure to recruit and onboard staff led to problems as the telehealth program unfolded.

6. Limitations

This project presents a case study of a rural healthcare facility where a telehealth program was implemented during the COVID-19 pandemic. While several findings and lessons may still hold true, results may not be applicable to other healthcare facilities, especially in urban locations. Recommendations for future studies would be to attempt to include additional facilities and compare the findings with facilities in more urban locations.

7. Conclusions

COVID-19 has had a huge impact on rural facilities. While telehealth services will not substitute for every clinical visit to a doctor’s office, it is also important to note that these services have the possibility of being an important alternate. This project allowed us to gain an understanding of how a telehealth program was implemented and to gain insights into how usage of these services changed over a period of time. Operations changed significantly and at times they need to be adjusted daily. High turnover or retirement of essential staff since the start of the pandemic can put tremendous strain on the remaining staff. Recruiting new staff can be extremely difficult in rural facilities. Getting people to take interest in a rural area is challenging, but when candidates are from areas of milder weather that are less affected by COVID-19 it is hard to provide enough incentives to get them to join the team. Work in regard to telehealth will be ongoing. Efforts are needed to educate the community about what advantages telehealth can offer. These findings can help healthcare leaders as they plan on implementing such programs in their facilities.

Acknowledgments

Maria Clark, Paul Kleinschmidt.

Author Contributions

Conceptualization, J.A. and J.S.; Methodology, J.A. and J.S.; Validation, J.A. and J.S.; Formal Analysis, J.A. and J.S.; Investigation, J.A. and J.S.; Data curation, J.A.; Writing—J.A. and J.S.; Writing—review and editing J.A. and J.S.; Visualization, J.A. and J.S.; Supervision, J.A. and J.S.; Project administration, J.A. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

IRB approval is not applicable for this study as data was not collected on human participants.

Informed Consent Statement

Not Applicable.

Conflicts of Interest

No conflict of Interest to Disclose.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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COMMENTS

  1. Case Study Methodology of Qualitative Research: Key Attributes and

    Introduction A case study is one of the most extensively used strategies of qualitative social research. Over the years, its application has expanded by leaps and bounds, and is now being employed in several disciplines of social science such as sociology, management, anthropology, psychology and others.

  2. Distinguishing case study as a research method from case reports as a

    Another type of study categorized as a case report is an "N of 1" study or single-subject clinical trial, which considers an individual patient as the sole unit of observation in a study investigating the efficacy or side effect profiles of different interventions.

  3. The case study approach

    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 ].

  4. Continuing to enhance the quality of case study methodology in health

    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 contex...

  5. (PDF) The case study as a type of qualitative research

    The case study as a type of qualitative research March 2013 Authors: A. Biba Rebolj Solution Focused Possibilities Abstract This article presents the case study as a type of...

  6. Case study research for better evaluations of complex interventions

    Published: 10 November 2020 Case study research for better evaluations of complex interventions: rationale and challenges Sara Paparini, Judith Green, Chrysanthi Papoutsi, Jamie Murdoch, Mark Petticrew, Trish Greenhalgh, Benjamin Hanckel & Sara Shaw BMC Medicine 18, Article number: 301 ( 2020 ) Cite this article 16k Accesses 35 Citations

  7. Case Study

    The definitions of case study evolved over a period of time. Case study is defined as "a systematic inquiry into an event or a set of related events which aims to describe and explain the phenomenon of interest" (Bromley, 1990).Stoecker defined a case study as an "intensive research in which interpretations are given based on observable concrete interconnections between actual properties ...

  8. Methodology or method? A critical review of qualitative case study reports

    Current methodological issues in qualitative case study research. The future of qualitative research will be influenced and constructed by the way research is conducted, and by what is reviewed and published in academic journals (Morse, Citation 2011).If case study research is to further develop as a principal qualitative methodological approach, and make a valued contribution to the field of ...

  9. Case study research

    This article describes case study research for nursing and healthcare practice. Case study research offers the researcher an approach by which a phenomenon can be investigated from multiple perspectives within a bounded context, allowing the researcher to provide a 'thick' description of the phenomenon.

  10. What Is a Case Study?

    Step 1: Select a case Step 2: Build a theoretical framework Step 3: Collect your data Step 4: Describe and analyze the case Other interesting articles When to do a case study A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject.

  11. Google Scholar

    Google Scholar provides a simple way to broadly search for scholarly literature. Search across a wide variety of disciplines and sources: articles, theses, books, abstracts and court opinions.

  12. Full article: A Case Study of the Implementation of Restorative Justice

    17,091 Views 2 CrossRef citations to date 0 Altmetric Listen Article A Case Study of the Implementation of Restorative Justice in a Middle School Jo Lauren Weaver & Jacqueline M. Swank Pages 1-9 | Published online: 19 Mar 2020 Cite this article https://doi.org/10.1080/19404476.2020.1733912 In this article Full Article Figures & data References

  13. Case study research for better evaluations of complex interventions

    We argue that case study research—currently denigrated as poor evidence—is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear. Main body

  14. Case Control Studies

    A case-control study is a type of observational study commonly used to look at factors associated with diseases or outcomes. The case-control study starts with a group of cases, which are the individuals who have the outcome of interest. The researcher then tries to construct a second group of individuals called the controls, who are similar to ...

  15. The case study approach

    The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. ... Article Google Scholar Pinnock H, Huby G, Powell A, Kielmann T, Price D ...

  16. Where and How Health Care Happens

    A case study in this issue examines the impact of at-home care. In "Rural Access to the Cancer Hospital at Home Care Model," Bridget Nicholson, PhD, APRN, of University of Utah Health and associates at the Huntsman Cancer Institute report that their program to provide acute and subacute care at home to rural patients being treated for cancer substantially reduced emergency department use ...

  17. 99 million people included in largest global vaccine safety study

    About the Global Data Vaccine Network. Established in 2019 and with data sourced from millions of individuals across six continents, the GVDN collaborates with renowned research institutions, policy makers, and vaccine related organisations to establish a harmonised and evidence-based approach to vaccine safety and effectiveness.

  18. The effectiveness of geothermal systems in cooling residential

    As a result of many studies and analyses that were carried out in Egypt by many researchers, the various geothermal energy resources in it were evaluated through the analysis based on geographic information systems for many places and the analysis of the geothermal characteristics of the Bahariya Oasis, the Western Desert, and the study of geothermal energy around the Red Sea.

  19. Case Study Analysis as an Effective Teaching Strategy: Perceptions of

    Background: Case study analysis is an active, problem-based, student-centered, teacher-facilitated teaching strategy preferred in undergraduate programs as they help the students in developing critical thinking skills.Objective: It determined the effectiveness of case study analysis as an effective teacher-facilitated strategy in an undergraduate nursing program.

  20. Shallow Synthesis of Knowledge in GPT-Generated Texts: A Case Study in

    Numerous AI-assisted scholarly applications have been developed to aid different stages of the research process. We present an analysis of AI-assisted scholarly writing generated with ScholaCite, a tool we built that is designed for organizing literature and composing Related Work sections for academic papers. Our evaluation method focuses on the analysis of citation graphs to assess the ...

  21. Commentary on Calcium Kidney Stone Patient with Normocalcemia

    This case study describes the workup, diagnosis, and successful treatment of a patient with a calcium kidney stone and a serum calcium concentration within the reference range. The investigation of the origin of the calcium stone included endocrine testing with the combination of low serum 25-OH vitamin D and elevated parathyroid hormone (PTH ...

  22. Key study in FDA abortion pill case at the Supreme Court was ...

    A key study in the case against the FDA's abortion pill approval at the Supreme Court has been retracted from an academic journal and its authors say the move is an "unprovoked and partisan ...

  23. A Case Study of Using Telehealth in a Rural Healthcare Facility to

    This case study aimed to gain an understanding of the implementation and usage of a telehealth program during the COVID-19 pandemic at a rural healthcare facility. An action research methodology, utilizing cycles of planning, implementation, review and adaptation was adopted to improve use of telehealth as COVID-19 cases continued to increase.