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Case Study – Methods, Examples and Guide

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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Muhammad Hassan

Researcher, Academic Writer, Web developer

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In This Section

Reflective Essay
Project Summary

How to Use This Case Study: A Guide for Students and Teachers

Migration and the Twentieth-Century South: An Overview
Study Questions
Population Statistics
Agricultural Statistics
Images of Farming
Business, Industry, and Government
Annotated Bibliography of Primary Sources
Acknowledgements

This case study is intended to help students develop a better understanding of why and how migration takes place and what the impact of migration is on the places people migrate to and the places people leave. More specifically, it is designed to help students develop a better understanding of migration in the twentieth century American South and of the role of migration in Southern history. The case study is also intended as an exercise in the use of primary sources and how the writing of good history depends on finding and carefully interpreting primary sources. The audience for this case study is college history students, although advanced high school students are more than capable of making use of it also.

Three North Carolina counties located on the Virginia border will be examined during the period from 1940-1999. A collection of primary sources* has been assembled that consists of on-site sources and links to primary sources at other web sites. These sources include interviews, statistics drawn from U.S. Census records, and photographs. Secondary sources** are also available in the form of a brief overview of migration on-site and links to a number of other sites with more extensive studies of migration and economic and social change in the South. A sizeable body of primary and secondary source material is thus available to students. In fact, there is more information on this site and at the web sites linked to this site than the typical student has the time or interest to read through. Students must, therefore, be selective with their reading both as to the sites they choose to explore and how closely they read particular texts. This too is what good historians do and indeed what all of us must learn to do in order to manage the tremendous amounts of information that come our way in this "Age of Information."

The study questions are the key to this case study; they are really a navigational aid that enables students to steer through the primary sources. Ideally, the answers derived from digging through the assembled primary sources will make the general analysis in the overview more meaningful and will flesh out with details what were before only seemingly vague generalizations. We hope students may also get a better handle on the "why" of migration by studying a small area so intensely. Questions in each unit in the study guide are organized from simple questions requiring simple answers to questions that require complex, analytical answers. The idea here is that the exercise will help students work through the step-by-step process of writing an historical analysis, a process that often leaves students sitting mystified behind piles of books and stacks of note cards. Teachers may assign a group of questions to students or, for a more extensive project, all of the questions. Teachers might also assign groups of questions to different discussion groups in a class and have each group develop an oral presentation based on their findings.

Where to begin? Begin with the " Overview ." Make your decision at that point as to whether you will to read some of the other secondary sources linked to the "Overview." Then move to the " Study Questions ." They will guide you to particular primary sources on and off thisweb site.

*Primary sources are firsthand accounts of a period or event in history by someone who was there or who talked to someone who was there. Government documents, pictures, newspaper accounts, diaries, government statistics, memoirs and interviews are all examples of primary sources. These sources need not be concerned with "major" events; they might record the annual harvest in a county, an industrial fire, a corn shucking, or the national divorce rate.

**Secondary sources are what historians do with primary sources. A secondary source is thus an analysis of a topic or issue that employs primary sources and other secondary sources. Is it possible to create a secondary source solely by relying on other secondary sources? The answer is "yes" but historians are suspicious of the validity of historical observations based solely on research in the secondary sources just as a farmer might be suspicious of anyone who claims to farm but never has dirty hands. While students may have no interest in writing history, most historians feel students should at least be aware of the connection between primary and secondary sources. This awareness, we believe, enhances the ability of students to critically assess secondary source material.

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The History of the Case Study at Harvard Business School

faculty and student engaged in a classroom case discussion

28 Feb 2017

Many first-time HBS Online participants are surprised to learn that, often, the professor is not at the center of their learning experience. Instead of long faculty lectures, the HBS Online learning model centers on smaller, more digestible pieces of content that require participants to interact with each other, test concepts, and learn from real-world examples.

Often, the professor fades into the background and lets the focus shift to interviews with executives, industry leaders, and small business owners. Some students might be left thinking, "Wait, where did that professor go? Why am I learning about a grocery store in Harvard Square?"

In the words of The Hitchhiker's Guide to the Galaxy , “Don’t panic.” These interviews, or cases, feature leaders at companies of all sizes and provide valuable examples of business concepts in action. This case study method forms the backbone of the Harvard Business School curriculum.

Back in the 1920s, HBS professors decided to develop and experiment with innovative and unique business instruction methods. As the first school in the world to design a signature, distinctive program in business, later to be called the MBA, there was a need for a teaching method that would benefit this novel approach.

HBS professors selected and took a few pages to summarize recent events, momentous challenges, strategic planning, and important decisions undertaken by major companies and organizations. The idea was, and remains to this day, that through direct contact with a real-world case, students will think independently about those facts, discuss and compare their perspectives and findings with their peers, and eventually discover a new concept on their own.

Central to the case method is the idea that students are not provided the "answer" or resolution to the problem at hand. Instead, just like a board member, CEO, or manager, the student is forced to analyze a situation and find solutions without full knowledge of all methods and facts. Without excluding more traditional aspects, such as interaction with professors and textbooks, the case method provides the student with the opportunity to think and act like managers.

Since 1924, the case method has been the most widely applied and successful teaching instrument to come out of HBS, and it is used today in almost all MBA and Executive Education courses there, as well as in hundreds of other top business schools around the world. The application of the case method is so extensive that HBS students will often choose to rely on cases, instead of textbooks or other material, for their research. Large corporations use the case method as well to approach their own challenges, while competing universities create their own versions for their students.

This is what the case method does—it puts students straight into the game, and ensures they acquire not just skills and abstract knowledge, but also a solid understanding of the outside world.

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A Better Way to Teach History

One professor is borrowing a method from Harvard Business School to engage students and inspire better decision-making skills.

In a spacious classroom in Aldrich Hall on the Harvard Business School campus, 100 students are passionately discussing a case called “Battle Over a Bank.” But these aren’t MBA students deliberating over how much the government should regulate the financial sector. This group of mostly undergraduates, guided by the award-winning Harvard Business School professor David Moss, is diving into the fierce 1791 debate over whether the Constitution could be interpreted to allow the fledgling U.S. government the power to form a bank at all.

This class, “History of American Democracy,” is no pedestrian historical survey course. It uses the case method—the business school’s signature teaching technique—to immerse undergraduates (as well as a limited number of HBS students) in critical episodes in the development of American democracy.

The field of history is often dismissed as dull, but educators like Moss are experimenting with innovative teaching strategies to teach history in a way that is effective, exciting, and productive. There’s “Reading like a Historian,” based at Stanford and aimed at the K-12 level, which explicitly hones the ability to take primary sources and interpret, construct meaning, recognize competing narratives, and contextualize as a historian would. “Reacting to the Past,” started at Barnard College by Mark Carnes, is a student-centered college curriculum consisting entirely of role-playing games. “Facing History and Ourselves,” which grew out of a course focused on the Holocaust, uses a multi-pronged approach to get young people in grades six through 12 thinking about the ramifications of genocide and mass violence as a way of reflecting on moral choices they themselves face in their own lives.

History education generates heated controversy among educators and policymakers. There is a long history of tension over which historical facts children should be learning in school and when, whether a particular set of proposed standards is too patriotic, too multicultural, or whitewashes uncomfortable truths. Controversies over the content and nature of what children are learning often fall along political lines: The Michigan State Board of Education recently delayed voting on its new social-studies standards because of a controversy over whether liberal bias was behind proposals to include civil rights in the curriculum before high school, while in Texas, critics repeatedly accuse textbook authors of reflecting conservative political views in their coverage of topics such as religion or slavery.

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Perhaps the most major current-day divide falls along the lines of content versus skills: Should history classes be about acquiring facts and information, or should they emphasize historical thinking abilities and processes? And if the latter, which skills and how might they best be taught? While a positivist view of history—the 19th-century notion that history was akin to a science, and that the accumulation of historical facts would eventually lead to an objective understanding of events—fell out of favor long ago, this idea seems to remain the operative assumption behind traditional history curricula that emphasize content, chronology, and comprehensiveness.

According to Bob Bain, a professor of history and education at the University of Michigan and faculty lead on the Big History Project , the debate over factual content versus skills—one that has actually waxed and waned ever since history emerged as a field of study a century and a half ago—pertains to a false dichotomy. “You can’t do historical thinking without facts, and you can’t acquire stuff without some sort of historical thinking,” he points out. A good history teacher can teach both effectively, agrees Elaine Carey, a history professor at St. John’s University and the former vice president of the teaching division of the American Historical Association. She emphasizes that teachers can teach “skills through content,” and that you “can’t understand historical continuity if you don’t have historical knowledge.”

The case method goes beyond historical skills and factual content; it aims to hone decision-making skills. Each case is a concentrated story about a specific episode in history. Students are asked what they would have decided had they been, say, an advocate arguing for compulsory public education in 1851, or Theodore Roosevelt deciding whether to intervene in a dispute between labor and industry in 1901. It’s not until after they have fully discussed the case that the historical outcome is revealed to them. (Class participation, even though it is mandatory, is enthusiastic: “We can have 40 hands in the air at any given moment,” Moss tells me.)

Few students think about history that way, according to Moss. Instead, they’re often taught that “what happened is what happened.” Unlike with many history courses, where students look back at historical events students in Moss’s course “play history forward. If you were in that place as that voter, that labor leader, or that congressperson, what decision would you have made?”

One of the reasons American children often appear to struggle in history, Bain says, is because their knowledge is primarily assessed through multiple-choice tests. Multiple-choice assessment, by nature, often privileges factual content over historical thinking. “If you’re testing historical content out of context, that might explain why they don’t do so well,” Bain says. He advocates embracing the use of narrative—even if that narrative is flawed or one-sided. “The grand narrative is pejorative to many in the historical profession—people say that it tries to inculcate a particular viewpoint in kids. But having a big picture or story is cognitively critical to historical knowledge.”

Similarly, history textbooks appear omniscient and objective, and tend to gloss over competing narratives. But educators say that understanding whose narrative is being told helps students to engage with it; even if it is wrong or they disagree with it, the narrative provides context and a more effective way to learn and remember. “The argument I make all the time is, it’s like if I were to ask someone to assemble a 1,000-piece jigsaw puzzle without the box-top picture of it. You could of course eventually put it together but the effort to match shapes and colors on each piece would be monumental, and you’d likely give up quite quickly. Such is what happens to many kids in school.”

It’s difficult to track down research corroborating the academic benefits of the case method, but anecdotal evidence speaks to its power. Moss tells me he has observed the results of story-based teaching in his classroom. “People remember cases incredibly well—and often at a level of detail that’s almost shocking. Stories stick in the mind, and when you learn history with a focus on particular stories it’s much easier to remember the pieces around them.”

David Kaufman, a student who took the course last year, says that discussing history through a series of cases allowed the students to “focus a lot more on the process than on, say, the actual legislative result, which I think was much richer.” It is well known that stories aid learning because of how memory is structured. The cognitive psychologist Jerome Bruner wrote of two modes of knowing: paradigmatic and narrative; with the latter, attention and emotion influence the strength of a memory. Stories activate emotion, which helps students stay engaged and remember. They also feed the human need to fit things into a coherent structure in order to make meaning of them.

All this makes the case method promising for high school, too, and some of Moss’s cases were indeed adopted for use by history teachers at public and private high schools in a pilot program beginning early last year. One of the participants, Eleanor Cannon, a history teacher at St. John’s School in Houston, expressed astonishment at how students who never thought of themselves as history types before grew to love history. “I’ve never had this experience as a teacher before, and it’s explicitly due to the case method—it’s a game changer.” Rather than merely know which decisions historical figures made, her students now understood why. Facts she had taught multiple times, such as that the Constitution was not handed down intact by the founders but emerged from a protracted period of intense tumult, debate, and compromise, made visceral sense now after students read and discussed a case on James Madison and the making of the Constitution. (As one student told Cannon, “I didn’t realize how much they argued!”)

Moss compares immersion in case after case to batting practice that helps train judgment. The idea is to help students develop an instinct for how to respond even to problems—whether they be furor over same sex marriage or a massive financial crisis—that feel unprecedented. Through sheer repetitive exposure to problems and problem-solving, students learn the art of decision-making—and develop better judgment—in “much the same way as you might learn a language. It’s not an algorithm, it’s the development of an instinct—at least in part,” says Moss. They also provide historical perspective when looking at problems today.

Take the current debate over immigration. Although none of Moss’s cases focuses principally on immigration, themes of exclusion/inclusion are woven throughout, potentially reminding readers that unpleasant historical episodes have happened again and again. A group of people will become accepted into the fold, only to see the fire turned on another one; who the “threatening” outgroup is always changing. “You can see it as deeply disturbing,” Moss says, “that there always seemed to be an outgroup that some Americans looked down upon, but you could also see that there is an ongoing process of expanding tolerance, over time. This doesn’t create an excuse for bigotry—absolutely not—but it does give you a little hope that when there is bigotry it’s not necessarily permanent; there is a chance to get past it, group by group, with the result eventually being a broader, more tolerant society.”

One of Moss’s arguments about democracy is that it is far more complex than people tend to realize—that “it is not a machine built to specification.” Instead, democracy can be understood as a living organism that thrives on productive tension, engagement, and change. Without movement, it would die. Moss mentions the de facto national motto first suggested in 1776 by Benjamin Franklin: E Pluribus Unum . “Out of many, one.” Franklin saw difference that achieves common purpose as a core strength of the country. If one were to apply this analogy to history, ongoing debates about how to teach it only enhance the field—as long as educators remain committed to the same shared goal of helping students understand the past in order to face the future. “The best ideas come out of tension, out of disagreeing,” Moss tells his students. “Tension is what ensures the best ideas win out.”

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Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Case Method Project

Harvard Business School →
Case Method Project →

Bringing case method teaching to high schools & colleges: U.S. History, Government, Civics & Democracy

About the project .

The Case Method Project is an initiative formed to achieve two goals:

Bring case method teaching to high schools and colleges
Use this methodology to deepen students’ understanding of American democracy

Based on the highly successful experience of Harvard Business School and other graduate and professional programs that use case-based teaching, we believe the case method can be employed to strengthen high school and college education as well, ensuring a more exciting, relevant, and effective experience for students and teachers across a range of subjects. We also believe the case method can be especially effective at engaging students with topics in history and democracy and that it presents a unique opportunity to help reverse the broad decline in civic education – and civic engagement – in the United States.

Curriculum

For current partners .

Already working with the Case Method Project?

Connect to other educators in our network and download case materials via ShareVault .

For Prospective Partners

Interested in learning more about the Case Method Project?

Find out how to bring the case method to your school.

Eleanor Cannon Houston, TX Eleanor Cannon Houston, TX

Maureen O’Hern Dorchester, MA Maureen O’Hern Dorchester, MA

Michael Gordon Munster, IN Michael Gordon Munster, IN

“ I have had few weeks in teaching that I enjoyed as much as doing this case....My biggest dilemma now is how many cases I want to fit into the year. ”

In the News

A Better Way to Teach History

The Atlantic

Rewriting History

HBS Alumni Bulletin

All Hail Partisan Politics

Harvard Gazette

How to Teach Civics in School

The Economist

Teaching History Through the Case Method

Explore more.

Case Teaching
Course Materials

T he case method is typically synonymous with business school curriculum. Through active case discussion, students put themselves in the proverbial shoes of a case protagonist, often a manager or leader of a company or organization facing a difficult business challenge. Students apply critical thinking skills to work through complicated problems and process contending points of view, then engage with their classmates in developing a solution together. This intellectual energy is the pedagogical “magic” instructors strive for.

Perhaps a lesser-known power of the case method, however, is in its applicability across a variety of topics and student levels. Take, for instance, history, government, civics, and democracy—topics that feel particularly pertinent given the roller-coaster US election and other polarizing political events around the world.

In an effort to bring these important topics, particularly American history, to life, historian David Moss, the Paul Whiton Cherington Professor of Business Administration at Harvard Business School (HBS), has taken the case method’s magic from the business school to the high school. In 2015, Moss launched a pilot program in 11 public, charter, and private high schools across the United States. He provided 23 history and civics teachers with historical cases that showcase the foundations of US democracy—as well as worksheets, assignment questions, and teaching plans. He then made the cases available for free to high school students to encourage case teaching among this group.

The goal of this program, called the Case Method Project , is to demonstrate that teaching with cases can strengthen high school and college education as well as ensure “a more exciting, relevant, and effective experience for students and teachers across a range of subjects,” according to its site.

“The results [of the Case Method Project] have been incredibly positive, especially in terms of strengthening students’ critical thinking, their retention and understanding of course material, and their civic interest and engagement.” David Moss

Since its initial launch, the program has grown considerably. Today Moss is working with over 350 teachers in more than 250 high schools across 45 states and the District of Columbia. “We’ve now reached well over 30,000 students as part of the initial pilot,” he says. “The project has grown considerably over the last several years, and the results have been incredibly positive, especially in terms of strengthening students’ critical thinking, their retention and understanding of course material, and their civic interest and engagement. Because of this success, we’re aiming to reach much larger numbers of teachers and students going forward through the new Case Method Institute for Education and Democracy, which started up this summer.”

The case method has proven remarkably effective in teaching high schoolers the critical thinking skills that the world’s future leaders so greatly need. Here, to help educators see the different ways and venues in which case teaching can be used, we showcase the collection of cases Moss authored and provided in support of this effort.

Democracy Cases to Use in Class

Here is a list of Moss’s cases , which you can use to engage students in conversations about US history and democracy. We hope you find these cases helpful.

James Madison, the ‘Federal Negative,’ and the Making of the U.S. Constitution (1787) and as a supplement: In Detail: Debt and Paper Money in Rhode Island (1786)

Battle Over a Bank: Defining the Limits of Federal Power Under a New Constitution (1791)

Democracy, Sovereignty, and the Struggle over Cherokee Removal (1836)

Banking and Politics in Antebellum New York (1838)

Property, Suffrage, and the "Right of Revolution" in Rhode Island, 1842

Debt and Democracy: The New York Constitutional Convention of 1846

The Struggle Over Public Education in Early America (1851)

A Nation Divided: The United States and the Challenge of Secession (1861)

Reconstruction A: The Crisis of 1877

Reconstruction B: Jury Rights in Virginia, 1877-1880

An Australian Ballot for California? (1891)

Labor, Capital, and Government: The Anthracite Coal Strike of 1902

The Jungle and the Debate over Federal Meat Inspection in 1906

The Battle Over the Initiative and Referendum in Massachusetts (1918)

Regulating Radio in the Age of Broadcasting (1927)

The Pecora Hearings (1932-34)

Martin Luther King and the Struggle for Black Voting Rights (1965)

Democracy and Women’s Rights in America: The Fight over the ERA (1982)

Manufacturing Constituencies: Race and Redistricting in North Carolina, 1993

Leadership and Independence at the Federal Reserve (2009)

Citizens United and Corporate Speech (2010)

Do you use the case method to spark discussion and debate on topics outside of business disciplines? Let us know .

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
Gives researchers the chance to collect information on why one strategy might be chosen over another
Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

It cannot necessarily be generalized to the larger population
Cannot demonstrate cause and effect
It may not be scientifically rigorous
It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
Explanatory case studies : These are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

Archival records : Census records, survey records, and name lists are examples of archival records.
Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research.

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
Read examples of case studies to gain an idea about the style and format.
Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal. The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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What the Case Study Method Really Teaches

Nitin Nohria

Seven meta-skills that stick even if the cases fade from memory.

It’s been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment, bias recognition, judgement, collaboration, curiosity, and self-confidence.

During my decade as dean of Harvard Business School, I spent hundreds of hours talking with our alumni. To enliven these conversations, I relied on a favorite question: “What was the most important thing you learned from your time in our MBA program?”

Nitin Nohria is the George F. Baker Professor of Business Administration, Distinguished University Service Professor, and former dean of Harvard Business School.

The Case Study method: 100 years young

On its 100th anniversary, the discussion-based learning method keeps evolving

Case study discussions can also take place in a variety of different contexts, whether studied in person, in hybrid formats or through our virtual classroom.

May 3, 2021

This year commemorates the 100 th anniversary of the first written case study, produced by Harvard Business School back in April 1921. IESE joins in the celebration because it’s one of the academic institutions that has helped spearhead the use of the case method outside the U.S. , educating more than 60,000 professionals with this methodology and producing around 6,200 original cases through more than 60 years of history.

But what is the case study method exactly, and why is it still relevant now?

The main reason the case method is still relevant today is that it works. It’s a dynamic, practical way to study, which puts students in the shoes of senior executives, allowing them to practice solving real-life business problems and making strategic decisions.

It is also an example of a learning methodology based on the exchange of ideas and debate. At IESE, we recognize that the best way to learn is through interacting with others, and having your perspectives and assumptions challenged and stretched . The case study is one example of how we do this, alongside a variety of other discussion-based learning methodologies , such as business simulations, coaching or experiential learning.

For the case method, this means that passively sitting in a lecture room doesn’t cut it. Instead, all participants are required to discuss and reflect on the issues at hand. Here, the professor acts more as a facilitator, guiding the conversation and teasing out the various ethical and business implications of each case. The discussions also draw upon the diverse industry experiences, cultural backgrounds and mindsets of each individual in class, further enriching the learning process.

New content and formats, same impact

Throughout the last 100 years, the case method has been able to adapt with the times by constantly evolving . Indeed, in the last three years, 200 new cases have been written by IESE professors on the most pressing issues happening now. An example of this is the case of how Barcelona-based Vall d’Hebron University Hospital managed the first wave of the COVID-19 outbreak.

Our cases also have a distinct international perspective, reflecting the diversity of the school, faculty and students. While many assume most case studies just focus on big North American companies, at IESE our cases cover not only big name companies like YouTube and Spotify but also companies in emerging countries and young startups. We also have one of the largest collections in the world of Spanish-language cases.

Having a diverse set of cases to study – and a diverse student body to discuss them with – is the key to encouraging those lively and enriching debates that are so crucial to broadening participants’ perspectives.

In addition to content, nowadays cases are available in a variety of formats , such as audio cases that allow participants to listen to a case as they would a podcast, and simulations, among others.

Case study discussions can also take place in a variety of different contexts, whether studied in person, in hybrid formats or through our virtual classroom. This reflects the fact that today’s managers require educational solutions that allow for flexibility , but that also guarantee interaction with others and personalized follow-up.

IESE has one of the largest collections of Spanish-language cases in the world. The full catalog is available in the IESE Publishing online store, which also distributes the cases of 15 leading universities. Here, we present some of the more recent challenges from cases that we have produced .

“At IESE, our focus is on delivering the best learning experience possible, regardless of the format or context. As technologies advance, the case method also continues to evolve. Yet the essence of how executives learn best – and the value that comes from sharing knowledge and exchanging viewpoints with a diverse set of peers – remains the same,” said Prof. Julia Prats .

case method

Historical Case Study

2020, Methods of Analysis

It would seem that historical method has always implied case study if interpreted as the history of single events, episodic history as different from universal history, courtes durées as different from longues durées. From the early twentieth century, historical case study was basically biography, particularities of individuals used to counter the “vast amount of generalization” marking most histories and textbooks (Nichols, 1927, p. 270). Yet historical case study, in the way historians think of it, is primarily a post-WWII methodology.

Related Papers

International Journal for Research in Applied Science & Engineering Technology (IJRASET)

IJRASET Publication

Historical research describes the past things what was happened. This is related with investigating, recording as well as interpreting the past events with respect to the in present perspectives. Historical research is a procedure for the observation with which researcher. It is a systematic collection and objective evaluation of the collected data with respect to the first occurrence to verify causes and effects related to the events with the help of these two explain the present events as well as anticipate for the future work purpose

Nadine Álvarez Montoya

Library & Information Science Research

Michael Widdersheim

Fr. B.M. Thomas

Historical method is technique developed to present past events in their correct perspective. It helps us to know how to write history, as the goal of historical writing is to reconstruct the past as nearly as it really happened, for this the material has to be used with great care. It involves diligently collecting of all relevant sources, critically examining the literal and real meaning of the text and penetrating or scrutiny to eliminate all possible errors. A historian also requires reason and imagination, skill and foresight, logic and intuition for presenting materials as he had to investigate things that took place decades or even hundreds or thousands of years ago without any trace of evidence. It is a process of making different parts of sources into integrated whole.

Albert Mills

Alpesh Nakrani

Anil Kumar Prasanna Devaramatha Magala

Historical methods of research are the process of systematically examining an account of what has happened in the past. It is not facts and dates or even a description of past events. The dynamic account of past events that involves an interpretation attempt to recapture the personalities and ideas of the events. One of the goals of historical research is to communicating of past events. In the field of library and information science, there are vast arrays of topics that may be considered for conducting historical research. For example, a researcher may choose to answer to questions about the development of any type of the libraries, the rise of technology and the benefits/ problems it brings, the development of preservation methods, famous personalities in the field, library statistics, or geographical demographics and how they affect library distribution.

Journal of Applied History

Jelle van Lottum

The past few years, the field of applied history has witnessed the publication of several manifestoes, the establishment of dedicated research centers, and the foundation of an academic journal. Conceptual discussions about the notion of applied history and the very fact that the methods and techniques of applied history are now part of the discipline of history provide further evidence of the field’s maturity. By offering an historiographical overview tracing the roots of applied history, this article will show that both discussions about the contemporary relevance and application of historical thinking, and the actual application of history to current events, possess a long history: applied history has been part and parcel of history writing since ancient times. Moreover, the article offers a discussion of recent debates about the concept and methods of applied history and concludes by mapping the trends that are shaping its current development.

Aaron Milavec

This article details the personal history of how a New Testament and church history professor abandoned traditional teaching methods as he became captivated by the Harvard Case Study Method and went on to create dozens of Case Studies designed to facilitate the interactive learning of his college and seminary students. The advantages and disadvantages of this methodology are examined, with special attention being given to the needs of adult learners who find all significant learning to be deep, personal, and transformative. The article illustrates how the author orientates his students to readjust their learning style to take advantage of a self-discovery mode of learning. Details are provided as to how the Guardian Angel and Learning Partner function to facilitate cooperative learning and the sharing of satisfaction beyond the classroom. Teaching with Case Studies results in a nine-fold increase in the interaction between students in the classroom. Students respond enthusiastically because Case Studies enables them to do deep thinking, and everyone comes into class with something to contribute. Adult learners, more especially, learn best with Case Studies because they thrive when they are figuring things out for themselves and going at their own pace. Former graduates regularly return to tell me, "You were my best teacher." They invariably point to some combination of their experience doing my Case Studies and my contagious enthusiasm for learning. They say, "The Case Studies taught me how sacred texts are initially shaped by and later end up shaping a faith community." Others tell me how they repeatedly used the deep lessons learned: "Not a week passes when I don't make use of my discoveries in one or the other of your Case Studies." For many years I stayed away from the Case Study Methodology because I judged that the time in the classroom was too precious to waste on ill-defined and open-ended discussions. . . .

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StatPearls [Internet].

Case study: 33-year-old female presents with chronic sob and cough.

Sandeep Sharma ; Muhammad F. Hashmi ; Deepa Rawat .

Affiliations

Last Update: February 20, 2023 .

Case Presentation

History of Present Illness: A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound (9 kg) intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has three children aged 15 months to 5 years. She is employed in a cookie bakery. She has two pet doves. She traveled to Mexico for a one-week vacation one year ago.

Allergies: No known medicine, food, or environmental allergies.

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Physical Exam:

Vitals: Temperature, 97.8 F; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 28

General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffuse rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

Initial Evaluation

Laboratory Studies: Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram staining.

Chest X-ray

Impression: Mild interstitial pneumonitis

Differential Diagnosis
Aspiration pneumonitis and pneumonia
Bacterial pneumonia
Immunodeficiency state and Pneumocystis jiroveci pneumonia
Carcinoid lung tumors
Tuberculosis
Viral pneumonia
Chlamydial pneumonia
Coccidioidomycosis and valley fever
Recurrent Legionella pneumonia
Mediastinal cysts
Mediastinal lymphoma
Recurrent mycoplasma infection
Pancoast syndrome
Pneumococcal infection
Sarcoidosis
Small cell lung cancer
Aspergillosis
Blastomycosis
Histoplasmosis
Actinomycosis
Confirmatory Evaluation

CT of the chest was performed to further the pulmonary diagnosis; it showed a diffuse centrilobular micronodular pattern without focal consolidation.

On finding pulmonary consolidation on the CT of the chest, a pulmonary consultation was obtained. Further history was taken, which revealed that she has two pet doves. As this was her third day of broad-spectrum antibiotics for a bacterial infection and she was not getting better, it was decided to perform diagnostic bronchoscopy of the lungs with bronchoalveolar lavage to look for any atypical or rare infections and to rule out malignancy (Image 1).

Bronchoalveolar lavage returned with a fluid that was cloudy and muddy in appearance. There was no bleeding. Cytology showed Histoplasma capsulatum .

Based on the bronchoscopic findings, a diagnosis of acute pulmonary histoplasmosis in an immunocompetent patient was made.

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe, or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks total. The response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving work of respiration. [1] [2] [3]

Histoplasmosis, also known as Darling disease, Ohio valley disease, reticuloendotheliosis, caver's disease, and spelunker's lung, is a disease caused by the dimorphic fungi Histoplasma capsulatum native to the Ohio, Missouri, and Mississippi River valleys of the United States. The two phases of Histoplasma are the mycelial phase and the yeast phase.

Etiology/Pathophysiology

Histoplasmosis is caused by inhaling the microconidia of Histoplasma spp. fungus into the lungs. The mycelial phase is present at ambient temperature in the environment, and upon exposure to 37 C, such as in a host’s lungs, it changes into budding yeast cells. This transition is an important determinant in the establishment of infection. Inhalation from soil is a major route of transmission leading to infection. Human-to-human transmission has not been reported. Infected individuals may harbor many yeast-forming colonies chronically, which remain viable for years after initial inoculation. The finding that individuals who have moved or traveled from endemic to non-endemic areas may exhibit a reactivated infection after many months to years supports this long-term viability. However, the precise mechanism of reactivation in chronic carriers remains unknown.

Infection ranges from an asymptomatic illness to a life-threatening disease, depending on the host’s immunological status, fungal inoculum size, and other factors. Histoplasma spp. have grown particularly well in organic matter enriched with bird or bat excrement, leading to the association that spelunking in bat-feces-rich caves increases the risk of infection. Likewise, ownership of pet birds increases the rate of inoculation. In our case, the patient did travel outside of Nebraska within the last year and owned two birds; these are her primary increased risk factors. [4]

Non-immunocompromised patients present with a self-limited respiratory infection. However, the infection in immunocompromised hosts disseminated histoplasmosis progresses very aggressively. Within a few days, histoplasmosis can reach a fatality rate of 100% if not treated aggressively and appropriately. Pulmonary histoplasmosis may progress to a systemic infection. Like its pulmonary counterpart, the disseminated infection is related to exposure to soil containing infectious yeast. The disseminated disease progresses more slowly in immunocompetent hosts compared to immunocompromised hosts. However, if the infection is not treated, fatality rates are similar. The pathophysiology for disseminated disease is that once inhaled, Histoplasma yeast are ingested by macrophages. The macrophages travel into the lymphatic system where the disease, if not contained, spreads to different organs in a linear fashion following the lymphatic system and ultimately into the systemic circulation. Once this occurs, a full spectrum of disease is possible. Inside the macrophage, this fungus is contained in a phagosome. It requires thiamine for continued development and growth and will consume systemic thiamine. In immunocompetent hosts, strong cellular immunity, including macrophages, epithelial, and lymphocytes, surround the yeast buds to keep infection localized. Eventually, it will become calcified as granulomatous tissue. In immunocompromised hosts, the organisms disseminate to the reticuloendothelial system, leading to progressive disseminated histoplasmosis. [5] [6]

Symptoms of infection typically begin to show within three to17 days. Immunocompetent individuals often have clinically silent manifestations with no apparent ill effects. The acute phase of infection presents as nonspecific respiratory symptoms, including cough and flu. A chest x-ray is read as normal in 40% to 70% of cases. Chronic infection can resemble tuberculosis with granulomatous changes or cavitation. The disseminated illness can lead to hepatosplenomegaly, adrenal enlargement, and lymphadenopathy. The infected sites usually calcify as they heal. Histoplasmosis is one of the most common causes of mediastinitis. Presentation of the disease may vary as any other organ in the body may be affected by the disseminated infection. [7]

The clinical presentation of the disease has a wide-spectrum presentation which makes diagnosis difficult. The mild pulmonary illness may appear as a flu-like illness. The severe form includes chronic pulmonary manifestation, which may occur in the presence of underlying lung disease. The disseminated form is characterized by the spread of the organism to extrapulmonary sites with proportional findings on imaging or laboratory studies. The Gold standard for establishing the diagnosis of histoplasmosis is through culturing the organism. However, diagnosis can be established by histological analysis of samples containing the organism taken from infected organs. It can be diagnosed by antigen detection in blood or urine, PCR, or enzyme-linked immunosorbent assay. The diagnosis also can be made by testing for antibodies again the fungus. [8]

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks. The patient's response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving the work of respiration.

The disseminated disease requires similar systemic antifungal therapy to pulmonary infection. Additionally, procedural intervention may be necessary, depending on the site of dissemination, to include thoracentesis, pericardiocentesis, or abdominocentesis. Ocular involvement requires steroid treatment additions and necessitates ophthalmology consultation. In pericarditis patients, antifungals are contraindicated because the subsequent inflammatory reaction from therapy would worsen pericarditis.

Patients may necessitate intensive care unit placement dependent on their respiratory status, as they may pose a risk for rapid decompensation. Should this occur, respiratory support is necessary, including non-invasive BiPAP or invasive mechanical intubation. Surgical interventions are rarely warranted; however, bronchoscopy is useful as both a diagnostic measure to collect sputum samples from the lung and therapeutic to clear excess secretions from the alveoli. Patients are at risk for developing a coexistent bacterial infection, and appropriate antibiotics should be considered after 2 to 4 months of known infection if symptoms are still present. [9]

Prognosis

If not treated appropriately and in a timely fashion, the disease can be fatal, and complications will arise, such as recurrent pneumonia leading to respiratory failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel obstruction leading to pulmonary hypertension and right-sided heart failure, and progressive fibrosis of lymph nodes. Acute pulmonary histoplasmosis usually has a good outcome on symptomatic therapy alone, with 90% of patients being asymptomatic. Disseminated histoplasmosis, if untreated, results in death within 2 to 24 months. Overall, there is a relapse rate of 50% in acute disseminated histoplasmosis. In chronic treatment, however, this relapse rate decreases to 10% to 20%. Death is imminent without treatment.

Pearls of Wisdom

While illnesses such as pneumonia are more prevalent, it is important to keep in mind that more rare diseases are always possible. Keeping in mind that every infiltrates on a chest X-ray or chest CT is not guaranteed to be simple pneumonia. Key information to remember is that if the patient is not improving under optimal therapy for a condition, the working diagnosis is either wrong or the treatment modality chosen by the physician is wrong and should be adjusted. When this occurs, it is essential to collect a more detailed history and refer the patient for appropriate consultation with a pulmonologist or infectious disease specialist. Doing so, in this case, yielded workup with bronchoalveolar lavage and microscopic evaluation. Microscopy is invaluable for definitively diagnosing a pulmonary consolidation as exemplified here where the results showed small, budding, intracellular yeast in tissue sized 2 to 5 microns that were readily apparent on hematoxylin and eosin staining and minimal, normal flora bacterial growth.

Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

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Histoplasma Contributed by Sandeep Sharma, MD

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Sharma S, Hashmi MF, Rawat D. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Using Systems Thinking for Translating Evidence into Practice: A Case Study of Embedding Shared Decision Making within a Federally Qualified Health Center Network

The following is a mixed-methods case study that examines how Access Community Health Network (ACCESS), a large federally qualified health center located in the Chicago metropolitan area, used a systems approach to incorporate Shared Decision Making into its practice model. Using both qualitative and quantitative methods including a survey of ACCESS staff and providers, as well as interviews with a range of providers and leadership, the study sought to answer the question: How successfully has ACCESS, as a complex primary care system, made Shared Decision Making an integral part of its Patient Centered Medical Home practice model?

With a high degree of consistency across both the survey and interview data, the study concludes that ACCESS has successfully shifted its culture towards Shared Decision Making and, over the course of the past several years, made it a part of its PCMH practice model. At the same time, there are still areas for improvement and ways that ACCESS can further embed SDM within its practice model. Opportunities exist to use this study as a foundation for further exploring the impact of SDM on patients and health outcomes (not a part of this study). Further, the results can be used by other complex health systems as a model for how to successfully integrate and translate best practice or innovation into care models.

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Cinco de Mayo 2024: History, meaning and why we celebrate it

On cinco de mayo, take some time to learn about the history and meaning of this day of remembrance — and how and where it’s celebrated now, by nbc staff • published may 3, 2024.

Sunday marks the 162nd anniversary of Cinco de Mayo. While it's a relatively minor holiday in Mexico , the annual fiesta is an excuse in the United States to indulge in margaritas, cervezas (beer), guacamole and tacos.

But what exactly does Cinco de Mayo celebrate? Brush up on its rich history and modern traditions below.

Is Cinco de Mayo the same as Mexican Independence Day?

Many people tend to confuse Cinco de Mayo with “Día de la Independencia,” or Mexico’s Independence Day. That holiday, also known as “El Grito de la Independencia,” is actually observed on Sept. 16, when Mexico celebrates its independence from Spain.

Get Southern California news, weather forecasts and entertainment stories to your inbox. Sign up for NBC LA newsletters.

Why Is Cinco de Mayo celebrated?

In Mexico, Cinco de Mayo is not a celebration but a day of remembrance, commemorating Mexico’s victory over the French during the 1862 Battle of Puebla. An outnumbered Mexican army — led by Ignacio Zaragoza, a 33-year-old Texan from Goliad — defeated the invading French forces at the small town of Puebla de Los Angeles during the Franco-Mexico War.

The retreat of the French troops represented a great victory for the people of Mexico, symbolizing the country’s ability to defend its sovereignty against a powerful foreign nation.

What is the history behind Cinco de Mayo?

The first American Cinco de Mayo celebrations date back to the 1860s, when Mexicans living in California commemorated the victory over France in Puebla. At that time, the United States was embroiled in a Civil War. News of the underdog Mexican army beating back Napoleon III’s forces gave new strength to California’s Latinos, who sought to stop the advances of the Confederate army.

"For Mexicans in the U.S., the Civil War and the French invasion of Mexico were like one war with two fronts. They were concerned about France, which sided with the Confederacy, being on America's doorstep,” David Hayes-Bautista, professor of medicine and director of the Center for the Study of Latino Health and Culture at the University of California Los Angeles, told NBC News .

The tradition of celebrating Cinco de Mayo has continued in Los Angeles without interruption since 1862, according to Hayes-Bautista, although the original reason and the history have gotten lost.

Mexican Independence Day is September 16 — NOT May 5!

14 Margarita Recipes to Celebrate National Margarita Day

Why did cinco de mayo become popular in the us.

4. Popularity of Cinco de Mayo in America

About a century later, Chicano activists rediscovered the holiday and embraced it as a symbol of ethnic pride. But the party-filled Cinco de Mayo that Americans celebrate today didn’t become popular until U.S. beer companies began targeting the Spanish-speaking population in the 1970s and 1980s, Jose Alamillo, a California professor of Chicano studies, told Time.com .

Today, Cinco de Mayo in the U.S. is primarily a celebration of Mexican-American culture, with the largest event in Los Angeles.

What are some authentic Cinco de Mayo recipes?

If you want to do Cinco de Mayo right, put down the taco, por favor . Contrary to popular belief, you won’t find ground beef tacos, nachos and frozen margaritas in Mexico on Cinco de Mayo. The traditional dish eaten in the town of Puebla on their big holiday is mole poblano, according to the Smithsonian.

Invented in the late 17th century, mole is a thick sauce made with chocolate, chiles, nuts and other spices. Traditionally, the sauce covers succulent chicken or turkey.

While mole recipes differ from family to family and by state in Mexico, they all have one thing in common: mole represents the heart of Mexican culture because it’s served on the most special of occasions, including weddings, baby showers and holidays.

To make this classic Mexican sauce, try this TODAY recipe from Lourdes Juarez.

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This project utilizes Exploratory Data Analysis (EDA) techniques to understand customer and loan attributes that influence the likelihood of loan default in an urban lending company.

sonali-guptaa/bank_loan_case_study

Folders and files, repository files navigation, project description:.

This project focuses on Exploratory Data Analysis (EDA) to identify patterns indicating potential loan default among urban customers applying for various types of loans. The dataset contains information about loan applications, including customer attributes and loan attributes.

Project Goal

The main objective is to identify patterns that indicate a customer's potential for payment difficulties. This information can be used for informed loan decisions such as:

Denying loans to high-risk applicants.
Reducing loan amounts for moderate-risk borrowers.
Setting higher interest rates for customers with a higher risk of default. By understanding the key factors behind loan defaults, the company aims to make better loan approval decisions.

Business Objectives:

The primary objective is to understand how customer attributes and loan attributes influence the likelihood of default. By identifying patterns indicating potential payment difficulties, the company can make informed decisions such as denying the loan, reducing the loan amount, or offering loans at higher interest rates to risky applicants. The ultimate goal is to improve the company's decision-making process regarding loan approval.

Data Analysis Tasks

This project performs various EDA tasks on a loan application dataset containing information on approved, cancelled, refused, and unused offer loan applications. The dataset includes two scenarios:

Customers with payment difficulties: Borrowers with late payments on initial installments.
Customers with on-time payments: Borrowers with a history of on-time payments.

The analysis focuses on the following aspects:

Missing Data Identification and Handling: Identifying missing data points and employing appropriate methods (e.g., imputation) to address them.
Outlier Detection: Identifying and investigating outliers in numerical variables to ensure accurate analysis.
Data Imbalance Assessment: Determining if the dataset has an imbalanced distribution of loan default cases and calculating the imbalance ratio.
Univariate, Segmented Univariate, and Bivariate Analysis: Analyzing the distribution of individual variables, comparing distributions across scenarios, and exploring relationships between variables and loan defaults.
Top Correlation Identification: Identifying the variables with the strongest correlations with loan default for both customer scenarios.

Deliverables

This project will deliver insights and visualizations obtained through EDA, including:

Identification of missing data and chosen handling methods.
Detection of outliers and justification for their treatment.
Assessment of data imbalance and its ratio.
Univariate, segmented univariate, and bivariate analysis results with visualizations (histograms, bar charts, boxplots, scatter plots, etc.).
Identification of top correlations for both customer scenarios with visualizations (correlation matrices or heatmaps).

This project will contribute to building a robust loan approval system by identifying key factors associated with loan defaults.

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A Study on the Use of Unsupervised, Supervised, and Semi-supervised Modeling for Jamming Detection and Classification in Unmanned Aerial Vehicles

In this work, first, unsupervised machine learning is proposed as a study for detecting and classifying jamming attacks targeting unmanned aerial vehicles (UAV) operating at a 2.4 GHz band. Three scenarios are developed with a dataset of samples extracted from meticulous experimental routines using various unsupervised learning algorithms, namely K-means, density-based spatial clustering of applications with noise (DBSCAN), agglomerative clustering (AGG) and Gaussian mixture model (GMM). These routines characterize attack scenarios entailing barrage (BA), single- tone (ST), successive-pulse (SP), and protocol-aware (PA) jamming in three different settings. In the first setting, all extracted features from the original dataset are used (i.e., nine in total). In the second setting, Spearman correlation is implemented to reduce the number of these features. In the third setting, principal component analysis (PCA) is utilized to reduce the dimensionality of the dataset to minimize complexity. The metrics used to compare the algorithms are homogeneity, completeness, v-measure, adjusted mutual information (AMI) and adjusted rank index (ARI). The optimum model scored 1.00, 0.949, 0.791, 0.722, and 0.791, respectively, allowing the detection and classification of these four jamming types with an acceptable degree of confidence.

Second, following a different study, supervised learning (i.e., random forest modeling) is developed to achieve a binary classification to ensure accurate clustering of samples into two distinct classes: clean and jamming. Following this supervised-based classification, two-class and three-class unsupervised learning is implemented considering three of the four jamming types: BA, ST, and SP. In this initial step, the four aforementioned algorithms are used. This newly developed study is intended to facilitate the visualization of the performance of each algorithm, for example, AGG performs a homogeneity of 1.0, a completeness of 0.950, a V-measure of 0.713, an ARI of 0.557 and an AMI of 0.713, and GMM generates 1, 0.771, 0.645, 0.536 and 0.644, respectively. Lastly, to improve the classification of this study, semi-supervised learning is adopted instead of unsupervised learning considering the same algorithms and dataset. In this case, GMM achieves results of 1, 0.688, 0.688, 0.786 and 0.688 whereas DBSCAN achieves 0, 0.036, 0.028, 0.018, 0.028 for homogeneity, completeness, V-measure, ARI and AMI respectively. Overall, this unsupervised learning is approached as a method for jamming classification, addressing the challenge of identifying newly introduced samples.

Collaborative Research: SaTC: CORE: Small: UAV-NetSAFE.COM: UAV Network Security Assessment and Fidelity Enhancement through Cyber-Attack-Ready Optimized Machine-Learning Platforms

Directorate for Computer & Information Science & Engineering

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Master of Science
Electrical and Computer Engineering

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Advisor/supervisor/committee chair, additional committee member 2, additional committee member 3, usage metrics.

Other engineering not elsewhere classified
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Open access
Published: 04 May 2024

Factors associated with non-fatal heart failure and atrial fibrillation or flutter within the first 30 days post COPD exacerbation: a nested case-control study

Emily L. Graul 1 ,
Clementine Nordon 2 ,
Kirsty Rhodes 2 ,
Shruti Menon 3 ,
Mahmoud Al Ammouri 1 ,
Constantinos Kallis 1 ,
Anne E. Ioannides 1 ,
Hannah R. Whittaker 1 ,
Nicholas S. Peters 4 &
Jennifer K. Quint 1

BMC Pulmonary Medicine volume 24 , Article number: 221 ( 2024 ) Cite this article

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An immediate, temporal risk of heart failure and arrhythmias after a Chronic Obstructive Pulmonary Disease (COPD) exacerbation has been demonstrated, particularly in the first month post-exacerbation. However, the clinical profile of patients who develop heart failure (HF) or atrial fibrillation/flutter (AF) following exacerbation is unclear. Therefore we examined factors associated with people being hospitalized for HF or AF, respectively, following a COPD exacerbation.

We conducted two nested case-control studies, using primary care electronic healthcare records from the Clinical Practice Research Datalink Aurum linked to Hospital Episode Statistics, Office for National Statistics for mortality, and socioeconomic data (2014-2020). Cases had hospitalization for HF or AF within 30 days of a COPD exacerbation, with controls matched by GP practice (HF 2:1;AF 3:1). We used conditional logistic regression to explore demographic and clinical factors associated with HF and AF hospitalization.

Odds of HF hospitalization (1,569 cases, 3,138 controls) increased with age, type II diabetes, obesity, HF and arrhythmia history, exacerbation severity (hospitalization), most cardiovascular medications, GOLD airflow obstruction, MRC dyspnea score, and chronic kidney disease. Strongest associations were for severe exacerbations (adjusted odds ratio (aOR)=6.25, 95%CI 5.10-7.66), prior HF (aOR=2.57, 95%CI 1.73-3.83), age≥80 years (aOR=2.41, 95%CI 1.88-3.09), and prior diuretics prescription (aOR=2.81, 95%CI 2.29-3.45).

Odds of AF hospitalization (841 cases, 2,523 controls) increased with age, male sex, severe exacerbation, arrhythmia and pulmonary hypertension history and most cardiovascular medications. Strongest associations were for severe exacerbations (aOR=5.78, 95%CI 4.45-7.50), age≥80 years (aOR=3.15, 95%CI 2.26-4.40), arrhythmia (aOR=3.55, 95%CI 2.53-4.98), pulmonary hypertension (aOR=3.05, 95%CI 1.21-7.68), and prescription of anticoagulants (aOR=3.81, 95%CI 2.57-5.64), positive inotropes (aOR=2.29, 95%CI 1.41-3.74) and anti-arrhythmic drugs (aOR=2.14, 95%CI 1.10-4.15).

Conclusions

Cardiopulmonary factors were associated with hospitalization for HF in the 30 days following a COPD exacerbation, while only cardiovascular-related factors and exacerbation severity were associated with AF hospitalization. Understanding factors will help target people for prevention.

Peer Review reports

Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) are associated with an increased risk of cardiovascular disease (CVD) [ 1 ] likely due to linked pathophysiology, hypoxic state, and an amplified systemic inflammatory response [ 2 , 3 ]. Previous studies have demonstrated an increased, immediate period of risk for hospitalized cardiovascular events following a COPD exacerbation compared with non-exacerbating patients, [ 1 , 4 ] with the risk highest within the first month and following a severe (hospitalized) exacerbation [ 1 , 5 , 6 ]. The 30 day risk of arrhythmias and heart failure (HF) following an exacerbation, [ 6 , 7 , 8 ] approach [ 4 , 6 ] or even surpass [ 7 , 9 ] 3-fold, compared to those who did not have an exacerbation.

Globally, the prevalence of HF in COPD is high, [ 10 ] and, of patients hospitalized for exacerbation, 20% have existing, undertreated HF [ 11 ]. Incident HF attributed to exacerbations is thought to come from the increase in pulmonary arterial pressures, low blood oxygen levels [ 12 ] and activation of adrenoceptors of the autonomic nervous system [ 12 , 13 ]. However, shared symptomology of HF and COPD exacerbations makes new HF diagnosis difficult, with HF often missed [ 3 , 12 , 14 ] or occurring in tandem; approximately 8% of people primarily diagnosed with HF also have a secondary diagnosis of exacerbation [ 15 ]. Studies have investigated COPD progression in HF [ 12 ] and conversely, HF progression across COPD phenotypes, [ 12 , 16 ] but few have focused on exacerbating COPD alone [ 15 ] and no studies have examined factors associated with hospitalization with a HF diagnosis following a COPD exacerbation.

Arrhythmias are also common among people with COPD, with prevalence ranging from 5 to 15% globally, [ 10 ] and atrial fibrillation (AF) is the most common arrhythmia [ 17 ]. AF diagnoses at the time of an exacerbation are also common, with estimates around 17% [ 18 ], but due to shared, nonspecific symptoms between AF and COPD, differential diagnosis can be difficult [ 19 ]. During a COPD exacerbation, changes in blood gases from hypoxia and rising pulmonary pressure can lead to electrophysiological and structural changes of the atrium, and together are thought to contribute to exacerbation-related disturbances in rhythm and progression of AF [ 6 , 10 , 19 , 20 , 21 ] The understanding of COPD progression alongside AF progression is unclear [ 19 ]. Few studies have examined factors associated with hospitalization for incident AF after an exacerbation, with the focus on the short-term [ 21 , 22 ]. Several have however investigated factors associated with concurrent AF at time of an exacerbation [ 18 , 23 ].

Therefore, using a primary-care defined COPD cohort from the Clinical Practice Research Datalink (CPRD) Aurum database linked with hospital, mortality, and socioeconomic deprivation data, we explored factors associated with incident hospitalization for non-fatal HF, or AF or atrial flutter, within the 30 days following a COPD exacerbation.

Study design and methods

Data source.

We obtained pseudonymized, routinely-collected electronic healthcare record data from CPRD Aurum, [ 24 ] a primary care database broadly representative by age, sex, deprivation, and regional distribution, [ 25 ] and covering approximately 20% of GP-registered patients in England [ 24 ]. Primary care data from the May 2022 build [ 24 ] were linked to the Office for National Statistics (ONS) for mortality, socioeconomic data from the 2015 Index of Multiple Deprivation (IMD), and secondary care data from NHS England’s Hospital Episode Statistics (HES) Admitted Patient Care (APC) database.

Source population

The source population were people with a COPD diagnosis who had been included in the Exacerbations of COPD and their OutcomeS on CardioVascular diseases (EXACOS-CV) observational open cohort study [ 4 ]. People were eligible for inclusion in that original cohort study if they met the following criteria: 1) aged 40 years or older, 2) had a COPD diagnosis using a validated algorithm (86.5% PPV) [ 26 ] 3) were eligible for linkage with HES, ONS, and IMD data, 4) had a smoking history (i.e., current or ex-smoker), 5) had continuous GP practice registration with acceptable quality data in the year before start of follow up, and 6) had data recorded after 1 st of January 2014.

Study design and population

We conducted two nested-case control studies, in parallel. The study population for each study consisted of COPD patients in the EXACOS-CV source population, who 1) experienced an exacerbation within cohort follow-up, 2) among the pool of eligible controls had at least 30 days of contributing data post-exacerbation, and 3) had no evidence of HF or arrhythmias in the year before exacerbation. People were excluded from the AF/flutter study population if, within the 30 days post-exacerbation, they had evidence of other non-AF arrhythmias (e.g., cardiac arrest) (Fig. 1 for study designs; Supplementary Figures 1 and 2 for HF and AF/flutter eligibility diagram respectively).

Study design for the parallel, nested case control studies. Abbreviations: HF=heart failure, AF/f = atrial fibrillation/flutter, GP=general practice, CV=cardiovascular. Two nested case control studies, for HF and AF/f respectively, were conducted among all patients who experienced an exacerbation at start of cohort follow up. Full definitions of demographic and clinical factors of interest are in the Supplementary materials

Cases were individuals with a hospitalized, cardiovascular event (HF or AF/flutter, respectively) within 1-30 days post COPD exacerbation. Cases were determined in the HES database using ICD-10 codes in the primary diagnostic position across all episodes in a single hospitalization. The date of admission was the date of the case (index date, HF or AF/flutter, respectively). Extended case definitions are in Supplementary Table 3 .

The set of controls per case was drawn among individuals in the study population who had no in-hospital diagnosis of the cardiovascular event-of-interest (HF or AF/flutter, respectively) and who had 30 days of contributing data post-exacerbation. Controls were assigned a pseudo-end date (i.e., 30 days post-exacerbation) on which to match. Controls were individually matched to cases on GP practice to account for unmeasurable potential clinical differences in disease management by clinicians, within a 30-day window of the index date, and could be used as a control for more than one case. For the HF analysis, controls were matched 2:1 and for the AF/flutter analysis, 3:1.

The choice of matching factors and ratios were chosen based on considerations of 1) maximizing the ratio itself for reasons of power and precision while 2) minimizing cases lost without a full set of controls. Only case sets with the full ratio of controls per case were included for analysis.

We examined factors potentially associated with hospitalization for HF or AF/flutter in the 30 days following an exacerbation of COPD. Factors included demographic characteristics: age (categorized into four age bands; 40-69, 70-74, 75-79, ≥80), sex, IMD quintiles, and ethnicity; and smoking status. Comorbidities included (hypertension, anxiety, depression and depressive symptoms, type II diabetes, chronic kidney disease (CKD), BMI [body mass index; using World Health Organization classification]). COPD factors included GOLD grade of airflow limitation (defined as 1 mild, 2 moderate, 3-4 severe/very severe), Medical Research Council (MRC) dyspnea score (1-2; 3; 4-5), exacerbation severity at cohort entry (moderate/severe) prior exacerbation frequency (infrequent (≤1) versus frequent (≥2) history in a year window preceding one year to cohort entry). Prior CVD history was evidence of the following anytime preceding the year before exacerbation date [acute coronary syndrome (ACS), arrhythmias, HF, ischemic stroke, pulmonary hypertension PH], COPD inhaled therapies, and major classes of cardiovascular medications (prescriptions defined two years before cohort entry). Covariate definitions are in Supplementary Table 4 .

We used validated definitions for COPD exacerbations. A moderate exacerbation was defined as a COPD-related primary care (GP) visit with either a code for exacerbation (including Lower Respiratory Tract Infection (LRTI) SNOMED-CT codes) and/or prescription for respiratory antibiotics and oral systemic corticosteroids not on the same day as an annual review, as validated in CPRD [ 27 ]. A severe exacerbation was defined as a hospitalization with an acute respiratory event code including COPD or bronchitis as a primary diagnosis, or a secondary diagnosis of COPD, as validated in HES [ 28 ]. We considered exacerbations to be the same event if recorded within 14 days in which case the highest level of severity was chosen.

We checked covariate missingness to assess use in adjusted models. Imputation was not considered for covariates with missing data, given the missingness mechanism was Missing-Not-At-Random (MNAR), violating the Missing-Completely-At-Random (MCAR) assumption premising imputation [ 29 ].

Codelists for primary care factors were generated using SNOMED-CT and British National Formulary ontologies; we used our standardizable, reproducible methodology, available on GitHub: for drug [ 30 ] and medical/phenotype codelists , respectively. Codelists for hospitalizations used ICD-10 codes. Codelists are available on our EXACOS-CV GitHub repository .

Statistical analysis

We compared separately the odds of hospitalization for HF or AF/flutter between the comparator groups for each factor, using conditional logistic regression. Our final model was adjusted for all covariates without substantial amount of missing data, including demographic factors, comorbidities, and COPD inhaled therapies and cardiovascular medications. In three sensitivity analyses, we repeated main analyses additionally adjusting for variables-of-interest with substantial missing data, respectively: GOLD, MRC, and CKD.

Analyses were performed using STATA v17.

These data were collected and provided by CPRD. Ethical approval was obtained through CPRD’s Research Data Governance Process (protocol number: 22_002377). The RECORD checklist for observational studies is in Supplementary Table 5 .

Characteristics of study participants

The HF dataset consisted of 1,569 cases experiencing an HF event within the first 30 days post-exacerbation, matched to 3,138 controls. The AF/flutter dataset consisted of 841 cases experiencing an AF/flutter event within the first 30 days post-exacerbation, matched to 2,523 controls. Tables 1 and 2 show the characteristics of the participants for HF and AF/flutter, respectively.

Across both study populations, cases tended to have had a severe exacerbation, were more likely to be older, male, an ex-smoker, have comorbidities including prior prevalent cardiovascular disease, and be prescribed cardiovascular medications. Cases and controls both tended to have infrequent exacerbation history, have prescriptions for long-acting therapies, but tended to not have prescriptions for short-acting inhaled therapies.

Factors associated with HF hospitalization 1-30 days post exacerbation

Age, type II diabetes, obesity, prior HF diagnosis, prior arrhythmia diagnosis, having a severe exacerbation, and most cardiovascular medications were associated with increased odds of being hospitalized for HF within 30 days of a COPD exacerbation (Table 1 ). The factors most strongly associated with HF were exacerbation severity (aOR=6.25, 95%CI 5.10-7.66), a prior HF diagnosis (aOR=2.57, 95%CI 1.73-3.83), age at least 80 years (≥80 vs. 40-69; aOR=2.41, 95%CI 1.88-3.09), and, of the cardiovascular medications, diuretics (aOR=2.81, 95%CI 2.29-3.45).

In sensitivity analyses, GOLD grade, MRC score, and history of CKD were all associated with an increased odds of being hospitalized for HF within the month post exacerbation.(Supplementary Table 1 ) The strongest associations were for CKD (aOR=1.85, 95%CI 1.46-2.35) and higher levels of airflow limitation and breathlessness (GOLD grade 3-4 Severe/Very Severe aOR=1.83, 95%CI 1.32-2.54, versus GOLD grade 1 Mild) (Score 4-5 MRC aOR=1.87, 95%CI 1.42-2.46, versus MRC 1-2).

Factors associated with AF/flutter hospitalization 1-30 days post exacerbation

Age, male sex, prior arrhythmia, prior PH, and having a severe exacerbation were associated with AF/flutter in the 30 days following an exacerbation. Most cardiovascular medications were also associated with AF/flutter (Table 2 ). The factors most strongly associated with AF were exacerbation severity (aOR=5.78 95%CI 4.45-7.50), age ≥80 years (aOR=3.15 95%CI 2.26-4.40), prior arrhythmia and PH (aOR=3.55, 95%CI 2.53-4.98; aOR=3.05, 95%CI 1.21-7.68), and of the cardiovascular medications, anticoagulants (aOR=3.81, 95%CI 2.57-5.64), positive inotropes (aOR=2.29, 95%CI 1.41-3.74) and anti-arrhythmic drugs (aOR=2.14, 95%CI 1.10-4.15).

In sensitivity analyses, GOLD grade, MRC score, and CKD had no association with AF/flutter (Supplementary Table 2 ).

In a primary care defined COPD population, this study examined the clinical profiles of people hospitalized for HF and for AF within a month post exacerbation. We observed that the odds of HF and of AF hospitalization were higher for people with severe, hospitalized exacerbations and with cardiovascular-related history. For HF analyses only, the odds of HF were also higher for people with microvascular factors (i.e., type II diabetes; obesity; CKD) and for people with pulmonary factors, namely those with worse GOLD grade of airflow limitation and higher levels of MRC breathlessness scores.

Heart failure

The pathophysiological links between COPD exacerbations and HF are recognized [ 31 , 32 , 33 ]. Upon exacerbation, dynamic lung hyperinflation from airflow limitation alongside heightened inflammation and hypoxia, can lead to increased strain on both the lungs and heart. The increased cardiopulmonary pressure can then lead to impaired contraction or filling of the left ventricle, namely HF with preserved or with reduced ejection fraction, respectively [ 31 , 32 , 33 ].

Few studies have investigated factors associated with HF in COPD alone, [ 15 , 34 , 35 , 36 ] of which only one [ 15 ] investigated hospitalized exacerbation with concurrent HF, but did not quantify this relationship with ORs, and was conducted in the US National Inpatient Sample (NIS) database. The remaining were post-hoc analyses of trials focused on stable COPD [ 34 , 35 , 36 ].

The strong magnitude of the association for exacerbation severity (hospitalization) but not for exacerbation frequency, suggests two points. First, from a healthcare service-level standpoint, patients hospitalized for exacerbations are more likely to be hospitalized for a future HF (i.e., re-admission) compared with patients whose exacerbation was managed in primary care. Second, clinically, exacerbation severity (e.g., greater intensity of inflammation) has a greater indication of a patients’ future cardiac state, rather than past exacerbation occurrence and management. Findings for older age were anticipated and align with previous studies [ 15 , 34 , 35 , 36 ].

The associations for history of HF, arrhythmia, type II diabetes, and CKD with post-exacerbation HF are unsurprising given their known independent relationships each with HF and exacerbations alone. Chronic, unmanaged HF can lead to future health service utilization for HF [ 16 , 37 ]. Arrhythmia-attributed cardiac remodeling can contribute to development of cardiomyopathy [ 38 ]. Diabetes is a risk factor for substantial HF progression [ 16 , 39 ], and separately a population-based study in COPD patients demonstrated an increased risk of cardiovascular mortality with type II diabetes [ 40 ]. Impaired renal hemodynamics and activation of the renin-angiotensin-aldosterone system (RAAS) can lead to HF, [ 41 ] and separately reduced kidney function is associated with future HF [ 42 ].

Our findings for cardiovascular medications indicate a certain treatment profile in primary care, leading up to the post-exacerbation HF hospitalization. The strongest association for diuretics suggests that leading up to future HF, patients perhaps are receiving treatment indicated for uncontrolled edema from existing HF, diabetic cardiomyopathy, or CKD for example.

GOLD and MRC as factors for post-exacerbation HF likewise were expected. Increased breathlessness and reduced lung function are not only symptoms of an imminent exacerbation or HF; equally, these factors can also indicate delayed diagnosis of unstable COPD or HF, [ 16 , 43 ] given their shared symptomology [ 3 , 12 , 14 ]. Reduced lung function can contribute to worsening prognosis and precipitate a future exacerbation or HF [ 16 , 43 ].

Atrial fibrillation

The pathophysiological mechanisms implicating AF post COPD exacerbation are also established [ 19 , 44 ]. At time of exacerbation, drastic increases in lung hyperinflation and impaired intrathoracic pressures can cause increased pulmonary vascular resistance and damage, leading to alterations to atrial electrophysiology [ 19 , 44 ]. Compromised gas exchange in the lungs can induce systemic inflammation and oxidative stress too, and also put strain on pulmonary vasculature, leading to abnormal atrial structure and ion-channel remodeling, [ 19 , 44 ] while certain treatments prescribed upon exacerbation are arrhythmogenic [ 19 , 44 ].

Only four studies have investigated patient profiles for AF development in unstable COPD, all hospital-based [ 18 , 21 , 22 , 23 ], of which two conducted in the US National Inpatient Sample (NIS) database [ 18 , 22 ]. Two examined factors associated with AF diagnosis after exacerbation [ 21 , 22 ] one of which patients had existing AF [ 21 ]. Two failed to quantify with ORs, only comparing baseline characteristics of exacerbating patients by status of concurrent AF [ 18 , 23 ].

Our findings for older age and male gender are not unexpected; studies similarly found these associations in exacerbating [ 18 , 22 ] and in stable COPD [ 45 ]. Unsurprisingly, exacerbation severity associated with future AF, again adding to the existing evidence of stronger associations for hospitalized exacerbation [ 1 , 6 ] and again, likewise to HF, suggests a distinction between healthcare service-level patient pathways, and intensity versus frequency.

The associations we found for history of PH and arrhythmias aligns with what was anticipated clinically. Electrophysiological and structural changes to the atrium over time, from either AF itself [ 20 ] or from chronic atrial stretching and fibrosis attributed to PH, [ 46 ] can lead to future AF. While a study using Euro Heart Survey data showed COPD as a factor for progression of paroxysmal to persistent AF (aOR=1.51, 95%CI 0.95-2.39) [ 20 ], neither of the two studies looking at patient profiles for post-exacerbation AF, looked at chronic, prevalent arrhythmias itself as a factor [ 21 , 22 ]. No studies have looked at PH, although the study among end-stage COPD patients in the NIS database found a weak association for pulmonary circulatory disorders (aOR=1.44, 95%CI 1.37-1.52) [ 22 ], compared the OR of about 3 for PH. A study found raised pulmonary artery pressure to be associated with AF (p<0.05), but failed to quantify, and it was small, underpowered, and not generalizable as it restricted to hospitalized COPD patients with existing AF [ 21 ].

The lack of associations for prior ACS, ischemic stroke, HF, and hypertension somewhat contradict the study among hospitalized, end-stage COPD patients, [ 22 ] where an association was found for HF (aOR=2.42; 95%CI: 2.36-2.48) and coagulopathy (aOR=1.23; 95%CI:1.16-1.31), but again this may reflect the more severe prognosis of these patients versus those in our study.

Likewise to HF, findings for cardiovascular medications indicate a certain treatment profile in primary care, leading up to the post-exacerbation AF hospitalization. Although we were unable to adjudicate by specific subtype of AF,(e.g., paroxysmal, persistent) the strongest associations for positive inotropes, anti-arrhythmic drugs, and anticoagulants may suggest that leading up to future AF, patients perhaps are receiving treatment to manage abnormal heart rate and/or rhythm, and/or to prevent clotting. Future research could investigate the respective treatment profile relative to paroxysmal AF and to persistent AF [ 47 ] to confirm and extend our findings.

Our null results for other comorbidities (i.e., depression and depressive symptoms, anxiety, BMI, CKD, and type-II diabetes) goes against studies finding an association for diabetes, [ 18 , 22 ] mixed findings for depression, [ 18 , 22 ] among other comorbidities. Yet these observed associations could be due to differing context; using the NIS database in a study population of only hospitalized, exacerbating, insured payors. GOLD airflow obstruction and MRC dyspnea score were not associated with post-exacerbation AF hospitalization, possibly as AF is often associated with vague symptoms of onset and not necessarily immediately thought about as a cause of increasing breathlessness in someone with COPD [ 44 , 48 , 49 ].

Methodological considerations

A key strength is our generalizable COPD cohort, defined within the electronic healthcare record with detailed data to examine and adjust for a range of factors. Unlike other studies, this allowed us to look at two patient pathways: cardiovascular-related hospitalizations post primary-care exacerbation, and re-admissions post hospitalized exacerbation. Our exclusion criteria allowed us to quantify the odds of new onset HF and AF hospitalizations following exacerbation, by ensuring no evidence of AF or HF in the year prior to exacerbation. We chose to study two common cardiovascular conditions in COPD, AF and HF. We could not subdivide HF and AF more granularly, because of insufficient statistical power and the inability to obtain electrocardiogram or echocardiogram results to adjudicate.

We used validated codes to define COPD [ 26 ] and COPD exacerbations [ 27 , 28 ] so misclassification is unlikely. Where possible, we used previously tested methods [ 30 ] and codes to define our factors-of-interest and codes were checked by a pulmonologist and/or cardiologist. The nested case control matched design allowed us to control for unmeasurable potential clinical differences in disease management by clinicians, by matching patients on GP practice.

To minimize selection bias among patients with measured factors only, we adjusted only for covariates without substantial missing data. We reserved GOLD, MRC, and CKD for sensitivity analyses; the associations of these factors with HF are generalizable only to patients with measurements (e.g., patients with greater healthcare monitoring, provision, or access). For this reason, the relationship for ethnicity could not be quantified, and given the data sparsity. For the HF analysis, we were unable to quantify B-type natriuretic peptide testing as a factor (BNP or NT-proBNP) because of 90% missing data for BNP (data not shown).

Confounding by indication is possible, particularly for the associations observed for cardiovascular medications (cases could have been more likely prescribed cardiovascular medications to manage a prevalent co-morbidity (perhaps with delayed diagnosis) that posed future cardiovascular risk, compared with controls) [ 50 ]. For example, although 12.8% of HF cases had prevalent HF diagnoses at baseline (201/1569), over 70% of HF cases were prescribed diuretics (1122/1569). Diuretics, particularly extended use of loop diuretics, can indicate possible, pre-HF diagnoses [ 51 ], given HF diagnoses tend to be delayed in COPD patients [ 14 , 37 , 51 ]. Taking this information together, this suggests a substantial proportion of cases could have been prescribed diuretics to manage possible-yet-undiagnosed HF, in which case, the later case-defining hospitalization was the delayed, first-time diagnosis of HF.

Our results for cardiovascular medications do not imply these medications are increasing the cardiovascular risk, rather they add to an understanding of the exacerbating patient profile. Furthermore, although these medications could indicate delayed CVD diagnosis, alternatively they could be medically indicated for management of a co-morbidity we did not adjust for, e.g., beta-blockers can be prescribed for thyroid conditions [ 52 ].

Implications for clinical practice

Within the month-window following an exacerbation, largely exacerbation intensity and cardiovascular-related management and disease history were associated with odds of incident HF and AF. For HF specifically, existing type II diabetes, CKD, lung function (GOLD grade), and levels of breathlessness (MRC) had an association too—but not for AF. These factors can help better identify patients most at-risk for HF and AF, to streamline efforts to allocate screening, vigilant monitoring, and prevention.

At the time of a COPD exacerbation, particularly hospitalized exacerbation, we recommend preemptively monitoring markers of possible HF, through taking medication history of loop diuretics, [ 51 ] and through BNP testing [ 53 ]. At present however, HF prevention is narrow in scope, with guidelines for early identification of HF not explicitly considering unstable COPD [ 53 , 54 ]. Our results suggest that HF monitoring should widen to include patients with COPD exacerbations.

Upon exacerbation, particularly hospitalized exacerbation, we recommend proactively screening for AF (e.g., electrocardiogram) [ 19 ] as AF commonly presents subclinically [ 17 ]. Still, at present, AF screening is narrow in scope; it is primarily conducted in patients with existing or suspected AF with the goal of preventing stroke, with AF guidelines not explicitly considering unstable COPD [ 17 , 55 ]. Our results suggest that AF screening should widen to include patients with COPD exacerbations, to help prevent future AF—even before stroke.

Availability of data and materials

Data are available on request from the CPRD. Their provision requires the purchase of a license, and this license does not permit the authors to make them publicly available to all. This work used data from the CPRD Aurum version collected in May 2022 and have clearly specified the data selected within the Methods section, and linked data in the Supplementary Materials . To allow identical data to be obtained by others, via the purchase of a license, the code lists will be provided upon request. Licenses are available from the CPRD ( http://www.cprd.com ): The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 10 South Colonnade, Canary Wharf, London E14 4PU.

Abbreviations

Chronic Obstructive Pulmonary Disease

Clinical Practice Research Datalink

Cardiovascular Disease

General practice

Hospital Episode Statistics

Index of Multiple Deprivation

Medical Research Council

Heart Failure
Atrial Fibrillation

Chronic Kidney Disease

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Acknowledgements

This study is based in part on data from the Clinical Practice Research Datalink obtained under license from the UK Medicines and Healthcare products Regulatory Agency. The data is provided by patients and collected by the National Health Service (NHS) as part of their care and support. The interpretation and conclusions contained in this study are those of the author/s alone.

This study was funded by AstraZeneca UK. CN, KR, and SM of the funding source took part in initial conceptualization and protocol design and the interpretation of results.

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Contributions

JQ takes responsibility for the content of the manuscript, including the data and analysis. EG, JQ, CN, KR, and SM conceptualized the study and designed the protocol. JQ, NP and EG contributed to the development of the codelists that defined the study variables. EG, CK contributed to the methodology. EG, HW, CK and AI accessed and verified the data. EG, CK and AI were responsible for data curation and management. EG, CK were responsible for formal analysis. EG wrote the original draft of the manuscript. EG, MA, JQ contributed to the literature review and clinical implications. All authors contributed and approved the final manuscript. All authors had final responsibility for the decision to submit for publication.

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Ethics approval and consent to participate.

CPRD has NHS Health Research Authority (HRA) Research Ethics Committee (REC) approval to allow the collection and release of anonymized primary care data for observational research [NHS HRA REC reference number: 05/MRE04/87]. Each year CPRD obtains Section 251 regulatory support through the HRA Confidentiality Advisory Group (CAG), to enable patient identifiers, without accompanying clinical data, to flow from CPRD contributing GP practices in England to NHS Digital, for the purposes of data linkage [CAG reference number: 21/CAG/0008]. The protocol for this research was approved by CPRD’s Research Data Governance (RDG) Process (protocol number: 22_002377 ) and the approved protocol is available upon request. Linked pseudonymized data was provided for this study by CPRD. Data is linked by NHS Digital, the statutory trusted third party for linking data, using identifiable data held only by NHS Digital. Select general practices consent to this process at a practice level with individual patients having the right to opt-out.

Patient consent for publication

Not applicable.

Competing interests

JQ reports grants from GlaxoSmithKline, Health Data Research UK, MRC, Asthma+Lung UK, Bayer, BI, AZ and Chiesi, outside this work and AZ for the conduct of this study. JQ has received personal fees for advisory board participation, consultancy or speaking fees from GlaxoSmithKline, Evidera, AstraZeneca, and Insmed. CN, KR, and SM are employees of AZ and hold stock and/or options in the company. HW reports grants from Health Data Research UK outside the submitted work. EG, CK, AI, and MA have nothing to disclose.

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Graul, E.L., Nordon, C., Rhodes, K. et al. Factors associated with non-fatal heart failure and atrial fibrillation or flutter within the first 30 days post COPD exacerbation: a nested case-control study. BMC Pulm Med 24 , 221 (2024). https://doi.org/10.1186/s12890-024-03035-4

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Title: sketchgpt: autoregressive modeling for sketch generation and recognition.

Abstract: We present SketchGPT, a flexible framework that employs a sequence-to-sequence autoregressive model for sketch generation, and completion, and an interpretation case study for sketch recognition. By mapping complex sketches into simplified sequences of abstract primitives, our approach significantly streamlines the input for autoregressive modeling. SketchGPT leverages the next token prediction objective strategy to understand sketch patterns, facilitating the creation and completion of drawings and also categorizing them accurately. This proposed sketch representation strategy aids in overcoming existing challenges of autoregressive modeling for continuous stroke data, enabling smoother model training and competitive performance. Our findings exhibit SketchGPT's capability to generate a diverse variety of drawings by adding both qualitative and quantitative comparisons with existing state-of-the-art, along with a comprehensive human evaluation study. The code and pretrained models will be released on our official GitHub.

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