No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Qualitative Methods in Health Services and Management Research: Pockets of Excellence and Progress, but Still a Long Way to Go
Abstract
The 10-year systematic review of published health services and management research by Weiner et al. (2011) chronicles the contributions of qualitative methods, highlights areas of substantial progress, and identifies areas in need of more progress. This article (Devers, 2011) discusses possible reasons for lack of progress in some areas--related to the under-supply of well-trained qualitative researchers and more tangible demand for their research--and mechanisms for future improvement. To ensure a robust health services research toolbox, the field must take additional steps to provide stronger education and training in qualitative methods and more funding and publication opportunities. Given the rapidly changing health care system post the passage of national health reform and the chalresearch issues associated with it, the health services research and management field will not meet its future challenges with quantitative methods alone or with a half-empty toolbox.
... Distinguishing rigor and quality in qualitative research is challenging because qualitative 1 methods are epistemologically diverse (Barbour 2001;Creswell 2007; Author YEAR.). 2 Qualitative methods appear in an expansive and variegated collection of PCOR and HSR studies 3 ranging from humanistic exploration to randomized trials. This diversity is a strength because it 4 allows for the theoretical and methodological flexibility necessary to engage with a novel topic 5 (16). ...
... Information gleaned from the review of this 1 secondary set of sources did not substantially alter the conclusions drawn from the primary 2 sources. 3 <INSERT TABLE 1> 4 5 Range of Approaches in Qualitative Research 6 Qualitative research incorporates a range of methods including in-depth interviews, focus 7 groups, participant-observation, ethnography and many others (26). Even within a single method 8 such as ethnography or interviewing, accepted approaches, as well as standards for rigor, vary 9 depending on the disciplinary and theoretical orientations of the researchers and project. ...
... Given this 1 intellectual diversity, it is inappropriate to use a single yardstick for all qualitative HSR. Rather, 2 assessments of qualitative rigor or quality must begin with an assessment of a study's theoretical 3 orientations and research objectives to ensure that rigor is assessed on a study's own terms. This 4 paper builds on previous discussions of qualitative rigor by describing how their dimensions of 5 rigor can be fruitfully expanded to include the assessment of studies that adopt exploratory, 6 descriptive, or comparative objectives. ...
Objective: To propose a framework for assessing the rigor of qualitative research that identifies and distinguishes between the diverse objectives of qualitative studies currently used in patient-centered outcomes and health services research (PCOR and HSR). Study Design: Narrative review of published literature discussing qualitative guidelines and standards in peer-reviewed journals and national funding organizations that support PCOR and HSR. Principal Findings: We identify and distinguish three objectives of current qualitative studies in PCOR and HSR: exploratory, descriptive, and comparative. For each objective, we propose methodological standards that can be used to assess and improve rigor across all study phases—from design to reporting. Similar to quantitative studies, we argue that standards for qualitative rigor differ, appropriately, for studies with different objectives and should be evaluated as such. Conclusions: Distinguishing between different objectives of qualitative HSR improves the ability to appreciate variation in qualitative studies as well as appropriately evaluate the rigor and success of studies in meeting their own objectives. Researchers, funders, and journal editors should consider how adopting the criteria for assessing qualitative rigor outlined here may advance the rigor and potential impact of qualitative research in patient-centered outcomes and health services research.
... She argues that while a certain degree of progress has been made, ''qualitative research still has a long way to go'', and that researchers should be better trained in qualitative and mixed-methods research to successfully apply them to the challenges of healthcare improvement. 43 Many resources exist to help researchers strengthen the reporting of QR. For example, Tong et al. developed a checklist of 32 items to be included in QR reports. ...
PurposeQualitative research (QR) take advantage of a wide range of methods and theoretical frameworks to explore people’s beliefs, perspectives, experiences, and behaviours and has been applied to many areas of healthcare. The aim of this review was to explore how QR has contributed to the field of perioperative anesthesiology.SourceWe performed a systematic scoping review of published QR studies pertaining to the field of perioperative anesthesiology in three databases (CINAHL, Pubmed, and Embase), published between January 2000 and June 2018. We extracted data regarding publication and researchers’ characteristics, main study objectives, and methodological details. Descriptive statistics were generated for each data extraction category.Principal findingsA total of 107 articles fulfilled our inclusion criteria. We identified 13 main research topics addressed by the included studies. Topics such as “patient safety,” “barriers to evidence-base medicine,” “patient experiences under local/regional anesthesia,” “training in practice,” “experiences of care,” and “implementation of changes in clinical practice” were commonly tackled. Others, such as “interprofessional communication”, “work environment,” and “patients’/healthcare professionals’ interactions” were less common. Qualitative research was often poorly reported and methodological details were frequently missing.Conclusion
Qualitative research has been used to explore an array of issues in perioperative anesthesiology. Some areas may benefit from further primary research, such as interprofessional communication or patient-centred care, while other areas may deserve a detailed systematic knowledge synthesis. We identified suboptimal reporting of qualitative methods and their link to study findings. Increased attention to quality criteria and reporting standards in QR is called for.
... Both the number of works and breadth of approaches have expanded in recent years (Morse, 2015(Morse, , 2016. Widespread use of qualitative approaches has been described in several areas of the health sciences, including clinical research (Atchan et al., 2016;Bressan et al., 2017;Cambon et al., 2016;Cooper et al., 2014;Feudtner, 2013;Gallagher et al., 2009;Hanson et al., 2017;Holloway & Galvin, 2017;Johnson & Obrien, 2016;Knudsen et al., 2012;Macdonald & Chalk, 2011;Miller et al., 2015;Nelson et al., 2015;Rapport et al., 2013;Rusinová et al., 2009;Shaw et al., 2010;Tong et al., 2016), public health research (Bower & Scambler, 2007;Jack, 2006;Padgett, 2012;Stoto et al., 2013;Tolley et al., 2016), health services and management research (Devers, 2011;Palinkas, 2014), translational research (Chesla, 2008;Tripp-Reimer & Doebbeling, 2004), dissemination and implementation research (Albright et al., 2013;Green et al., 2015;Hoagwood et al., 2015;Holtrop et al., 2018;McEvoy et al., 2014;National Cancer Institute Qualitative Research in Implementation Science Group, 2018;Southam-Gerow & Dorsey, 2014), and the health sciences generally (Bourgeault et al., 2013;Curry & Nunez-Smith, 2015;Morse, 2015Morse, , 2016. Moreover, funding for qualitative health research has become ever more available, in part because federal agencies are increasingly prioritizing patient perspectives (Vandermause et al., 2017). ...
Qualitative methodologies and methods are commonly used in health policy and systems research but have not been extensively characterized. We describe how qualitative approaches are used within the field and present a framework to aid researchers in study planning. To achieve these aims, we conducted a scoping literature review of 1 year of selected health policy and systems research and then coded publications based on their primary analytical foci. Four core themes emerged: policy or program content, an analysis of the substance of policies or program documents; policy or program environment, a study of the landscape of policies or programs; policy or program implementation, a study of the planned or actual execution of a policy or program; and organization or system operations, a study of the structure or function of health organizations or systems. We provide guidance on utilizing the framework and adhering to qualitative best practices during the process.
... In recent decades, the role of qualitative research in health services research (HSR) and allied fields has maintained steady, yet unsettled, interest and value. Evidence of steady interest includes publication of qualitative reviews and guidelines by leading journals including Health Services Research, 1 2 Medical Care Research and Review [3][4][5] and BMJ, 6 7 and by funders including the Robert Wood Johnson Foundation, 8 National Institutes of Health 9 10 and National Science Foundation. 11 12 In fields such as Patient-Centered Outcomes Research (PCOR) and implementation science, qualitative research has been embraced with particular enthusiasm for its ability to capture, advance and address questions meaningful to patients, clinicians and other healthcare system stakeholders. ...
The objective of this commentary is to develop a framework for assessing the rigour of qualitative approaches that identifies and distinguishes between the diverse objectives of qualitative health research, guided by a narrative review of the published literature on qualitative guidelines and standards from peer-reviewed journals and national funding organisations that support health services research, patient-centered outcomes research and other applied health research fields. In this framework, we identify and distinguish three objectives of qualitative studies in applied health research: exploratory, descriptive and comparative. For each objective, we propose methodological standards that may be used to assess and improve rigour across all study phases—from design to reporting. Similar to hierarchies of quality of evidence within quantitative studies, we argue that standards for qualitative rigour differ, appropriately, for studies with different objectives and should be evaluated as such. Distinguishing between different objectives of qualitative health research improves the ability to appreciate variation in qualitative studies and to develop appropriate evaluations of the rigour and success of qualitative studies in meeting their stated objectives. Researchers, funders and journal editors should consider how further developing and adopting the framework for assessing qualitative rigour outlined here may advance the rigour and potential impact of this important mode of inquiry.
... It is beyond the scope of this manuscript to address this discussion in depth, but one of the challenges that the HSR field has faced imperfectly has been the use of quantitative, qualitative methods, and mixed methods, consistently and effectively to solve the complex problems we address through our work. It has been noted that qualitative methods have not been employed as well as could be possible (Devers 2011). There are other methodologic developments that doctoral programs could consider exposing students to in some capacity, including machine learning and advanced causal inference methods beyond the commonly taught difference-in-difference, propensity score, and instrumental variable methods. ...
Objective:
To present revised core competencies for doctoral programs in health services research (HSR), modalities to deliver these competencies, and suggested methods for assessing mastery of these competencies.
Data sources and data collection:
Core competencies were originally developed in 2005, updated (but unpublished) in 2008, modestly updated for a 2016 HSR workforce conference, and revised based on feedback from attendees. Additional feedback was obtained from doctoral program directors, employer/workforce experts and attendees of presentation on these competencies at the AcademyHealth's June 2017 Annual Research Meeting.
Principal findings:
The current version (V2.1) competencies include the ethical conduct of research, conceptual models, development of research questions, study designs, data measurement and collection methods, statistical methods for analyzing data, professional collaboration, and knowledge dissemination. These competencies represent a core that defines what HSR researchers should master in order to address the complexities of microsystem to macro-system research that HSR entails. There are opportunities to conduct formal evaluation of newer delivery modalities (e.g., flipped classrooms) and to integrate new Learning Health System Researcher Core Competencies, developed by AHRQ, into the HSR core competencies.
Conclusions:
Core competencies in HSR are a continually evolving work in progress because new research questions arise, new methods are developed, and the trans-disciplinary nature of the field leads to new multidisciplinary and team building needs.
... And, secondly, we note that qualitative methodology (consensus techniques) allow obtaining quantitative estimates determining the degree of agreement among participants (Pope & Mays;Devers, 2011). ...
Observational and descriptive studies (ODS) represent between 70 % and 80 % of the designs utilized in biomedical publications of the different scientific journals. Despite this, there are no tools to guide writers and to assist reviewers in reporting results with this type of research design. The aim of this study was to report the characteristics of a validated checklist for reporting the results using ODS as research designs in an English version. Two-stage study with qualitative methodology. In a first stage, a proposal was designed, by collecting items and domains from an extensive review of the literature. In the second, an instrument was developed by applying reduction items and domains through a panel of 45 experts comprised of clinical academics, reviewers and editors of biomedical journals, and experts in research methodology. These worked determining the validity of facade and content of the instrument. The items and domains incorporated into the final instrument were those in which over 80 % of agreement was achieved between the participants (36 of 45). In this way an instrument was created composed of 19 items, grouped into four domains. Characteristics of the design, construction and validation of a checklist that could help authors, reviewers and journal editors to write and review articles using ODS as research designs to report results was reported.
... Traditionally, health care research has made a greater use of quantitative research designs, but an increasing awareness of the important con tribution of qualitative research to health research is evi dent. [21][22][23][24] Mixed methods, where data from quantitative and qualitative methods are integrated, are increasingly being used across the social sciences. We propose that the adop tion of the tenets of lifespan development theory, while not requiring mixed methods, does highlight the usefulness of this approach to truly recognize and appreciate the multi dimensionality of human experience. ...
Orthopedic surgical care, like all health care today, is in flux owing to an aging population and to chronic medical conditions leading to an increased number of people with illnesses that need to be managed over the lifespan. The result is an ongoing shift from curing acute illnesses to the management and care of chronic illness and conditions. Theoretical models that provide a useful and feasible vision for the future of health care and health care research are needed. This review discusses how the lifespan development model used in some disciplines within the behavioural sciences can be seen as an extension of the biopsychosocial model. We posit that the lifespan development model provides useful perspectives for both orthopedic care and research. We present key concepts and recommendations, and we discuss how the lifespan development model can contribute to new and evolving perspectives on orthopedic outcomes and to new directions for research. We also offer practical guidelines on how to implement the model in orthopedic practice.
... Multiple attempts have been made to establish such guidelines, but qualitative scholars do not agree on which guidelines are appropriate and helpful. 21,22 It may be sensible to recognize that there are multiple forms and applications of qualitative analysis and that different standards may be appropriate for single-case exploratory studies and for multiplecase comparative studies. ...
When making health care decisions, patients and consumers use data but also gather stories from family and friends. When advising patients, clinicians consult the medical evidence but also use professional judgment. These stories and judgments, as well as other forms of narrative, shape decision making but remain poorly understood. Furthermore, qualitative research methods to examine narrative are rarely included in health science research. We illustrate how narratives shape decision making and explain why it is difficult but necessary to integrate qualitative research on narrative into the health sciences. We draw on social-scientific insights on rigorous qualitative research and our ongoing studies of decision making by patients with cancer, and we describe new tools and approaches that link qualitative research findings with the predominantly quantitative health science scholarship. Finally, we highlight the benefits of more fully integrating qualitative research and narrative analysis into the medical evidence base and into evidencebased medical practice. © 2016 Project HOPE- The People-to-People Health Foundation, Inc.
... In transcribing, confidentiality was ensured by use of codes instead of names. Transcribed data was read and re-read by the researcher several times for familiarity and general understanding of the scope of context of key information [13] . When the scripts were read and re-read, interesting contents based on themes were grouped together into categories. ...
... 7 An editorial about health services research also highlighted the need to develop skills and train people in qualitative research and mixed methods and the need for structural changes in journal publications, such as longer word lengths and skilled reviewers, to facilitate qualitative research. 144 Simons 145 reported her personal experience of being a trial co-ordinator and carrying out a qualitative case study within the trial for a PhD, offering a different, but complementary, perspective. Simons 145 highlighted the difficulties of both being engaged with a trial and undertaking qualitative research that challenged the trial, taking care not to damage the experiment while doing the qualitative research, being very rigid in her interviewing technique compared with a sociologist she worked with. ...
Background:
Researchers sometimes undertake qualitative research with randomised controlled trials (RCTs) of health interventions.
Objectives:
To systematically explore how qualitative research is being used with trials and identify ways of maximising its value to the trial aim of providing evidence of effectiveness of health interventions.
Design:
A sequential mixed methods study with four components.
Methods:
(1) Database search of peer-reviewed journals between January 2008 and September 2010 for articles reporting the qualitative research undertaken with specific trials, (2) systematic search of database of registered trials to identify studies combining qualitative research and trials, (3) survey of 200 lead investigators of trials with no apparent qualitative research and (4) semistructured telephone interviews with 18 researchers purposively sampled from the first three methods.
Results:
Qualitative research was undertaken with at least 12% of trials. A large number of articles reporting qualitative research undertaken with trials (n=296) were published between 2008 and 2010. A total of 28% (82/296) of articles reported qualitative research undertaken at the pre-trial stage and around one-quarter concerned drugs or devices. The articles focused on 22 aspects of the trial within five broad categories. Some focused on more than one aspect of the trial, totalling 356 examples. The qualitative research focused on the intervention being trialled (71%, 254/356), the design and conduct of the trial (15%, 54/356), the outcomes of the trial (1%, 5/356), the measures used in the trial (3%, 10/356), and the health condition in the trial (9%, 33/356). The potential value of the qualitative research to the trial endeavour included improving the external validity of trials and facilitating interpretation of trial findings. This value could be maximised by using qualitative research more at the pre-trial stage and reporting findings with explicit attention to the implications for the trial endeavour. During interviews, three models of study were identified: qualitative research as peripheral to the trial, qualitative research as an 'add-on' to the trial and a study with qualitative research and trial as essential components, with the third model offering more opportunity to maximise the value of the qualitative research. Interviewees valued the use of qualitative research with trials and identified team structures and wider structural issues which gave more value to the trial than the qualitative research as barriers to maximising the value of the qualitative research.
Conclusion:
A large number of articles were published between 2008 and 2010, addressing a wide range of aspects of trials. There were examples of this research affecting the trial by facilitating interpretation of trial findings, developing and refining interventions for testing in the trial and changing the measures used in the trial. However, researchers were not necessarily maximising the value of qualitative research undertaken with trials to the endeavour of generating evidence of effectiveness of health interventions. Researchers can maximise value by promoting its use at the pre-trial stage to ensure that the intervention and trial conduct is optimised at the main trial stage, being explicit about the conclusions for the trial endeavour in peer-reviewed journal articles reporting the qualitative research and valuing the contribution of the qualitative research as much as the trial. Future recommendations for researchers include: plan the qualitative research, design and implement studies not trials, use qualitative research at the feasibility and pilot stage of trials, be explicit in publications about the impact of the qualitative research on the trial and implications for the trial endeavour, undertake in-depth qualitative research, allow qualitative research to take a challenging role and develop a learning environment around the use of qualitative research and trials.
Funding:
This project was funded by the Medical Research Council (MRC) as part of the MRC-National Institute for Health Research Methodology Research programme.
... Nowadays, there is consensus that in health and health care research both approaches are needed and the combination of quantitative and qualitative elements in mixedmethod approaches is seen as most appropriate to enhance the understanding in these research fields. In addition, many recent qualitative research publications focus on methodological issues such as the improvement of interview techniques, the establishment of quality criteria, as well as the development of methods for the synthesis of qualitative research, with the aim of improving qualitative research in general, and in health and health care in particular (Hasseler 2007;Kroll et al. 2007; Barnett-Page & Thomas 2009;Kelly 2010;Devers 2011;Merry et al. 2011;Morse 2011;Reynolds et al. 2011) Using the same approach as applied in the study of Hoff and Witt (2000, cit. in Weiner et al. 2011), Weiner et al. (2011 authored an interesting review focusing on qualitative research in health services and management research over a 10-year period. In total, they selected nine health services and management journals published between 1998 and 2008 and analyzed the quantity, characteristics, and quality of qualitative research studies. ...
Health care utilization can be regarded as a complex process influenced by the individual’s health status, individual and collective norms and value, the structure of the health care and social welfare system as well as by general societal conditions. It is well known that not only need factors impact the use of health care and medical services. Other aspects, such as enabling and predisposing factors, as defined in Andersen’s Behavioral Model of Health Care Use (Anderson & Davidson 2001), are highly relevant and constitute facilitating or hindering determinants of health care utilization (see Chap. 2 by von Lengerke et al.).
To date, plenty of empirical studies are available to describe health care utilization in general, as well as for specific diseases or settings, most of whom use quantitative research methods. However, the processes of health care utilization are not fully explored so far and there is still a need for in-depth analyses. For this purpose, qualitative approaches provide an excellent opportunity to elaborate on mechanisms of health care utilization and to develop new or rather to develop existing theoretical frameworks.
... Due to the heterogeneity and complexity of the studies regarding patient groups, health service innovations, and research targets, and to provide a richer source of evidence, we chose an approach combining quantitative and qualitative narrative evaluation of the selected articles [39]. Qualitative methods are useful for exploring key domains in health service research [40]. The data were explored using content analysis to break them down into categories (or typologies) relevant to this review [41]. ...
Over the last two decades, the number of studies on electronic symptom reporting has increased greatly. However, the field is very heterogeneous: the choices of patient groups, health service innovations, and research targets seem to involve a broad range of foci. To move the field forward, it is necessary to build on work that has been done and direct further research to the areas holding most promise. Therefore, we conducted a comprehensive review of randomized controlled trials (RCTs) focusing on electronic communication between patient and provider to improve health care service quality, presented in two parts. Part 2 investigates the methodological quality and effects of the RCTs, and demonstrates some promising benefits of electronic symptom reporting.
To give a comprehensive overview of the most mature part of this emerging field regarding (1) patient groups, (2) health service innovations, and (3) research targets relevant to electronic symptom reporting.
We searched Medline, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, and IEEE Xplore for original studies presented in English-language articles published from 1990 to November 2011. Inclusion criteria were RCTs of interventions where patients or parents reported health information electronically to the health care system for health care purposes and were given feedback.
Of 642 records identified, we included 32 articles representing 29 studies. The included articles were published from 2002, with 24 published during the last 5 years. The following five patient groups were represented: respiratory and lung diseases (12 studies), cancer (6), psychiatry (6), cardiovascular (3), and diabetes (1). In addition to these, 1 study had a mix of three groups. All included studies, except 1, focused on long-term conditions. We identified four categories of health service innovations: consultation support (7 studies), monitoring with clinician support (12), self-management with clinician support (9), and therapy (1). Most of the research (21/29, 72%) was conducted within four combinations: consultation support innovation in the cancer group (5/29, 17%), monitoring innovation in the respiratory and lung diseases group (8/29, 28%), and self-management innovations in psychiatry (4/29, 14%) and in the respiratory and lung diseases group (4/29, 14%). Research targets in the consultation support studies focused on increased patient centeredness, while monitoring and self-management mainly aimed at documenting health benefits. All except 1 study aiming for reduced health care costs were in the monitoring group.
RCT-based research on electronic symptom reporting has developed enormously since 2002. Research including additional patient groups or new combinations of patient groups with the four identified health service innovations can be expected in the near future. We suggest that developing a generic model (not diagnosis specific) for electronic patient symptom reporting for long-term conditions may benefit the field.
Research is about choosing. It requires asking and answering core questions, such as: What do I (or we) want to do, and why? Who will do it, and how? When will it be done, and why? Where will it be done, and why? How will it be done, and why? Research involves more than selecting a series of procedures. One of my aims is to help myself and others make better choices about research.
Objective:
Determine current health services research (HSR) publication trends in major general otolaryngology journals.
Study design:
Bibliometric analysis.
Methods:
All main issues of 8 high-impact general-interest otolaryngology journals published worldwide in 2002, 2005, 2008, and 2011 were searched for HSR-related publications. To qualify as HSR, the abstract of the article must discuss access to care, cost, delivery of care, financing, health organizational or system issues, quality of care, resource utilization, and/or health outcomes. Otolaryngology topics were classified as general, pediatrics, oncology, otology and neurotology, sleep disorders, sinonasal disease, facial plastics, and/or laryngology. Other key measures included study authorship and external sponsorship or mechanism of support.
Results:
Of 5958 total articles, 449 (7.5%) qualified as HSR. There was a statistically significant increase in the number of HSR publications across all journals from 2002 to 2011 (P < .001). Outcomes research (337, 75.1%) was the most common type of HSR being published. The most common subject was oncology (112, 24.9%), whereas the least represented was trauma and facial plastics (4, 0.9%). First and corresponding authors were based in 31 countries, although the United States was the predominant country of origin. Nearly 95% of HSR articles in the current sample demonstrated multidisciplinary authorship. An estimated 22.9% of first authors and 17.8% of corresponding authors were female. Two-thirds of HSR publications reported no external sponsor, whereas the remainder was supported most commonly by philanthropy and hospital-based sources.
Conclusion:
Health services research is an international, multidisciplinary field of inquiry with an increasing presence in major otolaryngology journals.
Context
Based on evidence that β-blockers can reduce mortality in patients
with acute myocardial infarction (AMI), many hospitals have initiated performance
improvement efforts to increase prescription of β-blockers at discharge.
Determination of the factors associated with such improvements may provide
guidance to hospitals that have been less successful in increasing β-blocker
use.Objectives
To identify factors that may influence the success of improvement efforts
to increase β-blocker use after AMI and to develop a taxonomy for classifying
such efforts.Design, Setting, and Participants
Qualitative study in which data were gathered from in-depth interviews
conducted in March-June 2000 with 45 key physician, nursing, quality management,
and administrative participants at 8 US hospitals chosen to represent a range
of hospital sizes, geographic regions, and changes in β-blocker use rates
between October 1996 and September 1999.Main Outcome Measures
Initiatives, strategies, and approaches to improve care for patients
with AMI.Results
The interviews revealed 6 broad factors that characterized hospital-based
improvement efforts: goals of the efforts, administrative support, support
among clinicians, design and implementation of improvement initiatives, use
of data, and modifying variables. Hospitals with greater improvements in β-blocker
use over time demonstrated 4 characteristics not found in hospitals with less
or no improvement: shared goals for improvement, substantial administrative
support, strong physician leadership advocating β-blocker use, and use
of credible data feedback.Conclusions
This study provides a context for understanding efforts to improve care
in the hospital setting by describing a taxonomy for classifying and evaluating
such efforts. In addition, the study suggests possible elements of successful
efforts to increase β-blocker use for patients with AMI.
Randomized clinical trials have demonstrated the efficacy of β-blocker
use in reducing mortality and future cardiac events after acute myocardial
infarction (AMI).1 Based on substantial evidence,
clinical practice guidelines for AMI published by the American College of
Cardiology and the American Heart Association2
strongly recommend the use of β-blockers for secondary prevention after
AMI.
Despite the evidence and the published guidelines, studies have repeatedly
demonstrated wide variation and underuse of β-blockers.3- 13
The American Medical Association has reminded physicians of the importance
of β-blocker use after AMI,14 and both
the Health Care Financing Administration and the National Committee for Quality
Assurance have adopted β-blocker use after AMI as a quality-of-care indicator.
Physicians and hospitals thus have considerable motivation to increase the
use of β-blockers after AMI. Yet factors associated with successful improvement
efforts to increase their use over time in the hospital setting are poorly
understood.
Identifying factors associated with successful performance improvement
in the use of β-blockers after AMI can provide guidance to hospitals
that have been less successful in increasing their use over time. Also, the
lessons learned from improving the use of β-blockers may be relevant
to other efforts to improve clinical care and patient outcomes. The first
step toward understanding the strategies used by hospitals is to carefully
and systematically collect information about their approaches, with particular
attention to factors associated with success. Despite the substantial attention
given to changing physicians' practices15- 19
and improving quality in clinical care,20- 25
efforts to classify the essential characteristics of initiatives for improvement
in AMI care are limited, and few studies have systematically explored the
factors that are common to the more successful improvement efforts directed
at increasing β-blocker use after AMI.
To address this topic, we designed a qualitative study intended to provide
an in-depth perspective on the ways that hospitals are improving care for
patients with AMI. The objectives of this study were to develop a taxonomy
that can be used to classify and evaluate hospital-based performance improvement
efforts in the care of patients with AMI with particular focus on β-blocker
use, and to explore how essential factors varied among higher- and lower-performing
hospitals.
Over the past 10 years, the field of health services and management research has seen renewed interest in the use of qualitative research methods. This article examines the volume and characteristics of qualitative research articles published in nine major health services and management journals between 1998 and 2008. Qualitative research articles comprise 9% of research articles published in these journals. Although the publication rate of qualitative research articles has not kept pace with that of quantitative research articles, citation analysis suggests that qualitative research articles contribute comparably to the field's knowledge base. A wide range of policy and management topics has been examined using qualitative methods. Case study designs, interviews, and documentary sources were the most frequently used methods. Half of qualitative research articles provided little or no detail about key aspects the study's methods. Implications are discussed and recommendations are offered for promoting the publication of qualitative research.
We undertook focus groups, interviews, and an online survey with health care consumers as part of a recent project to assist purchasers in communicating more effectively about health care evidence and quality. Most of the consumers were ages 18-64; had health insurance through a current employer; and had taken part in making decisions about health insurance coverage for themselves, their spouse, or someone else. We found many of these consumers' beliefs, values, and knowledge to be at odds with what policy makers prescribe as evidence-based health care. Few consumers understood terms such as "medical evidence" or "quality guidelines." Most believed that more care meant higher-quality, better care. The gaps in knowledge and misconceptions point to serious challenges in engaging consumers in evidence-based decision making.
This manuscript presents an initial description of doctoral level core competencies for health services research (HSR). The competencies were developed by a review of the literature, text analysis of institutional accreditation self-studies submitted to the Council on Education for Public Health, and a consensus conference of HSR educators from US educational institutions. The competencies are described in broad terms which reflect the unique expertise, interests, and preferred learning methods of academic HSR programs. This initial set of core competencies is published to generate further dialogue within and outside of the US about the most important learning objectives and methods for HSR training and to clarify the unique skills of HSR training program graduates.
Checklists can be useful improving qualitative research methods, but overzealous and uncritical use can be counterproductive Reducing qualitative research to a list of technical procedures (such as purposive sampling, grounded theory, multiple coding, triangulation, and respondent validation) is overly prescriptive and results in “the tail wagging the dog” None of these “technical fixes” in itself confers rigour; they can strengthen the rigour of qualitative research only if embedded in a broader understanding of qualitative research design and data analysis Otherwise we risk compromising the unique contribution that systematic qualitative research can make to health services research. This paper gave rise to some debate in the BMJ's rapid response section and has been instrumental in the issuing of several invitations to speak at international symposia. Research Group 4 - Quality of Life and Quality of Care in Acute and Chronic Illness
The financial implications of implementing quality improvements are often poorly understood. Simply put, does improving quality yield a return on investment? We examine four cases--management of high-cost pharmaceuticals, diabetes management, smoking cessation, and wellness programs in the workplace--to understand the financial and clinical implications of improving care. We explore costs and benefits, in both the short and the long term, to four stakeholders with different and sometimes conflicting interests: providers, purchasers and employers, individual patients, and society. Finally, we recommend policy changes to better align financial incentives for superior quality of care.
We wanted to review and synthesize published criteria for good qualitative research and develop a cogent set of evaluative criteria.
We identified published journal articles discussing criteria for rigorous research using standard search strategies then examined reference sections of relevant journal articles to identify books and book chapters on this topic. A cross-publication content analysis allowed us to identify criteria and understand the beliefs that shape them.
Seven criteria for good qualitative research emerged: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability. General agreement was observed across publications on the first 4 quality dimensions. On the last 3, important divergent perspectives were observed in how these criteria should be applied to qualitative research, with differences based on the paradigm embraced by the authors.
Qualitative research is not a unified field. Most manuscript and grant reviewers are not qualitative experts and are likely to embrace a generic set of criteria rather than those relevant to the particular qualitative approach proposed or reported. Reviewers and researchers need to be aware of this tendency and educate health care researchers about the criteria appropriate for evaluating qualitative research from within the theoretical and methodological framework from which it emerges.
To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements.
In-depth interviews, hospital surveys, and Health Quality Alliance data.
We conducted a qualitative study using in-depth interviews with clinical and administrative staff (N = 99) at hospitals reporting strong influence (n = 6) as well as hospitals reporting limited influence (n = 6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data.
In-depth, open-ended interviews; hospital survey.
Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes.
The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals.
To lay the foundation for an explicit review and dialogue concerning the criteria that should be used to evaluate qualitative health services research. Clear criteria are critical for the discipline because they provide a benchmark against which research can be assessed.
Existing literature in the social sciences and health services research, particularly in primary care and medicine.
Traditional criteria for evaluating qualitative research are rooted in the philosophical perspective (positivism) most closely associated with quantitative research and methods. As a result, qualitative research and methods may not be used as frequently as they can be and research results generated from qualitative studies may not be disseminated as widely as possible. However, alternative criteria for evaluating qualitative research have been proposed that reflect a different philosophical perspective (post-positivism). Moreover, these criteria are tailored to the unique purposes for which qualitative research is used and the research designs traditionally employed. While criteria based on these two different philosophical perspectives have much in common, some important differences exist.
The field of health services research must engage in a collective, "qualitative" process to determine which criteria to adopt (positivist or post-positivist), or whether some combination of the two is most appropriate. Greater clarity about the criteria used to evaluate qualitative research will strengthen the discipline by fostering a more appropriate and improved use of qualitative methods, a greater willingness to fund and publish "good" qualitative research, and the development of more informed consumers of qualitative research results.
Based on evidence that beta-blockers can reduce mortality in patients with acute myocardial infarction (AMI), many hospitals have initiated performance improvement efforts to increase prescription of beta-blockers at discharge. Determination of the factors associated with such improvements may provide guidance to hospitals that have been less successful in increasing beta-blocker use.
To identify factors that may influence the success of improvement efforts to increase beta-blocker use after AMI and to develop a taxonomy for classifying such efforts.
Qualitative study in which data were gathered from in-depth interviews conducted in March-June 2000 with 45 key physician, nursing, quality management, and administrative participants at 8 US hospitals chosen to represent a range of hospital sizes, geographic regions, and changes in beta-blocker use rates between October 1996 and September 1999.
Initiatives, strategies, and approaches to improve care for patients with AMI.
The interviews revealed 6 broad factors that characterized hospital-based improvement efforts: goals of the efforts, administrative support, support among clinicians, design and implementation of improvement initiatives, use of data, and modifying variables. Hospitals with greater improvements in beta-blocker use over time demonstrated 4 characteristics not found in hospitals with less or no improvement: shared goals for improvement, substantial administrative support, strong physician leadership advocating beta-blocker use, and use of credible data feedback.
This study provides a context for understanding efforts to improve care in the hospital setting by describing a taxonomy for classifying and evaluating such efforts. In addition, the study suggests possible elements of successful efforts to increase beta-blocker use for patients with AMI.
Health services research core competencies (Final Report) Rockville, MD: Author. Retrieved from http://www.ahrq.gov/fund/ training/hsrcomp.htm Agency for Healthcare Research and Quality Health services research core competencies (Final Report) Rockville, MD: Author. Retrieved from http
- Healthcare Agency
- Research
- Quality
Agency for Healthcare Research and Quality. (2005). Health services research core competencies (Final Report). Rockville, MD: Author. Retrieved from http://www.ahrq.gov/fund/
training/hsrcomp.htm
Agency for Healthcare Research and Quality. (2008). Health services research core competencies (Final Report). Rockville, MD: Author. Retrieved from http://www.ahrq.gov/fund/
training/hsrcomp08.htm
Qualitative research guidelines project. Retrieved from http
- D J Cohen
- B J Crabtree
Cohen, D. J., & Crabtree, B. J. (2006). Qualitative research guidelines project. Retrieved from
http://www.qualres.org/
Qualitative methods in health services research [Special issue]
- K J Devers
- S Sofaer
- T C Rundall
Devers, K. J., Sofaer, S., & Rundall, T. C. (Eds.). (1999). Qualitative methods in health services
research [Special issue]. Health Services Research, 34(5 Pt. 2).