Search

Quantitative research is designed to test well-specified hypotheses, determine whether an intervention did more harm than good, and find out how much a risk factor predisposes persons to disease. Equally important, qualitative research offers insight into emotional and experiential phenomena in health care to determine what, how, and why. There are 4 essential aspects of qualitative analysis. First, the participant selection must be well reasoned and their inclusion must be relevant to the research question. Second, the data collection methods must be appropriate for the research objectives and setting. Third, the data collection process, which includes field observation, interviews, and document analysis, must be comprehensive enough to support rich and robust descriptions of the observed events. Fourth, the data must be appropriately analyzed and the findings adequately corroborated by using multiple sources of information, more than 1 investigator to collect and analyze the raw data, member checking to establish whether the participants' viewpoints were adequately interpreted, or by comparison with existing social science theories. Qualitative studies offer an alternative when insight into the research is not well established or when conventional theories seem inadequate. JAMA. 2000;284:357-362 [ABSTRACT FROM AUTHOR]

Background: Health systems guidance (HSG) are systematically developed statements that assist with decisions about options for addressing health systems challenges, including related changes in health systems arrangements. However, the development, appraisal, and reporting of HSG poses unique conceptual and methodological challenges related to the varied types of evidence that are relevant, the complexity of health systems, and the pre-eminence of contextual factors. To address this gap, we are conducting a program of research that aims to create a tool to support the appraisal of HSG and further enhance HSG development and reporting. The focus of this paper was to conduct a knowledge synthesis of the published and grey literatures to determine quality criteria (concepts) relevant for this process., Methods: We applied a critical interpretive synthesis (CIS) approach to knowledge synthesis that enabled an iterative, flexible, and dynamic analysis of diverse bodies of literature in order to generate a candidate list of concepts that will constitute the foundational components of the HSG tool. Using our review questions as compasses, we were able to guide the search strategy to look for papers based on their potential relevance to HSG appraisal, development, and reporting. The search strategy included various electronic databases and sources, subject-specific journals, conference abstracts, research reports, book chapters, unpublished data, dissertations, and policy documents. Screening the papers and data extraction was completed independently and in duplicate, and a narrative approach to data synthesis was executed., Results: We identified 43 papers that met eligibility criteria. No existing review was found on this topic, and no HSG appraisal tool was identified. Over one third of the authors implicitly or explicitly identified the need for a high-quality tool aimed to systematically evaluate HSG and contribute to its development/reporting. We identified 30 concepts that may be relevant to the appraisal of HSG and were able to cluster them into three meaningful domains: process principles, content, and context principles., Conclusions: Our study showed the role that the quality criteria play in the development, appraisal, and reporting of HSG and demonstrated the link and resonance within and between the various concepts in the three domains.

Background: Health system guidance (HSG) provides recommendations aimed to address health system challenges. However, there is a paucity of methods to direct, appraise, and report HSG. Earlier research identified 30 candidate criteria (concepts) that can be used to evaluate the quality of HSG and guide development and reporting requirements. The objective of this paper was to describe two studies aimed at evaluating the importance of these 30 criteria, design a draft HSG appraisal tool, and test its usability., Methods: This study involved a two-step survey process. In step 1, respondents rated the 30 concepts for appropriateness to, relevance to, and priority for health system decisions and HSG. This led to a draft tool. In step 2, respondents reviewed HSG documents, appraised them using the tool, and answered a series of questions. Descriptive analyses were computed., Results: Fifty participants were invited in step 1, and we had a response rate of 82 %. The mean response rates for each concept within each survey question were universally favorable. There was also an overall agreement about the need for a high-quality tool to systematically direct the development, appraisal, and reporting of HSG. Qualitative feedback and a consensus process by the team led to refinements to some of the concepts and the creation of a beta (draft) version of the HSG tool. In step 2, 35 participants were invited and we had a response rate of 74 %. Exploratory analyses showed that the quality of the HSGs reviewed varied as a function of the HSG item and the specific document assessed. A favorable consensus was reached with participants agreeing that the HSG items were easy to understand and easy to apply. Moreover, the overall agreement was high for the usability of the tool to systematically direct the development (85 %), appraisal (92 %), and reporting (81 %) of HSG. From this process, version 1.0 of the HSG appraisal tool was generated complete with 32 items (and their descriptions) and 4 domains., Conclusions: The final tool, named the Appraisal of Guidelines for Research and Evaluation for Health Systems (AGREE-HS) (version 1), defines expectations of HSG and facilitates informed decisions among policymakers on health system delivery, financial, and governance arrangements.

Background: Cardiac procedure guidelines often include psychosocial criteria for selecting patients that potentially introduce social value judgements into clinical decisions and decisions about the rationing of care. The aim of this study was to investigate the terms and justifications for and the meanings of psychosocial patient characteristics used in cardiac procedure guidelines., Methods: We selected English-language guidelines published since 1990 and chapters in textbooks published since 1989. These guidelines amalgamated multiple sources of evidence and expertise and made recommendations regarding patient selection for specific procedures. A multidisciplinary team of physicians and social scientists extracted passages regarding psychosocial criteria and developed categories and conceptual relationships to describe and interpret their content., Results: Sixty-five papers met the criteria for inclusion in the study. Forty-five (69%) mentioned psychosocial criteria as procedure indications or contraindications. The latter fell into several categories, including behavioural and psychological issues, relationships with significant others, financial resources, social roles and environmental circumstances., Interpretation: Psychosocial characteristics are portrayed as having 2 roles in patient selection: as risk factors intrinsic to the candidate or as indicators of need for special intervention. Guidelines typically simply list psychosocial contraindications without clarifying their specific nature or providing any justification for their use. Psychosocial considerations can help in the evaluation of patients for cardiac procedures, but they become ethically controversial when used to restrict access. The use of psychosocial indications and contraindications could be improved by more precise descriptions of the psychosocial problem at issue, explanations regarding why the criterion matters and justification of the characteristic using a biological rationale or research evidence.

Clinical practice guidelines are expanding their scope of authority from clinical decision making to collective policy making, and promise to gain ground as resource allocation tools in coming years. A close examination of how guidelines approach patient selection criteria offers insight into their ethical implications when used as resource allocation or rationing instruments. The purposes of this paper are: a) to examine the structure of allocative reasoning found in clinical guidelines; b) to identify the ethical principles implied and compare how guidelines enact these principles with how explicit systems-level rationing exercises and health policy analyses have approached them; and c) to offer some preliminary suggestions for how these ethical issues might be addressed in the process of guideline development. The resulting framework can be used by guideline developers and users to understand and address some of the ethical issues raised by guidelines for the use of scarce technologies.

The second part of this 2-part series on how to interpret qualitative research addresses, "what are the results," and, "how do they help me care for my patients?" Qualitative analysis is a process of summarizing and interpreting data to develop theoretical insights that describe and explain social phenomena such as interactions, experiences, roles, perspectives, symbols, and organizations. Key results are often illustrated with excerpts from interview transcripts, field notes, or documents. The results of a qualitative research report are best understood as an empirically based contribution to ongoing dialogue and exploration. Empirically based theory evolves from a process of exploration, discovery, analysis, and synthesis. Each concept should be defined carefully in a way that is meaningful to the reader. Concepts should be adequately developed and illustrated when theoretical conclusions are drawn. Arguments should be explained and justified. The qualitative research report ideally should address how the findings relate to other theories in the field. The qualitative study can provide a useful road map for understanding and navigating similar social settings interactions, or relationships. JAMA. 2000;284:478-482

To rationalize and restrict health care spending, policy, makers in many jurisdictions have withdrawn insurance or funding for selected health care technologies. Numerous analytic frameworks and applied exercises have emerged to guide decisions about "which" services to cut. But in their focus on choice-making processes, these efforts have paid little attention to the problem of defining and dividing the set of technologies to choose among. If technology assessment refers to methods for weighing services for their relative value, the term technology assembly might be used to refer to methods for framing the technological trade-offs to enroll in such contests. This article examines technology assemblies found in several types of theoretical and applied rationing exercises (including Oregon's Medicaid rationing process, economic evaluation literature, citizen "values" surveys, and Canadian provincial deinsurance policies). Based on this review, some key conceptual conventions and problems in technology assembly can be identified. The boundaries between health technologies are fuzzy, interlocked, layered, and continuously moving. Consequently, the defining features of technological trade-offs are inevitably socially constructed and negotiated. Trade-offs can be arranged along numerous dimensions, and the divisions typically correspond to broader political, administrative, and ethical dilemmas in health policy. Examples include equity among demographic classes, concepts of need, legitimacy of therapeutic goals, and so forth. Insights into the process of constructing technological trade-offs may help policy makers better question what technologies they are looking at and why, before moving on to the task of determining which ones to cover.

Objective: To examine several hospital-based procedures for systematic utilization differences between the genders and among ethnic groups (Asian, black, Latino, and white)., Methods: California hospital discharges in 1989 and 1990 were sampled by principal diagnosis. Odds ratios for treatment by demographic class were estimated for heart transplantation, kidney transplantation, extracorporeal shockwave lithotripsy, hip replacement, carotid endarterectomy, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, pacemaker implant, and automatic cardioverter-defibrillator implant. Logistic regression controlled for insurance status, age, diagnosis, and comorbidity count., Results: The following results were statistically significant (P < .05). Males' odds of receiving most procedures exceeded those of females by 115% (odds ratio, 2.15) for coronary artery bypass grafting, 86% for heart transplantation, 38% for defibrillator implants, 34% for angioplasty, 28% for pacemaker implants, and 24% for hip replacement. Whites' odds of receiving several procedures exceeded those of blacks by 204% for kidney transplantation, 186% for defibrillator implant, 144% for coronary artery bypass grafting, 127% for endarterectomy, and 100% for angioplasty. Whites' odds of receiving some procedures also exceeded those of Latinos by 72% for angioplasty, 58% for kidney transplantation, and 49% for coronary artery bypass grafting. Whites' odds of receiving endarterectomy or angioplasty exceeded those of Asians by 108% and 30%, respectively. Asians had 113% higher odds than whites of receiving hip replacement., Conclusions: The array of utilization differences across 4 demographic comparisons and 9 hospital procedures suggests systematic trends in high-technology allocation. Generally, women received procedures less often than men and minorities less than whites.