difference of case study and research

Case Study vs. Research

What's the difference.

Case study and research are both methods used in academic and professional settings to gather information and gain insights. However, they differ in their approach and purpose. A case study is an in-depth analysis of a specific individual, group, or situation, aiming to understand the unique characteristics and dynamics involved. It often involves qualitative data collection methods such as interviews, observations, and document analysis. On the other hand, research is a systematic investigation conducted to generate new knowledge or validate existing theories. It typically involves a larger sample size and employs quantitative data collection methods such as surveys, experiments, or statistical analysis. While case studies provide detailed and context-specific information, research aims to generalize findings to a broader population.

Further Detail

Introduction.

When it comes to conducting studies and gathering information, researchers have various methods at their disposal. Two commonly used approaches are case study and research. While both methods aim to explore and understand a particular subject, they differ in their approach, scope, and the type of data they collect. In this article, we will delve into the attributes of case study and research, highlighting their similarities and differences.

A case study is an in-depth analysis of a specific individual, group, event, or phenomenon. It involves a detailed examination of a particular case to gain insights into its unique characteristics, context, and dynamics. Case studies often employ multiple sources of data, such as interviews, observations, and documents, to provide a comprehensive understanding of the subject under investigation.

One of the key attributes of a case study is its focus on a specific case, which allows researchers to explore complex and nuanced aspects of the subject. By examining a single case in detail, researchers can uncover rich and detailed information that may not be possible with broader research methods. Case studies are particularly useful when studying rare or unique phenomena, as they provide an opportunity to deeply analyze and understand them.

Furthermore, case studies often employ qualitative research methods, emphasizing the collection of non-numerical data. This qualitative approach allows researchers to capture the subjective experiences, perspectives, and motivations of the individuals or groups involved in the case. By using open-ended interviews and observations, researchers can gather rich and detailed data that provides a holistic view of the subject.

However, it is important to note that case studies have limitations. Due to their focus on a specific case, the findings may not be easily generalized to a larger population or context. The small sample size and unique characteristics of the case may limit the generalizability of the results. Additionally, the subjective nature of qualitative data collection in case studies may introduce bias or interpretation challenges.

Research, on the other hand, is a systematic investigation aimed at discovering new knowledge or validating existing theories. It involves the collection, analysis, and interpretation of data to answer research questions or test hypotheses. Research can be conducted using various methods, including surveys, experiments, and statistical analysis, depending on the nature of the study.

One of the primary attributes of research is its emphasis on generating generalizable knowledge. By using representative samples and statistical techniques, researchers aim to draw conclusions that can be applied to a larger population or context. This allows for the identification of patterns, trends, and relationships that can inform theories, policies, or practices.

Research often employs quantitative methods, focusing on the collection of numerical data that can be analyzed using statistical techniques. Surveys, experiments, and statistical analysis allow researchers to measure variables, establish correlations, and test hypotheses. This objective approach provides a level of objectivity and replicability that is crucial for scientific inquiry.

However, research also has its limitations. The focus on generalizability may sometimes sacrifice the depth and richness of understanding that case studies offer. The reliance on quantitative data may overlook important qualitative aspects of the subject, such as individual experiences or contextual factors. Additionally, the controlled nature of research settings may not fully capture the complexity and dynamics of real-world situations.

Similarities

Despite their differences, case studies and research share some common attributes. Both methods aim to gather information and generate knowledge about a particular subject. They require careful planning, data collection, analysis, and interpretation. Both case studies and research contribute to the advancement of knowledge in their respective fields.

Furthermore, both case studies and research can be used in various disciplines, including social sciences, psychology, business, and healthcare. They provide valuable insights and contribute to evidence-based decision-making. Whether it is understanding the impact of a new treatment, exploring consumer behavior, or investigating social phenomena, both case studies and research play a crucial role in expanding our understanding of the world.

In conclusion, case study and research are two distinct yet valuable approaches to studying and understanding a subject. Case studies offer an in-depth analysis of a specific case, providing rich and detailed information that may not be possible with broader research methods. On the other hand, research aims to generate generalizable knowledge by using representative samples and quantitative methods. While case studies emphasize qualitative data collection, research focuses on quantitative analysis. Both methods have their strengths and limitations, and their choice depends on the research objectives, scope, and context. By utilizing the appropriate method, researchers can gain valuable insights and contribute to the advancement of knowledge in their respective fields.

Comparisons may contain inaccurate information about people, places, or facts. Please report any issues.

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

Whatever field you're in, ATLAS.ti puts your data to work for you

Download a free trial of ATLAS.ti to turn your data into insights.

Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

Ready to jumpstart your research with ATLAS.ti?

Conceptualize your research project with our intuitive data analysis interface. Download a free trial today.

Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

Ready to analyze your data with ATLAS.ti?

See how our intuitive software can draw key insights from your data with a free trial today.

• Privacy Policy

Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

You may also like

Questionnaire – Definition, Types, and Examples

Observational Research – Methods and Guide

Quantitative Research – Methods, Types and...

Qualitative Research Methods

Explanatory Research – Types, Methods, Guide

Survey Research – Types, Methods, Examples

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, automatically generate references for free.

• Knowledge Base
• Methodology
• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

Published on 5 May 2022 by Shona McCombes . Revised on 30 January 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organisation, 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 analyse the case.

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.

Prevent plagiarism, run a free check.

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

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.

If you find yourself aiming to simultaneously investigate and solve an issue, consider conducting action research . As its name suggests, action research conducts research and takes action at the same time, and is highly iterative and flexible. 

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

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 .

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

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 analyse 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.

Cite this Scribbr article

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

McCombes, S. (2023, January 30). Case Study | Definition, Examples & Methods. Scribbr. Retrieved 14 May 2024, from https://www.scribbr.co.uk/research-methods/case-studies/

Is this article helpful?

Shona McCombes

Other students also liked, correlational research | guide, design & examples, a quick guide to experimental design | 5 steps & examples, descriptive research design | definition, methods & examples.

Home » Education » Difference Between Action Research and Case Study

Difference Between Action Research and Case Study

Main difference – action research vs case study.

Research is the careful study of a given field or problem in order to discover new facts or principles. Action research and case study are two types of research, which are mainly used in the field of social sciences and humanities. The main difference between action research and case study is their purpose; an action research study aims to solve an immediate problem whereas a case study aims to provide an in-depth analysis of a situation or case over a long period of time.

1. What is Action Research?      – Definition, Features, Purpose, Process

2. What is Case Study?      – Definition, Features, Purpose, Process

What is Action Research

Action research is a type of a research study that is initiated to solve an immediate problem. It may involve a variety of analytical, investigative and evaluative research methods designed to diagnose and solve problems. It has been defined as “a disciplined process of inquiry conducted by and for those taking the action. The primary reason for engaging in action research is to assist the “actor” in improving and/or refining his or her actions” (Sagor, 2000). This type of research is typically used in the field of education. Action research studies are generally conductors by educators, who also act as participants.

Here, an individual researcher or a group of researchers identify a problem, examine its causes and try to arrive at a solution to the problem. The action research process is as follows.

Action Research Process

• Identify a problem to research
• Clarify theories
• Identify research questions
• Collect data on the problem
• Organise, analyse, and interpret the data
• Create a plan to address the problem
• Implement the above-mentioned plan
• Evaluate the results of the actions taken

The above process will keep repeating. Action research is also known as cycle of inquiry or cycle of action since it follows a specific process that is repeated over time.

What is a Case Study

A case study is basically an in-depth examination of a particular event, situation or an individual. It is a type of research that is designed to explore and understand complex issues; however, it involves detailed contextual analysis of only a limited number of events or situations. It has been defined as “an empirical inquiry that investigates a contemporary phenomenon within its real-life context; when the boundaries between phenomenon and context are not clearly evident; and in which multiple sources of evidence are used.” (Yin, 1984)

Case studies are used in a variety of fields, but fields like sociology and education seem to use them the most. They can be used to probe into community-based problems such as illiteracy, unemployment, poverty, and drug addiction. 

Case studies involve both quantitative and qualitative data and allow the researchers to see beyond statistical results and understand human conditions. Furthermore, case studies can be classified into three categories, known as exploratory, descriptive and explanatory case studies.

However, case studies are also criticised since the study of a limited number of events or cases cannot easily establish generality or reliability of the findings. The process of a case study is generally as follows:

Case Study Process

• Identifying and defining the research questions
• Selecting the cases and deciding techniques for data collection and analysis
• Collecting data in the field
• Evaluating and analysing the data
• Preparing the report

Action Research : Action research is a type of a research study that is initiated to solve an immediate problem.

Case Study : Case study is an in-depth analysis of a particular event or case over a long period of time.                         

Action Research : Action research involves solving a problem.

Case Study : Case studies involve observing and analysing a situation.

Action Research : Action research studies are mainly used in the field of education.

Case Study : Case studies are used in many fields; they can be specially used with community problems such as unemployment, poverty, etc.

Action Research : Action research always involve providing a solution to a problem.

Case Study : Case studies do not provide a solution to a problem.

Participants

Action Research : Researchers can also act as participants of the research.

Case Study : Researchers generally don’t take part in the research study.

Zainal, Zaidah.  Case study as a research method . N.p.: n.p., 7 June 2007. PDF.

 Soy, Susan K. (1997).  The case study as a research method . Unpublished paper, University of Texas at Austin.

Sagor, Richard.  Guiding school improvement with action research . Ascd, 2000.

Image Courtesy: Pixabay

About the Author: Hasa

Hasanthi is a seasoned content writer and editor with over 8 years of experience. Armed with a BA degree in English and a knack for digital marketing, she explores her passions for literature, history, culture, and food through her engaging and informative writing.

​You May Also Like These

Leave a reply cancel reply.

Organizing Your Social Sciences Research Assignments

• Annotated Bibliography
• Analyzing a Scholarly Journal Article
• Group Presentations
• Dealing with Nervousness
• Using Visual Aids
• Grading Someone Else's Paper
• Types of Structured Group Activities
• Group Project Survival Skills
• Leading a Class Discussion
• Multiple Book Review Essay
• Reviewing Collected Works
• Writing a Case Analysis Paper
• Writing a Case Study
• About Informed Consent
• Writing Field Notes
• Writing a Policy Memo
• Writing a Reflective Paper
• Writing a Research Proposal
• Generative AI and Writing
• Acknowledgments

A case study research paper examines a person, place, event, condition, phenomenon, or other type of subject of analysis in order to extrapolate  key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with greater clarity. A case study research paper usually examines a single subject of analysis, but case study papers can also be designed as a comparative investigation that shows relationships between two or more subjects. The methods used to study a case can rest within a quantitative, qualitative, or mixed-method investigative paradigm.

Case Studies. Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

How to Approach Writing a Case Study Research Paper

General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in the Organizing Your Social Sciences Research Paper writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

• The case represents an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
• The case provides important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
• The case challenges and offers a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in current practice. A case study analysis may offer an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
• The case provides an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings so as to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
• The case offers a new direction in future research? A case study can be used as a tool for an exploratory investigation that highlights the need for further research about the problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of east central Africa. A case study of how women contribute to saving water in a rural village of Uganda can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community. This example of a case study could also point to the need for scholars to build new theoretical frameworks around the topic [e.g., applying feminist theories of work and family to the issue of water conservation].

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work.

In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

• What is being studied? Describe the research problem and describe the subject of analysis [the case] you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
• Why is this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
• What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
• How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

• Place relevant works in the context of their contribution to understanding the case study being investigated . This would involve summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
• Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to investigate the research problem and the underlying research questions.
• Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your use of a case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
• Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
• Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
• Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
• Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in relation to explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular case [i.e., subject of analysis] and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that constitutes your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; and, c) what were the consequences of the event in relation to the research problem.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experiences they have had that provide an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of their experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using them as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem [e.g., why is one politician in a particular local election used to show an increase in voter turnout from any other candidate running in the election]. Note that these issues apply to a specific group of people used as a case study unit of analysis [e.g., a classroom of students].

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, historical, cultural, economic, political], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, explain why you are studying Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research suggests Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut off? How might knowing the suppliers of these trucks reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should clearly support investigation of the research problem and linked to key findings from your literature review. Be sure to cite any studies that helped you determine that the case you chose was appropriate for examining the problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your analysis of the case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is common to combine a description of the results with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings Remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations revealed by the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research if that is how the findings can be interpreted from your case.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and any need for further research.

The function of your paper's conclusion is to: 1) reiterate the main argument supported by the findings from your case study; 2) state clearly the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
• If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in or the preferences of your professor, the concluding paragraph may contain your final reflections on the evidence presented as it applies to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were engaged with social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood more in terms of managing access rather than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis that leave the reader questioning the results.

Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent] knowledge is more valuable than concrete, practical [context-dependent] knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

• << Previous: Writing a Case Analysis Paper
• Next: Writing a Field Report >>
• Last Updated: May 7, 2024 9:45 AM
• URL: https://libguides.usc.edu/writingguide/assignments

Research Writing and Analysis

• NVivo Group and Study Sessions
• SPSS This link opens in a new window
• Statistical Analysis Group sessions
• Using Qualtrics
• Dissertation and Data Analysis Group Sessions
• Defense Schedule - Commons Calendar This link opens in a new window
• Research Process Flow Chart
• Research Alignment Chapter 1 This link opens in a new window
• Step 1: Seek Out Evidence
• Step 2: Explain
• Step 3: The Big Picture
• Step 4: Own It
• Step 5: Illustrate
• Annotated Bibliography
• Literature Review This link opens in a new window
• Systematic Reviews & Meta-Analyses
• How to Synthesize and Analyze
• Synthesis and Analysis Practice
• Synthesis and Analysis Group Sessions
• Problem Statement
• Purpose Statement
• Conceptual Framework
• Theoretical Framework
• Quantitative Research Questions
• Qualitative Research Questions
• Trustworthiness of Qualitative Data
• Analysis and Coding Example- Qualitative Data
• Thematic Data Analysis in Qualitative Design
• Dissertation to Journal Article This link opens in a new window
• International Journal of Online Graduate Education (IJOGE) This link opens in a new window
• Journal of Research in Innovative Teaching & Learning (JRIT&L) This link opens in a new window

Writing a Case Study

What is a case study?

A Case study is: 

• An in-depth research design that primarily uses a qualitative methodology but sometimes​​ includes quantitative methodology.
• Used to examine an identifiable problem confirmed through research.
• Used to investigate an individual, group of people, organization, or event.
• Used to mostly answer "how" and "why" questions.

What are the different types of case studies?

Note: These are the primary case studies. As you continue to research and learn

about case studies you will begin to find a robust list of different types. 

Who are your case study participants?

What is triangulation ? 

Validity and credibility are an essential part of the case study. Therefore, the researcher should include triangulation to ensure trustworthiness while accurately reflecting what the researcher seeks to investigate.

How to write a Case Study?

When developing a case study, there are different ways you could present the information, but remember to include the five parts for your case study.

Was this resource helpful?

• << Previous: Thematic Data Analysis in Qualitative Design
• Next: Journal Article Reporting Standards (JARS) >>
• Last Updated: May 16, 2024 8:25 AM
• URL: https://resources.nu.edu/researchtools

• Open access
• Published: 27 June 2011

The case study approach

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

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

779k Accesses

1040 Citations

37 Altmetric

Metrics details

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

Peer Review reports

Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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

Google Scholar  

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

Article   CAS   PubMed   PubMed Central   Google Scholar  

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

Article   Google Scholar  

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

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

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

Article   PubMed   Google Scholar  

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

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

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

PubMed   PubMed Central   Google Scholar  

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

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

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

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

Article   PubMed Central   Google Scholar  

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

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

CAS   PubMed   PubMed Central   Google Scholar  

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

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

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

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

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

Mason J: Qualitative researching. 2002, London: Sage

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

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

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

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

Article   PubMed   PubMed Central   Google Scholar  

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

Article   CAS   PubMed   Google Scholar  

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

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

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

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

Book   Google Scholar  

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

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

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

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

Pre-publication history

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

Download references

Acknowledgements

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

Author information

Authors and affiliations.

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

Sarah Crowe & Anthony Avery

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

Kathrin Cresswell, Ann Robertson & Aziz Sheikh

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

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Sarah Crowe .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors' contributions

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

Rights and permissions

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

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 29 November 2010

Accepted : 27 June 2011

Published : 27 June 2011

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

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

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

BMC Medical Research Methodology

ISSN: 1471-2288

• General enquiries: [email protected]

Published: 5 April 2024 Contributors: Tim Mucci, Cole Stryker

Big data analytics refers to the systematic processing and analysis of large amounts of data and complex data sets, known as big data, to extract valuable insights. Big data analytics allows for the uncovering of trends, patterns and correlations in large amounts of raw data to help analysts make data-informed decisions. This process allows organizations to leverage the exponentially growing data generated from diverse sources, including internet-of-things (IoT) sensors, social media, financial transactions and smart devices to derive actionable intelligence through advanced analytic techniques.

In the early 2000s, advances in software and hardware capabilities made it possible for organizations to collect and handle large amounts of unstructured data. With this explosion of useful data, open-source communities developed big data frameworks to store and process this data. These frameworks are used for distributed storage and processing of large data sets across a network of computers. Along with additional tools and libraries, big data frameworks can be used for:

• Predictive modeling by incorporating artificial intelligence (AI) and statistical algorithms
• Statistical analysis for in-depth data exploration and to uncover hidden patterns
• What-if analysis to simulate different scenarios and explore potential outcomes
• Processing diverse data sets, including structured, semi-structured and unstructured data from various sources.

Four main data analysis methods  – descriptive, diagnostic, predictive and prescriptive  – are used to uncover insights and patterns within an organization's data. These methods facilitate a deeper understanding of market trends, customer preferences and other important business metrics.

IBM named a Leader in the 2024 Gartner® Magic Quadrant™ for Augmented Data Quality Solutions.

Structured vs unstructured data

What is data management?

The main difference between big data analytics and traditional data analytics is the type of data handled and the tools used to analyze it. Traditional analytics deals with structured data, typically stored in relational databases . This type of database helps ensure that data is well-organized and easy for a computer to understand. Traditional data analytics relies on statistical methods and tools like structured query language (SQL) for querying databases.

Big data analytics involves massive amounts of data in various formats, including structured, semi-structured and unstructured data. The complexity of this data requires more sophisticated analysis techniques. Big data analytics employs advanced techniques like machine learning and data mining to extract information from complex data sets. It often requires distributed processing systems like Hadoop to manage the sheer volume of data.

These are the four methods of data analysis at work within big data:

The "what happened" stage of data analysis. Here, the focus is on summarizing and describing past data to understand its basic characteristics.

The “why it happened” stage. By delving deep into the data, diagnostic analysis identifies the root patterns and trends observed in descriptive analytics.

The “what will happen” stage. It uses historical data, statistical modeling and machine learning to forecast trends.

Describes the “what to do” stage, which goes beyond prediction to provide recommendations for optimizing future actions based on insights derived from all previous.

The following dimensions highlight the core challenges and opportunities inherent in big data analytics.

The sheer volume of data generated today, from social media feeds, IoT devices, transaction records and more, presents a significant challenge. Traditional data storage and processing solutions are often inadequate to handle this scale efficiently. Big data technologies and cloud-based storage solutions enable organizations to store and manage these vast data sets cost-effectively, protecting valuable data from being discarded due to storage limitations.

Data is being produced at unprecedented speeds, from real-time social media updates to high-frequency stock trading records. The velocity at which data flows into organizations requires robust processing capabilities to capture, process and deliver accurate analysis in near real-time. Stream processing frameworks and in-memory data processing are designed to handle these rapid data streams and balance supply with demand.

Today's data comes in many formats, from structured to numeric data in traditional databases to unstructured text, video and images from diverse sources like social media and video surveillance. This variety demans flexible data management systems to handle and integrate disparate data types for comprehensive analysis. NoSQL databases , data lakes and schema -on-read technologies provide the necessary flexibility to accommodate the diverse nature of big data.

Data reliability and accuracy are critical, as decisions based on inaccurate or incomplete data can lead to negative outcomes. Veracity refers to the data's trustworthiness, encompassing data quality, noise and anomaly detection issues. Techniques and tools for data cleaning, validation and verification are integral to ensuring the integrity of big data, enabling organizations to make better decisions based on reliable information.

Big data analytics aims to extract actionable insights that offer tangible value. This involves turning vast data sets into meaningful information that can inform strategic decisions, uncover new opportunities and drive innovation. Advanced analytics, machine learning and AI are key to unlocking the value contained within big data, transforming raw data into strategic assets.

Data professionals, analysts, scientists and statisticians prepare and process data in a data lakehouse, which combines the performance of a data lakehouse with the flexibility of a data lake to clean data and ensure its quality. The process of turning raw data into valuable insights encompasses several key stages:

• Collect data: The first step involves gathering data, which can be a mix of structured and unstructured forms from myriad sources like cloud, mobile applications and IoT sensors. This step is where organizations adapt their data collection strategies and integrate data from varied sources into central repositories like a data lake, which can automatically assign metadata for better manageability and accessibility.
• Process data: After being collected, data must be systematically organized, extracted, transformed and then loaded into a storage system to ensure accurate analytical outcomes. Processing involves converting raw data into a format that is usable for analysis, which might involve aggregating data from different sources, converting data types or organizing data into structure formats. Given the exponential growth of available data, this stage can be challenging. Processing strategies may vary between batch processing, which handles large data volumes over extended periods and stream processing, which deals with smaller real-time data batches.
• Clean data: Regardless of size, data must be cleaned to ensure quality and relevance. Cleaning data involves formatting it correctly, removing duplicates and eliminating irrelevant entries. Clean data prevents the corruption of output and safeguard’s reliability and accuracy.
• Analyze data: Advanced analytics, such as data mining, predictive analytics, machine learning and deep learning, are employed to sift through the processed and cleaned data. These methods allow users to discover patterns, relationships and trends within the data, providing a solid foundation for informed decision-making.

Under the Analyze umbrella, there are potentially many technologies at work, including data mining, which is used to identify patterns and relationships within large data sets; predictive analytics, which forecasts future trends and opportunities; and deep learning , which mimics human learning patterns to uncover more abstract ideas.

Deep learning uses an artificial neural network with multiple layers to model complex patterns in data. Unlike traditional machine learning algorithms, deep learning learns from images, sound and text without manual help. For big data analytics, this powerful capability means the volume and complexity of data is not an issue.

Natural language processing (NLP) models allow machines to understand, interpret and generate human language. Within big data analytics, NLP extracts insights from massive unstructured text data generated across an organization and beyond.

Structured Data

Structured data refers to highly organized information that is easily searchable and typically stored in relational databases or spreadsheets. It adheres to a rigid schema, meaning each data element is clearly defined and accessible in a fixed field within a record or file. Examples of structured data include:

• Customer names and addresses in a customer relationship management (CRM) system
• Transactional data in financial records, such as sales figures and account balances
• Employee data in human resources databases, including job titles and salaries

Structured data's main advantage is its simplicity for entry, search and analysis, often using straightforward database queries like SQL. However, the rapidly expanding universe of big data means that structured data represents a relatively small portion of the total data available to organizations.

Unstructured Data

Unstructured data lacks a pre-defined data model, making it more difficult to collect, process and analyze. It comprises the majority of data generated today, and includes formats such as:

• Textual content from documents, emails and social media posts
• Multimedia content, including images, audio files and videos
• Data from IoT devices, which can include a mix of sensor data, log files and time-series data

The primary challenge with unstructured data is its complexity and lack of uniformity, requiring more sophisticated methods for indexing, searching and analyzing. NLP, machine learning and advanced analytics platforms are often employed to extract meaningful insights from unstructured data.

Semi-structured data

Semi-structured data occupies the middle ground between structured and unstructured data. While it does not reside in a relational database, it contains tags or other markers to separate semantic elements and enforce hierarchies of records and fields within the data. Examples include:

• JSON (JavaScript Object Notation) and XML (eXtensible Markup Language) files, which are commonly used for web data interchange
• Email, where the data has a standardized format (e.g., headers, subject, body) but the content within each section is unstructured
• NoSQL databases, can store and manage semi-structured data more efficiently than traditional relational databases

Semi-structured data is more flexible than structured data but easier to analyze than unstructured data, providing a balance that is particularly useful in web applications and data integration tasks.

Ensuring data quality and integrity, integrating disparate data sources, protecting data privacy and security and finding the right talent to analyze and interpret data can present challenges to organizations looking to leverage their extensive data volumes. What follows are the benefits organizations can realize once they see success with big data analytics:

Real-time intelligence

One of the standout advantages of big data analytics is the capacity to provide real-time intelligence. Organizations can analyze vast amounts of data as it is generated from myriad sources and in various formats. Real-time insight allows businesses to make quick decisions, respond to market changes instantaneously and identify and act on opportunities as they arise.

Better-informed decisions

With big data analytics, organizations can uncover previously hidden trends, patterns and correlations. A deeper understanding equips leaders and decision-makers with the information needed to strategize effectively, enhancing business decision-making in supply chain management, e-commerce, operations and overall strategic direction.  

Cost savings

Big data analytics drives cost savings by identifying business process efficiencies and optimizations. Organizations can pinpoint wasteful expenditures by analyzing large datasets, streamlining operations and enhancing productivity. Moreover, predictive analytics can forecast future trends, allowing companies to allocate resources more efficiently and avoid costly missteps.

Better customer engagement

Understanding customer needs, behaviors and sentiments is crucial for successful engagement and big data analytics provides the tools to achieve this understanding. Companies gain insights into consumer preferences and tailor their marketing strategies by analyzing customer data.

Optimized risk management strategies

Big data analytics enhances an organization's ability to manage risk by providing the tools to identify, assess and address threats in real time. Predictive analytics can foresee potential dangers before they materialize, allowing companies to devise preemptive strategies.

As organizations across industries seek to leverage data to drive decision-making, improve operational efficiencies and enhance customer experiences, the demand for skilled professionals in big data analytics has surged. Here are some prominent career paths that utilize big data analytics:

Data scientist

Data scientists analyze complex digital data to assist businesses in making decisions. Using their data science training and advanced analytics technologies, including machine learning and predictive modeling, they uncover hidden insights in data.

Data analyst

Data analysts turn data into information and information into insights. They use statistical techniques to analyze and extract meaningful trends from data sets, often to inform business strategy and decisions.

Data engineer

Data engineers prepare, process and manage big data infrastructure and tools. They also develop, maintain, test and evaluate data solutions within organizations, often working with massive datasets to assist in analytics projects.

Machine learning engineer

Machine learning engineers focus on designing and implementing machine learning applications. They develop sophisticated algorithms that learn from and make predictions on data.

Business intelligence analyst

Business intelligence (BI) analysts help businesses make data-driven decisions by analyzing data to produce actionable insights. They often use BI tools to convert data into easy-to-understand reports and visualizations for business stakeholders.

Data visualization specialist

These specialists focus on the visual representation of data. They create data visualizations that help end users understand the significance of data by placing it in a visual context.

Data architect

Data architects design, create, deploy and manage an organization's data architecture. They define how data is stored, consumed, integrated and managed by different data entities and IT systems.

IBM and Cloudera have partnered to create an industry-leading, enterprise-grade big data framework distribution plus a variety of cloud services and products — all designed to achieve faster analytics at scale.

IBM Db2 Database on IBM Cloud Pak for Data combines a proven, AI-infused, enterprise-ready data management system with an integrated data and AI platform built on the security-rich, scalable Red Hat OpenShift foundation.

IBM Big Replicate is an enterprise-class data replication software platform that keeps data consistent in a distributed environment, on-premises and in the hybrid cloud, including SQL and NoSQL databases.

A data warehouse is a system that aggregates data from different sources into a single, central, consistent data store to support data analysis, data mining, artificial intelligence and machine learning.

Business intelligence gives organizations the ability to get answers they can understand. Instead of using best guesses, they can base decisions on what their business data is telling them — whether it relates to production, supply chain, customers or market trends.

Cloud computing is the on-demand access of physical or virtual servers, data storage, networking capabilities, application development tools, software, AI analytic tools and more—over the internet with pay-per-use pricing. The cloud computing model offers customers flexibility and scalability compared to traditional infrastructure.

Purpose-built data-driven architecture helps support business intelligence across the organization. IBM analytics solutions allow organizations to simplify raw data access, provide end-to-end data management and empower business users with AI-driven self-service analytics to predict outcomes.

An official website of the United States government

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

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

• Publications
• Account settings

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

• Advanced Search
• Journal List
• BMC Med Res Methodol

The case study approach

Sarah crowe.

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

Kathrin Cresswell

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

Ann Robertson

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

Anthony Avery

Aziz sheikh.

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

Introduction

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

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

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

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

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

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

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

What is a case study?

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

Definitions of a case study

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

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

What are case studies used for?

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

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

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

How are case studies conducted?

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

Defining the case

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

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Potential pitfalls and mitigating actions when undertaking case study research

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

Conclusions

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

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

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

http://www.biomedcentral.com/1471-2288/11/100/prepub

Acknowledgements

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

• Yin RK. Case study research, design and method. 4. London: Sage Publications Ltd.; 2009. [ Google Scholar ]
• Keen J, Packwood T. Qualitative research; case study evaluation. BMJ. 1995; 311 :444–446. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J. et al. Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009; 6 (10):1–11. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO) 2008. http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf
• Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T. et al. Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010; 41 :c4564. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P. the Patient Safety Education Study Group. Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010; 15 :4–10. doi: 10.1258/jhsrp.2009.009052. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van Harten WH, Casparie TF, Fisscher OA. The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002; 60 (1):17–37. doi: 10.1016/S0168-8510(01)00187-7. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stake RE. The art of case study research. London: Sage Publications Ltd.; 1995. [ Google Scholar ]
• Sheikh A, Smeeth L, Ashcroft R. Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002; 52 (482):746–51. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• King G, Keohane R, Verba S. Designing Social Inquiry. Princeton: Princeton University Press; 1996. [ Google Scholar ]
• Doolin B. Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998; 13 :301–311. doi: 10.1057/jit.1998.8. [ CrossRef ] [ Google Scholar ]
• George AL, Bennett A. Case studies and theory development in the social sciences. Cambridge, MA: MIT Press; 2005. [ Google Scholar ]
• Eccles M. the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG) Designing theoretically-informed implementation interventions. Implementation Science. 2006; 1 :1–8. doi: 10.1186/1748-5908-1-1. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A. Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005; 365 (9456):312–7. [ PubMed ] [ Google Scholar ]
• Sheikh A, Panesar SS, Lasserson T, Netuveli G. Recruitment of ethnic minorities to asthma studies. Thorax. 2004; 59 (7):634. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Hellström I, Nolan M, Lundh U. 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005; 4 :7–22. doi: 10.1177/1471301205049188. [ CrossRef ] [ Google Scholar ]
• Som CV. Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005; 18 :463–477. doi: 10.1108/09513550510608903. [ CrossRef ] [ Google Scholar ]
• Lincoln Y, Guba E. Naturalistic inquiry. Newbury Park: Sage Publications; 1985. [ Google Scholar ]
• Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001; 322 :1115–1117. doi: 10.1136/bmj.322.7294.1115. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mays N, Pope C. Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000; 320 :50–52. doi: 10.1136/bmj.320.7226.50. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mason J. Qualitative researching. London: Sage; 2002. [ Google Scholar ]
• Brazier A, Cooke K, Moravan V. Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008; 7 :5–17. doi: 10.1177/1534735407313395. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Miles MB, Huberman M. Qualitative data analysis: an expanded sourcebook. 2. CA: Sage Publications Inc.; 1994. [ Google Scholar ]
• Pope C, Ziebland S, Mays N. Analysing qualitative data. Qualitative research in health care. BMJ. 2000; 320 :114–116. doi: 10.1136/bmj.320.7227.114. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cresswell KM, Worth A, Sheikh A. Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010; 10 (1):67. doi: 10.1186/1472-6947-10-67. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001; 358 :483–488. doi: 10.1016/S0140-6736(01)05627-6. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yin R. Case study research: design and methods. 2. Thousand Oaks, CA: Sage Publishing; 1994. [ Google Scholar ]
• Yin R. Enhancing the quality of case studies in health services research. Health Serv Res. 1999; 34 :1209–1224. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Green J, Thorogood N. Qualitative methods for health research. 2. Los Angeles: Sage; 2009. [ Google Scholar ]
• Howcroft D, Trauth E. Handbook of Critical Information Systems Research, Theory and Application. Cheltenham, UK: Northampton, MA, USA: Edward Elgar; 2005. [ Google Scholar ]
• Blakie N. Approaches to Social Enquiry. Cambridge: Polity Press; 1993. [ Google Scholar ]
• Doolin B. Power and resistance in the implementation of a medical management information system. Info Systems J. 2004; 14 :343–362. doi: 10.1111/j.1365-2575.2004.00176.x. [ CrossRef ] [ Google Scholar ]
• Bloomfield BP, Best A. Management consultants: systems development, power and the translation of problems. Sociological Review. 1992; 40 :533–560. [ Google Scholar ]
• Shanks G, Parr A. Proceedings of the European Conference on Information Systems. Naples; 2003. Positivist, single case study research in information systems: A critical analysis. [ Google Scholar ]

Preferences of physicians for treatment-related toxicity vs. recurrence in melanoma (GERMELATOX-A): the doctors’ perspective

• Open access
• Published: 14 May 2024
• Volume 150 , article number  252 , ( 2024 )

Cite this article

You have full access to this open access article

• Katharina C. Kähler 1 ,
• Ralf Gutzmer 2 ,
• Yenny Angela 2 ,
• Elisabeth Livingstone 3 ,
• Georg Lodde 3 ,
• Frank Meiss 4 ,
• David A. Rafei-Shamsabadi 4 ,
• Sera S. Weyer-Fahlbusch 5 ,
• Dorothée Nashan 5 ,
• Carmen Loquai 6 ,
• Jessica C. Hassel 7 ,
• Michael M. M. Sachse 8 ,
• Lara V. Maul 10 , 9 ,
• Lucie Heinzerling 11 ,
• Markus V. Heppt 12 , 14 ,
• Chiara Colapietro 1 ,
• Judith Rusch 13 &
• Christine Blome 13  

44 Accesses

1 Altmetric

Explore all metrics

Introduction

Adjuvant treatment with immune checkpoint inhibitors, such as PD1-antibodies (ICI) ± CTLA4-antibodies (cICI) or targeted therapy with BRAF/MEK inhibitors (TT), has shown a significant improvement in disease-free survival (DFS) for high-risk melanoma patients. However, due to specific side effects, the choice of treatment is often influenced by the risk of toxicity. Therefore, the role of physicians in treatment decisions of patients is crucial. This study investigated for the first time in a multicenter setting the attitudes and preferences of dermatooncologists in Germany and Switzerland regarding adjuvant treatment with (c)ICI and TT.

In the GERMELATOX-A study, 108 physicians (median age: 32 yrs, 67.6% female) from 11 skin cancer centers were surveyed to rate typical side effect scenarios of (c)ICI and TT treatments and then compared to patients’ ratings evaluated in a previous analysis from the same centers. The scenarios described mild-to-moderate or severe toxicity and included melanoma relapse leading to death. The physicians were asked about the level of side effects they would tolerate in exchange for a reduction in melanoma relapse and an increase in survival at 5 years.

The preferences of physicians and patients revealed significant differences regarding adjuvant melanoma treatment with (c)ICI and TT ( p  < 0.05). Compared to patients, physicians tend to value a melanoma relapse less severe, according to a visual analog scale. They were also less threatened by all scenarios of side effects during adjuvant treatment with (c)ICI or TT, compared to patients. Physicians required lower risk reductions for disease-free survival (DFS) and overall survival (OS) for both ICI and TT and their drug-related side effects to accept these treatments. In case of severe side effects, physicians required similar 5-year DFS rates for ICI and TT (60–65%), while patients needed a 15% improvement of 5-year DFS for ICI compared to TT (80%/65%). For survival, physicians expected an OS improvement of + 10% for all three treatment modalities, whereas patients required a higher increase: + 18–22% for ICI and + 15% for TT.

Our study highlights the importance of understanding the patient’s perspective and a potential difference to the doctor’s view when making decisions about adjuvant melanoma treatment with (c)ICI and TT, especially as these treatments are increasingly being implemented in earlier stages.

Similar content being viewed by others

Preferences of German and Swiss melanoma patients for toxicities versus melanoma recurrence during adjuvant treatment (GERMELATOX-A-trial)

The survivorship experience for patients with metastatic melanoma on immune checkpoint and BRAF-MEK inhibitors

Revisiting the association between skin toxicity and better response in advanced cancer patients treated with immune checkpoint inhibitors

Avoid common mistakes on your manuscript.

Over the years, significant advancements have been made in the treatment of melanoma, particularly with the introduction of targeted therapies and immunotherapies for patients with advanced melanoma (Garutti et al 2022 ). These treatments have been successful in the metastatic setting and have now progressed to the adjuvant setting, where they can benefit high-risk patients. High-risk melanoma is defined as a deep invasive primary tumor with or without ulceration (AJCC (8th edition) stage IIB and IIC) or with regional nodal disease (AJCC stage III). The 10-year melanoma-specific survival rates range from 84% for AJCC stage II down to 69% for AJCC stage III (Gershenwald et al 2017 ). While patients with thinner melanomas can be cured by surgery alone, increasing tumor thickness is associated with the risk of relapse and metastatic disease. Therefore, the healthcare provider and the patient must decide when to use adjuvant therapy, whether to treat in the adjuvant setting or wait until recurrence, and whether the benefits of adjuvant therapy outweigh the risks.

Adjuvant therapies such as immune checkpoint blockade or targeted therapy have been approved and are now considered standard of care not only for high-risk patients but also for intermediate-risk patients in AJCC stage IIB. These therapies have shown improvements in disease-free survival (DFS) and distant metastasis survival (DMFS), which can serve as a surrogate parameter for overall survival (Kobeissi and Tarhini 2022 ; Long et al. 2022 ). Adjuvant therapy is considered potentially curative and can prevent relapse and the poor outcomes seen in metastatic disease. In stage IV, adjuvant treatment with PD1-antibodies (ICI) ± CTLA4-antibodies (cICI), has also been demonstrated to be very effective and is, therefore, increasingly used in daily routine (Livingstone et al. 2022 ).

The toxicity of targeted therapy, dabrafenib and trametinib, is characterized by symptoms such as fever, gastrointestinal symptoms, joint pain, a decrease in the left ventricular function, and eye disorders (Lazaroff and Bolotin 2023 ) that can also impair quality of life (Scarpato et al. 2022 ; Lai-Kwon et al. 2023 ) In contrast, immune checkpoint inhibitors (c(ICI)) can induce autoimmune toxicity in nearly every organ system and a small subset of patients with a fatal course (Wang et al 2018 ). Despite the frequency of side effects, in the majority of patients, health-related quality of life (HrQoL) is not or only temporarily impaired (Bottomley et al. 2021 ; Khattak et al. 2022 ; Pedersen et al 2023 ; Lai-Kwon et al. 2023 ). However, in case of severe side effects, HRQoL may be persistently impaired, which can eventually lead to treatment stop (Pedersen et al. 2023 ; Wang et al. 2018 ).

In contrast to TT, (c)ICI has the potential for severe side effects that may be chronic and may be fatal or accompanied by a deterioration for quality of life (Wang et al. 2018 ; Schulz et al. 2022 ). Therefore, it is important to discuss the risks and benefits of therapy with the patient considering the benefits and risks of the treatment. Especially in adjuvant treatment, physicians need to discuss the individual risk–benefit ratio with eligible patients thoroughly. The physician’s beliefs may influence this decision-making process, so it is important to be aware of any differences between patients’ and physicians’ attitudes toward toxicity. Currently, there is limited knowledge about the differences between melanoma patients and their physicians concerning their preferences toward the toxicity of adjuvant melanoma treatment (Krammer et al. 2014 ; Weiss et al. 2020 ). However, it is known that patients and physicians may rate the benefit–risk ratios differently in other tumor entities (Zhang et al. 2023 ).

We conducted a study to evaluate the attitudes of dermatooncologists towards toxicity during adjuvant treatment and compared the results with a patient cohort we previously evaluated in these melanoma centers (Kähler et al. 2023 ). We aimed to identify any differences between melanoma patients and their treating physicians regarding the risk–benefit of adjuvant treatment in melanoma. There is limited data available about physician preferences for benefit versus toxicity in these treatments in the adjuvant setting. This study is the first to investigate, in a multicenter approach, how dermatooncologists value different spectrums of toxicity of adjuvant immunotherapy and targeted therapy in direct comparison to their patients.

Physicians, patients and study centers

This is a cross-sectional, observational, non-interventional questionnaire study that involved ten German and one Swiss skin cancer center with high expertise in treating melanoma. The study included dermatologists and dermatology residents who were familiar with the treatment of melanoma and worked in a German/Swiss melanoma center where melanoma patients are diagnosed, resected, and treated with systemic therapy by dermatooncologists.

The group of physicians was compared with previously evaluated patients with low-risk melanoma, defined as T1a, at least 8 weeks after initial diagnosis, no sentinel node biopsy or significant co-morbidities (Kähler et al. 2023 ). The rationale for low-risk melanoma patients was to choose a patient cohort with the experience of melanoma diagnosis, but not in the situation of having to decide for or against adjuvant treatment, to avoid ethical conflicts potentially induced by this study that may influence a patient’s decision.

We collected information on various sociodemographic factors, including age, gender, marital status, employment status, and working hours. We also asked about previous experience with cancer and co-morbidities. Additionally, we evaluated professional data such as the frequency of contact with melanoma patients, frequency of prescription of adjuvant treatment, duration of being a dermato-oncologist, percentage of subjects treated with mild side effects, and percentage of subjects treated with severe toxicity.

Treatment trade-off

A survey tool that met the objective of our study was not available, so we created a new questionnaire. The questionnaire’s treatment scenarios were based on the literature and the expertise of two clinical dermato-oncologists. Pre-testing of the questionnaire for comprehensibility was done by three independent physicians and four volunteering patients provided feedback was used to revise it.

To elicit preferences, we used a paper-based treatment-trade-off task. Participants were asked to imagine having melanoma with a 30% chance of 5-year DFS and a 50% chance of 5-year OS. We described three treatments (TT, ICI, or cICI treatment), including the nature and probability of side effects, and asked participants to choose their preferred treatment. Additionally, we evaluated preferences for the recurrence of melanoma after adjuvant treatment, resulting in 12 different scenarios (an example is provided in the supplementary).

Scenario 1 = TT without side effects.

Scenario 2 = TT with mild to moderate side effects.

Scenario 3 = TT with severe side effects.

Scenario 4 = ICI without side effects.

Scenario 5 = ICI with mild to moderate side effects.

Scenario 6 = ICI with mild to moderate side effects and abnormal blood values.

Scenario 7 = ICI with severe side effects.

Scenario 8 = cICI without side effects.

Scenario 9 = cICI with mild to moderate side effects.

Scenario 10 = cICI with mild to moderate side effects and abnormal blood values.

Scenario 11 = cICI with severe side effects.

Scenario 12 = Recurrence of melanoma after adjuvant treatment (only rated for acceptability).

In contrast to previous uses of treatment-trade-off, participants were not presented a series of different DFS and OS rates for each scenario (1). Instead, the participants were requested to specify the minimum number of prevented recurrences or deaths necessary for them to opt for the treatment instead of not receiving any treatment. In other words, they were asked to state the required chances of DFS and OS that would make them choose the treatment over the alternative of no treatment. The statement to be completed, for example, “I would choose the treatment described in scenario 1 if it would prevent a relapse in at least ___ of these 70 patients.”

Participants were additionally asked to rate the acceptability of each scenario using visual analog scales (VAS) ranging from 0% = completely unbearable to 100% = completely bearable.

Thus, for each scenario, participants rated the minimally required increase in DFS and OS, respectively, as well as acceptability using the VAS.

Primary endpoint

The primary objective was to determine preferences for adjuvant treatment with severe side effects in terms of the minimum required benefit, as defined in the treatment trade-off task, which was an additional chance of 5-year DFS.

Secondary endpoints

To identify preferences for adjuvant treatments with mild to moderate and severe side effects during (c)ICI and TT, we needed to determine the minimum benefit required in terms of the additional chance of 5-year DFS and 5-year OS. This will be stated in the treatment trade-off task.

Additional assessments

We asked physicians to rate their preference for infusion or oral medication on a 5-point scale from “completely agree” to “do not agree at all”.

Self-applied medication : “It is okay for me to take the medicine on my own”.

Supervised medication : “It seems beneficial to me to have the drug administered under the supervision of a doctor”.

Rather visits than self-application : “I’m happy to put up with infusions and more frequent visits to the doctor, as long as I then don’t have to be responsible for taking the medicine myself”.

Acceptance of long doctor’s appointments : “I can accept that an appointment with infusion and medical examination can take several hours”.

Compliance with a strict intake schedule : “I can stick to a precise schedule for taking pills”.

Importance of treatment method (infusion vs. pill): “The way I get the medicine administered (infusion or pills) matters to me”.

In addition, participants rated their preference for dosage via infusion vs. pill on a horizontal VAS from − 100 (infusion) to + 100 (pills) and 0 indicating “undecided”.

The same data as previously for patients (Kähler et al 2023 ) were assessed in this second part of the study for physicians: preferences, socio-demographics, and self-experience with cancer.

Sample size calculation

The number of participants to be included was determined according to the primary endpoint of preferences for BRAF/MEKi treatment. To determine the percentage of participants who would choose BRAF/MEKi treatment at a 5-year-DFS of 65% or lower with a 95% confidence interval width of ± 10 percentage points, 104 analyzable data sets were needed (or less if the distribution of participants would differ from 50:50; calculated with PASS Sample Size 2008).

Statistical approach

For all variables, descriptive statistics were computed (frequencies, percentages, mean, median, and/or standard deviation (SD), as applicable).

Participants were excluded from the OS, DFS, or VAS analysis, respectively, if they misordered two or more pairs of scenarios (e.g. lower rank for mild-to-moderate side effects than for severe side effects in otherwise identical scenarios) as this was regarded as an indicator of insufficient understanding of the rating task.

OS, DFS, and VAS were analyzed as the arithmetic mean along with the 95% confidence interval. Differences between treatment scenarios were tested with paired samples t tests. Preferences for the different scenarios (PFS, OS, VAS) were tested for differences for statistically significant differences between treatment scenarios and between physicians and patients using paired samples t tests.

Significance levels equal to or below 0.05 were considered statistically significant; no adjustment for multiple testing was performed.

The association of treatment preferences (DFS, OS, VAS) with important characteristics (socio-demographic data, self-experience with cancer, psychological constructs) was assessed using bivariate tests (Pearson correlations or t-tests, depending on variable scaling).

All 115 physicians who gave informed consent could be included in the analysis. From the analysis of the different scenario ratings, between 7 and 11 questionnaires had to be excluded, with n = 108 analyzable for the primary endpoint (Fig.  1 ). Out of 165 patients who have been analyzed in a previous part of the study (Kähler et al. 2023 ), 3 had to be excluded from analysis for different reasons. Regarding the analysis of the scenario ratings, between 11 and 25 patients had to be excluded, with n = 137 analyzable for the primary endpoint.

Study flowchart represented included, excluded, and analyzed physicians in comparison to previously analyzed patients (Kähler et al. 2023 )

Characteristics of physicians

Dermatologists were between 25 and 60 years of age (mean 33.9 years, median 32.0, SD 7.7), 67% were female. Most were in a relationship or married and living with one person. Median working hours were 42 per week (Table  1 ).

Physicians had a median of 40 patient contacts per month, according to Table  2 . Their experience as a physician ranged from 0.1 to 35 years, with a median of 3.5. They reported that severe side effects were more common in patients during cICI (median 30%) than in TT or ICI (median 10%). The experience of physicians as clinical dermatologists or the frequency of consultations with melanoma patients did not correlate with scenario ratings, except for scenario 3 (severe side effects during TT), as shown in Table  3 .

Patient characteristics

To describe the group of patients analyzed in our previous study, we present the socio-demographic characteristics of the full analysis set, which included 162 patients (Kähler et al. 2023 ). The patient cohort was predominantly German/Swiss (95%), with the remaining 5% having different nationalities. The group was almost equally divided between male (47%) and female (57%) subjects. The patients’ ages ranged from 24 to 93 years, with a median age of 60 years. The median time since melanoma diagnosis was 1 year (SD 5 years, range: 0–32 years). Most patients were married and living with one person, and the majority were either employed (with a median of 39 h/week) or retired.

Scenario rating concerning disease-free survival

In various scenarios, physicians required significantly fewer prevented relapses to accept the treatment and its side effects compared to patients (Tables  4 , 5 , 6 ).

In case of severe side effects, physicians required for TT a median reduction of 30 out of 70 relapses (mean 31.6, SD 17.8, range 1–70, 95% confidence interval 28.1–35). Physicians needed identical numbers of relapses prevented for TT (30) and (c)ICI (35) compared to patients who required 15 additional prevented relapses at 5 yrs for (c)ICI (50) compared to TT (35). In other words, physicians required similar 5-year DFS rates for ICI and TT (60–65%). Patients needed a 15% improvement of 5-year DFS for ICI compared to TT (80%/65.0%).

In case of no side effects, both physicians and patients requested a similar reduction in relapses. The ratings were 10/10 for TT, 10/10 for ICI, and 10/15 for cICI. However, when mild-to-moderate side effects were present, the situation changed. Physicians requested a significantly lower number of prevented relapses compared to patients. The ratings were 20/30 for TT, 15/20 for ICI, and 16/29 for cICI. Most of the scenarios were statistically different from each other, as shown in Table  6 .

Scenario rating concerning overall survival

In case of no or mild-to-moderate side effects, physicians require a lower number of prevented deaths (5 and 10 for TT, 5 and 5 for ICI, 5 and 10 for cICI; median, Table  8 ) than patients (5 and 15 for TT, 5 and 15 for ICI, 10 and 20 for cICI; median, Kähler et al. 2023 ). Most physician ratings of scenarios were statistically different from each other (Table  7 ). Acceptance decreased with the severity of side effects. For TT with severe side effects, physicians and patients required a median of 15/25 avoided deaths and 20/30 avoided deaths for ICI or 20/35 deaths in case of cICI ( p  < 0.001), respectively.

For survival, in case of mild-to-moderate side effects, physicians expected an equal OS improvement (+ 5 to 10%) for all three treatment modalities, whereas patients required an increase of 15–22% for 5-year melanoma survival (ICI + 18 to 22% compared to TT + 15%; Kähler et al. 2023 ). In case of severe toxicity, physicians expected an equal OS improvement (+ 15 to 20%) for all three treatment modalities, whereas patients required an increase of 25–35% for 5-year melanoma survival ((c)ICI + 30 to 35% compared to TT + 25%).

The average ratings regarding OS were statistically different for most scenarios in both patients and physicians (table not shown).

Scenario rating by socioeconomic characteristics

There was a weak correlation ( r  < 0.3) between age and DFS ratings with older patients tending to require higher effectiveness to accept a treatment. In physicians, in contrast, gender, income, or co-morbidities did not show any association with DFS or OS rating.

Impact of self-experience of cancer on scenario rating

3.5% of physicians experienced cancer themselves (Table  8 ). Additionally, 67% of physicians had close persons affected by cancer. Our study showed that previous cancer experience did not correlate with PFS, OS, and scenario ratings in either group, except for a significant OS rating for scenarios 8 and 9 (cICI without side effects or only with mild-to-moderate side effects) in the patient cohort who had previous cancer experience.

The average ratings for PFS scenarios were similar for both patients with and without cancer experience. However, the average ratings for OS scenarios were also similar between the two groups, except for scenarios 8 and 9, which showed some differences (data not shown).

Dosage form preferences: infusion vs. oral medication

90% of physicians and 63% of patients (Kähler et al. 2023 ) agreed that it was acceptable to take their medicine on their own (Table  9 ). Physicians were more likely to agree with this statement than patients. Both patients and physicians rather disagreed to prefer supervised medication, and there was no significant difference between the two groups in this regard.

On average, patients and physicians disagreed that they would accept infusions and doctor visits, with physicians being more opposed to this idea. However, both groups were willing to accept appointments that take several hours, and most of them stated that they could stick to a precise intake schedule, with physicians being more confident in this regard.

Interestingly, more patients than physicians had a strong preference for a particular administration method (infusion or pills), and this difference was highly significant (Table  10 ).

According to the results of the horizontal VAS, most physicians and patients preferred pills over infusions, with a median score of 31 and 41.5 (Table  11 ) on a scale ranging from − 100 (infusion preferred) to + 100 (pills preferred). However, a significant number of participants chose “0,” indicating no preference. The mean score was 26.1, with a standard deviation of 61.6 and a range of − 100 to 100, based on a sample size of 161 patients. Patients generally did not see any benefits in supervised medication. On average, they disagreed with the idea of preferring infusions and doctor visits, and tended to prefer appointments that took several hours. Patients also stated that they could adhere to a precise intake schedule and that the method of administration (infusion or pills) was important to them.

Our study revealed that patients and physicians have differing perspectives on toxicity during adjuvant therapy. The doctor´s view has been evaluated in dermatooncologists of 11 melanoma centers.

Association with physicians’ and patients’ characteristics

Noteworthy, the group of physicians is healthier, younger, more educated, wealthier, and less affected by previous cancer diagnoses compared to the patient cohort (Kähler et al. 2023 ).

In the physician cohort factors such as age, gender, professional experience, and intensity of contact with melanoma patients did not show any correlation with the ratings of scenarios related to melanoma treatment.

For patients, we know that their ability to communicate treatment side-effects, comorbidities, and their view on the treatment risk/benefit profile has been identified as a critical driver of clinical decisions in adjuvant AJCC stage III disease (Livingstone et al. 2021 ).

Older melanoma patients tended to require higher effectiveness to accept an adjuvant treatment, this was reflected in the DFS ratings (Kähler et al 2023 ). The effect sizes were small though. These results are similar to our previous GERMELATOX analysis that evaluated patient preferences for adjuvant interferon-alpha (Kähler et al. 2016 ). In contrast, Weilandt et al. showed in a discrete choice approach in melanoma patients that increasing age, toxicity, and impact on their daily routine were more relevant than efficacy (Weilandt et al. 2021 ). They also found that married patients and patients with a higher level of education have higher expectations of treatment efficacy (Weilandt et al. 2021 ). In our study, a pre-existing cancer diagnosis did not influence average scenario ratings regarding acceptability or DFS in patients (Kähler et al 2023 ). Average scenario ratings regarding OS also did not differ between patients with experience with cancer and those without, except for scenarios 8 and 9 (cICI without or only mild to moderate side effects) but, again, with small effect sizes only (Kähler et al. 2023 ).

Physicians should be aware of the difference in perspectives between the patient and themselves and guide the informed consent process accordingly. Atkinson et al. found that physicians favored adjuvant therapy for their patients in 35% of cases, favored observation in 35% of cases, and had no preference in 29% of cases. Although these preferences were not communicated to the patients, the patient´s choice regarding adjuvant therapy (treatment vs. observation only) showed a significant, albeit small, correlation with the physician’s preference (treatment vs. observation only/no preference) (Atkinson et al. 2023 ).

Difference between the perception of TT versus (c)ICI

In our study, physicians and patients had different perspectives on the side effects of TT and ICI. Physicians were less concerned by IO toxicity and potentially long-lasting side effects and generally had a less negative view of toxicity maybe due to their awareness of the benefits of successful side effect management. Patients, on the other hand, were more willing to accept severe side effects induced by TT compared to (c)ICI. Patients rated potentially lethal or not resolving side effects induced by (c)ICI worse. However, most of the scenarios were rated as completely unacceptable by less than 1% of the patients and 0% of the physicians, showing the immense willingness of German and Swiss patients to tolerate treatment-related side effects.

Interestingly, patients were more willing to accept TT-associated pyrexia if the drug efficacy and, therefore, their outcome benefit is known (Mansfield et al. 2021 ), physicians should focus on precise and adequate information in the informed consent process.

The more negative perception of severe side effects during adjuvant treatment with (c)ICI compared to TT has also been confirmed by the comparison of the acceptability of scenarios. This can be explained by the possibility of long-lasting toxicity with sequelae and as well potentially fatal course of autoimmune side effects. A trial with structured interviews of melanoma physicians and nurses identified severe immune-related treatment side-effects overall and recurrence-free survival as highly influential factors in their immunotherapy decision-making (Livingstone et al. 2020 ). Melanoma patients scored higher on HRQoL social well-being at pre-treatment of ICI, were more likely to endorse positive statements about adjuvant immunotherapy, and perceived that their physician preferred adjuvant therapy combined with lower decisional regret and higher satisfaction, even if they experienced toxicity or recurrence (Atkinson et al. 2023 ). This may have an impact on patient–physician discussions and patient reflection at the time of treatment choice. Decisional regret was also lower in patients in that trial who had undergone lymph node dissection consistent with the idea that more aggressive treatment may be associated with less decisional regret (Atkinson et al. 2023 ). Therefore, the aspect of decisional regret should be considered and communicated in informed consent processes.

The difference in the mode of administration between c(ICI) and TT might also be a reason for melanoma patients to rate TT superior to (c)ICI. Most patients and dermatologists in our trial stated it was acceptable for them to take the medicine on their own. For dermatologists, this was significantly more the case than for patients. The majority did not see benefits in supervised medication. Most patients and dermatologists stated they could stick to a precise intake schedule, which was even more pronounced in dermatologists. More patients than dermatologists stated having a strong preference for an administration method (infusion or pills), which was highly significant. Our patients preferred the autonomy of an oral medication whereas the melanoma cohort of Weilandt and co-workers showed in their analysis that patients favored infusions. This might be explained by the fact that in our patient cohort, the decision for melanoma treatment and treatment regimen was an entirely fictitious scenario. Therefore, our patients might value the autonomy of an oral medication higher, whereas patients facing the adjuvant treatment decision in a real scenario perhaps might somewhat be overwhelmed by the challenge of understanding the process and therefore prefer to delegate the treatment responsibility regarding medication intake to their physician. Stellato and co-workers showed in a Canadian cohort that physicians assigned the highest preference for orally administered treatments (corresponding to the dosing regimen for dabrafenib–trametinib), melanoma patients had a similar preference for orally administered treatments and infusions administered over 30 min every 3 weeks (corresponding to the dosing regimen for pembrolizumab) (Stellato et al. 2019 ).

Do current treatment options meet our expectations?

We observed that physicians tend to accept a less significant treatment benefit by adjuvant treatment as compared to patients. This might be because physicians are not personally involved in the treatment process. A study by Weiss et al. suggests that previous cancer experience could affect treatment outcome ratings. Patients and physicians who have had personal cancer experience tended to value life prolongation by melanoma treatment more positively than healthy controls or physicians without personal cancer experience (Weiss et al. 2020 ).

In our trial, physicians tended to rate melanoma relapse less negatively than patients (Kähler et al. 2023 ), which could be due to their more optimistic view of treatment options and outcomes.

For DFS patients’ expectations towards efficacy differed between the three treatment modalities only by a range of 6 percentage points, despite the distinct rate of grade 3–4 adverse events (ranging from 14.4 to 71.0%, Table  12 , Kähler et al. 2023 ).

In general, the clinical trials conducted by Dummer et al. ( 2020 ), Larkin et al. ( 2023 ), Livingstone et al. ( 2022 ), and Schadendorf et al. ( 2022 ) have shown that the treatment efficacy is capable of meeting the expectations in terms of DFS found in our physician cohort. However, some follow-up data are still immature, and for cICI, only 4-year DFS data are available so far. Physicians and patients expected higher DFS rates for TT and ICI in case of severe side effects than shown for these treatment options in clinical studies (Kähler et al. 2023 ). In this situation, the efficacy would not be high enough for the patients. For OS (Table  13 ), the results are similar, but in case of severe side effects, the gap between expectations and the efficacy demonstrated in clinical trials so far seems to be smaller in case of using cICI. The gap between the expectations from risks and benefits of TT and ICI is more noticeable compared to cICI. This suggests that patients may not value the risk–benefit ratio as much as they do for cICI. However, it is important to note that cICI is only administered to specific patients in the adjuvant setting in AJCC stage IV.

In contrast, the expectations of the physician cohort for OS are concordant with the results from clinical trials for the available treatment options, as well as for severe toxicity.

Krammer et al. showed in their trial that attitudes towards toxicity and benefit vastly differed between healthy participants, physicians and melanoma patients. Whereas melanoma patients showed a high willingness to endure side effects despite very small survival gains (down to 1 extra week) or even only hope with no survival benefit, healthy controls were more critical, while physicians were the most therapy adverse (Krammer et al. 2014 ). Stellato et al. described that patients preferred an increased probability of remaining cancer-free over 21 months whereas physicians prioritized remaining alive over 36 months (Stellato et al. 2019 ).

Limitations of the study

Our study had some limitations. Firstly, the physician cohort we selected was mostly female and younger than a typical patient cohort; however, this corresponds with the typical composition of this group of persons. Secondly, we used a previously analyzed patient population with only low-risk melanoma as surrogates for those in later disease stages, due to ethical reasons. Thirdly, we did not analyze the perceptions of adjuvant melanoma treatment over time, so we may have missed possible changes in the individual course of the disease. However, evidence suggests that the tumor stage does not necessarily influence patients’ preferences (Atkinson et al. 2023 ). Fourthly, the usual melanoma patient cohort consists of more male than female patients, while in our study, more female patients were willing to participate. Finally, patient preferences were elicited based on hypothetical scenarios, which may not be completely comparable to real-life treatment decisions.

Overall, our study revealed a significant information and knowledge gap between physicians and patients, indicating different perspectives on treatment side effect perception. The most important goal should be to increase patients’ confidence in current treatment modalities and the competence of their physician. Physicians should be able to change their perspective to improve their understanding of possible reasons for patients declining adjuvant treatment.

Atkinson TM, Hay JL, Young Kim S, Schofield E, Postow MA, Momtaz PW et al (2023) Decision-making and health-related quality of life in patients with melanoma considering adjuvant immunotherapy. Oncologist 28(4):351–357. https://doi.org/10.1093/oncolo/oyac266 . ( PMID: 36745014; PMCID: PMC10078893 )

Article   PubMed   PubMed Central   Google Scholar  

Bottomley A, Coens C, Mierzynska J, Blank CU, Mandala M, Long GV et al (2021) Adjuvant pembrolizumab versus placebo in resected stage III melanoma (EORTC 1325-MG/KEYNOTE-054): health-related quality-of-life results from a double-blind, randomised, controlled, phase 3 trial. Lancet Oncol 22(5):655–664. https://doi.org/10.1016/S1470-2045(21)00081-4

Article   CAS   PubMed   Google Scholar  

Dummer R, Hauschild A, Santinami M, Atkinson V, Mandala M, Kirkwood JM et al (2020) Five-year analysis of adjuvant dabrafenib plus trametinib in stage III melanoma. N Engl J Med 383(12):1139–1148. https://doi.org/10.1056/NEJMoa2005493

Garutti M, Bergnach M, Polesel J, Palmero L, Pizzichetta MA, Puglisi F (2022) BRAF and MEK inhibitors and their toxicities: a meta-analysis. Cancers (basel). https://doi.org/10.3390/cancers15010141

Article   PubMed   Google Scholar  

Gershenwald JE, Scolyer RA, Hess KR, Sondak VK, Long GV, Ross MI et al (2017) Melanoma staging: evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 67(6):472–492. https://doi.org/10.3322/caac.21409

Kaehler KC, Blome C, Forschner A, Gutzmer R, Haalck T, Heinzerling L et al (2016) Preferences of German melanoma patients for interferon (IFN) alpha-2b toxicities (the DeCOG “GERMELATOX survey”) versus melanoma recurrence to quantify patients’ relative values for adjuvant therapy. Medicine (baltimore) 95(46):e5375. https://doi.org/10.1097/MD.0000000000005375

Kähler KC, Hüning S, Nashan D, Meiss F, Rafei-Shamsabadi DA, Rissmann H et al (2023) Preferences of German and Swiss melanoma patients for toxicities versus melanoma recurrence during adjuvant treatment (GERMELATOX-A-trial). J Cancer Res Clin Oncol 149(13):11705–11718. https://doi.org/10.1007/s00432-023-05027-z . ( Epub 2023 Jul 5. PMID: 37405475; PMCID: PMC10465664 )

Article   CAS   PubMed   PubMed Central   Google Scholar  

Khattak MA, Luke JJ, Long GV, Ascierto PA, Rutkowski P, Schadendorf D et al (2022) Adjuvant pembrolizumab versus placebo in resected high-risk stage II melanoma: health-related quality of life from the randomized phase 3 KEYNOTE-716 study. Eur J Cancer 176:207–217. https://doi.org/10.1016/j.ejca.2022.08.004

Kobeissi I, Tarhini AA (2022) Systemic adjuvant therapy for high-risk cutaneous melanoma. Ther Adv Med Oncol 14:17588359221134088. https://doi.org/10.1177/17588359221134087

Krammer R, Heinzerling L (2014) Therapy preferences in melanoma treatment-willingness to pay and preference of quality versus length of life of patients, physicians and healthy controls. PLoS ONE 9(11):e111237. https://doi.org/10.1371/journal.pone.0111237 . ( PMID: 25369124; PMCID: PMC4219712 )

Lai-Kwon J, Inderjeeth AJ, Lisy K, Sandhu S, Rutherford C, Jefford M (2023) Impact of immune checkpoint inhibitors and targeted therapy on health-related quality of life of people with stage III and IV melanoma: a mixed-methods systematic review. Eur J Cancer 184:83–105. https://doi.org/10.1016/j.ejca.2023.02.005 . ( Epub 2023 Feb 18. Erratum in: Eur J Cancer. 2023 Sep;190:112937. PMID: 36907021 )

Larkin J, Del Vecchio M, Mandalá M, Gogas H, Arance Fernandez AM, Dalle S et al (2023) Adjuvant nivolumab versus ipilimumab in resected stage III/IV melanoma: 5-year efficacy and biomarker results from CheckMate 238. Clin Cancer Res 29(17):3352–3361. https://doi.org/10.1158/1078-0432.CCR-22-3145 . ( PMID: 37058595; PMCID: PMC10472092 )

Lazaroff J, Bolotin D (2023) Targeted therapy and immunotherapy in melanoma. Dermatol Clin 41(1):65–77. https://doi.org/10.1016/j.det.2022.07.007

Livingstone A, Agarwal A, Stockler MR, Menzies AM, Howard K, Morton RL (2020) Preferences for immunotherapy in melanoma: a systematic review. Ann Surg Oncol 27(2):571–584. https://doi.org/10.1245/s10434-019-07963-y

Livingstone A, Dempsey K, Stockler MR, Howard K, Long GV, Carlino MSM et al (2021) Adjuvant immunotherapy recommendations for stage III melanoma: physician and nurse interviews. BMC Cancer 21(1):1014. https://doi.org/10.1186/s12885-021-08752-1.PMID:34507552;PMCID:PMC8434723

Livingstone E, Zimmer L, Hassel JC, Fluck M, Eigentler TK, Loquai C et al (2022) Adjuvant nivolumab plus ipilimumab or nivolumab alone versus placebo in patients with resected stage IV melanoma with no evidence of disease (IMMUNED): final results of a randomised, double-blind, phase 2 trial. Lancet 400(10358):1117–1129. https://doi.org/10.1016/S0140-6736(22)01654-3

Long GV, Luke JJ, Khattak MA, de la Cruz Merino L, Del Vecchio M, Rutkowski P et al (2022) Pembrolizumab versus placebo as adjuvant therapy in resected stage IIB or IIC melanoma (KEYNOTE-716): distant metastasis-free survival results of a multicentre, double-blind, randomised, phase 3 trial. Lancet Oncol 23(11):1378–1388. https://doi.org/10.1016/S1470-2045(22)00559-9

Mansfield C, Myers K, Klein K, Patel J, Nakasato A, Ling YL et al (2021) Risk tolerance in adjuvant and metastatic melanoma settings: a patient perspective study using the threshold technique. Future Oncol 17(17):2151–2167. https://doi.org/10.2217/fon-2020-1193

Pedersen S, Holmstroem RB, von Heymann A, Tolstrup LK, Madsen K, Petersen MA et al (2023) Quality of life and mental health in real-world patients with resected stage III/IV melanoma receiving adjuvant immunotherapy. Acta Oncol 62(1):62–69. https://doi.org/10.1080/0284186X.2023.2165449

Scarpato L, Festino L, Vanella V, Madonna G, Mastroianni M, Palla M, Ascierto PA (2022) Dermatologic adverse events associated with targeted therapies for melanoma. Expert Opin Drug Saf 21:385–395. https://doi.org/10.1080/14740338.2022.1986000 . ( Epub 2021 Nov 2 PMID: 34595993 )

Schadendorf D, Hauschild A, Mandalà M, Kirkwood JM, Robert C, Grob J-J et al (2022) Adjuvant dabrafenib plus trametinib (D + T) versus placebo in patients with resected stage III BRAFV600-mutant melanoma: updated 5-year distant metastases-free survival (DMFS) analysis of COMBI-AD. J Clin Oncol 40(16 suppl):9563–9563. https://doi.org/10.1200/JCO.2022.40.16_suppl.9563

Article   Google Scholar  

Schulz TU, Zierold S, Sachse MM, Pesch G, Tomsitz D, Schilbach K et al (2022) Persistent immune-related adverse events after cessation of checkpoint inhibitor therapy: prevalence and impact on patients’ health-related quality of life. Eur J Cancer 176:88–99. https://doi.org/10.1016/j.ejca.2022.08.029

Stellato D, Thabane M, Eichten C, Delea TE (2019) Preferences of Canadian patients and physicians for adjuvant treatments for melanoma. Curr Oncol 26(6):e755–e765. https://doi.org/10.3747/co.26.5085 . ( Epub 2019 Dec 1. PMID: 31896946; PMCID: PMC6927775 )

Wang DY, Salem JE, Cohen JV, Chandra S, Menzer C, Ye F et al (2018) Fatal toxic effects associated with immune checkpoint inhibitors: a systematic review and meta-analysis. JAMA Oncol 4(12):1721–1728. https://doi.org/10.1001/jamaoncol.2018.3923

Weilandt J, Diehl K, Schaarschmidt ML, Kiecker F, Sasama B, Pronk M et al (2021) Patient preferences for treatment of advanced melanoma: impact of comorbidities. J Dtsch Dermatol Ges 19(1):58–70. https://doi.org/10.1111/ddg.14293

Weiss J, Kirchberger MC, Heinzerling L (2020) Therapy preferences in melanoma treatment- willingness to pay and preference of quality versus length of life of patients, physicians, healthy individuals and physicians with oncological disease. Cancer Med 9(17):6132–6140. https://doi.org/10.1002/cam4.3191

Zhang M, He X, Wu J, Xie F (2023) Differences between physician and patient preferences for cancer treatments: a systematic review. BMC Cancer 23(1):1126. https://doi.org/10.1186/s12885-023-11598-4

Download references

Open Access funding enabled and organized by Projekt DEAL. The work was supported by Novartis.

Author information

Authors and affiliations.

Department of Dermatology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany

Katharina C. Kähler & Chiara Colapietro

Department of Dermatology, Johannes Wesling Medical Center Minden, Ruhr University Bochum Medical School, Bochum, Germany

Ralf Gutzmer & Yenny Angela

Department of Dermatology, University Hospital Essen, Essen, Germany

Elisabeth Livingstone & Georg Lodde

Department of Dermatology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany

Frank Meiss & David A. Rafei-Shamsabadi

Department of Dermatology, Dortmund, Germany

Sera S. Weyer-Fahlbusch & Dorothée Nashan

Department of Dermatology, Klinikum Bremen-Ost, Gesundheitnord gGmbH, Bremen, Germany

Carmen Loquai

Medical Faculty Heidelberg, Department of Dermatology and National Center for Tumor Diseases (NCT), Heidelberg University, NCT Heidelberg, a partnership between DKFZ and University Hospital Heidelberg, Heidelberg, Germany

Jessica C. Hassel

Department of Dermatology, Bremerhaven, Germany

Michael M. M. Sachse

Department of Dermatology, University Hospital Basel, Basel, Switzerland

Lara V. Maul

Department of Dermatology, University Hospital Zurich, Zurich, Switzerland

Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany

Lucie Heinzerling

Department of Dermatology, Uniklinikum Erlangen, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany

Markus V. Heppt

Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Judith Rusch & Christine Blome

Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nuremberg (CCC ER-EMN), Erlangen, Germany

You can also search for this author in PubMed   Google Scholar

Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Katharina C. Kähler and Christine Blome. The first draft of the manuscript was written by Katharina C. Kähler and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Katharina C. Kähler .

Ethics declarations

Conflict of interest.

KCK serves as consultant to Philogen, BMS, MSD, Sanofi Aventis, Immunocore and received travel grants and speaker fees from Philogen, Pierre Fabre, BMS, MSD, Sun Pharma, Sanofi Aventis, Novartis, Medac and has received research support by Novartis. RG reports grants or contracts from Novartis, Sun Pharma, Amgen, Sanofi, Merck-Serono, Kyowa-Kirin, and Almirall-Hermal; payment or honoraria for lectures, presentation, manuscript writing or educational events from Roche Pharma, Bristol Myers Squibb, Novartis, Merck Sharp & Dohme, Almirall-Hermal, Amgen, and Merck-Serono; support for attending meetings and/or travel from Sun Pharma, Pierre Fabre, and Boehringer-Ingelheim; participation on a data safety monitoring board or advisory board for Roche Pharma, Bristol Myers Squibb, Novartis, Merck Sharp & Dohme, Almirall-Hermal, Amgen, Pierre Fabre, Merck-Serono, Sun Pharma, Merck-Serono, Sanofi, 4SC and Immunocore. YA received honoraria and travel grants from BMS, MSD, Novartis, Almirall Hermal, SUN, Sanofi, Pierre-Fabre. EL served as consultant and/or has received honoraria from Bristol-Myers Squibb, Merck Sharp & Dohme, Novartis, Pierre-Fabre, Sanofi, Sunpharma, Takeda and travel support from Bristol-Myers Squibb, Pierre- Fabre, Sunpharma and Novartis, outside the submitted work. GL received travel support from Sun Pharma, Pierre Fabre, research funding from Novartis. FM served as consultant and/or has received honoraria from Novartis, Bristol-Myers Squibb, Merck Sharp & Dohme, Pierre Fabre, Sanofi Genzyme, Sun Pharma and travel support from Novartis, Sun Pharma, Pierre Fabre and Merck Sharp & Dohme, outside the submitted work. DARS served as consultant and/or has received honoraria from BMS, MSD, Pierre Fabre, Sanofi Genzyme, Roche, Novartis, Sun Pharma. SWF has no conflicts. DN has no conflicts. CL served for advisory Boards and received speakers fees and travel reimbursement from BMS, MSD, Merck, Almirall Hermal, Sanofi, Immunocore, Sun Pharma, Biontech, Pierre Fabre, Merck, Novartis. JCH served for advisory boards and received speakers fees and travel reimbursement from Amgen, BMS, Delcath, GSK, Immunocore, MSD, Novartis, Onkowissen, Pierre Fabre, Sanofi, Sunpharma. MMS has received consulting fees from Novartis and Sanofi. LVM has served as advisor and/or received speaking fees and/or participated in clinical trials sponsored by Almirall, Amgen, Eli Lilly, Incyte, MSD, Novartis, Pierre Fabre, Roche, and Sanofi outside of the current work. LH Lucie Heinzerling declares speakers and advisory board honoraria from Bristol-Myers Squibb GmbH & Co. KGaA, Immunocore Ireland Ltd, Kyowa Kirin GmbH, MSD Sharp & Dohme GmbH, Novartis Pharma GmbHm Pieris Pharmaceuticals, Pierre Fabre Pharma GmbH, Sanofi-Aventis Deutschland GmbH, Stemline Therapeutics Switzerland GmbH, SUN Pharmaceutical Europe Industries BV, Therakos (UK) LTD. Patents: IL-12 plasmid DNA; VEGF-D for lymphangiogenesis; soluble prognostic marker for melanoma. Clinical studies within the institution: Agenus, AstraZeneca Inc., Bristol Myers Squibb, Huya Bioscience, IO Biotech, Merck Sharp & Dohme GmbH, Pfizer, Pierre Fabre, Regeneron, Replimune, Sanofi Aventis. MVH has received honoraria from Sanofi, Almirall, Biofrontera, Galderma, Novartis, BMS, MSD, Roche, Immunocore, Sun Pharmaceuticals, Pierre Fabre. CC has no conflicts. JR has no conflicts. CB has received speaker honoraria, research grants and/or awards from Amgen/Celgene, AstraZeneca, Bauerfeind, Hartmann, Helios Klinik Leisnig, Janssen-Cilag, Kreussler, Lilly, Mapi Group, medi, Pfizer, Stiefel Laboratories, The EuroQol Group, UCB, and Urgo.

Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Christian-Albrechts-University Kiel (2nd March 2020/D435/20).

Consent to participate

All patients have given written informed consent.

Additional information

Publisher's note.

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

An abstract containing parts of the submitted data has been accepted as poster at the ASCO Annual Meeting in 2022.

Rights and permissions

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

Reprints and permissions

About this article

Kähler, K.C., Gutzmer, R., Angela, Y. et al. Preferences of physicians for treatment-related toxicity vs. recurrence in melanoma (GERMELATOX-A): the doctors’ perspective. J Cancer Res Clin Oncol 150 , 252 (2024). https://doi.org/10.1007/s00432-024-05713-6

Download citation

Received : 23 February 2024

Accepted : 18 March 2024

Published : 14 May 2024

DOI : https://doi.org/10.1007/s00432-024-05713-6

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

• Physician preferences
• Treatment toxicity
• Adjuvant treatment
• Find a journal
• Publish with us
• Track your research