How to Read and Evaluate Case Reports

By Martha Brown Menard, PhD, LMT
December 6, 2016

How to Read and Evaluate Case Reports

By Martha Brown Menard, PhD, LMT
December 6, 2016

A case report, the most basic form of practice-based research, is a detailed account of the history, presenting symptoms, assessment, observations, treatment and follow-up of an individual client or patient, discussed in the context of prior and potential future research. Many people use the term case study synonymously with case report. Technically speaking, case report is used more often in health care research and has a very specific format, while case study is used more often in the social sciences and can have a much broader focus; for example, a case study that focuses on a business, organization, or program. The case report lends itself to a combined or mixed methods approach to research design through the incorporation of both quantitative and qualitative data.

Because case reports are based on the description and observations of an individual case, they cannot provide strong evidence of cause and effect. A useful case report emphasizes the clinical applicability of the information presented, and places a single instance into a larger context.

A case report documents the kind of critical thinking and clinical judgment in which health care practitioners engage every day. It authenticates the continuous and iterative process of researching and evaluating the client's condition, determining or revising a treatment plan, and then evaluating the effectiveness of applied interventions according to meeting the client's stated goals.

Case Reports (Case Studies)

The case report is one of the simplest forms of descriptive study, and usually features some unusual aspect of health history, assessment, or effect of treatment; although it will occasionally be used to present a typical or textbook example of a case and its successful resolution, or to report an innovation in assessment or treatment. Although the case report does not provide the same weight of evidence as a randomized, controlled trial, it is valuable as a basis for developing new hypotheses. Case reports or studies may also be used to report adverse responses to treatment or to document unusual events, thus alerting other practitioners to these occurrences.

What separates the case study from a clinical anecdote is a compelling rationale for its presentation, a review of the pertinent literature, thorough description, relevant detail, and a discussion of contradictory evidence or observations, along with directions for future investigations or recommendations for working with similar cases.

Case Series

Case series take the case study method a step further by combining individual studies of similar patients; they are often the first indication of a new disease or an adverse effect resulting from a new procedure. A good example is the July 1981 report from the CDC1 describing an unusual number of cases of Kaposi's sarcoma among young, previously healthy gay men at a time when this form of cancer was typically only seen in the elderly. This case series was one of several reports that heralded the beginning of the AIDS epidemic.

Case studies and case series raise potential research questions, but cannot usually provide evidence of a valid association or causal relationship.

Reading a Case Report

The general format for a case report is similar to what we see in other journal articles. Author affiliation and any sources of funding are standard, followed by an abstract. Guidelines for medical case reports have been published2 and suggested modifications to these specifically for massage therapy have also been recently published.3

Introduction

The case report should contain an introduction with a review of the literature, which provides background information and a context of previous research into which this case study fits. The relevance or significance of the research question may also be addressed here. The review of the literature may also provide a rationale for any outcome measures used, along with information on their reliability and validity if these are not well known. A good review of the literature summarizes the existing research on a topic and sets the stage for the rest of the case report.

Case History

Usually, a pertinent description of the clinical presentation of an individual client or patient follows. It should be brief, clear, and adequate, giving relevant health history and background information, such as occupation or other activities that are related to the client's presenting complaint or treatment goals. The therapist may outline their treatment goals here as well.

Methods

The methods section will describe the case report design (usually before-and-after treatment), the outcome measures selected, how these were measured or documented, any assessments performed and the results of any medical tests, and may include photos or other illustrations. The reference ranges or normal values for any medical tests mentioned should be included for readers who may be unfamiliar with these. A description of the treatment protocol(s) used, sufficient for general replication, should also be included.

Results

The results section contains only the verbal and visual summary of the outcome data. It may take the form of a table showing quantitative pre- and post-treatment measures, a graphical summary of any data analysis including a timeline, and/or a qualitative description of the client's experience, often in the client's own words. Two BioMed Central journals, the Journal of Medical Case Reports and its sister publication, Cases Journal, now include a "patient's perspective" section, authored by the patient, to add an additional layer of detail to the traditional case report format. This is a good example of the growing trend toward a combined or mixed methods approach in health care research.

Discussion

The discussion section of a case report is similar to the discussion section of other clinical journal articles. In this section, the author examines and discusses the evidence presented in the results, in terms of the stated study question and objective. The results in relation to other relevant research may also be considered, as well as other plausible explanations for the results. Limitations of the study can be addressed here.

Depending on the study objective, the author may also discuss implications for other practitioners in terms of the assessment or management of a condition. Almost always, the author makes recommendations for future research, particularly hypotheses to be explored or tested as a consequence of the information presented in the case.

Acknowledgments may follow the discussion section, but come before the references. Acknowledgements are used to thank people who provided substantial help to the author or authors in designing or conducting the case report, or in preparing the manuscript. The client or patient may be thanked generally, but their name should not be mentioned at any point in the case study / report.

References

The final section of a case report is the reference section. These should always be pertinent and completely accurate, and preferably from peer-reviewed sources. Only the necessary number of relevant papers should be cited.

Evaluating Case Reports and Case Series: Questions to Consider

  • Is the research objective or purpose of the case report clearly stated?
  • Is the subject interesting or relevant to your practice?
  • Is there a clear statement of the clinical importance of the case(s)? Are references provided?
  • Is all relevant patient data or history reported in sufficient detail?
  • Is any assessment performed or treatment provided described adequately? Could you replicate it?
  • Are other plausible explanations for the results considered?
  • Are the strengths and weaknesses, implications, and relevance to other similar cases or studies discussed?
  • Are directions for future studies in this area or the management of similar cases discussed?

The case report or study is intended to be descriptive and observational in nature, and tells a clinically relevant story that has unique value to the practice of health care. In a case report, the individual presentation is examined in the context of current knowledge and is shared for the purpose of educating other practitioners or stimulating further scientific inquiry and the development of new understanding or knowledge. Case reports can provide valuable lessons learned and enhance clinical practice.

Case reports or studies are useful for communicating about a variety of clinical situations including unusual events, adverse responses, and treatment innovations. Case reports can suggest new hypotheses to be developed, and are an important original contribution to the research literature.

Think of the case report as a more formal documentation of the processes of evidence-informed practice and continuous clinical assessment that practitioners engage in every day.

References

  1. Centers for Disease Control and Prevention. Pneumocystis pneumonia - Los Angeles. MMWR Morb Mortal Wkly Rep, 30 Aug 1981;45(34):729-33.
  2. Gagnier JJ, Kienle G, Altman DG, et al. "The CARE Guidelines: consensus-based clinical case reporting guideline development. Global Advances in Health and Medicine: Improving Healthcare Outcomes Worldwide, 2 Sep 2013;2(5):38-43.
  3. Munk N, Boulanger K. Adaptation of the CARE guidelines for therapeutic massage and bodywork publications: efforts to improve the impact of case reports. International Journal of Therapeutic Massage & Bodywork, 3 Sep 2014;7(3):32-40.