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Global health case reports.

These are case reports that focus on the causes of ill health, the social determinants of health and access to healthcare services, prevailing local and national issues that affect health and wellbeing, and the challenges in providing care to vulnerable populations or with limited resources.

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24 January 2024

Unusual association of diseases/symptoms :

Obstetrics and gynaecology :

5 March 2024

Case report :

18 October 2023

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Case Reports by specialty

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• Geriatric medicine
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• Infectious diseases
• Obstetrics and gynaecology
• Ophthalmology
• Orthopaedics
• Paediatrics
• Respiratory medicine
• Rheumatology

Global Health Competition

Every year BMJ Case Reports selects authors of global health case reports to join our editorial team as a global health associate editor.

This is an opportunity to gain some editorial experience or join our team on research and educational projects. Students and graduates may apply.

Simply select Global Health Competition when you submit.

Latest Articles

9 August 2024

Paediatrics :

8 August 2024

The CASE Journal

• Submit your case
• Author guidelines
• Editorial team
• Indexing & metrics
• Competitions
• Calls for cases & news

Guidelines for authors

We welcome cases written about real people, in real organisations, who have to make real decisions. Cases can be developed from primary data and/or secondary data. Cases can have some information disguised which will need to be outlined in your research methods section in the teaching note, and the real individuals and/or company need to provide consent for the publication of the disguised case. We do not publish fictional cases.

Before you submit your case and IM, Compact Case and Teaching Note, industry note, technical note, critical incident or article to The CASE Journal , please check that your submission complies with the following:

• Do not include a synopsis or abstract – save it for the instructors’ manual.
• The case must be factual : that is, using real people, real companies, real situations – no composites. You may disguise the company and individuals involved (note that on the first page of the case), but this does not relieve you of the responsibility for obtaining a release.
• All cases must be written in the past tense , except for direct quotes. Cases written in the present tense will be returned without review.
• Cases do not have to have a decision focus; illustrative, descriptive, and analytical cases are welcome at The Case Journal.
• Use 1” margins, single spacing, and clearly numbered exhibits or appendices. Number all tables, appendices, attachments, illustrations, exhibits, maps, and other sorts of ancillary material sequentially, using the generic “Exhibit” as the identifier.

Case study writing guide

Instructors' manual

The instructors' manual should contain the following information (at minimum):

• Include an appropriate synopsis describing the context of the case, the dilemma being faced, and the discipline the case is relevant for.
• Detail a set of teaching objectives appropriate for the stated target audience.
• Provide a research methods section that details the types of data used to develop the case.
• Include a 90-minute multi-media teaching plan, including suggested classroom facilitation questions and activities.
• Include a set of assignment questions with exemplary answers that align with the teaching objectives, and relate to the dilemma being faced in the case.
• Use recent literature, theory, or research findings to analyse the case study and provide model answers to the assignment questions.
• Include a specific set of instructions as to how this case can be used in a live environment and the ways in which an educator might want to consider adapting the teaching plan to use it in this way.
• You are welcome to include an epilogue of the case, of what really happened, if known.

Compact Cases

The CASE Journal publishes Compact Cases designed to provide sufficient information to motivate student learning, illustrate concepts and provide discussion opportunities in a shorter case format. Compact Cases must meet all of the guidelines for Cases, but are limited to 500-1,000 words in length (just about two single-spaced pages). Compact cases have a briefer Teaching Note (described below) instead of a full Instructor’s manual.

Teaching Note

Only Compact Cases utilise a Teaching Note. Do not utilise these guidelines for cases that exceed 1,000 words in length. The Teaching Note should contain:

• Abbreviated abstract
• Case usage (level and course)
• Learning objectives (usually one or two)
• Discussion questions (usually no more than three)
• Theory Discussion (more tightly focused than for full length case)
• Answers to Discussion Questions
• Teaching Tips/Activities
• Epilogue (if known)
• Authors must provide a structured abstract of no more than 400 words for their case, this is to be completed on the title page.  The structured abstract is to be split into the following sections; Synopsis, Research Methodology, Relevant Courses and Levels & Theoretical Basis.  Authors must also provide a minimum of 5 keywords for their case study.

Teaching note writing guide

Teaching cases submitted for publication should not have been published before in their current or substantially similar form, or be under consideration for publication with any ISSN/ ISBN registered publication. Please see Emerald’s originality guidelines for details. Authors submitting teaching cases for publication warrant that the work is not an infringement of any existing copyright and will indemnify the publisher against any breach of such warranty. For ease of dissemination and to ensure proper policing of use, papers and contributions become the legal copyright of the publisher unless otherwise agreed. The editor may make use of iThenticate software for checking the originality of submissions received.

Permissions

Prior to teaching case submission, authors must clear permission to use any content that has not been created by them. Failure to do so may lead to lengthy delays in publication. Emerald is unable to publish any content which has permissions outstanding. The rights that Emerald require evidence of clearance for, are:

• Non-exclusive rights to reproduce the material.
• Print and electronic rights.
• Worldwide English language rights.
• To use the material for the life of the work (i.e., there should be no time restrictions on the re-use of material, e.g., a one-year licence).

When reproducing tables, figures or excerpts from another source, it is expected that:

• Authors obtain the necessary written permission in advance from any third party owners of copyright for the use in print and electronic formats of any of their text, illustrations, graphics, or other material, in their manuscript. Permission must also be cleared for any minor adaptations of any work not created by them.
• If an author significantly adapts any material, the author must inform the copyright holder of the original work.
• Authors obtain any proof of consent statements.
• Authors must always acknowledge the source in figure captions and refer to the source in the reference list.
• Authors should not assume that any content which is freely available on the web is free to use. Authors should check the website for details of the copyright holder to seek permission for re-use.

Emerald is a member of the STM Association and participates in the reciprocal free exchange of material with other STM members. This may mean that in some cases, authors do not need to clear permission for re-use of content. If so, please highlight this upon submission. For more information and additional help, please follow the Permissions for your Manuscript guide.

Consent to publish – release form

All teaching cases submitted for review must include appropriate signed permissions from case Protagonists, e.g., CEO; company directors or any employee given authority by the organisation; or the person or persons under review, granting full permission to publish the case. Written permission must also be obtained if you include any material for which someone other than yourself or the case subject/protagonist, own the copyright. Please see Permissions section above for more detail. Please refer to our Consent to publish – Release Form as an example of the required release form.

Defamation / Libel

If inaccurate, unsubstantiated or emotive statements are made about organisations or people in a submitted case, Emerald reserves the right to request changes to the text from the author or to reject the case prior to publication.

Critiques and reviews of organisations, products and services are acceptable but comments must be constructive and must not:

• Expose groups or individuals to hatred, ridicule or contempt;
• Cause them to be shunned or avoided;
• Lower them in the estimation of right-thinking members of society generally;
• Disparage them in their business, trade, office or profession.

Final Submission

Authors should note that proofs are not supplied prior to publication. The manuscript will be considered to be the definitive version of the teaching case. Therefore, any requests for changes after the final submission will not be granted. The author must ensure that the final submission is complete, grammatically correct and without spelling or typographical errors.

Editor-in-Chief

• Christopher Craig Murray State University, USA [email protected]

Associate Editor

• Mike Annett MacEwan University, Canada
• David Desplaces Tommy and Victoria Baker School of Business, The Citadel, Charleston, USA - USA
• Sanjib Dutta ICFAI Business School - India
• Keith Harris Kansas State University, USA
• Tulsi Jayakumar SP Jain Institute of Management and Research - India
• Ismail Karabas Murray State University - USA
• Sonia Mehrotra S.P. Mandali's Prin.L.N.Welingkar Institute of Management Development and Research - India
• Oznur Yurt The Open University - UK
• Melissa Close Emerald Publishing - USA [email protected]

Journal Editorial Office (For queries related to pre-acceptance)

• Rimalee Vijay Pillay Emerald Publishing [email protected]

Supplier Project Manager (For queries related to post-acceptance)

• Uday Bhan Emerald Publishing [email protected]

Editorial Advisory Board

• Balaji Abraham Indian Institute of Management Ranchi - India
• Erin Bass University of Nebraska Omaha - USA
• Liza M. Coboa Missouri State University - United States
• Steve Congden University of Hartford, USA - USA
• Nada Elnahla Maynooth University School of Business - Ireland
• Kelly Fisher West Chester University, Pennsylvania, USA
• Matthew Fisher Lam Family College of Business, San Francisco State University, USA
• Bindiya Gupta Karnavati University - India
• James Hilliard Fox School of Business, Temple University, Philadelphia, USA
• Richard Hoffman Salisbury University - United States
• Sarah Holtzen Missouri Southern State University, - United States
• Patrik Hultberg Kalamazoo College, USA - USA
• George Joesph University of Massachusetts Lowell - United States
• Brooke Klassen University of Saskatchewan - Canada
• Kenneth Levitt Frostburg State University, USA - USA
• Paddy Lonergan Manchester Metropolitan University - United Kingdom
• Anne Macy Paul & Virginia Engler College of Business, West Texas A&M University, USA
• Matthew J. Mazzei Samford University - United States
• Patrick McHugh Brown University - United States
• William Naumes University of New Hampshire, USA - USA
• Richard Oxarart Murray State University - USA
• Joy Pahl St Norbert College - United States
• Kumar Ramchandani LJ Institute of Management Studies - India
• Marlene Reed Baylor University, USA
• Stuart Rosenberg Monmouth University, New Jersey, USA
• Kathryn Savage Northern Arizona University, USA - USA
• Karin Schnarr Wilfrid Laurier University, Canada
• Vivian Steinhauser Pontifical Catholic University of Rio de Janeiro, Brazil
• George (Jody) Tompson University of Tampa - United States
• Joseph Trendowski Mount St. Joseph University - USA
• Sumedha Tuteja Department of Finance, Institute of Management Studies Ghaziabad, Ghaziabad, India
• Jorge Manuel Vareda Gomes University of Lisbon, Portugal
• Al Warner Pennsylvania State University - United States
• Miriam Weismann Florida International University - USA
• Rebecca Wilson-Mah Royal Roads University, Canada - Canada
• Angela da Rocha Pontifical Catholic University of Rio de Janeiro, Brazil - Brazil

Citation metrics

CiteScore 2023

Further information

CiteScore is a simple way of measuring the citation impact of sources, such as journals.

Calculating the CiteScore is based on the number of citations to documents (articles, reviews, conference papers, book chapters, and data papers) by a journal over four years, divided by the number of the same document types indexed in Scopus and published in those same four years.

For more information and methodology visit the Scopus definition

CiteScore Tracker 2024

(updated monthly)

CiteScore Tracker is calculated in the same way as CiteScore, but for the current year rather than previous, complete years.

The CiteScore Tracker calculation is updated every month, as a current indication of a title's performance.

Publication timeline

Time to first decision

Time to first decision , expressed in days, the "first decision" occurs when the journal’s editorial team reviews the peer reviewers’ comments and recommendations. Based on this feedback, they decide whether to accept, reject, or request revisions for the manuscript.

Data is taken from submissions between 1st June 2023 and 31st May 2024

Acceptance rate

The acceptance rate is a measurement of how many manuscripts a journal accepts for publication compared to the total number of manuscripts submitted expressed as a percentage %

Data is taken from submissions between 1st June 2023 and 31st May 2024 .

The CASE Journal is abstracted and indexed by

Case writing competitions.

We partner with various organisations around the world to offer a range of case writing competitions. Our competition winners receive international recognition and a cash prize, and cases may be considered for international publication.

Find out how you can apply and details of our previous winners.

Calls for cases

Case teaching methodologies.

The CASE Journal is pleased to partner with the CASE Association to produce this special issue of research articles on the teaching case method. The purpose of this special issue is to produce a series of best-practice articles from educ...

The CASE Journal 2023 Best Case Award

Emerald Publishing and The CASE Journal are pleased to announce the winners of the 2023 Best Case award. Every year, the editorial team at The CASE Journal selects one case from the previous year's v...

Winners of the 1st Indigenous Voices Case Writing Competition announced

We are very pleased to announce the winners of the Indigenous Voices Case Writing Competition....

Winners of the 2023 Emerald/Case for Women competition

In partnership with The Case for Women, Forté, and Graduate Business Curriculum (GBC) Roundtable, Emerald Publishin...

The Case Journal 2022 Best Case award

Emerald Publishing and The CASE Journal are pleased to announce the winner of the 2022 Best Case Award. Every year, the editorial team at The CASE Journal selects one case from the previous year's volume to receive the annual Best Case A...

Changes to TCJ's Author Payment Policy

Effective immediately, TCJ is pleased to announce that we will begin paying all cases $100 upon publication. The decision to update our author payment policy coincides with the renewal of TCJ's collaboration with our long-time partner, The CASE As...

Winners of the 2021 TCJ Compact Case Competition

Emerald Publishing and The CASE Journal are pleased to announce the winners of the 2021 TCJ Compact Case Competition. Unlike traditional 8 - 10 page case study narratives, compact cases are designed to be read in 15 minutes; allowing an ...

2020 CASE/Emerald Best Case Award winner announced

The CASE Association have recently announced the winner of the 2020 CASE/Emerald Best Case Award. Criteria included: Quality of the case based on: Engaging writing style ...

TCJ Editorials

Recent editorials from TCJ: Case r...

The CASE Journal accepted into Scopus

We’re delighted to let you know that TCJ has been accepted into Scopus.  This is fantastic news, endorsing the quality of our content, and an important step in cases being acknowledged as a valuable academic contribution and a fantastic refle...

2018 CASE/Emerald Best Case Award Winner Announced in Delaware

The CASE Association recently announced the winner of the 2018 CASE/Emerald Best Case Award during The CASE Association’s 2019 Annual Meeting in Wilmington, Delaware. Criteria included: Quality of the case bas...

The CASE Journal welcomes compact cases for publication

Components of a compact case.

Compact Cases are intended to be no more than 1,000 words in length (about two single-spaced pages).  Keep this in mind as you write by watching the word count as you write.  In Microsoft Word, the word count can be viewed in the bottom ...

Literati awards

The CASE Journal - Literati Award Winners 2020

We are pleased to announce our 2020 Literati Award winners. Outstanding Paper Startup on a budget: winning n...

The CASE Journal (the official journal of The CASE Association) presents students with a modern interpretation of discussion-based teaching, and equips the next generation of business professionals with the acumen to solve strategic problems in enterprise.

Aims and scope

The CASE Journal (TCJ) invites submission of the following:

• Cases: TCJ publishes factual teaching cases spanning the full spectrum of business and management disciplines. 
• Compact cases: These cases must be factual and are limited to 500-1,000 words. The goal is to make cases accessible, readable and more engaging for students. 
• New forms: TCJ is interested in exploring new types of cases that go beyond the conventional models. Cases utilising innovative technology or twists on traditional formats are welcome. 
• Articles and conceptual papers: TCJ also invites submissions of articles relating to case teaching, case writing, case reviewing, and similar topics. Conceptual papers and papers reporting original research as well as the applied implications of others’ research in terms of case teaching, research, and instruction are welcome, as are creative learning, research and writing methods that have been tested in the classroom or in practice, including critical incidents and industry or technical notes.

All cases must be accompanied by an Instructor’s Manual providing the target audience, relevant theoretical concepts or models, research methodology, discussion questions, and suggested responses and teaching strategies.

Virtual special issues

Compact cases - virtual issue.

Unlike traditional 8-10-page case study narratives, compact cases, which can be read in 15 minutes, allow for an immediate classroom discussion around a single theme.

Responsible consumption – virtual issue

Find out more about our virtual special issue on responsible consumption.

This journal is aligned with our responsible management goal

We aim to champion researchers, practitioners, policymakers and organisations who share our goals of contributing to a more ethical, responsible and sustainable way of working.

Related journals

This case study is part of our Accounting finance & economics collection. Explore our Accounting finance & economics subject area to find out more.  

See all related journals

Emerging Markets Case Studies

Emerging Markets Case Studies (EMCS) enables faculty to adopt the right case for them, from regions and companies that...

International Journal of Ethics and Systems

The International Journal of Ethics and Systems is a multidisciplinary journal publishing peer review research on ethics...

Studies in Economics and Finance

Covering both finance and the intersection between finance, financial markets and economics, Studies in Economics and...

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We currently have access to several business case study journals and they are listed below. Most of these journals are available online. To search for additional journals, please use the journal search feature of BU Libraries Search .

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Clinical Case Studies

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• Description
• Aims and Scope
• Editorial Board
• Abstracting / Indexing
• Submission Guidelines

The only journal devoted entirely to psychotherapy case studies, Clinical Case Studies presents innovative psychotherapy cases involving individual, couples, and family therapy. Whether you are a psychologist, counselor, psychiatrist, clinical social worker, family therapist, professor or student of psychotherapy, you’ll find Clinical Case Studies to be a necessary part of your library. The easy-to-follow case presentation format allows you to learn how interesting and challenging cases were assessed and conceptualized, and how treatment followed such conceptualization. This practical format allows clinicians to replicate successful treatments in their own practices. Cases presented in the journal will follow a 12-point format including Title Page, Abstract, and References.

Title Page Abstract

• Theoretical and Research Basis for Treatment 
• Case Introduction
• Presenting complaints
• Case Conceptualization (this is where the clinician’s thinking and treatment selection come to the forefront)
• Course of Treatment and Assessment of Progress
• Complicating Factors
• Access and Barriers to Care
• Treatment Implications of the case
• Recommendations to Clinicians and Students

The journal is multidisciplinary, publishing contributions from practitioners and single case researchers. The journal is sure to be an important tool for the classroom as well as daily practice.

Questions should be directed to the Clinical Case Studies Editorial Office by email: [email protected] . This journal is a member of the Committee on Publication Ethics (COPE) .

Clinical Case Studies seeks manuscripts of innovative and novel psychotherapy treatment cases that articulate various theoretical frameworks (behavioral, cognitive-behavioral, gestalt, humanistic, psychodynamic, rational-emotive therapy, existential, systems, and others). All manuscripts will require an abstract and must adhere to the following format: (1) Theoretical and Research Basis, (2) Case Introduction, (3) Presenting Complaints, (4) History, (5) Assessment, (6) Case Conceptualization (this is where the clinician’s thinking and treatment selection come to the forefront), (7) Course of Treatment and Assessment of Progress, (8) Complicating Factors (including medical management), (9) Access and Barriers to Care, (10) Follow-up (how and how long), (11) Treatment Implications of the Case, (12) Recommendations to Clinicians and Students, and References.

• EMBASE/Excerpta Medica
• Psychological Abstracts

Manuscript submission guidelines can be accessed on Sage Journals .

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To order single issues of this journal, please contact SAGE Customer Services at 1-800-818-7243 / 1-805-583-9774 with details of the volume and issue you would like to purchase.

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Page 1 of 146

Acute acquired comitant esotropia associated with Lhermitte–Duclos disease: a case report

Acute acquired comitant esotropia caused by prolonged near work, such as the use of digital devices, has been frequently reported in recent years. However, intracranial examination is necessary even for patien...

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Treatment of supracondylar fractures of the humerus in adults using a novel anatomical locking plate on the anterior distal humerus: a case report

Due to its unique anatomical characteristics, supracondylar fractures of the humerus are often difficult to achieve firm fixation with internal fixation equipment, resulting in delayed functional exercise, oft...

Primary aldosteronism with hypokalemic rhabdomyolysis: a case report and review of the literature

Hypokalemic rhabdomyolysis is a rare clinical manifestation of primary aldosteronism, making its diagnosis challenging, particularly when it becomes the primary presenting symptom. Herein, we present a case of...

Complete response in a lung adenocarcinoma with pleural metastases initially treated with gefitinib and switched to osimertinib after cerebral oligo-progression with unknown T790M mutation: a case report and review of literature

First- and second-generation anti-epithelial growth factor receptor tyrosine kinase inhibitors have shown great efficacy in the treatment of advanced adenocarcinoma with epithelial growth factor receptor mutat...

Swyer–James–Macleod syndrome mimicking pulmonary embolism in adults: a case report

Swyer–James–MacLeod syndrome (SJMS) is a rare lung condition characterized by a unilateral lung hyperlucency and reduction in the pulmonary vasculature, with or without the presence of bronchiectasis. In the 1...

Spontaneous hemopneumothorax causing life-threatening hemorrhage: a case report

Spontaneous hemopneumothorax is a rare condition that can be life-threatening if not promptly diagnosed and treated. We report a case of early treatment with transcatheter arterial embolization and video-assis...

Dengue and leptospirosis coinfection: a case series

Both dengue and Leptospira infections are endemic to tropical and subtropical regions, with their prevalence increasing in recent decades. Coinfection with these pathogens presents significant diagnostic chall...

Glycyrrhizic acid induced acquired apparent mineralocorticoid excess syndrome with a hyperadrenergic state: a case report

Syndrome of apparent mineralocorticoid excess (AME) is characterized by excessive MR stimulation despite low levels of aldosterone. 11Beta-hydroxysteroid dehydrogenase-2 (11βDSH-2) inactivates cortisol to cort...

Acute abducens nerve palsy following coronavirus disease 2019 vaccination: a case report

Abducens nerve palsy is the most common isolated ocular cranial nerve palsy. In adults, nontraumatic etiologies of isolated sixth cranial nerve palsy can include vascular disease, inflammation, tumors, and a p...

Polypoid heterotopic gastric mucosa: in terminal ileum causing extensive lower gastrointestinal bleeding without Meckel’s diverticulum: a case report

Heterotopic gastric mucosa (HGM) can be located in various parts of the gastrointestinal tract. As a rare anomaly in the small intestine, it can become complicated by intussusception, obstruction, gastrointest...

An immunocompetent lady with invasive aspergillosis presenting as disseminated lesions: a case report

Invasive Aspergillosis is a fungal infection caused by Aspergillus species, typically posing life-threatening risks to immunocompromised individuals. While occurrences in immunocompetent hosts are rare, a rece...

Anesthesia management for cesarean section in a woman with chronic renal failure and heart failure: a case report

Pregnancy in a woman with heart and chronic renal failure can lead to life-threatening complications for both mother and child. Although such cases are often delivered by cesarean section, few reports have des...

Improving oxygenation in a patient with respiratory failure due to morbid obesity by applying airway pressure release ventilation: a case report

Morbidly obese patients occasionally have respiratory problems owing to hypoventilation. Airway pressure release ventilation is one of the ventilation settings often used for respiratory management of acute re...

An uncommon encounter: crossed fused renal ectopia with singular ureter: a case report

Crossed fused renal ectopia (CFRE) is a common congenital anomaly where one kidney is positioned abnormally on the opposite side of the midline, often fused with the other kidney. However, single ureter draini...

Patient with Herlyn–Werner–Wunderlich syndrome and endometriosis achieves successful full-term pregnancy (40 weeks and 6 days): a case report

Herlyn–Werner–Wunderlich syndrome , a rare Müllerian ducts congenital disease, is characterized by a diphtheritic uterus, blind hemivagina, and ipsilateral renal agenesis. Diagnosis is at young age by ultrasou...

Connected to the cloud at time of death: a case report

Our case report provides the first clinical evaluation of autopsy practices for a patient death that occurs on the cloud. We question how autopsy practices may require adaptation for a death that presents via ...

Subdural empyema—a rare complication of chronic otitis media: a case report

Subdural empyema is an extremely rare and fatal intracranial complication of chronic otitis media. Due to its rarity and vague symptoms, it is often diagnosed late if not completely missed; specially in develo...

Primary pulmonary meningioma presenting as a pulmonary ground glass nodule: a case report and review of the literature

A primary pulmonary meningioma is an extremely rare entity. Primary pulmonary meningiomas manifested with a ground glass nodule are a very rare occurrence in clinical practice.

Severe hypoglycemia in a diabetic patient with pituitary apoplexy: a case report

Hypoglycemia is a common occurrence in diabetic patients. But unlike non diabetic patients, its causes are frequently related to drugs they are receiving to control blood glucose. But this may not always be th...

Letter to the Editor: Atypical duplex appendix arising from the ascending colon: a case report

The original article was published in Journal of Medical Case Reports 2024 18 :188

Lymphomatosis cerebri caused by adult T cell leukemia/lymphoma: a differential diagnosis for depression: a case report

Primary central nervous system lymphoma is rare, and primary central nervous system T cell lymphoma is relatively uncommon, contributing to < 5% of all cases. Lymphomatosis cerebri, a rare subtype of primary c...

Arthroscopic reduction and internal fixation for fracture of the posterior process of the talus (Shepherd’s fracture): a case report

Fracture of the lateral tubercle of the posterior process of the talus (Shepherd fracture) is an uncommon injury seen in sport. It is secondary either to indirect trauma on the plantarflexed foot or to high-im...

Preserved walking function without postoperative reconstruction for pelvic Ewing’s sarcoma: a case report

Ewing’s sarcoma is a primary bone tumor predominantly observed in children and adolescents, necessitating a multidisciplinary treatment approach. While localized cases have a 5-year survival rate of 60–70%, th...

Stevens–Johnson syndrome-toxic epidermal necrolysis overlap in a patient taking quetiapine and famotidine: a case report

Stevens–Johnson syndrome-toxic epidermal necrolysis (SJS-TNE) overlap is a rare skin disorder characterized by erythema, blisters, extensive exfoliation, epidermal detachment, the involvement of multiple mucos...

Scrub typhus with hemorrhagic stroke: a case report

Scrub typhus, caused by Orientia tsutsugamushi , rarely leads to central nervous system involvement. Although intracerebral bleeding is rare due to endemicity and a significant proportion of underdiagnoses, it sho...

Superficial temporal artery aneurysm misdiagnosed in a patient with long-term migraine headache treatment: a case report

Superficial temporal artery aneurysm is a rare vascular abnormality without specific clinical symptoms. In this case report, we present the case of a patient with superficial temporal artery aneurysm who was d...

Effect of exercise on cluneal nerve entrapment neuropathy: a case report

Low back pain is an important disability problem frequently encountered in the clinic. In the literature, it has been shown that neuropathic pain in chronic low back pain is quite common in patients. Although ...

Usability of a novel Hounsfield units measurement procedure to quantify intercorporal bone graft remodeling in patients after posterior lumbar interbody fusion: a case series

There is a lack of knowledge about the biological process of intercorporal bone graft remodeling after posterior lumbar interbody fusion surgery and whether this process is associated with changes in back pain...

A differential expression of an identical mutation in CYP17A1 gene in two infertility patients: a case report

17-Hydroxylase deficiency is the rarest form of congenital adrenal hyperplasia, a disorder that affects steroidogenesis, causing abnormal hormone levels. Studies have shown a clear association between 17-hydro...

A rare case of trigeminal trophic syndrome with periorbital cellulitis and full-thickness upper eyelid defect in an undiagnosed patient with human immunodeficiency virus: a case report

Trigeminal trophic syndrome is a rare cranial and facial condition caused by damage to the central or peripheral branches of the trigeminal nerve. This syndrome consists of a triad of anesthesia, paresthesia, ...

Primary leiomyosarcoma of epididymis: a case report

Leiomyosarcoma is a tumor that can develop in any organ that contains smooth muscles. Although leiomyosarcoma is common, its epididymal localization is quite rare.

Radiotherapy for subependymal giant cell astrocytoma: time to challenge a historical ban? A case report and review of the literature

Subependymal giant cell astrocytoma is a benign brain tumor that occurs in patients with tuberous sclerosis complex. Surgical removal is the traditional treatment, and expert opinion is strongly against the us...

Dengue rhabdomyolysis successfully treated with hemoperfusion using CytoSorb® in combination with continuous renal replacement therapy: a case report

Dengue fever is a mosquito-borne viral infection with a broad spectrum of clinical manifestations. Expanded dengue syndrome includes unusual manifestations that do not fall into the categories of dengue fever,...

Enzyme replacement therapy and immunotherapy lead to significant functional improvement in two children with Pompe disease: a case report

Pompe disease, a rare autosomal recessive disorder caused by acid alpha-glucosidase deficiency, results in progressive glycogen accumulation and multisystem dysfunction. Enzyme replacement therapy with recombi...

Whole-genome sequencing of multidrug-resistant Escherichia coli causing urinary tract infection in an immunocompromised patient: a case report

Escherichia coli is a major human pathogen responsible for a broad range of clinical illnesses. It has been linked to endemic and epidemic nosocomial diseases caused by multidrug-resistant pathogens in Sudan as w...

Palinacousis in amyloidosis: exploring the hallucinatory phenomenon in brain pathology—a case report

Hereditary transthyretin amyloidosis, caused by transthyretin gene mutations, progresses with systemic impact and often presents peripheral neuropathy. Recent research reveals central nervous system involvemen...

Dexmedetomidine as a total intravenous anesthetic in pediatric patients undergoing cleft lip and palate surgery: a case series

Surgery for pediatric cleft lip and palate repair often utilizes high-dose opioids and inhaled anesthesia, thereby causing postoperative complications such as desaturation and/or severe agitation after anesthe...

Diffuse large B-cell lymphoma in the uterus with unexpected manifestations: a case report

Lymphoid neoplasm is a common disease, arising from lymphoid cells. It is divided into Hodgkin lymphoma and non-Hodgkin lymphoma. Non-Hodgkin lymphoma can be intranodular or extranodular, which happens in 25% ...

Challenges in the diagnosis and treatment of pure non-gestational uterine choriocarcinoma in a child: a case report

Diagnosing non-gestational uterine choriocarcinoma in children is challenging because of its rarity and nonspecific imaging findings. Herein, we report a case of non-gestational uterine choriocarcinoma in a ch...

Intracranial dissemination of Klebsiella pneumoniae originating from pulmonary infection: a case report

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• Volume 21, Issue 1
• What is a case study?
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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

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

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

Benefits and limitations of case studies

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

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

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

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

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

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

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

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

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

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

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

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

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

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

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

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

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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• Open access
• Published: 27 June 2011

The case study approach

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

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

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

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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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.

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• All Headlines

Top 40 Most Popular Case Studies of 2021

Two cases about Hertz claimed top spots in 2021's Top 40 Most Popular Case Studies

Two cases on the uses of debt and equity at Hertz claimed top spots in the CRDT’s (Case Research and Development Team) 2021 top 40 review of cases.

Hertz (A) took the top spot. The case details the financial structure of the rental car company through the end of 2019. Hertz (B), which ranked third in CRDT’s list, describes the company’s struggles during the early part of the COVID pandemic and its eventual need to enter Chapter 11 bankruptcy. 

The success of the Hertz cases was unprecedented for the top 40 list. Usually, cases take a number of years to gain popularity, but the Hertz cases claimed top spots in their first year of release. Hertz (A) also became the first ‘cooked’ case to top the annual review, as all of the other winners had been web-based ‘raw’ cases.

Besides introducing students to the complicated financing required to maintain an enormous fleet of cars, the Hertz cases also expanded the diversity of case protagonists. Kathyrn Marinello was the CEO of Hertz during this period and the CFO, Jamere Jackson is black.

Sandwiched between the two Hertz cases, Coffee 2016, a perennial best seller, finished second. “Glory, Glory, Man United!” a case about an English football team’s IPO made a surprise move to number four.  Cases on search fund boards, the future of malls,  Norway’s Sovereign Wealth fund, Prodigy Finance, the Mayo Clinic, and Cadbury rounded out the top ten.

Other year-end data for 2021 showed:

• Online “raw” case usage remained steady as compared to 2020 with over 35K users from 170 countries and all 50 U.S. states interacting with 196 cases.
• Fifty four percent of raw case users came from outside the U.S..
• The Yale School of Management (SOM) case study directory pages received over 160K page views from 177 countries with approximately a third originating in India followed by the U.S. and the Philippines.
• Twenty-six of the cases in the list are raw cases.
• A third of the cases feature a woman protagonist.
• Orders for Yale SOM case studies increased by almost 50% compared to 2020.
• The top 40 cases were supervised by 19 different Yale SOM faculty members, several supervising multiple cases.

CRDT compiled the Top 40 list by combining data from its case store, Google Analytics, and other measures of interest and adoption.

All of this year’s Top 40 cases are available for purchase from the Yale Management Media store .

And the Top 40 cases studies of 2021 are:

1.   Hertz Global Holdings (A): Uses of Debt and Equity

2.   Coffee 2016

3.   Hertz Global Holdings (B): Uses of Debt and Equity 2020

4.   Glory, Glory Man United!

5.   Search Fund Company Boards: How CEOs Can Build Boards to Help Them Thrive

6.   The Future of Malls: Was Decline Inevitable?

7.   Strategy for Norway's Pension Fund Global

8.   Prodigy Finance

9.   Design at Mayo

10. Cadbury

11. City Hospital Emergency Room

13. Volkswagen

14. Marina Bay Sands

15. Shake Shack IPO

16. Mastercard

17. Netflix

18. Ant Financial

19. AXA: Creating the New CR Metrics

20. IBM Corporate Service Corps

21. Business Leadership in South Africa's 1994 Reforms

22. Alternative Meat Industry

23. Children's Premier

24. Khalil Tawil and Umi (A)

25. Palm Oil 2016

26. Teach For All: Designing a Global Network

27. What's Next? Search Fund Entrepreneurs Reflect on Life After Exit

28. Searching for a Search Fund Structure: A Student Takes a Tour of Various Options

30. Project Sammaan

31. Commonfund ESG

32. Polaroid

33. Connecticut Green Bank 2018: After the Raid

34. FieldFresh Foods

35. The Alibaba Group

36. 360 State Street: Real Options

37. Herman Miller

38. AgBiome

39. Nathan Cummings Foundation

40. Toyota 2010

• Introduction
• Conclusions
• Article Information

Logistic regression model with adjusted odds ratio adjusting for race, ethnicity, sex, and age. Pacific Islander included Native Hawaiian or Other Pacific Islander. Other race included any race not otherwise specified or unspecified race. Hanging included strangulation or suffocation. OR indicates odds ratio.

Logistic regression model with adjusted odds ratio adjusting for race, ethnicity, and sex. Pacific Islander included Native Hawaiian or Other Pacific Islander. Other race included any race not otherwise specified or unspecified race. Hanging included strangulation or suffocation. OR indicates odds ratio.

eTable. Availability of State, Territory, and Jurisdiction Data for NVDRS Web-based Injury Statistics Query and Reporting System (WISQARS) and Restricted Access Database (RAD)

Data Sharing Statement

• Youth Suicide, Mental Health, and Firearm Access JAMA Network Open Invited Commentary July 30, 2024 Lisa M. Horowitz, PhD, MPH; John V. Campo, MD; Jeffrey A. Bridge, PhD

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Chaudhary S , Hoffmann JA , Pulcini CD, et al. Youth Suicide and Preceding Mental Health Diagnosis. JAMA Netw Open. 2024;7(7):e2423996. doi:10.1001/jamanetworkopen.2024.23996

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Youth Suicide and Preceding Mental Health Diagnosis

• 1 Department of Pediatrics and Emergency Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
• 2 Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
• 3 Department of Emergency Medicine and Pediatrics, University of Vermont Medical Center and Children’s Hospital, University of Vermont Larner College of Medicine, Burlington, Vermont
• 4 Children’s Hospital Association, Lenexa, Kansas
• 5 Department of Pediatrics, Section of Hospital Medicine, University of Arkansas for Medical Sciences, Little Rock
• 6 Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia
• 7 Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles
• 8 Section of Pediatric Surgery, CS Mott Children’s Hospital, University of Michigan Ann Arbor
• 9 Department of Emergency Medicine, Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee
• 10 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
• 11 Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
• 12 Department of Emergency Medicine, Massachusetts General Hospital, Boston
• 13 Department of Pediatrics, Children’s National Hospital, George Washington University, Washington, DC
• Invited Commentary Youth Suicide, Mental Health, and Firearm Access Lisa M. Horowitz, PhD, MPH; John V. Campo, MD; Jeffrey A. Bridge, PhD JAMA Network Open

Question   What characteristics of youth suicide decedents and suicide circumstances are associated with having a documented mental health diagnosis?

Findings   This cross-sectional study of 40 618 youth suicide decedents from the Centers for Disease Control and Prevention National Violent Death Reporting System found 24 192 decedents (59.6%) had no previously documented mental health diagnosis and 19 027 (46.8%) died by firearm suicide. The odds of having a documented mental health diagnosis were lower among racially and ethnically minoritized youths and among youths who used firearms.

Meaning   These findings suggest that a critical need exists for comprehensive youth suicide prevention strategies, including early identification of mental health concerns, equitable access to mental health services, and universal lethal means counseling.

Importance   Suicide is a leading cause of death among US youths, and mental health disorders are a known factor associated with increased suicide risk. Knowledge about potential sociodemographic differences in documented mental health diagnoses may guide prevention efforts.

Objective   To examine the association of documented mental health diagnosis with (1) sociodemographic and clinical characteristics, (2) precipitating circumstances, and (3) mechanism among youth suicide decedents.

Design, Setting, and Participants   This retrospective, cross-sectional study of youth suicide decedents aged 10 to 24 years used data from the Centers for Disease Control and Prevention National Violent Death Reporting System from 2010 to 2021. Data analysis was conducted from January to November 2023.

Exposures   Sociodemographic characteristics, clinical characteristics, precipitating circumstances, and suicide mechanism.

Main Outcomes and Measures   The primary outcome was previously documented presence of a mental health diagnosis. Associations were evaluated by multivariable logistic regression.

Results   Among 40 618 youth suicide decedents (23 602 aged 20 to 24 years [58.1%]; 32 167 male [79.2%]; 1190 American Indian or Alaska Native [2.9%]; 1680 Asian, Native Hawaiian, or Other Pacific Islander [4.2%]; 5118 Black [12.7%]; 5334 Hispanic [13.2%]; 35 034 non-Hispanic; 30 756 White [76.1%]), 16 426 (40.4%) had a documented mental health diagnosis and 19 027 (46.8%) died by firearms. The adjusted odds of having a mental health diagnosis were lower among youths who were American Indian or Alaska Native (adjusted odds ratio [aOR], 0.45; 95% CI, 0.39-0.51); Asian, Native Hawaiian, or Other Pacific Islander (aOR, 0.58; 95% CI, 0.52-0.64); and Black (aOR, 0.62; 95% CI, 0.58-0.66) compared with White youths; lower among Hispanic youths (aOR, 0.76; 95% CI, 0.72-0.82) compared with non-Hispanic youths; lower among youths aged 10 to 14 years (aOR, 0.70; 95% CI, 0.65-0.76) compared with youths aged 20 to 24 years; and higher for females (aOR, 1.64; 95% CI, 1.56-1.73) than males. A mental health diagnosis was documented for 6308 of 19 027 youths who died by firearms (33.2%); 1691 of 2743 youths who died by poisonings (61.6%); 7017 of 15 331 youths who died by hanging, strangulation, or suffocation (45.8%); and 1407 of 3181 youths who died by other mechanisms (44.2%). Compared with firearm suicides, the adjusted odds of having a documented mental health diagnosis were higher for suicides by poisoning (aOR, 1.70; 95% CI, 1.62-1.78); hanging, strangulation, and suffocation (aOR, 2.78; 95% CI, 2.55-3.03); and other mechanisms (aOR, 1.59; 95% CI, 1.47-1.72).

Conclusions and Relevance   In this cross-sectional study, 3 of 5 youth suicide decedents did not have a documented preceding mental health diagnosis; the odds of having a mental health diagnosis were lower among racially and ethnically minoritized youths than White youths and among firearm suicides compared with other mechanisms. These findings underscore the need for equitable identification of mental health needs and universal lethal means counseling as strategies to prevent youth suicide.

Suicide is the second leading cause of death for US youths aged 10 to 14 years and the third leading cause of death for youths aged 15 to 24 years, with nearly one-half due to firearms. 1 From 2010 to 2021, 71 820 youths aged 10 to 24 years died by suicide with a near 50% increase in annual suicide rates over this period. 1 Prior studies indicate that less than one-half of youths who die by suicide have a previously documented mental health (MH) problem or diagnosis. 2 , 3 No studies utilizing recent data have examined whether documentation of prior MH diagnosis varies by sociodemographic and clinical characteristics.

As youth suicide rates have increased, disparities have widened. Among racial and ethnic groups, American Indian and Alaska Native youths have the highest rate of suicide overall (41.9 per 100 000 youths in 2020) while the rate of suicide has risen the fastest among Black youths (6.9 per 100 000 youths in 2010 and 12.9 per 100 000 youths in 2020—an 87% increase). 1 , 4 Racially and ethnically minoritized youths experience inequities in access to MH services, resulting in disparities in outcomes. 5 , 6 These disparities persisted and widened after the onset of the COVID-19 pandemic, which brought social isolation and stressors at home, decreased access to timely MH services, and increased access to firearms. 7 - 11 During the first year of the pandemic, there were significantly more suicides than expected among male youths, children aged 5 to 12 years, youths aged 18 to 24 years, non-Hispanic American Indian and Alaska Native youths, and Black youths, as well as more firearm suicides than expected. 12

Despite shifting patterns of MH service use and increased firearm accessibility, few studies have evaluated which population subgroups are most likely to have a known MH diagnosis prior to youth suicide. Early identification and documentation of an MH disorder, a known factor associated with increased risk of suicide, may facilitate timely targeted suicide prevention efforts and access to MH services. 13 , 14 In the context of increased firearm access, identification of these intervenable characteristics is vitally important for suicide prevention. Therefore, our objective was to examine the association of sociodemographic characteristics, suicide mechanism, clinical characteristics, and precipitating circumstances with having a documented MH diagnosis among youth suicide decedents.

This retrospective, cross-sectional study was determined exempt from human participants research and the requirement of informed consent by the institutional review board of Emory University and followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline. 15 The study population included US youths aged 10 to 24 years that died by suicide between January 1, 2010, and December 31, 2021. We used mortality data from the National Violent Death Reporting System (NVDRS) Restricted Access Database. NVDRS is a state-based surveillance system that collects data on all violent deaths including suicide, homicide, legal intervention death, unintentional firearm death, and death of undetermined intent that might have been caused by violence. 16 Data are collected from 3 required data sources: death certificates, coroner and medical examiner records, and law enforcement reports. 16 We included data from all available states and territories that contribute data to NVDRS, which increased from 16 states in 2010 to 49 states, the District of Columbia, and Puerto Rico in 2021 (eTable in Supplement 1 ). 17 At the time of the analysis, NVDRS data were available through 2021.

Suicide cases were determined based on International Classification of Diseases, Tenth Revision ( ICD-10 ) cause of death codes (X60-X84, Y87.0, and U03) and/or based on evidence from source documents, with the final manner of death assigned by trained NVDRS abstractors. 16 Suicide was assigned if death resulted from use of force against oneself and a collection of evidence indicated that use of force was intentional. 16 , 18

The primary outcome was the presence of a previously documented MH diagnosis among youth suicide decedents. To identify this outcome, we utilized the MH problem variable defined by NVDRS as (1) the decedent has a current MH diagnosis as categorized by Diagnostic and Statistical Manual of Mental Disorders Fifth Edition ( DSM-5 ), not including from alcohol or other substance dependence, or (2) source documents (death certificate, coroner or medical examiner report, and police report) list the decedent as being treated for an MH problem, potentially from family member report or current prescription. 18

Sociodemographic characteristics included race (American Indian or Alaskan Native; Asian, Native Hawaiian, or Other Pacific Islander; Black; White; multiple race category, and other [defined as any race not otherwise specified] or unspecified), ethnicity (Hispanic or non-Hispanic), age group (10-14 years, 15-19 years, and 20-24 years), and sex (female and male). Race and ethnicity were reported from combined raw data available from source documents (including death certificates, coroner and medical examiner records, and law enforcement reports) and verified by NVDRS investigator teams. Acknowledging race and ethnicity are social constructs, and racially and ethnically minoritized populations often have inequitable access to MH services, race and ethnicity were included as covariates in the analyses. 19 , 20

Clinical characteristics included MH variables such as depressed mood, suicidality (suicide disclosure, history of nonsuicidal self-harm or self-injury, history of suicidal thoughts, or attempts), and substance misuse (alcohol and/or substance abuse). These MH characteristics were considered separate from a documented MH diagnosis. Decedents were categorized as having depressed mood if the they were perceived by themselves or others as depressed at the time of death; the definition does not require a clinical diagnosis of depression or that depression directly contributed to death. 18

Precipitating circumstances were identified per coroner or medical examiner and law enforcement reports as having contributed to suicide death. Decedents could have multiple precipitating circumstances. We included precipitating circumstances regarding interpersonal problems, other life stressors (such as criminal, civil legal, school, or financial) and recent crises (defined as within 2 weeks prior to death).

Suicide mechanisms were defined as firearms; poisonings; hanging, strangulation, or suffocation; and other (which included motor vehicle, falls, and sharp or blunt instruments). Location of suicide was categorized as home, other, or unknown.

We conducted descriptive analysis with counts and frequencies of suicide deaths by sociodemographic and clinical characteristics, precipitating circumstances, location, and mechanism. We performed χ 2 tests of proportions to assess differences in the proportion of suicide decedents with and without a documented MH diagnosis by sociodemographics, mechanism, and location. We used multivariable logistic regression to determine sociodemographic and clinical characteristics, precipitating factors, and mechanisms associated with the presence of a documented MH diagnosis. We constructed a model using the full cohort and then performed stratified analysis by age group. All models were adjusted for race, ethnicity, sex, and age group. Results were reported as adjusted odds ratios (aORs) and 95% CIs. All hypothesis testing was 2-sided, with statistical significance set at P  < .05. All statistical analyses were performed with SAS version 9.4 (SAS Institute). Data analysis was conducted from January to November 2023.

We identified 40 618 suicide decedents aged 10 to 24 years (23 602 aged 20 to 24 years [58.1%]; 32 167 male [79.2%]; 1190 American Indian or Alaska Native [2.9%]; 1680 Asian, Native Hawaiian, or Other Pacific Islander [4.2%]; 5118 Black [12.7%]; 30 756 White [76.1%]; 1017 multiple race category [2.5%]; 673 other or unspecified race [1.7%]; 184 unknown race [0.5%]); 5334 Hispanic [13.2%]; and 35 034 non-Hispanic [86.8%]). Most suicides occurred at home (25 174 [64.8%]) ( Table 1 ). The most common precipitating circumstances were intimate partner problems (10249 [25.2%]) and family relationship problems (4462 [13.3%]) ( Table 2 ).

Among youth suicide decedents, 16 426 (40.4%) had a documented MH diagnosis and 24 192 (59.6%) had no documented diagnosis. Across individual groups, White youths had the highest rate of MH diagnosis (13 153 youths [42.8%]) and American Indian or Alaska Native youths had the lowest rate (333 youths [28.0%]); among Hispanic youths, 1959 (36.7%) had an MH diagnosis. Slightly more than one-half of female youths had an MH diagnosis (4429 youths [52.4%]), compared with 11 994 male youths (37.3%) ( Table 1 ). Compared with those without an MH diagnosis, decedents with an MH diagnosis had higher rates of depressed mood (5879 youths [35.8%] vs 5765 youths [23.8%]), suicidal intent disclosure (4518 youths [27.5%] vs 4430 youths [18.3%]), and history of suicidal thoughts (6650 youths [48.2%] vs 3904 youths [19.9%]). Table 2 shows the association of preceding MH diagnosis with suicidality and self-harm, substance problems, precipitating circumstances, and crisis within the 2 weeks prior to death.

In comparison with White youths who died by suicide, there were lower adjusted odds of having a documented MH diagnosis among American Indian and Alaska Native youths (aOR, 0.45; 95% CI, 0.39-0.51); Asian, Native, Hawaiian, or Other Pacific Islander youths (aOR, 0.58; 95% CI, 0.52-0.64); and Black youths (aOR, 0.62; 95% CI, 0.58-0.66) ( Figure 1 ). The ORs by race tended to narrow as youths aged, such as among Black youths aged 10 to 14 years (aOR, 0.47; 95% CI, 0.37-0.59), 15 to 19 years (aOR, 0.58; 95% CI, 0.52-0.65), and 20 to 24 years (aOR, 0.66; 95% CI, 0.61-0.71) ( Figure 2 ). Compared with non-Hispanic youths, Hispanic youths had lower adjusted odds of having an MH diagnosis (aOR, 0.76; 95% CI, 0.72-0.82) ( Figure 1 ). Compared with youths aged 20 to 24 years, the adjusted odds were lower for youths aged 10 to 14 years (aOR 0.70, 95% CI, 0.65-0.76) but were not statistically different for youths aged 15 to 19 years (aOR, 0.97; 95% CI, 0.93-1.01). Females had higher adjusted odds (aOR, 1.64; 95% CI, 1.56-1.73) of having a documented MH diagnosis compared with males .

There were higher adjusted odds of having a documented MH diagnosis among youths with depressed mood (aOR, 1.75; 95% CI, 1.67-1.83), with each suicidality or self-harm characteristic, and with substance abuse (aOR, 1.86; 95% CI, 1.76-1.97) when compared with youths without those characteristics ( Table 3 ). Youths had higher odds of having a documented MH diagnosis if they had family relationship problems (aOR, 1.37; 95% CI, 1.29-1.47) or experienced child abuse (aOR, 3.39; 95% CI, 2.93-3.91) compared with youths without those precipitating circumstances. Youths with intimate partner problems had lower odds of having a documented MH diagnosis (aOR, 0.90, 95% CI, 0.86- 0.94) than youths without intimate partner violence problems.

An MH diagnosis was documented for 6308 of 19 027 youths who died by firearms (33.2%); 1691 of 2743 youths who died by poisonings (61.6%); 7017 of 15 331 youths who died by hanging, strangulation, or suffocation (44.2%); and 1407 of 3181 youths who died by other mechanisms (44.8%). Among decedents with a documented MH diagnosis, the most common mechanism was hanging, strangulation, or suffocation (7017 decedents [42.7%]). Among decedents without a documented MH diagnosis, the most common mechanism was firearms (12 719 decedents [52.6%]). Among all decedents, 19 027 [46.8%] died by firearms. In the multivariable model, compared with youths who died by firearms, youths who died by poisonings (aOR, 2.78; 95% CI, 2.55-3.03); hanging, strangulation, or suffocation (aOR, 1.70; 95% CI, 1.62-1.78); and other mechanisms (aOR, 1.59; 95% CI, 1.47-1.72) had higher adjusted odds of having a documented MH diagnosis ( Figure 1 ). Likewise, within each age group stratum, youths who died by poisonings and hanging, strangulation, or suffocation had higher adjusted odds of having a documented MH diagnosis compared with those who died by firearms.

In this cross-sectional study of youth suicides across the US that utilized the most recently available NVDRS data, we found that approximately 3 of 5 youth suicide decedents did not have a documented MH diagnosis. Racially and ethnically minoritized, male, and younger youths were less likely to have a documented MH diagnosis prior to suicide death than White, female, and older youths, respectively. Furthermore, youths who used a firearm, the mechanism with the highest case fatality rate, 22 , 23 were far less likely to have a documented MH diagnosis.

Despite older literature that demonstrated that many youths who die by suicide have not received adequate MH screening and services, it appears that challenges persist in the identification of youths at risk even amid the current growing MH crisis. In this updated evaluation of suicide decedents within NVDRS, which captures the largest proportion to date (56.6% of US youth suicide decedents 1 ), rates of documented MH diagnoses did not improve substantially from prior studies. From 2003 to 2012, only 34.6% of youth suicide decedents aged 5 to 11 years and 34.8% of youth suicide decedents aged 12 to 14 years had a documented known MH problem. 3 , 24 Similarly, from 2013 to 2018, only 42.1% of youth suicide decedents aged 10 to 19 years had a known MH condition. 2 This low rate of documented MH diagnosis among youth suicide decedents may reflect inadequate detection of MH needs, the impulsive nature of suicidal acts, increased access to more lethal means such as firearms, or alternative risk factors such as increased stressful life circumstances. 9 , 25 , 26

We found significant racial and ethnic disparities in MH diagnoses among youths who died by suicide. This is consistent with prior literature 6 that found only approximately 35% of Black youths had a documented current MH problem prior to death across age groups. Missed MH diagnosis among racially and ethnically minoritized youths who die by suicide may result from inequitable access to MH screening and diagnosis. 19 On the other hand, racially and ethnically minoritized youths might have lower rates of MH diagnoses because they experienced other factors associated with increased risk of suicide besides MH conditions, including structural racism, discrimination, exposure to adverse childhood experiences, poverty, and lack of opportunity in certain neighborhoods. 27 - 34 To counter these risk factors, suicide prevention efforts for racially and ethnically minoritized youths should include trauma-informed, culturally sensitive MH services, increased diversity in the MH workforce, and investments in school-based MH services, where Black youths are more likely than White youths to receive care. 19 , 35 Such efforts could incorporate preventive interventions, grounded in cognitive-behavioral therapy, developed to counter stressors associated with systemic racism. 6 , 36 Suicide prevention programming delivered in nontraditional community settings by individuals with lived experience may garner more receptivity and trust among Black youths than prevention efforts delivered in traditional health care settings. 32 , 37 - 40

We found significant age differences in rates of MH diagnosis, with lower odds of having an MH diagnosis prior to suicide among youths aged 10 to 14 years compared with those aged 20 to 24 years. This finding is particularly notable because suicide rates have risen to become the second leading cause of death in youths aged 10 to 14 years. 1 Among even younger children, during the first year of COVID-19 pandemic, non-Hispanic White 5- to 12-year-olds had a 31% increase in suicides over the expected number. 12 Prior work suggests that suicide vulnerability may progress developmentally, from an impulsive response among younger children to a response to depressed mood or emotional distress during adolescence and adulthood. 3 , 24 Suicide prevention strategies for young children in primary care and community settings should focus on fostering resilience, promoting peer and family connectedness, and empowering children with strategies to cope with stress and adversity. 14

Regarding suicide mechanism, firearms were the most commonly utilized method among youths in our study, which differs from previous NVDRS work in which hanging, strangulation, and suffocation was the most common method among youths. 2 , 3 This difference could be due to increased availability and accessibility of firearms over the course of our study period or inclusion of youths aged 20 to 24 years. 9 , 25 Recent studies also demonstrate increased use of firearms as suicide mechanism. 12 Similar to a prior study, 2 we found that decedents without a documented MH diagnosis were far more likely to utilize a firearm than those with a documented MH diagnosis. Furthermore, in one study, 41 24% of teens and young adults spent less than 5 minutes between the decision to attempt suicide and the actual attempt. These impulsive attempts were more likely among those involved in a physical altercation and less likely among those who were depressed. 41 This finding speaks to the need for universal lethal means counseling, delivered in community and school settings, regardless of whether youths have a known MH diagnosis. Teens should be involved in conversations about the risks of firearms given that many can easily access firearms. 42 , 43 Among US teens, 44.2% perceived that they could access a firearm, while 20.2% perceived they could access a firearm within less than 5 minutes. 42

Suicide prevention strategies are needed for the estimated 22.6 million US children living in households with firearms, of whom 4.5 million are exposed to firearms stored loaded and unlocked. 44 More than 75% of guns used in youth suicide are owned by a family member, most commonly parents, 45 and the presence of a firearm in the home is associated with an increased risk of youth suicide. 46 - 48 This risk can be mitigated with secure firearm storage, including storing all guns locked, unloaded, with ammunition stored locked and in a separate location. 46 Likewise, support and passage of state child access protection (CAP) laws, specifically negligence CAP laws, effectively reduce youth firearm suicide rates. 49 , 50

Youths with depressed mood and suicidality characteristics, similar to prior literature, 2 had higher odds of having a documented MH diagnosis. However, in our study, no MH diagnosis was documented in about one-half of youths noted to be depressed (at the time of or in the weeks leading up to death) or who had previously disclosed suicide intent within the month prior to death. Both nonsuicidal self-injury and previous suicide attempt are predictors of suicide among adolescents. 16 , 51 - 53 However, at least 1 in 4 decedents with a history of nonsuicidal self-injury and 1 in 4 with a prior suicide attempt had no documented MH diagnosis. These youths presumably were not connected to MH services. Thus, attention is needed to increase accessibility of MH screening, diagnosis, and treatment in both primary care and specialty MH settings.

Family relationship and intimate partner problems were the most common circumstances experienced by youth decedents overall. Previous youth suicide studies have found higher rates of family and friend relationship problems among younger youths, while intimate partner problems were more prevalent in older age groups. 2 , 3 , 24 Promoting connectedness and strengthening relationships among youths and parents or caregivers can protect against youth suicide. 24 , 54 The Surgeon General 2021 call to action for suicide prevention 40 delineates exemplars of evidence-based programs (eg, Sources of Strength and Good Behavior Game) that enhance social connectedness within families, school, and communities, including peer norm programs and community engagement activities. 55 , 56

For precipitating circumstances among youth decedents in our study, the likelihood of having a documented MH diagnosis varied across family and life stressors, with no significant difference in the likelihood of having an MH diagnosis for any of the individual crisis variables. This speaks to youths’ challenges with adapting to family or life stressors and acute crisis regardless of the presence of an MH disorder. Additionally, teaching coping skills and increasing family and societal supports could prevent precipitating life circumstances.

There are limitations with this study. First, NVDRS is not a representative national sample because various states began contributing data during different years. However, NVDRS capture rates of youth suicide deaths in the Web-based Injury Statistics Query and Reporting System have increased from 28.0% in 2010 to 87.4% in 2021. 1 Second, documentation of an MH diagnosis was defined by source records (ie, coroner, medical examiner, or law enforcement) and family member accounts; some decedents may have had an MH diagnosis that was unknown, undiagnosed, or unreported. However, utilization of these source records increases the likelihood of detecting MH diagnoses relative to administrative datasets that rely solely on billing diagnosis codes. Third, we could not conduct analyses using sexual orientation and gender identity variables due to a substantial degree of missingness. Fourth, the study was limited to analyses of quantitative data fields in NVDRS; incident narratives from law enforcement, coroner, and medical examiner reports were not examined for this study.

In conclusion, most youth suicide decedents in this detailed, recent national sample did not have a documented MH diagnosis, signaling inadequate detection of MH needs. Youths who died by firearm suicide, the most common mechanism, had the lowest rate of documented MH diagnosis, highlighting the importance of universal lethal means counseling and CAP laws to increase barriers to firearm access. Social inequities may contribute to differences in MH diagnoses prior to suicide among racially and ethnically minoritized youths. These findings underscore the critical need to increase equitable access to MH screening, diagnosis, and treatment for all youths. Given the low rates of MH diagnoses among youth suicide decedents, prevention efforts must also address family and life stressors in tandem with MH risk factors. Both increased identification of unmet MH needs and universal, community-based approaches are needed to prevent youth suicide.

Accepted for Publication: April 28, 2024.

Published: July 30, 2024. doi:10.1001/jamanetworkopen.2024.23996

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Chaudhary S et al. JAMA Network Open .

Corresponding Author: Sofia Chaudhary, MD, Department of Pediatrics and Emergency Medicine, Emory University School of Medicine, 1547 E Clifton Rd NE, 2nd Floor, Atlanta, GA 30322 ( [email protected] ).

Author Contributions: Mr Zamani and Mr Hall had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Fleegler and Goyal are co–senior authors.

Concept and design: Chaudhary, Hoffmann, Pulcini, Zamani, Hall, Jeffries, Myers, Fein, Zima, Ehrlich, Hargarten, Fleegler, Goyal.

Acquisition, analysis, or interpretation of data: Chaudhary, Hoffmann, Zamani, Hall, Myers, Fein, Zima, Alpern, Sheehan, Fleegler, Goyal.

Drafting of the manuscript: Chaudhary, Hoffmann, Zamani, Jeffries, Fein, Fleegler.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Zamani, Hall.

Administrative, technical, or material support: Pulcini, Myers, Ehrlich.

Supervision: Fein, Zima, Ehrlich, Hargarten, Sheehan, Fleegler, Goyal.

Conflict of Interest Disclosures: Dr Hoffmann reported receiving grants from Children's Research Fund Junior Board outside the submitted work. Dr Fein reported receiving fees for a patent owned by Children’s Hospital of Philadelphia licensed to Potential for the Behavioral Health Screen-Emergency Department. No other disclosures were reported.

Group Information: All members of the Children’s Hospital Association Research in Gun Related Events (CHARGE) Collaborative are study authors.

Disclaimer: This research uses data from the National Violent Death Reporting System (NVDRS), a surveillance system designed by the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control. The findings are based, in part, on the contributions of the funded states, territories, and jurisdictions that collected violent death data and the contributions of their partners, including personnel from law enforcement, vital records, medical examiners or coroners, and crime laboratories. The analyses, results, and conclusions presented here represent those of the authors and do not necessarily reflect those of CDC. Persons interested in obtaining data files from NVDRS should contact CDC National Center for Injury Prevention and Control (4770 Buford Hwy, NE, MS 106-10, Atlanta, GA 30341-3717; 1-800-CDC-INFO).

Meeting Presentation: This paper was presented at the National Violent Death Reporting System Conference; May 16, 2023; Milwaukee, Wisconsin; the American Academy of Pediatrics National Conference and Exhibition; October 22, 2023; Washington, DC; and the National Research Conference for the Prevention of Firearm Related Harms; November 1, 2023; Chicago, IL.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: Contributors to this report included participating NVDRS programs based in US states, territories, and jurisdictions; participating state, territory, and jurisdiction agencies, including state, territory, and jurisdiction health departments, vital registrars’ offices, coroners’ and medical examiners’ offices, crime laboratories, and local and state, territory, and jurisdiction law enforcement agencies. NVDRS acknowledges its partner organizations: the Safe States Alliance, American Public Health Association, International Association of Chiefs of Police, National Association of Medical Examiners, National Association for Public Health Statistics and Information Systems, National Violence Prevention Network, Council of State and Territorial Epidemiologists, and Association of State and Territorial Health Officials; federal agencies, including the US Department of Justice, Bureau of Justice Statistics; other stakeholders, researchers, and foundations, including Harvard University Injury Control Research Center and the Joyce Foundation, the National Institute for Occupational Safety and Health, and the National Center for Health Statistics of the Centers for Disease Control and Prevention.

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1) A Strategic Analysis of Aegon, Ltd. (2023) Author’s Details:  (1) Amber Horton- Business Department, CUNY School of Professional Studies  (2) Herbert Sherman- Long Island University – Brooklyn Abstract : This strategic case analysis focuses upon Aegon Ltd., more commonly known as simply “Aegon,” an international financial services firm headquartered in The Hague, Netherlands. Aegon offers a wide variety of investment, insurance, and retirement solutions to its nearly 24 million customers worldwide. Its portfolio of businesses includes its fully owned businesses in the United States and the United Kingdom, a global asset manager, as well as joint ventures in Spain, Portugal, China, France, and Brazil. This strategic analysis includes the use of the following external/environmental analysis tools (PESTLE, Five Forces and Competitor Analyses) as well as internal analyses (VRIO, Value Chain and Functional) which are presented in table form. All of these analyses culminate in a SWOT analysis of the firm Keywords: Case study, strategic analysis, international, financial services. [Download Full Paper] [Page 01-17] ================================================================================

2) Effect of Citrullus colocynthis Juice Pulp Extract on High Fat Induced Author Details:Mariam Olawunmi Ibrahim- Ladoke Akintola University of Technology Abstract : Obesity is a chronic disease caused by an imbalance in the amount of energy consumed and the amount of energy expended. Citrullus colocynthis ( known as bitter apple)  is a desert viney plant that grows in sandy, arid soils. It is rich in various bioactive compounds such as essential oils, glycosides, flavonoids, alkaloids, and fatty acids. This study evaluated the effect of citrus colocynthis on the lipid profile of high-fat diet-induced obese rats. Forty-two male albino rats weighing between 200-250g were divided into six groups of seven rats each. Group 1 contains animals fed with normal feed and water (control group), group 2 contains animals receiving 150mg/kg Citrullus colocynthis and fed with high cholesterol diet, group 3 contains animals receiving 75mg/kg Citrullus colocynthis and fed with high cholesterol diet, group 4 contain animals fed high cholesterol diet only, group 5 contain animals receiving 150mg/kg Citrullus colocynthis and fed with normal diet and group 6 contain animals receiving 75mg/kg Citrullus colocynthis and fed with normal diet. The animals were sacrificed after three months, blood was collected for biochemical evaluation. The administration of high-cholesterol diet-induced obesity was indicated by an increase in body mass index, Lee index, and specific rate of body mass gain in the group fed with high cholesterol diet only when compared to the control group. The serum was analyzed for cholesterol, triglyceride, low-density lipoprotein, and high-density lipoprotein, significant decrease in high-density lipoprotein and an increase in cholesterol, triglyceride, and low-density lipoprotein levels was observed in the group that fed with high cholesterol diet only when compared to the control group and the group that is fed with high cholesterol diet and treated with 150mg/kg of the extract, while significance increase in high-density lipoprotein and decrease in cholesterol, triglyceride, low-density lipoprotein levels were observed in the group that was given 150mg/kg of the extract only when compared to the control group and the group that was fed high cholesterol diet only. In conclusion this study suggested that Citrullus colocynthis juice pulp extract is effective in the treatment of obesity as evidenced by a reduction in the levels of cholesterol, triglycerides, and LDL, while there is an increase in the level of HDL, due to the presence of phytochemical constituents in the plant. Keywords: Citrullus Colocynthis, obesity, overweight, genetics, cardiovascular dysfunction [Download Full Paper] [Page 18-36] ================================================================================

3) Foreign Currency Exchange Rate and Return on Assets of Listed Manufacturing Firms in Nigeria Author’s Details:Adesola Adebayo AKANDE 1 AMEDU, Emmanuella Orhunwakho 2 [email protected] +2348037067714 Abstract : This study examined the foreign currency exchange rate effect on Return on Assets of listed manufacturing firms in Nigeria between 2013 – 2022. Financial data of ten selected manufacturing firms quoted on the Nigeria stock exchange that embark on production of industrial and consumer goods were collected through CBN Statistical Bulletin and annual reports of the selected companies. The obtained data were analysed with E-view version 9.0. The result showed a positive-relationship between the Real Effective Exchange Rate and the return on assets metrics as the Granger Causality Wald Tests-result offers insights into potential causality relationships of the economic variables. The study concludes that the significant interactions between financial performance variables and the real exchange rate of an economy dictates a broad spectrum of economic opportunity indicators in a complex and interconnected economy and it remains essential to grasp the dynamics due to the global economic intertwinements and external forces capable of shaping Nigeria economy at any rate. With this, the result of the study provides a guidepost to manufacturers in their transactions with their trade partners across the border.  The study strongly recommends the utilization of Real Currency Exchange rate by financial and economic regulators in Nigeria to enhance manufacturing entity’s performance financially in developing economy Keywords: Exchange Rate, Real Exchange Rate, Nominal Exchange Rate, Interest Rate, ROA.  [Download Full Paper] [Page 37-48] ================================================================================

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A new framework of land use simulation for land use benefit optimization based on gmop-plus model—a case study of haikou.

1. Introduction

2. materials and methods, 2.1. study area, 2.2. data sources and pre-processing, 2.2.1. data sources, 2.2.2. data pre-processing, 2.3. research methodology, 2.3.1. gmop-based land use scenario setting methodology, 2.3.2. plus model-based land use simulation modeling, 3. results and analysis, 3.1. analysis of spatial patterns of land use in simulation scenarios, 3.2. analysis of changes in land use structure under simulation scenarios, 3.3. analysis of land use benefits under simulation scenarios, 3.4. influence of diverse driving factors on lucc, 4. discussion, 4.1. an optimization method for land use simulation coupled with the gmop-plus model, 4.2. future land use patterns, 4.3. recommendations for optimizing land use development patterns, 4.4. problems and prospects, 5. conclusions, author contributions, data availability statement, conflicts of interest.

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Fu, H.; Liang, Y.; Chen, J.; Zhu, L.; Fu, G. A New Framework of Land Use Simulation for Land Use Benefit Optimization Based on GMOP-PLUS Model—A Case Study of Haikou. Land 2024 , 13 , 1257. https://doi.org/10.3390/land13081257

Fu H, Liang Y, Chen J, Zhu L, Fu G. A New Framework of Land Use Simulation for Land Use Benefit Optimization Based on GMOP-PLUS Model—A Case Study of Haikou. Land . 2024; 13(8):1257. https://doi.org/10.3390/land13081257

Fu, Hui, Yaowen Liang, Jie Chen, Ling Zhu, and Guang Fu. 2024. "A New Framework of Land Use Simulation for Land Use Benefit Optimization Based on GMOP-PLUS Model—A Case Study of Haikou" Land 13, no. 8: 1257. https://doi.org/10.3390/land13081257

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