significance of case study in education

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In This Article Expand or collapse the "in this article" section Case Study in Education Research

Introduction, general overview and foundational texts of the late 20th century.

• Conceptualisations and Definitions of Case Study
• Case Study and Theoretical Grounding
• Choosing Cases
• Methodology, Method, Genre, or Approach
• Case Study: Quality and Generalizability
• Multiple Case Studies
• Exemplary Case Studies and Example Case Studies
• Criticism, Defense, and Debate around Case Study

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Case Study in Education Research by Lorna Hamilton LAST REVIEWED: 21 April 2021 LAST MODIFIED: 27 June 2018 DOI: 10.1093/obo/9780199756810-0201

It is important to distinguish between case study as a teaching methodology and case study as an approach, genre, or method in educational research. The use of case study as teaching method highlights the ways in which the essential qualities of the case—richness of real-world data and lived experiences—can help learners gain insights into a different world and can bring learning to life. The use of case study in this way has been around for about a hundred years or more. Case study use in educational research, meanwhile, emerged particularly strongly in the 1970s and 1980s in the United Kingdom and the United States as a means of harnessing the richness and depth of understanding of individuals, groups, and institutions; their beliefs and perceptions; their interactions; and their challenges and issues. Writers, such as Lawrence Stenhouse, advocated the use of case study as a form that teacher-researchers could use as they focused on the richness and intensity of their own practices. In addition, academic writers and postgraduate students embraced case study as a means of providing structure and depth to educational projects. However, as educational research has developed, so has debate on the quality and usefulness of case study as well as the problems surrounding the lack of generalizability when dealing with single or even multiple cases. The question of how to define and support case study work has formed the basis for innumerable books and discursive articles, starting with Robert Yin’s original book on case study ( Yin 1984 , cited under General Overview and Foundational Texts of the Late 20th Century ) to the myriad authors who attempt to bring something new to the realm of case study in educational research in the 21st century.

This section briefly considers the ways in which case study research has developed over the last forty to fifty years in educational research usage and reflects on whether the field has finally come of age, respected by creators and consumers of research. Case study has its roots in anthropological studies in which a strong ethnographic approach to the study of peoples and culture encouraged researchers to identify and investigate key individuals and groups by trying to understand the lived world of such people from their points of view. Although ethnography has emphasized the role of researcher as immersive and engaged with the lived world of participants via participant observation, evolving approaches to case study in education has been about the richness and depth of understanding that can be gained through involvement in the case by drawing on diverse perspectives and diverse forms of data collection. Embracing case study as a means of entering these lived worlds in educational research projects, was encouraged in the 1970s and 1980s by researchers, such as Lawrence Stenhouse, who provided a helpful impetus for case study work in education ( Stenhouse 1980 ). Stenhouse wrestled with the use of case study as ethnography because ethnographers traditionally had been unfamiliar with the peoples they were investigating, whereas educational researchers often worked in situations that were inherently familiar. Stenhouse also emphasized the need for evidence of rigorous processes and decisions in order to encourage robust practice and accountability to the wider field by allowing others to judge the quality of work through transparency of processes. Yin 1984 , the first book focused wholly on case study in research, gave a brief and basic outline of case study and associated practices. Various authors followed this approach, striving to engage more deeply in the significance of case study in the social sciences. Key among these are Merriam 1988 and Stake 1995 , along with Yin 1984 , who established powerful groundings for case study work. Additionally, evidence of the increasing popularity of case study can be found in a broad range of generic research methods texts, but these often do not have much scope for the extensive discussion of case study found in case study–specific books. Yin’s books and numerous editions provide a developing or evolving notion of case study with more detailed accounts of the possible purposes of case study, followed by Merriam 1988 and Stake 1995 who wrestled with alternative ways of looking at purposes and the positioning of case study within potential disciplinary modes. The authors referenced in this section are often characterized as the foundational authors on this subject and may have published various editions of their work, cited elsewhere in this article, based on their shifting ideas or emphases.

Merriam, S. B. 1988. Case study research in education: A qualitative approach . San Francisco: Jossey-Bass.

This is Merriam’s initial text on case study and is eminently accessible. The author establishes and reinforces various key features of case study; demonstrates support for positioning the case within a subject domain, e.g., psychology, sociology, etc.; and further shapes the case according to its purpose or intent.

Stake, R. E. 1995. The art of case study research . Thousand Oaks, CA: SAGE.

Stake is a very readable author, accessible and yet engaging with complex topics. The author establishes his key forms of case study: intrinsic, instrumental, and collective. Stake brings the reader through the process of conceptualizing the case, carrying it out, and analyzing the data. The author uses authentic examples to help readers understand and appreciate the nuances of an interpretive approach to case study.

Stenhouse, L. 1980. The study of samples and the study of cases. British Educational Research Journal 6:1–6.

DOI: 10.1080/0141192800060101

A key article in which Stenhouse sets out his stand on case study work. Those interested in the evolution of case study use in educational research should consider this article and the insights given.

Yin, R. K. 1984. Case Study Research: Design and Methods . Beverley Hills, CA: SAGE.

This preliminary text from Yin was very basic. However, it may be of interest in comparison with later books because Yin shows the ways in which case study as an approach or method in research has evolved in relation to detailed discussions of purpose, as well as the practicalities of working through the research process.

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What is the Impact and Importance of Case Study in Education?

Before we explain the significance of case study in education these days for high education, let us explain the first, ‘What is a case study? However, it consists of three major parts that you need to consider for writing. Starting with a problem, outline different available solutions, and offer proven results exhibits that the product or service is an optimum solution for the problem.

What is a Case Study in Education?

Well, a case study is a method of research regarding any specific questions, which allows a person to investigate why and how it happens. Based on education, a case study is that who can use the research for many purposes. It lets the student describe various factors and interaction with each other in authentic contexts. It offers multiple learning opportunities and experiences for scholars by influencing the diverse practice of theories.

Importance of Case Study in Education

It is also considered the source of valuable data regarding diversity and complexity of educational commitments and settings. It plays a vital role in putting theories into regular practice. It is always necessary for the student to realize the clarity in nature and focus of the case study. Considering the significance, Casestudyhelp.com brings the best Case Study Help Any Academic Level for students exerting for acquiring top grades.

What are the Advantages of Case Studies in Class ?

Case studies are assigned to higher classes students, which proved very beneficial to the students, especially in the classroom. Students can actively engage in the discovery of the principles by conceptualizing from the examples. Furthermore, they develop skills like

• Problem-solving
• Coping with ambiguities
• Analytical/ quantitative/qualitative tools according to the case and
• Decision making in complex situations

Method of a Writing Case Study at Casestudyhelp.com!

When teachers give students a Case Study Topic by a teacher, they have to attack each case with the following checklist or go for best and reasonable Case Study Help for Any Topic at casestudyhelp.com!

• Thoroughly read the case and formulate own opinions before sharing ideas with others in the class. You must identify the problems on your own, and offer solutions and best alternatives alongside. Before the study converses, you need to form your own outline and course of action.
• Focus on the three major parts of a case study considering the starting with a problem, outline different accessible solutions, offer predictable results that exhibit the product/service is an optimal solution for the problem.
• Prepare to engage in data collection, collecting data in the field, carry out data evaluation and analysis to write the report.

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Making Learning Relevant With Case Studies

The open-ended problems presented in case studies give students work that feels connected to their lives.

To prepare students for jobs that haven’t been created yet, we need to teach them how to be great problem solvers so that they’ll be ready for anything. One way to do this is by teaching content and skills using real-world case studies, a learning model that’s focused on reflection during the problem-solving process. It’s similar to project-based learning, but PBL is more focused on students creating a product.

Case studies have been used for years by businesses, law and medical schools, physicians on rounds, and artists critiquing work. Like other forms of problem-based learning, case studies can be accessible for every age group, both in one subject and in interdisciplinary work.

You can get started with case studies by tackling relatable questions like these with your students:

• How can we limit food waste in the cafeteria?
• How can we get our school to recycle and compost waste? (Or, if you want to be more complex, how can our school reduce its carbon footprint?)
• How can we improve school attendance?
• How can we reduce the number of people who get sick at school during cold and flu season?

Addressing questions like these leads students to identify topics they need to learn more about. In researching the first question, for example, students may see that they need to research food chains and nutrition. Students often ask, reasonably, why they need to learn something, or when they’ll use their knowledge in the future. Learning is most successful for students when the content and skills they’re studying are relevant, and case studies offer one way to create that sense of relevance.

Teaching With Case Studies

Ultimately, a case study is simply an interesting problem with many correct answers. What does case study work look like in classrooms? Teachers generally start by having students read the case or watch a video that summarizes the case. Students then work in small groups or individually to solve the case study. Teachers set milestones defining what students should accomplish to help them manage their time.

During the case study learning process, student assessment of learning should be focused on reflection. Arthur L. Costa and Bena Kallick’s Learning and Leading With Habits of Mind gives several examples of what this reflection can look like in a classroom: 

Journaling: At the end of each work period, have students write an entry summarizing what they worked on, what worked well, what didn’t, and why. Sentence starters and clear rubrics or guidelines will help students be successful. At the end of a case study project, as Costa and Kallick write, it’s helpful to have students “select significant learnings, envision how they could apply these learnings to future situations, and commit to an action plan to consciously modify their behaviors.”

Interviews: While working on a case study, students can interview each other about their progress and learning. Teachers can interview students individually or in small groups to assess their learning process and their progress.

Student discussion: Discussions can be unstructured—students can talk about what they worked on that day in a think-pair-share or as a full class—or structured, using Socratic seminars or fishbowl discussions. If your class is tackling a case study in small groups, create a second set of small groups with a representative from each of the case study groups so that the groups can share their learning.

4 Tips for Setting Up a Case Study

1. Identify a problem to investigate: This should be something accessible and relevant to students’ lives. The problem should also be challenging and complex enough to yield multiple solutions with many layers.

2. Give context: Think of this step as a movie preview or book summary. Hook the learners to help them understand just enough about the problem to want to learn more.

3. Have a clear rubric: Giving structure to your definition of quality group work and products will lead to stronger end products. You may be able to have your learners help build these definitions.

4. Provide structures for presenting solutions: The amount of scaffolding you build in depends on your students’ skill level and development. A case study product can be something like several pieces of evidence of students collaborating to solve the case study, and ultimately presenting their solution with a detailed slide deck or an essay—you can scaffold this by providing specified headings for the sections of the essay.

Problem-Based Teaching Resources

There are many high-quality, peer-reviewed resources that are open source and easily accessible online.

• The National Center for Case Study Teaching in Science at the University at Buffalo built an online collection of more than 800 cases that cover topics ranging from biochemistry to economics. There are resources for middle and high school students.
• Models of Excellence , a project maintained by EL Education and the Harvard Graduate School of Education, has examples of great problem- and project-based tasks—and corresponding exemplary student work—for grades pre-K to 12.
• The Interdisciplinary Journal of Problem-Based Learning at Purdue University is an open-source journal that publishes examples of problem-based learning in K–12 and post-secondary classrooms.
• The Tech Edvocate has a list of websites and tools related to problem-based learning.

In their book Problems as Possibilities , Linda Torp and Sara Sage write that at the elementary school level, students particularly appreciate how they feel that they are taken seriously when solving case studies. At the middle school level, “researchers stress the importance of relating middle school curriculum to issues of student concern and interest.” And high schoolers, they write, find the case study method “beneficial in preparing them for their future.”

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Using Case Study in Education Research

• Lorna Hamilton - University of Edinburgh, UK
• Connie Corbett-Whittier - Friends University, Topeka, Kansas
• Description

This book provides an accessible introduction to using case studies. It makes sense of literature in this area, and shows how to generate collaborations and communicate findings.

The authors bring together the practical and the theoretical, enabling readers to build expertise on the principles and practice of case study research, as well as engaging with possible theoretical frameworks. They also highlight the place of case study as a key component of educational research.

With the help of this book, graduate students, teacher educators and practitioner researchers will gain the confidence and skills needed to design and conduct a high quality case study.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

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'Drawing on a wide range of their own and others' experiences, the authors offer a comprehensive and convincing account of the value of case study in educational research. What comes across - quite passionately - is the way in which a case study approach can bring to life some of the complexities, challenges and contradictions inherent in educational settings. The book is written in a clear and lively manner and should be an invaluable resource for those teachers and students who are incorporating a case study dimension into their research work' - Ian Menter, Professor of Teacher Education, University of Oxford

'This book is comprehensive in its coverage, yet detailed in its exposition of case study research. It is a highly interactive text with a critical edge and is a useful tool for teaching. It is of particular relevance to practitioner researchers, providing accessible guidance for reflective practice. It covers key matters such as: purposes, ethics, data analysis, technology, dissemination and communities for research. And it is a good read!' - Professor Anne Campbell, formerly of Leeds Metropolitan University

'This excellent book is a principled and theoretically informed guide to case study research design and methods for the collection, analysis and presentation of evidence' -Professor Andrew Pollard, Institute of Educaiton, University of London

This publication provides easy text, giving differing viewpoints to establish definitions for case study research. This book has been recommended to the Fd students to support projects of action research.

This has again been recommended for students on the Foundation Degree and Degree programmes as it is an easy text, providing differing viewpoints to establish definitions for case study research. Additionally recommended on the reading list for the BA programmes to provide a clearer insight into using Case Studies in preschool and school environments.

This is an excellent book - very clear

This text clearly discusses the case study approach and would be useful for both undergraduate and post graduate learners.

An easily accessible text, giving alternative points of view on what case study research actually is and how it might be interpreted at doctoral level.

This is a pleasant read with a number of useful group and individual tasks for students to engage with as they think through designing and doing a project. These tasks for useful not just for case studies but can be adapted as students consider other research designs.

Offers a good understanding of case study research in a clear and accessible manner. A perfect starting point for the researcher new to the case study method and will also offer the experienced researcher some useful tips and insights.

This text is clearly written and argues strongly for using case study in educational research, despite the challenges this approach faces in the dynamic world of shifting research paradigms. Step-by-step guidance from initial ideas through to the reality of undertaking case study in educational research is helpful

The book is written in a practical way, which gives a clear guide for undergraduate students especially for those who are using case study in education research. I will definitely add this book to recommended reading lists.

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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 Jr. Professor at Harvard Business School and the former dean of HBS.

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Methodology

• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, 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 .

Table of contents

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 analyze the case, other interesting articles.

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

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

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.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

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

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

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.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

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 analyze 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.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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The Importance of Case Study Research in Educational Settings

• Şenay Ozan Leymun
• Hatice Ferhan Odabaşı
• Işıl Kabakçı Yurdakul

Case study is a research method which is used to answer how and why questions regarding an issue to be investigated, with no researcher control over variables and when the case is current. There are many factors that affect the phenomenon in the studied case, these factors and their interactions are described by the case study. It is a fact that case study can be used for many purposes in educational research because it enables the capacity to describe a lot of factors and their interact with each other in real contexts. Case studies offer an opportunity to learn from experiences and influence the practice of theories. Case studies are valuable data sources for researchers in view of the complexity and diversity of educational settings and purposes. Case study research has an important role in putting theories into practice, thus developing the practice in the field of educational sciences. In this regard, it is important that the nature and the focus of the case study is clear. The aim of this study is to explain the focus and nature of the case study research method to investigate its importance in educational settings and to offer suggestions for practice to researchers.

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Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature

Susan f. mclean.

Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA.

Introduction

Case-based learning (CBL) is a newer modality of teaching healthcare. In order to evaluate how CBL is currently used, a literature search and review was completed.

A literature search was completed using an OVID© database using PubMed as the data source, 1946-8/1/2015. Key words used were “Case-based learning” and “medical education”, and 360 articles were retrieved. Of these, 70 articles were selected to review for location, human health care related fields of study, number of students, topics, delivery methods, and student level.

All major continents had studies on CBL. Education levels were 64% undergraduate and 34% graduate. Medicine was the most frequently represented field, with articles on nursing, occupational therapy, allied health, child development and dentistry. Mean number of students per study was 214 (7–3105). The top 3 most common methods of delivery were live presentation in 49%, followed by computer or web-based in 20% followed by mixed modalities in 19%. The top 3 outcome evaluations were: survey of participants, knowledge test, and test plus survey, with practice outcomes less frequent. Selected studies were reviewed in greater detail, highlighting advantages and disadvantages of CBL, comparisons to Problem-based learning, variety of fields in healthcare, variety in student experience, curriculum implementation, and finally impact on patient care.

Conclusions

CBL is a teaching tool used in a variety of medical fields using human cases to impart relevance and aid in connecting theory to practice. The impact of CBL can reach from simple knowledge gains to changing patient care outcomes.

Medical and health care-related education is currently changing. Since the advent of adult education, educators have realized that learners need to see the relevance and be actively engaged in the topic under study. 1 Traditionally, students in health care went to lectures and then transitioned into patient care as a type of on-the-job training. Medical schools have realized the importance of including clinical work early and have termed the mixing of basic and clinical sciences as vertical integration. 2 Other human health-related fields have also recognized the value of illustrating teaching points with actual cases or simulated cases. Using clinical cases to aid teaching has been termed as case-based learning (CBL).

There is not a set definition for CBL. An excellent definition has been proposed by Thistlewaite et al in a review article. In their 2012 paper, a CBL definition is “The goal of CBL is to prepare students for clinical practice, through the use of authentic clinical cases. It links theory to practice, through the application of knowledge to the cases, using inquiry-based learning methods”. 3

Others have defined CBL by comparing CBL to a similar yet distinct clinical integration teaching method, problem-based learning (PBL). PBL sessions typically used one patient and had very little direction to the discussion of the case. The learning occurred as the case unfolded, with students having little advance preparation and often researching during the case. Srinivasan et al compared CBL with PBL 4 and noted that in PBL the student had little advance preparation and very little guidance during the case discussion. However, in CBL, both the student and faculty prepare in advance, and there is guidance to the discussion so that important learning points are covered. In a survey of students and faculty after a United States medical school switched from PBL to CBL, students reported that they enjoyed CBL better because there were fewer unfocused tangents. 4

CBL is currently used in multiple health-care settings around the world. In order to evaluate what is now considered CBL, current uses of CBL, and evaluation strategies of CBL-based curricular elements, a literature review was completed.

This review will focus on human health-related applications of CBL-type learning. A summary of articles reviewed is presented with respect to fields of study, delivery options for CBL, locations of study, outcomes measurement if any, number of learners, and level of learner's education. These findings will be discussed. The rest of this review will focus on expanding on the article summary by describing in more detail the publications that reported on CBL. The review is organized into definitions of CBL, comparison of CBL with PBL, and the advantages of using CBL. The review will also examine the utility and usage of CBL with respect to various fields and levels of learner, as well as the methods of implementation of CBL in curricula. Finally, the impact of CBL training on patient and health-care outcomes will be reviewed. One wonders with the proliferation of articles that have CBL in the title, whether or not there has been literature defining exactly what CBL is, how it is used, and whether or not there are any advantages to using CBL over other teaching strategies. The rationale for completing this review is to assess CBL as a discrete mode of transmitting medical and related fields of knowledge. A systematic review of how CBL is accomplished, including successes and failures in reports of CBL in real curricula, would aid other teachers of medical knowledge in the future. Examining the current use of CBL would improve the current methodology of CBL. Therefore, the aims of this review are to discover how widespread the use of CBL is globally, identify current definitions of CBL, compare CBL with PBL, review educational levels of learners, compare methods of implementation of CBL in curricula, and review CBL reports on outcomes of learning.

A literature search was completed using an OVID© database search with PubMed as the database, 1946 to August 1, 2015. The search key words were “Case Based Learning, Medical Education”. Investigational Review Board declined to review this project as there were no human subjects involved and this was an article review. A total of 360 articles were retrieved. Articles were excluded for the following reasons: unable to find complete article on the search engine OVID, unable to find English language translation, article did not really describe CBL, article was not medically or health related, or article did not describe human beings. Articles that originated in another language but had English language translation were included.

After excluding the articles as described, 70 of these articles were selected to review for location of study, description of CBL used, human health care-related fields of study, number of students if available, topics of study, method of delivery, and level of student (eg, graduate or undergraduate). Students were considered undergraduate if they were considered undergraduate in their field. For example, medical students were considered undergraduate, because they would still have to undergo more training to become fully able to practice. If the student was in the terminal degree, then that was considered a study of graduate students. For example, nutrition students were listed as graduate students. CBL encounters for both residents and independent practitioners who were in their final training prior to practice were listed as graduates. Residents were listed under graduate medical education. If a group had already graduated, they were listed as graduates. For example, MDs who participated in a continuing medical education (CME)-type CBL were listed as graduate type of student. Articles that did not list the total number of students were included, as one of the purposes of this review was to discover how widespread the use of CBL was globally, and what types of students and types of delivery were used. By including descriptive articles that were not specific, the global use of CBL could attempt to be assessed. Including locations of studies would then help decide whether CBL was isolated from the Western countries or has it truly spread around the world.

In order to review how CBL was used, in addition to where it was used, the method of delivery was assessed. Method of delivery refers to how the total educational content was delivered. Articles were reviewed for description of exactly how material was imparted to learners. Since many authors described their learning methods in detail, an attempt was undertaken to classify these methods. Method of delivery was classified as follows: live was considered a live presentation of the case, this could be a description, a patient, or a simulated patient. Computer or web based meant that the case and content were web based. Mixed modalities meant that more than two modalities were used during presentation. For example, if an article described assigned reading, lectures, small group discussions, a live case-based session, and patient interactions, then that article would be described as mixed modalities.

Method of evaluation of the educational intervention was also reviewed. The multiple ways in which the interventions were evaluated varied. A survey of how the learners viewed the intervention was frequent. Tests of knowledge gained were frequent, and these ranged from written, to oral, to Observed Skills Clinical Examination (OSCE). Another way by which CBL intervention knowledge was evaluated was review of practice behavior in clinicians. These multiple ways to evaluate the introduction of CBL into a curriculum are summarized in a table.

Results are presented in simple frequencies and percentages. SPSS (Statistical Program for the Social Sciences, IBM) version 22 was used for analysis.

All continuously inhabited continents had studies on CBL ( Fig. 1 ). North America is represented with the most with 54.9% of articles, followed by Europe (25.4%) and Asia, including India, Australia, and New Zealand (15.5%). South America had 2.8% and Africa had 1%. 5 – , 75

CBL use worldwide.

Level of education was undergraduation in 45 (64%) articles and graduation in 24 (34%) articles, with one article having both levels. One study with both faculty and residents was considered as a type of graduate education. The types of fields of study varied ( Fig. 2 ). The most represented field was medicine including traditional Chinese medicine, with articles also on nursing, occupational therapy, allied health, child development, and dentistry. The number of students ranged from 7 to 3105 and the mean number of students was 214. One study reported on the use of teams of critical care personnel, in which it was mentioned that there were three persons per team usually. Thus, the number of students was multiplied: 40 teams x 3 = 120 in total. The total number of students were 9884 from the 46 papers that explicitly stated the number of students.

Fields of study.

Methods of delivery also varied ( Fig. 3 ). The most common method of delivery was live presentation (49%), followed by computer or web based (20%) and then mixed modalities (19%). Method of evaluation or outcomes was studied ( Fig. 4 ). Survey (36%), test (17%), and test plus survey (16%) were the top three methods of evaluation of a CBL learning session. Lesser in frequency was review of practice behavior (9%), test plus OSCE (9%), and others. Review of practice behavior could include reviewing prescription writing, or in one case reviewing the number of adverse drug events reported spontaneously in Portugal. 65

Mode of delivery of CBL.

Method of evaluation.

Discussion and Review

CBL is used worldwide. There was a large variety of fields of medicine. The numbers reported included a wide range of number of learners. Some studies were descriptive, and it was hard to know exactly how many students were involved. This problem was noted in another recent review. 3 CBL was used in various educational levels, from undergraduate to graduate. The number of students ranged from very small studies of 7 students to over 3000 students. The media used to deliver a CBL session varied, from several live forms to paper and pencil or internet-based media. The outcomes measurement to review if CBL sessions were successful ranged from surveys of participants to knowledge tests to measures of patient outcomes. In order to further analyze the worldwide use of CBL, the articles are reviewed below in more detail.

Definition of CBL

CBL has been used in medical fields since at least 1912, when it was used by Dr. James Lorrain Smith while teaching pathology in 1912 at the University of Edinburgh. 63 , 68 Thistlewaite et al 3 pointed out in a recent review of CBL that “There is no international consensus as to the definition of case-based learning (CBL) though it is contrasted to problem based learning (PBL) in terms of structure. We conclude that CBL is a form of inquiry based learning and fits on the continuum between structured and guided learning.” They offer a definition of CBL: “The goal of CBL is to prepare students for clinical practice, through the use of authentic clinical cases. It links theory to practice, through the application of knowledge to the cases, using inquiry-based learning methods.” 3

Another pathology article from Africa, describing a course in laboratory medicine for mixed graduate medical education (residents) and CME for clinicians, defines CBL: “Case-based learning is structured so that trainees explore clinically relevant topics using open-ended questions with well-defined goals.” 7 The exploring that students or trainees do factors into other definitions. In a dental education article originating in Turkey, the authors remark: “The advantages of the case-based method are promotion of self-directed learning, clinical reasoning, clinical problem solving, and decision making by providing repeated experiences in class and by enabling students to focus on the complexity of clinical care.” 8 Another definition of CBL was offered in a physiology education paper regarding teaching undergraduate medical students in India: “What is CBL? By discussing a clinical case related to the topic taught, students evaluated their own understanding of the concept using a high order of cognition. This process encourages active learning and produces a more productive outcome.” 13 In an article published in 2008, regarding teaching graduate pharmacology students, CBL was defined as “Case-based learning (CBL) is an active-learning strategy, much like problem-based learning, involving small groups in which the group focuses on solving a presented problem.” 45 Another study, which was from China regarding teaching undergraduate medical student's pharmacology, describes CBL as “CBL is a long-established pedagogical method that focuses on case study teaching and inquiry-based learning: thus, CBL is on the continuum between structured and guided learning.” 63 It is apparent that the definition requires at least: (1) a clinical case, (2) some kind of inquiry on the part of the learner, which is all of the information to be learned, is not presented at first, (3) enough information presented so that there is not too much time spent learning basics, and (4) a faculty teaching and guiding the discussion, ensuring that learning objectives are met. In most studies, CBL is not presented as free inquiry. The inquiry may be a problem or question. Based on the fact that a problem is expected to be solved or question answered, the information covered cannot be completely new, or the new information must be presented alongside the case.

A modern definition of CBL is that CBL is a form of learning, which involves a clinical case, a problem or question to be solved, and a stated set of learning objectives with a measured outcome. Included in this definition is that some, but not all, of the information is presented prior to or during the learning intervention, and some of the information is discovered during the problem solving or question answering. The learner acquires some of the learning objectives during the CBL session, whether it is live, web based, or on paper. In contrast, if all of the information were given prior or during the session, without the need for inquiry, then the session would just be a lecture or reading.

Comparison of CBL and PBL

CBL is not the first and only method of inquiry-based education. PBL is similar, with distinct differences ( Fig. 5 ). In many papers, CBL is compared and contrasted with PBL in order to define CBL better. PBL is also centered around a clinical case. Often the objectives are less clearly defined at the outset of the learning session, and learning occurs in the course of solving the problem. There is a teacher, but the teacher is less intrusive with the guidance than in CBL. One comparison of CBL to PBL was described in an article on Turkish dental school education: “… CBL is effective for students who have already acquired foundational knowledge, whereas PBL invites the student to learn foundational knowledge as part of researching the clinical case.” Study, of postgraduate education in an American Obstetrics and Gynecology residency, describes CBL as “CBL is a variant of PBL and involves a case vignette that is designed to reflect the educational objectives of a particular topic.” 54 In an overview of CBL and PBL in a dental education article from the United States, the authors note that the main focus of PBL is on the cases and CBL is more flexible in its use of clinical material. 16 The authors quote Donner and Bickley, 70 stating that PBL is “… a form of education in which information is mastered in the same context in which it will be used … PBL is seen as a student-driven process in which the student sets the pace, and the role of the teacher becomes one of guide, facilitator, and resource … (p294).” The authors note that where PBL has the student as the driver , in CBL the teachers are the drivers of education, guiding and directing the learning much more than in PBL. 16 The authors also note that there has not been conclusive evidence that PBL is better than traditional lecture-based learning (LBL) and has been noted to cover less material, some say 80% of a curriculum. 71 It is apparent that PBL has been used to aid case-related teaching in medical fields.

Differences in CBL and PBL.

Two studies highlight the advantages and disadvantages of CBL compared with PBL. Both studies report on major curriculum shifts at three major medical schools. The first study, published in 2005, reported on the performance outcomes during the third-year clerkship rotations at Southern Illinois University (SIU). 19 At SIU, during the 1994–2002 school years, there was both a standard (STND) and PBL learning tract offered for the preclinical years, years 1–2. During the PBL tract, basics of medicine were taught in small group tutoring sessions using PBL modules and standardized patients. In addition, there was a weekly live clinical session. The two tracts were compared over all those years with respect to United States Medical Licensing Exam© (USMLE) test performance on Steps 1 and 2, and also overall grades and subcategories on the six third-year clerkships. So the two tracks had differing years 1–2 and the same year 3. Results noted that the PBL track had more women and older students, so these variables were set out as covariates analyzing other scores. Comparing the PBL versus STND tracks, USMLE scores were statistically equal over the years 1994–2002. PBL was 204.90 ± 21.05 and STND was 205.09 ± 23.07 ( P , 0.92); Step 2 scores were PBL 210.17 ± 21.83, STND 201.32 ± 23.25 ( P , 0.15). Clerkship overall scores were overall statistically significantly higher for PBL tract students in Obstetrics and Gynecology and Psychiatry ( P = 0.02, P < 0.001, respectively) and statistically not different for other clerkships. Clerkship subcategory analysis demonstrated statistically significantly higher scores for PBL tract students in clinical performance, knowledge and clinical reasoning, noncognitive behaviors, and percent honors grades, with no difference in the percentage of remediations. The school decided to switch to a single-tract curriculum after 2002. The problems noted with the PBL curriculum involved recruiting PBL faculty and faculty acceptance of student interactions, and also assessment issues. Faculty had to be trained to teach in PBL, which was time consuming and interfered with the process of learning by students. In addition, some faculty felt that the teachers should determine the learner's needs and not vice versa. The PBL assessment tools were novel and not immediately accepted by the faculty. 19 Other schools noted similar problems with PBL: it is different than LBL, and difficult to teach, as it is extremely learner centered. Learning objectives are essentially generated by the student, making faculty control over learning difficult. At this school, the difficulties in using PBL contributed to its abandonment as a stand-alone curriculum tract.

The difficulties in using PBL were associated with changes in other medical schools. Two medical schools in the United States, namely, University of California, Los Angeles, and University of California, Davis, changed from a PBL method to a CBL method for teaching a course entitled Doctoring , which was a small group faculty led course given over years 1–3 in both schools. 4 Both schools had a typical PBL approach, with little student advance preparation, little faculty direction during the session, and a topic that was initially unknown to the student. After the shift in curriculum to CBL, there were still small group sessions, but the students were expected to do some advance reading, and the faculty members were instructed to guide or direct the problem solving. Since in both schools the students and faculty had some experience with PBL before the shift, a survey was used to assess student and faculty experiences and perceptions of the two methods. Both students and faculty preferred CBL (89% of students and 84% of faculty favored CBL). Reasons for preference of CBL over PBL were as follows: fewer unfocused tangents (59% favoring CBL, odds ratio [OR] 4.10, P = 0.01), less busywork (80% favoring CBL, OR 3.97 and P = 0.01), and more opportunities for clinical skills application (52%, OR 25.6, P = 0.002). 4 In summary, these two reports indicate that while a case-oriented learning session can prepare students for both tests of knowledge and also clinical reasoning, PBL has the problems of difficult to initiate faculty or teachers in teaching this way, difficult to cover a large amount of clinical ground, and difficulty in assessment. CBL, on the other hand, has advantages of flexibility in using the case and offers the same reality base that offers relevance for the adult health-care learner. In addition, CBL appears to be accepted by the faculty that may be practicing clinicians and offers a way to teach specific learning objectives. These advantages of CBL led to it being the preferred method of case-related learning at these two large medical schools.

Advantages of CBL and deeper learning

Another touted advantage of CBL is deeper learning. That is, learning that goes beyond simple identification of correct answers and is more aligned with either evidence of critical thinking or changes in behavior and generalizability of learning to new cases. Several articles described this aspect of CBL. One article was set at a tertiary care hospital, the Mayo Clinic, and was a teaching model for quality improvement to prevent patient adverse events. 33 The students were clinicians, and the course was a continuing education or postgraduate course. The authors in the Quality Improvement, Information Technology, and Medical Education departments created an online CBL module with three cases representing the most common type of patient adverse events in internal medicine. The authors use Kirkpatrick's outcomes hierarchy to assess the level of critical thinking after the CBL intervention. Kirkpatrick's outcomes hierarchy is based on four levels: the first, reaction of learner to educational intervention, the second, actual learning: acquiring knowledge or skills, the third, behavior or generalizing lessons learned to actual practice, and the fourth, results that would be patient outcomes. 72 The authors note that as one moves up this hierarchy, learning is more difficult to measure. A survey can measure hierarchy level 1, a written test, and level 2. Behavior is more difficult but still able to be measured. The authors measured critical thinking in physicians, taking their Quality Improvement course by measuring critical reflection by a survey. The authors constructed a reflection survey, which asked course participants about items constructed to assess their level of reflection on the cases. Least reflective levels consisted of habitual action, and most critically, reflective items asked physicians if they would change the way they do things based on the cases. The results of their intervention showed that physicians had the lowest scores in reaching the higher levels of reflective thinking. However, the reflection scores were shown to be associated with physicians’ perceptions of case relevance ( P = 0.01) and event generalizability ( P = 0.001). This study was the first to evaluate physician's reflections after a CBL module on adverse events. The assumption is that deeper learning will be more likely to lead to behavioral changes.

Another attempt to measure deeper learning was reported from a dental school in Turkey. 8 The authors compared a CBL course with an older LBL course from the previous year by using “SOLO” taxonomy, developed by Biggs and Collis. 73 SOLO taxonomy rates the learning outcomes from prestructural through extended abstract. For example, in unistructural, the second item of SOLO, items could be “define”, “identify”, or “do a simple procedure”, whereas in the “extended abstract” level, the items are “evaluate”, “predict”, “generalize”, “create”, “reflect”, or “hypothesize” in higher mental order tasks. 8 A post-test was used to measure the responses on the test. The test questions were assigned to SOLO categories. In the first three categories of SOLO taxonomy questions, there was no statistical difference in scores between LBL and CBL groups. In the last two or higher categories of questions based on SOLO taxonomy, there was a statistically significant increase in the scores for relational and extended types of questions for the CBL group ( P = 0.014 and 0.026, respectively). This review shows a benefit in higher level learning using a CBL program. Again, the assumption is that by inducing higher order mental tasks, deeper learning will occur and behavioral change will follow.

Two other studies discussed the levels of thinking and preparation for practice. One study compared students in interdisciplinary (ID) versus single-discipline students (SD; clinical anatomy) in a Graduate School for Health Sciences in Missouri, U.S. The two groups had slightly different cases. The ID group had complex ID cases and answered multiple choice questions about the cases. The SD group had cases in their discipline and answered multiple choice cases around the case. The assessment tool was the Watson-Glaser Critical Thinking Appraisal. The mean scores of both groups were not statistically different. However, ID students who scored below the median on the pretest scored significantly higher on the posttest. While this study set out to compare the differences in SD vs ID teaching using CBL, it also compared the effects of an ID course on critical thinking and it appears to be synergistic with improving scores for students who started below the median on testing. This is important in education programs, because while mean scores may not rise, if less students are scoring lower, then less students will fail the course and have to repeat.

The second paper that attempted to measure higher learning outcomes queried dental school graduates who had completed a CBL course during their dental school training. 22 The survey was designed to assess the CBL curriculum with respect to actual job requirements of practicing dentists. The graduates spanned 16 years, from 1990 to 2006, and the survey was conducted in 2007–2008. The response rate was 41%. The findings were that the CBL course was associated with positive correlations in “research competence”, “interdisciplinary thinking”, “practical dental skills”, “team work”, and “independent learning/working”. Other items including “problem-solving skills”, “psycho-social competence”, and “business competence” were not scored as highly with respondents. This article measured self-reported competencies and not the competencies as assessed by independent observers. However, it does attempt to link CBL with the actual practice with which it was attempting to teach, which is one of the generally accepted benefits of CBL.

In summary, CBL is defined as an inquiry structured learning experience utilizing live or simulated patient cases to solve, or examine a clinical problem, with the guidance of a teacher and stated learning objectives. Advantages of using CBL include more focusing on learning objectives compared with PBL, flexibility on the use of the case, and ability to induce a deeper level of learning by inducing more critical thinking skills.

Uses of CBL with respect to various fields and various levels in health-care training

CBL is used to impart knowledge in various fields in health care and various fields of medicine. The findings in this review showed that articles demonstrated the use of CBL in medicine, 2 , 4 – , 7 , 9 , 10 , 12 – , 14 , 18 – , 21 , 24 – , 26 , 30 , 33 , 34 , 36 , 37 , 39 – , 44 , 46 , 48 – , 62 , 64 – , 67 dentistry, 8 , 15 , 16 , 22 , 23 , 28 pharmacology, 11 , 27 , 29 , 35 , 45 , 63 occupational and physical therapy, 31 nursing, 5 , 21 , 38 , 47 , 51 allied health fields, 32 and child development. 17

Eighteen fields of medicine were seen in this review, from internal medicine and surgery to palliative medicine and critical care ( Fig. 2 , “fields of study”). Several articles highlight ID care or interprofessional care. A 2011 article in critical care medicine demonstrated the utility of both simulators and CBL on behaviors in critical situations of critical care teams of physicians and nurses. 5 Palliative care 21 and primary care 51 , 59 articles also reported on using a CBL course for learning with physicians and nurses. An article from the United Arab Emirates discussed how CBL better prepared participants for critical situations as well as basic primary care. 59

CBL is also used in various levels, including undergraduate education in the professions, graduate education, and postgraduate education. One field that uses CBL for all levels is surgery. Several articles describe surgical undergraduate medical education. One article describes using a paper and pencil plus live review sessions on improving student knowledge as tested by a standardized test in surgery. 6 Another paper from Germany describes initiation of a CBL curriculum for medical students and lists the pitfalls in establishing this curriculum. 26 A third undergraduate paper in a medical school course in surgery describes utilizing CBL and a more structured curriculum to aid in knowledge gains. A study utilizing both surgical simulators for laparoscopic procedural skills and CBL for clinical knowledge and reasoning demonstrates learning enhancement using CBL in surgical residents, or graduate surgical training. 20 In this study, scores in both procedural ratings during surgery for residents and also knowledge scores when presented with complications from surgery both rated higher in the CBL-enhanced course. Graduate use of CBL in surgery is frequent. CME courses are taught in trauma, which features lectures, skill stations, and simulation-based CBL. 74 Advanced Trauma Life Support (ATLS) certification is required for all surgeons who practice in a designated trauma center in the United States. 74 In addition, the American College of Surgeons publishes a self-assessment course entitled “SESAP” or Surgical Education and Self-Assessment Program, which is a web or CD-ROM course that is largely case based, with commentaries. 75 These two courses are widely available and are constantly revised to reflect new advances in patient care research. The use of CBL programs was employed in undergraduate and graduate including postgraduate fields in this review.

Use of CBL in rural and underserved areas

One practical use of CBL is to use CBL to enhance knowledge in rural or underserved areas. An excellent example of CBL is the Project Extension for Community Healthcare Outcomes (ECHO) program in Arizona and Utah states, United States. 10 , 12 This program was based on the Project ECHO program initially devised at the University of New Mexico Health Sciences Center in 2003. 10 In Arizona and Utah, the CDC helped fund a program to teach primary care providers and also provide access to specialist to treat hepatitis C virus (HCV)-infected patients. The primary aim was to increase treatment, as new drugs have become available, which are highly effective in treating HCV. The program works by recruiting primary care physician to participate. An initial teaching session is held on site at the health-care clinic in the rural or underserved area. Then, the provider teams are asked to participate in “tele ECHO” clinics in which participants present cases and have experts in HCV treatment comment. There are also educational sessions. Ninety providers participated, with 66% or 73% being primary care providers in rural or community health centers and not at universities. Over one and a half years, 280 patients were enrolled with 46.1% starting treatment. Other patients were likely not able to be treated, as their laboratory values indicated advanced liver disease. The percentage starting treatment was more than twice as many as expected to receive treatment prior to the project, based on historical controls. In addition to showing how CBL can impact rural medical care, this study is an example of learning assessment measured in patient outcomes.

A second CBL project was used in the United Arab Emirates to train rural practitioner's vital aspects of primary and emergency care using a CBL project. 60 The learners were able to provide feedback to the teachers as to the topics needed. This demonstrates the potential for interaction between teachers and learners using CBL, as it is a practical way to teach active practitioners. A third demonstration of using CBL in rural areas is in a report on teaching laboratory medicine in Africa. 7 In Sub-Saharan Africa, there is low trust in laboratory medicine services due in part to lower the quality of laboratories. This problem directly impacts patient care. Multiple international agencies are assisting the clinical laboratories in Sub-Saharan Africa in order to improve the quality of service. According to this report, the quality problem has led to decreased trust in laboratory medicine in the region. The course, given at Addis Ababa University in Ethiopia, was initiated to provide knowledge and also increase trust in laboratory medicine. The participants were 21 residents (graduate medical education), 3 faculty members, and 4 laboratory workers. The course was structured with both lectures and cases. Students were given homework for the differing cases. The assessments were both knowledge gains and also surveys of satisfaction for the course. Ratings on the survey were by ratings on a Likert scale of 1 (least valuable) to 5 (most valuable). Regarding the methods of delivery, the CBL sessions were rated highest with 85% of learners rating them as most valuable. In all, 81% rated case discussions as most valuable. Lectures received the most valuable rating by 65%. On the 12 question pre-/posttest, the mean score rose and also the number of questions answered correctly by the majority of learners. 7 These reports from three continents demonstrate that CBL is a practical way to impart knowledge in a diverse range of topics to clinicians who may be remote from a medical university.

Delivery of CBL: implementation and media

As illustrated in the above examples of use of CBL in rural settings, CBL use is varied as to the delivery method and implementation. Several articles demonstrate the importance of preparation for use in CBL. As many practitioners and students in all fields likely have more experience with LBL, participating in a course with CBL requires a different strategy and mindset in order to reach learning objectives. Preparation of both students and teachers in a CBL format is also very important for success. Two studies highlight the preparation and implementation of CBL: one not as successful as the other. In a qualitative study of introducing a new CBL format series to undergraduate medical students based in Sweden, the authors found that preparation of both students and faculty was likely inadequate for complete success. This study, held at the Karolinska Institutet, described the implementation of a CBL format for learning surgery during a semester course. All LBL classes were replaced with CBL sessions. The authors noted that at this time, there were organizational obstacles to starting a CBL course: lack of time and funds for faculty training. As such, faculty training was delayed and decreased. The study was a survey of five students and five faculty, who were picked from larger pools. There was a lot of criticism by students that the CBL needed more structure, or that the faculty often turned the CBL session more into a lecture session. The faculty described problems with getting the students to engage, and also with the lack of preparation for teaching in that format. Still, the overall impression was that CBL could increase interactive learning for this level of student. 26 This study demonstrates how lack of adequate preparation can impact a CBL experience for both faculty and students.

Another article demonstrated the differences in student motivation for autonomous learning, which was different, depending on how CBL was introduced. In a study of child development students in Sweden, there were four group methods to compare how students learned, depending on how CBL was introduced. The four groups were as follows: (1) LLL or all lecture, (2) CCCC or all CBL, (3) LCLC in which lecture and CBL were alternated in each session after the introduction, and (4) LLCC, in which there were three sessions with all lectures, two mixed lecture plus CBL, and two CBL only lectures to finish. There was a knowledge pretest and post-test to assess what the authors call prior knowledge (pretest) and achievement (posttest). Student motivation for learning was assessed by means of a modified Academic Self-Regulation Scale. 76 The results were that achievement scores and also autonomous motivation were both the highest in the LLCC group, or the group in which CBL was introduced after LBL. The authors conclude that students are more prepared for CBL after some foundational knowledge is imparted. These two articles demonstrate that both teacher and student preparation is necessary for a successful CBL learning encounter.

Use of CBL to impact patients and measurement of results

As described earlier, the Kirkland model of learning and assessment of outcomes includes assessment of the results of the training as its final method of assessing an intervention. In other words, how did the training impact patient care or its surrogate marker? Four recent studies illustrated how CBL can impact patient care. 10 , 12 , 40 , 54 , 69 The first, already described, is the Project ECHO for HCV treatment, which resulted in 46.1% of patients in the areas affected being started on treatment, and a large proportion of those treated being started on the newer antivirals. The second study was a study on practices by primary care physicians on treating diabetic patients. In this study, 122 primary care physicians (Family and Internal Medicine) at 18 sites were divided into three groups to enhance diabetes care. Group A received surveys and no intervention and served as a control group; group B received Internet-based software with three cases in a virtual patient encounter. The cases had simulated time and could include laboratory and medication orders and follow-up visits. After the cases, the physicians received feedback in the form of what an expert would do. Group C received the same CBL as group B with the addition of 60 minutes of verbal feedback and instruction from a physician opinion leader. The authors were able to obtain clinical data for the results. The results were that group B had a significant decline in hemoglobin A1C measures, the most common means of assessing glucose control over time in diabetics, while groups A and C did not. Groups B and C had a significant decline in prescribing metformin in patients with contraindications also. This demonstrates favorable clinical results using a CBL intervention. 40 The third was a study to institute chlamydia screening in offices. While the intervention did not globally increase chlamydia screening, the impact was that there was less of a decay on chlamydia screening in the intervention groups. 54 The last study demonstrated a CBL study in Portugal, which demonstrated an increase in reporting of adverse drug events after a CBL intervention in a study population of over 4000 physicians. 69 These four articles describe the use of CBL to impart medical knowledge and the use of patient outcomes to assess that learned knowledge. This is the ultimate test of learning for health-care practitioners: knowledge that improves patient care.

Limitations of this Review

This review was an attempt to classify a term, case-based learning , which is used frequently. In reviewing articles, this term was used as a search term. It is possible that articles written which would fit the definition of CBL but were termed differently by the individuals writing that article might have been missed. In addition, foreign language articles were not retrieved if there was not an English translation. There may be additional articles that would be instructional in other languages. The higher number of articles retrieved from North America may be biased by using a United States database. In an attempt to describe the various articles, which were termed case-based learning , the methods of delivery and evaluation were described in terms familiar to medical personnel. In the learning situation, these terms might be describing slightly different experiences. For example, several articles described the use of an observed skills examination to evaluate the learner; this examination was classified as “observed skills clinical examination or OSCE”. These OSCEs might have been more, or less, stringent. In defense of the search strategy, since the objective of the article was to write about what is currently considered case-based learning , this item was used as the search term. In order to classify and further define what exactly is CBL and how it is used, putting into discrete categories the described methods of delivery and evaluation was necessary, or else the review would reduce to a listing of separate articles without being able to provide a meaningful commentary.

CBL is a tool that involves matching clinical cases in health care-related fields to a body of knowledge in that field, in order to improve clinical performance, attitudes, or teamwork. This type of learning has been shown to enhance clinical knowledge, improve teamwork, improve clinical skills, improve practice behavior, and improve patient outcomes. CBL advantages include providing relevance to the adult learner, allowing the teacher more input into the direction of learning, and inducing learning on a deeper level. Learners or students in health care-related fields will one day need to interact with patients, and so education that relates to patient is particularly relevant. Relevance is an important concept in adult education. CBL was found to be used in all continents. Even limiting the search to English and English translations, articles were found on all continuously inhabited continents. This finding demonstrates that the use of CBL is not isolated to Western countries, but is used worldwide. In addition, based on the number and variety of fields of medicine and health care reported, CBL is used across multiple fields.

In reviewing the worldwide use of CBL, several constants became apparent. One is that this involves a case as a stimulant for learning. The second is that advance preparation of the learner is necessary. The third is that a set of learning objectives must be adhered to. A comparison with PBL across several articles revealed that most teachers who use CBL, in contrast to PBL, need to get through a list of learning objectives, and in so doing, must provide enhanced guidance to the learning session. That adherence to learning objectives was evident in most articles. There were varied methods of delivery, depending on the learning situation. That is one of the practical aspects of learning sessions termed case-based learning or CBL. The teachers used cases within their realm of teaching and adapted a CBL approach to their situation; for example, live CBL might be used with medical students, video cases might be used with practitioners. CBL differs from PBL in that it can cover a larger amount of topics because of the stated learning objectives, and guidance from the teacher or facilitator who does not allow unguided tangents, which may delay covering the stated objectives. Contrasting CBL with CBL, in PBL, the focus is on the process of learning as much as the topic, whereas in CBL, the learning objectives are stated at the outset, and both learners and teachers try to adhere to these. Because there are stated objectives at the outset of the learning experience in CBL, these objectives can be tested to see if they are met. These tests of knowledge were explored as methods of evaluation, which varied.

The methods of evaluation ran the range of Kirkpatrick's hierarchy of learning. One of the important aspects of CBL which was explored was that perhaps CBL could induce learning on a deeper level. And so going up the hierarchy of learning, some evaluations were simple surveys of the learners/and or the teachers on how they liked the CBL intervention. Some were tests of knowledge or skills learned. A few studies evaluated practice behavior; that is, going beyond knowledge learned into what behaviors that knowledge induced. The last hierarchy was how the knowledge learned from CBL affected actual patients: a few studies revealed that patient outcomes were affected positively from CBL. Thus, published studies of CBL spanned the hierarchy of learning, from opinions of the activity to actual patients affected by the learning of practitioners.

In summary, CBL was found to be practiced worldwide, by various practitioners, in various fields. CBL delivery was found to be varied to the situation. Methods of evaluation for CBL included all the steps on Kirkpatrick's hierarchy of learning and demonstrated that CBL could be shown conclusively to produce deeper learning.

To repeat the definition included earlier in this review, CBL is a form of learning that involves a clinical case, a problem or question requiring student thought, a set of learning objectives, information given prior and during the learning intervention, and a measured outcome.

CBL imparts relevance to medical and related curricula, is shown to tie theory to practice, and induce deeper learning. CBL is practical and efficient as a mode of teaching for adult learners. CBL is certain to become part of every medical and health profession's curriculum.

Author Contributions

Conceived the concepts: SFM. Analyzed the data: SFM. Wrote the first draft of the manuscript: SFM. Made critical revisions: SFM. The author reviewed and approved of the final manuscript.

Peer Review: Four peer reviewers contributed to the peer review report. Reviewers’ reports totaled 779 words, excluding any confidential comments to the Academic Editor.

Competing Interests: Author discloses no external Funding sources.

Funding: SFM has been selected as a local site primary investigator for a study of a new tissue insert for use in surgical repair of ventral hernia. The study is sponsored by BARD-Davol Inc.

Paper subject to independent expert single-blind peer review. All editorial decisions made by independent Academic Editor. Upon submission manuscript was subject to anti-plagiarism scanning. Prior to publication all authors have given signed confirmation of agreement to article publication and compliance with all applicable ethical and legal requirements, including the accuracy of author and contributor information, disclosure of Competing Interests and Funding sources, compliance with ethical requirements relating to human and animal study participants, and compliance with any copyright requirements of third parties. This journal is a member of the Committee on Publication Ethics (COPE).

4 Case Studies: Schools Use Connections to Give Every Student a Reason to Attend

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Students who feel connected to school are more likely to attend and perform well, and less likely to misbehave and feel sad and hopeless. There are even health benefits well into adulthood linked to a strong connection to school as an adolescent.

But schools are confronting a range of problems that stem at least in part from a lack of connection—perhaps most visibly: stubborn, nationwide increases in chronic absenteeism .

As they try to boost attendance and keep students engaged, some schools are turning to strategies built around the idea of connectedness. They’ve taken steps to more deliberately cultivate trusting relationships among students and adults in the building. They’ve tried to boost students’ participation in extracurricular activities to ensure they have a place at school where they feel as if they belong. And they’ve collected student feedback on what they’re learning and responded accordingly.

The work lines up with school connectedness strategies the U.S. Centers for Disease Control and Prevention has said are effective at reducing unhealthy behaviors and strengthening students’ engagement.

Here’s how two high schools and two school districts are putting student connectedness at the center of their improvement efforts.

Dive into each case study:

• Making 9th graders feel seen and heard
• Probing why some students feel they don’t belong
• Making relationships part of an early-warning system
• Using connections to battle chronic absenteeism

A Chicago school wants 9th graders to feel seen and heard

Thomas Kelly College Preparatory, Chicago

Educators at Thomas Kelly College Preparatory have homed in on freshman year as a key time to make sure students have a strong connection to the Chicago high school.

“If you’re a 9th grader, nothing is more important to you than belonging,” said Grace Gunderson, a counselor at the 1,700-student school who leads its newly formed freshman success team. “If we can get those kids involved in band or, ‘Hey, I play on the soccer team,’ or, ‘Hey, I always eat lunch in Ms. Gunderson’s office,’ now they have a connection. They have a reason to keep coming to school.”

Kelly’s efforts began with hearing from students. In the first iteration of a survey called Elevate that the school now administers to all students quarterly, students said they didn’t think teachers cared about them, they thought classes were boring, and they didn’t think what they were learning was relevant to what they wanted to do in life, Principal Raul Magdaleno said.

With that insight, school staff—led by the five-member freshman success team—deployed a range of initiatives, both large and small, to foster belonging. They worked on making sure students had a relationship with a trusted adult, that more were participating in extracurricular activities, that the school building was inviting, and that students knew their opinions mattered.

One effort was a “Freshman Cafe,” a spring event last year where nearly all the school’s 500 freshmen sat down one-on-one with an adult for five to 10 minutes and discussed how the school year had gone, asked questions about sophomore year, reviewed attendance and grades and set goals for the remainder of the year, and talked about clubs they could join. Staff members ranging from the dean to security guards participated.

Before the current freshman class arrived at Kelly last summer, the school started sending regular communications to incoming 9th graders introducing them to the school and staff members, held community-building activities for incoming freshmen run by college mentors through a “Freshman Connection” program, and hosted an outdoor “Freshman Fiesta” with snacks and swag, where students had the chance to meet teachers.

It’s definitely still a work in progress. But I think the students understand now that we want their feedback, we genuinely want to know what they think, and they feel as if their opinions are valued.

And once the school year began, the freshman success team made sure an adult would regularly check in with students flagged as high risk in the Chicago schools’ “Risk and Opportunity” framework, which uses 8th grade attendance and grades to predict students’ likelihood of success in high school.

The school relied on teachers and other staff members in the building who volunteered to do these check-ins as well as college-age mentors working through a community group, the Brighton Park Neighborhood Council, “just so they have somebody else aside from their teachers that’s talking to them, that shows them that they care, that they’re interested in their experience,” said Griselda Esparza, an assistant principal at Kelly.

In classrooms, after students said they thought classes were boring and disconnected, Kelly made this year the year of “meaningful work,” with teachers starting to rethink their instruction to make it more “culturally relevant and rigorous,” Magdaleno said.

Teachers have started working in their professional learning communities to examine whether what they’re teaching is personally relevant to students and connected to life outside the classroom. They’re also focused on whether students have opportunities to make choices about what they’re learning.

“It’s definitely still a work in progress,” Gunderson said. “But I think the students understand now that we want their feedback, we genuinely want to know what they think, and they feel as if their opinions are valued.”

A New York district probes why some students feel they don’t belong

Arlington Central School District, New York

When the Arlington Central school district in New York surveyed students after their return to campus from pandemic closures, staff discovered that older students, students of color, and students in special education felt a weaker sense of belonging at school.

So, staff from the 7,800-student district started speaking with students from those populations to get to the bottom of the problem.

In focus groups, students told staff that books they read in class weren’t relevant and that they weren’t hearing enough viewpoints in history classes. Students who weren’t athletes or musicians said they had no way to connect to their school community.

“We learned a lot, and that helped us prioritize,” said Daisy Rodriguez, the district’s assistant superintendent for curriculum, instruction, and assessment.

A first response was holding high school activity fairs, bringing information to students about clubs they could join rather than having them seek it out on their own. More informally, administrators sat with kids in the cafeteria to talk to them about their interests and potential clubs to add to the school’s roster.

Working with department coordinators, the district conducted curriculum audits, looking at the texts students were assigned and exploring whether they could swap in more relevant and current selections. And the high school added career and technical education offerings.

High school students also sit on curriculum teams, Rodriguez said. “They give us immediate feedback on programs and resources that we’re thinking about and if it makes sense to them,” she said.

At the district’s middle schools, Arlington last year established regular advisory periods, with groups of students assigned to the same adviser all three years so they can form stronger connections and don’t have to hit reset every fall. The time is set aside for regular check-ins and social-emotional learning.

We know that when kids feel like they belong in school, they have better attendance, they have better academic achievement, and just greater social-emotional support.

“Students have reported that they do feel that it’s helpful for them because they actually have a space that they can go to and talk about things that they can’t talk about necessarily in other settings,” Rodriguez said.

The district wants older students to lead more of these sessions in coming years, and it would ultimately like to bring advisory periods to the high school.

At the elementary level, students now have daily morning meetings, a time set aside for social-emotional learning and work on communication skills.

So far, the district has seen some positive results—a reduction in chronic absenteeism that Rodriguez attributes at least in part to the district’s work on connectedness.

“We know that when kids feel like they belong in school, they have better attendance, they have better academic achievement, and just greater social-emotional support,” she said.

A New Mexico high school makes relationships part of its early-warning system

Manzano High School, Albuquerque, N.M.

Manzano High School in Albuquerque, N.M., relies on a dedicated advisory time so students build strong connections with staff who can then spot warning signs that a student might be falling behind.

The 30-minute advisory period that happens every Monday isn’t new to the 1,300-student high school. What’s new about it is that, over the past couple of years, advisers have been expected to check in with their advisees and, using the school’s student-information system, review their grades, attendance, and behavior over the prior week.

If a student is struggling, the adviser fills out a referral form and sends it to one of the school’s five student-success teams, each of which includes an academic counselor. That team starts working with the student to identify a root cause of their challenges and potential solutions.

The advisory period’s conversion to a key component of Manzano’s early warning, or student success, system has involved training for staff members on becoming deliberate listeners and lunch-and-learn sessions on building relationships with students, said Jeanie Stark, the school’s student-success systems coordinator.

“When you’re listening to the students, it’s listening to what they’re saying and maybe even listening to a little bit beyond that to get to that root cause,” she said. “And you may or may not respond right away.”

It’s still a work in progress. The school has work to do to ensure all advisers are using the student-success system as the framework for conversations with students, Principal Rachel Vigil said.

Attendance has improved this year, and the number of students requiring student-success-team referrals has been dropping, Stark said. But a more immediate sign that the check-ins and related work have been successful is feedback from students.

Last spring, Manzano staff interviewed students whom advisers had referred to a student-success team. Of all the help they’d received, the regular check-ins were the most meaningful and helpful, the students said.

“Students were saying, ‘We do better when we have people doing those one-on-one check-ins,’” Vigil said. “Just, ‘Hey, how are you doing?’ It doesn’t even have to be academic.”

Grades and attendance data are readily available through the student-information system, Stark said, but students “want a lot of communication. They want that teacher to talk to them, and they want them to tell them how they’re doing.”

Now, the Albuquerque district wants to spread Manzano’s work. It’s working with other high schools in the city to craft their own student-success systems, and some of Albuquerque’s middle schools are figuring out what a student-success system looks like for younger students, said Sheri Jett, Albuquerque’s associate superintendent for school climate and supports, a new position.

Working with the student-survey company Panorama, Albuquerque has also begun conducting regular student surveys on students’ skills, habits, and mindset. Manzano staff hope these surveys will provide them with even more student feedback they can use to tailor their student-success system.

In Washington state, a district uses connections to battle chronic absenteeism

Tacoma Public Schools, Washington state

The Tacoma, Wash., school district’s work over the past two years to cut chronic absenteeism has revolved around strategies to strengthen students’ bonds to peers and trusted adults while using student and family feedback as a guide.

“We believe the relationship is the intervention,” said Laura Allen, the director of the 28,000-student district’s whole-child department , the hub for much of the school system’s student-wellness work.

With a grant from Washington’s state education agency, Tacoma two years ago hired a district attendance and engagement counselor to lead work on boosting attendance. As part of that work, the district surveyed students and families to find out why kids attend school and why they miss it.

“The No. 1 reason why kids said they come to school was to see their friends,” Allen said. “It doesn’t mean that they don’t want to do well academically, but that friendship connection was first and foremost.”

With that knowledge in hand, schools worked on creating new clubs that could provide more students opportunities to spend time with friends and foster a sense of belonging.

District data showed that Indigenous and LGBTQ+ students were more likely to attend school irregularly, so staff helped create new affinity groups aimed at giving students from those populations a place to “feel seen and heard,” said Jimmy Gere, the attendance and engagement counselor.

Some schools formed attendance clubs to build connections with students at risk of being chronically absent and work through problems that could keep them from coming to school.

Newly formed building attendance teams—sometimes existing teams that expanded their focus to include attendance—took inventories of their schools’ existing interventions for at-risk students, held listening sessions with students and staff, and took school-specific steps to address attendance challenges.

Tacoma also began working with two community organizations that provide mentors who regularly meet with students during school hours, checking in with them and working with them on social-emotional skills.

These experiences show students that “good things happen at school, whether it’s with your teachers or staff that are there every day or community partners that are set up to deliver their services within the school,” Gere said.

And one new initiative provides younger students with a safe way to get to school while giving older students a paid internship and course credit.

The Walking School Bus is an organized group of students who walk to school together each day, led by a high school student route leader or Tacoma educator, stopping at established points to pick up more students. It was a response to feedback from parents who said their kids didn’t have a safe way to get to school, presenting a barrier to attendance.

Younger students build relationships with high school students, and high school students gain a service-learning opportunity—one of the CDC’s identified strategies for building school connectedness.

“There’s an element of mentorship because elementary kids love high school kids,” Gere said.

Tacoma has seen attendance inch up since it started these initiatives. Average daily attendance has been 88.3 percent so far this year, up from 85.6 percent in 2021-22, before these initiatives began, district data show. But it’s still early, and future funding for some of the work is uncertain as the state attendance grant comes to a close alongside other federal COVID-relief money.

Still, Tacoma will be able to carry on much of the work based on building connections, Allen said. For students, she said, “it is all about making sure that they know that they’re seen and that they’re loved.”

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ORIGINAL RESEARCH article

This article is part of the research topic.

GIS and MCDM Techniques as Tools for Navigating to a Greener Future by Harnessing Onshore and Offshore Wind Energy

Wind farm site selection using GIS-based mathematical modeling and fuzzy logic tools: A case study of Burundi Provisionally Accepted

• 1 University of Rwanda, Rwanda
• 2 University of Mauritius, Mauritius

The final, formatted version of the article will be published soon.

The electricity generated from nuclear plants and petroleum-based products has a negative influence on the environment as a whole. It has shown the utility to search out and promote the utilization of renewable, environmentally friendly, and sustainable energy sources such as solar, wind, and geothermal. Nowadays, Wind energy resource has quickly emerged as the world's fastest-growing energy source. However, the selection of the most suitable places for developing a wind farm is a crucial challenge that can be seen as a problem of site selection, which involves numerous conflicting variables. Therefore, it is classified as an MCDM (multi-criteria decision-making) problem. The main objective of this research is to determine the best locations in Burundi for the installation of wind farms. The Fuzzy Analytic Hierarchy Process (FAHP) was used to weigh the criteria considering their relative importance. This study considers several key factors when determining the optimal location for a wind farm. These factors include wind speed, slope, proximity to the grid network, distance to roads, and land use/land cover (LULC). Furthermore, a geographic information system (GIS) is utilized to generate the final suitability wind farm locations map. The obtained results indicate that 20.91% of the whole study area is suitable nevertheless, only 1.96% is tremendously suitable for wind turbine placement. The western part of Burundi is the optimal area for constructing a wind farm, and the most is in Lake Tanganyika.

Keywords: Fuzzy theory, Wind farm location, decision-making, Fuzzy-analytic hierarchy process, restriction factors

Received: 10 Dec 2023; Accepted: 15 Apr 2024.

Copyright: © 2024 Placide and Lollchund. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Mx. GATOTO Placide, University of Rwanda, Kigali, Rwanda

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• Open access
• Published: 15 April 2024

Life expectancy, long-term care demand and dynamic financing mechanism simulation: an empirical study of Zhejiang Pilot, China

• Xueying Xu 1 ,
• Yichao Li 2 &
• Hong Mi 2  

BMC Health Services Research volume  24 , Article number:  469 ( 2024 ) Cite this article

Metrics details

China has piloted Long-Term Care Insurance (LTCI) to address increasing care demand. However, many cities neglected adjusting LTCI premiums since the pilot, risking the long-term sustainability of LTCI. Therefore, using Zhejiang Province as a case, this study simulated mortality-adjusted long-term care demand and the balance of LTCI funds through dynamic financing mechanism under diverse life expectancy and disability scenarios.

Three-parameter log-quadratic model was used to estimate the mortality from 1990 to 2020. Mortality with predicted interval from 2020 to 2080 was projected by Lee-Carter method extended with rotation. Cohort-component projection model was used to simulate the number of older population with different degrees of disability. Disability data of the older people is sourced from China Health and Retirement Longitudinal Study 2018. The balance of LTCI fund was simulated by dynamic financing actuarial model.

Life expectancy of Zhejiang for male (female) is from 80.46 (84.66) years in 2020 to 89.39 [86.61, 91.74] (91.24 [88.90, 93.25]) years in 2080. The number of long-term care demand with severe disability in Zhejiang demonstrates an increasing trend from 285 [276, 295] thousand in 2023 to 1027 [634, 1657] thousand in 2080 under predicted mean of life expectancy. LTCI fund in Zhejiang will become accumulated surplus from 2024 to 2080 when annual premium growth rate is 5.25% [4.20%, 6.25%] under various disability scenarios, which is much higher than the annual growth of unit cost of long-term care services (2.25%). The accumulated balance of LTCI fund is sensitive with life expectancy.

Conclusions

Dynamic growth of LTCI premium is essential in dealing with current deficit around 2050 and realizing Zhejiang’s LTCI sustainability in the long-run. The importance of dynamic monitoring disability and mortality information is emphasized to respond immediately to the increase of premiums. LTCI should strike a balance between expanding coverage and controlling financing scale. This study provides implications for developing countries to establish or pilot LTCI schemes.

Peer Review reports

The lack of sufficient long-term care (LTC) for older individuals has become a pressing concern in both developed and developing countries with global population aging and increased longevity [ 1 ]. Although healthy life expectancy generally increased over last decades [ 2 ], the episode of disability in older people could have catastrophic impact on their household welfare [ 3 ]. Several developed countries, such as the Netherlands, Germany, and Japan, have established social long-term care insurance (LTCI) to address LTC demands of households with disabled older individuals. This approach proves more efficient in pooling disability risks than private LTCI [ 4 , 5 ]. Nonetheless, many developed countries had to reform their LTCI systems to deal with increasing aging population with LTC demands, often by raising premiums. Even though, these adjustments usually had time lags which affected the long-term sustainability of LTCI schemes. However, establishing social LTCI in developing countries proves more challenging than in developed countries because the lower income of residents restricts the financing capacity of LTCI. In addition, the lack of high-quality death registration and health survey data hinders optimizing LTCI systems design according to changing LTC demands, particularly in developing countries or small areas [ 6 ].

Massive evidence shows that there will be a steady and slow increase in life expectancy [ 7 , 8 , 9 ]. Evidence from developed countries shows that the long-term care needs increasing rapidly because of the increasing life expectancy [ 10 , 11 ]. The trend of the gap between life expectancy and healthy life expectancy is still inconclusive [ 12 ], which also affects the identification of LTC needs [ 13 ]. There is still mixed conclusion of disability and LTC demands trend in the future based on the three different assumptions of health transitions [ 14 , 15 , 16 ]. Whereas, there is less evidence regarding the assessment of LTC needs under different mortality scenarios. Zeng, et al. [ 17 ] calculated long-term care needs under different life expectancy scenarios, but the setting of life expectancy was relatively subjective. Besides, many studies in country-level controlled the impact of underreported mortality on the LTCI system by using modified mortality data [ 18 , 19 ], but few studies in the provincial level took that into consideration.

Most countries such as Germany and the Netherlands adopt a fixed percentage of income model to collect social LTCI premiums from individuals [ 20 ], and a few countries such as Singapore adopt a fixed amount premium model [ 21 ]. The premium of Germany LTCI has been 3.05% of gross income or 3.40% if individuals aged 23 and above without children since 2020 [ 22 ]. The Netherlands also has a tax-funded LTCI with the compulsory contribution of 9.65% of taxable income since 2017 [ 20 ]. In Singapore, fixed amount premium of LTCI is determined by the age of starting contribution and sex. The premium for a 30-year-old male (female) is around 200 (250) Singapore Dollars in 2020 [ 21 ], with an increase of 2% per year from 2020 to 2025 [ 23 ]. Financing parameters from both models should be adjusted regularly to ensure sustainability [ 24 , 25 ]. In China, both models are adopted in different LTCI pilot areas [ 26 ], but the areas that adopt the fixed amount of premium have not increased the premium level since the pilot, which affects long-term sustainability.

OECD countries will face high pressure of LTCI financing because of increasing average public LTC expenditures to 2.3% of GDP in 2040 for the future financing level of LTCI [ 27 ]. Therefore, an adjustment factor is suggested incorporated to simulate LTCI fund to reduce future financing pressure [ 22 ], but a higher short-term financing will bring greater resistance to reforms. Most simulation studies on China’s LTCI, based on fixed percentage of income model, demonstrated that LTCI financing will increase rapidly based on different disability scenarios [ 28 , 29 , 30 , 31 ]. Some studies also simulated LTCI financing based on fixed amount of premium model [ 32 , 33 ], but they did not consider its variation under different mortality scenarios. Only one study modified the mortality in a pilot city by using national mortality data when simulating the dynamic financing burden [ 34 ]. However, it only simulated to 2040 which did not cover plateau period of China’s aging.

China, as a developing country, pioneered social LTCI schemes in 2016. Local governments were granted significant autonomy, resulting in fragmented LTCI structures due to regional disparities in the pilot cities [ 35 ]. Thus it has become crucial to ensure the sustainability of China’s LTCI pilot areas. Zhejiang Province stands as a representative case among these pilot areas and its five cities (Tonglu, Ningbo, Jiaxing, Yiwu and Whenzhou) have piloted LTCI since 2017. Zhejiang has standardized disability assessments, coverage groups, benefit levels, and financing amounts of LTCI in province-level by 2022 [ 36 ]. It faces rapid aging ahead with high life expectancy in China. Notably, Zhejiang, one of the areas with fixed amount of premium of LTCI in China, has never increased its fixed premium since the pilot’s inception [ 36 ]. This lack of financing adjustment coupled with inflationary pressures strains Zhejiang’s LTCI fund. Zhejiang has capacities to facilitate LTCI operations through modified financing mechanism as the demonstration zone for the Initiative of Common Prosperity in China. Therefore, it can serve as a practical model for other developing countries establishing LTCI schemes to evaluate life expectancy and LTC demand parameters and guide its LTCI financing.

In summary, massive studies predict the LTC needs in developed countries and China. However, most of the studies on LTCI financing in China pilots overlook the potential death underreporting in census and uncertainty of mortality in projection period, which may misestimate the future LTC needs and financing pressure. In addition, current studies on the sustainability of China’s LTCI rarely involve the dynamic financing adjustment of fixed amount of premium model, and most studies do not cover the plateau period of China’s aging in the future, which may underestimate the financing level to achieve sustainable LTCI. Therefore, drawing from the Zhejiang Province case in China, this study proposes a dynamic financing mechanism to achieve a balance between sustainability and efficiency in social LTCI schemes, utilizing a simulation model with limited mortality and disability information. Our aim is to offer insights for developing countries to establish or pilot LTCI schemes. Three research questions will be addressed:

What is the long-term trend of life expectancy in Zhejiang from 1990 to 2080?

What extent of LTC demand will be reached among older people in Zhejiang from 2023 to 2080, with aging process?

What level of LTCI dynamic financing standards will achieve an actuarial equilibrium of the LTCI fund in Zhejiang, with rising life expectancy and LTC demand?

Data sources

For demographic data, the age-specific mortality and the population number by gender are from population census of Zhejiang Province in 1990, 2000, 2010 and 2020. The population census, which has been conducted once every 10 years since 1990, is a complete account of the entire population, mortality and fertility by age and sex in each census year and has the province-level representativeness of Zhejiang. Child mortality data is from Chinese Center for Disease Control and Prevention (CDC) in 1990–2013 [ 37 ], and official annual data of Zhejiang reported u p to 2020 [ 38 ]. Chinese CDC sorted and estimated under-5 mortality rates in China before 2013 with county-level and province-level representativeness, including data in Zhejiang. Data on the prevalence rate of disability of the older people is sourced from China Health and Retirement Longitudinal Study (CHARLS) in 2018. CHARLS is a national representative survey which covers a wide range of topics related to the adults aged 45 and above, including demographic information and health status. The national prevalence rate of disability by age and sex from CHARLS is used as a proxy for Zhejiang referring to existing research, due to lack of latest representative disability data in Zhejiang [ 39 ]. Older people are defined as those aged 60 and above based the statistical standards from World Health Organization [ 40 ], whose age groups are covered by CHARLS. The benefit criteria and financing criteria data is from the LTCI official regulations of pilot cities in Zhejiang [ 41 , 42 , 43 , 44 , 45 ]. Healthcare Consumer Price Index (CPI) from 2010 to 2020 in Zhejiang is from National Bureau of Statistics of China, covering the socio-economic indicators at province-level [ 46 ]. The change rate of total fertility of China from 2020 to 2080 is from World Population Prospects 2022 which forecasted fertility in country-level around the world [ 47 ].

Estimation of mortality pattern with three-parameter model life table approach

Model life tables methods are widely used in simulation of mortality for their effectiveness and accessibility to overcome the limited mortality information in developing countries [ 48 , 49 ]. Two-parameters log-quadratic model considering the child and adult mortality overcomes the shortage of Coale-Demeny and UN model life tables, among those model life tables methods [ 50 ]. Three-parameter log-quadratic model is designed on this to calculate the life table considering extra old-age mortality parameter with an adjustment of intercept with real census information [ 51 ]. It is so-called developing countries mortality database (DCMD) model which was adopted in the World Population Prospects 2019 since the three-parameter log-quadratic model life table was initially used in those developing countries without the high-quality mortality data [ 52 ]. The basic function of DCMD model is showed below:

This study used adjusted DCMD model to estimate the mortality in Zhejiang from 1990 to 2020 to make it usable for open population conditions. Child mortality ( \({\,}_{5}{q_0}\) ) is the first parameter of DCMD model, and adult mortality ( \({\,}_{{45}}{q_{15}}\) ) is the second parameter to be compared with estimated adult mortality ( \({\,}_{{45}}{\hat {q}_{15}}\) ) from two-parameter log-quadratic model with adjustment factor \(k\) . Specifically, child mortality by gender in consecutive years is estimated by sex ratio of child mortality in China [ 53 ]. Adult mortality in census years is calculated from census life table directly as the register completeness of adults’ death is higher in China [ 53 ]. Moreover, we averaged old-age mortality estimated from two-parameter log-quadratic model and from survival model for midpoint of old-age mortality between censuses (1995, 2005 and 2015) [ 51 ]. We averaged old-age mortality from two-parameter log-quadratic model and from census life table calculations for census years (1990, 2000, 2010 and 2020). The adjusted DCMD model was constructed on the incorporated old-age mortality. After that, the cubic hermite polynomial interpolation approach (pchip package in R) was adopted to estimate adult and old-age mortality from 1990 to 2020 [ 54 ]. The life table for consecutive years was estimated with DCMD model.

After that, Lee-Carter method extended with rotation (LC_ER) (mortcast package in R) was used to forecast the mortality up to 2080 [ 55 ], which provides critical death parameters to assess the LTCI demands in our case area. Since in low mortality countries, mortality decline is decelerating at younger ages and accelerating at older ages [ 56 ], the static assumption of mortality decline of traditional Lee-Carter model would be anomalous in long-term projection. LC_ER is a time-varying Lee-Carter model considering the changes of mortality decline between different age groups when modeling, which was widely recognized and adopted by World Population Prospects 2022 [ 57 , 58 ]. Therefore, potential LTCI demands change caused by changes in old-age mortality decline in long-term projections could be captured by LC_ER. The predicted mean of life expectancy would be set as the medium life expectancy scenario, and the lower and upper 95% predicted interval would be set as the low and high life expectancy scenarios.

Number of severe disabled older adults

LTCI beneficiaries refer to the severe disabled population according to the rules of LTCI in Zhejiang [ 36 ]. The study used the cohort-component projection (CCP) method to forecast the number of older population of Zhejiang from 2020 to 2080 [ 59 ]. The number of age-specific population by sex from Zhejiang population census 2020 was used as the base population of CCP model. Furthermore, the age-specific prevalence rate of disability from CHARLS 2018 was calculated. After that, the number of severe disabled older adults as the LTCI beneficiaries was calculated by multiplying age-specific older population and prevalence rate of disability. The basic project method is as follows:

\({\,}_{{x+1}}P_{x}^{{t+1}}\) represents the population of single age groups with the age of x to x  + 1 at the t  + 1 time. \(\left[ {{L^t}(x+1)/{L^t}(x)} \right]\) represents the survival ratio of age x to x  + 1 at t time. \(N{I^*}\) represents the net migration numbers in the corresponding age group from the t to t +  1 period, from other regions to Zhejiang.

Our estimated mortality will be used in CCP model. Since the total fertility of Zhejiang is lower than that of China, this study assumed that the total fertility of Zhejiang would start at 1.04 in 2020 based on Zhejiang population census [ 60 ]. Then, the future trend of Zhejiang’s total fertility would follow the United Nations’ estimated change rate of total fertility of China from 2020 to 2080 [ 47 ]. For net migration, The Census Survival Ratio Method was used to estimate the migration pattern based on the census data [ 61 ]. As one of the highest net in-migration provinces since 2010, Zhejiang will face the lower net in-migration intensity and be close to migration equilibrium in 2040 [ 62 ]. Based on this, it is assumed that the net migration rate in Zhejiang will experience a linear decrease and realize migration equilibrium by 2045.

Disability is defined as a difficulty in performing at least one of six Activities in Daily Living (ADL) [ 63 ], including bathing, dressing, eating, getting in/out of bed, using the toilet, and controlling urination and defecation in CHARLS. Then, mild disability is defined as having difficulty in 1–2 items of ADL, moderate disability as having difficulty in 3–4 items of ADL, and severe disability as having difficulty in at least 5 items of ADL [ 64 , 65 ]. Based on the discussion on the Disease Expansion, Disease Compression and Dynamic Equilibrium Theory [ 66 ], three different scenarios in changing disability were calculated [ 16 ]: a 0.8% annual decrease for age-specific prevalence rate of disability as the low disability scenario, the constant age-specific prevalence rate of disability as the middle disability scenario, and a 0.8% annual increase for age-specific prevalence rate of disability as the high disability scenario.

Dynamic financing actuarial model of social LTCI schemes

The study built a macro simulation model to further simulate the expenditure, financing and fund balance of LTCI based on the projection of severe disabled older population ( \(DisOP\) ) aged 60 and above and contribution population ( \(CP\) ) of LTCI aged 20 and above. The macro model is showed below:

In Formula (4), \(LTCE\) means LTC expenditures, \(HbdcCost\) , \(IcCost\) , \(HbdmcCost\) and \(NhcCost\) represent the unit cost of home-based daily living care (HBDC), institutional care, home-based daily living & medical care (HBDMC) and nursing hospital care per person per year, respectively. Among them, HBDC means that beneficiaries only receive formal daily living care services at home but without any medical care. HBDMC means that beneficiaries receive both formal daily living care services and professional medical care services at home. The difference of institutional care and nursing hospital care lies in that the former focuses more on daily living care, while the latter specializes in medical care. From 2023 to 2080, the unit cost of each type of LTC services is given an increase of 2.25% annually based on the average increase of healthcare CPI from 2010 to 2020. \(\alpha \) means the percentage of different types of LTC services utilization. Formula (5) describes the dynamic financing model and current balance of LTCI every year. \(premiu{m_{{t_0}}}\) is the fixed amount of premiums of LTCI in our base period. \(\lambda \) is annual growth of the amount of LTCI premiums. Formula (6) shows the accumulated balance of LTC fund which is determined by the current balance and the accumulated balance in previous period. \(\gamma \) is the interest rate of LTCI fund which represents the time value of the LTCI fund. Taking the inflation rate (2.25%) as a reference in the simulation process, we test the minimum value of \(\lambda \) that ensures a consistently positive accumulated balance in the LTCI fund up to 2080 across various disability scenarios.

Parameters of LTCI schemes in Zhejiang Province, China

The policies of LTCI schemes in five pilot cities in Zhejiang are sorted in Additional Table 1  (see Additional file 1 ) [ 41 ]. The LTCI schemes in Jiaxing City are representative among five pilot cities of LTCI in Zhejiang. Firstly, Jiaxing is the first city covering all employees and urban and rural residents equitably with the same benefits and premium since the adoption of LTCI (in 2017), which has navigated the reform of LTCI in Zhejiang. Secondly, LTCI benefits in Jiaxing are at the middle level among the five pilot cities, which is representative of average level in Zhejiang. The maximum benefits of HBDC in Jiaxing are lower than those in Yiwu and Wenzhou, and equal to those in Tonglu and Ningbo. Besides, the maximum benefits of institutional care are also lower than those in Yiwu, but higher than those in Tonglu and Ningbo. Overall, Jiaxing’s LTCI benefits stay average in Zhejiang. Thirdly, LTCI financing criteria in Jiaxing align with Ningbo and Tonglu (90 Chinese Yuan (CNY)/person/year), reflecting the standards across five cities. Therefore, this study adopted Jiaxing’s LTCI criteria as the parameters of LTCI simulations in Zhejiang. The unit costs of HBDC, institutional care, HBDMC and nursing hospital care are set at 1200 CNY/month, 2100 CNY/month, 1680 CNY/month and 1680 CNY/month in 2024 according to LTCI maximum benefits in Jiaxing (see Additional Table 1 , Additional file 1 ) [ 41 ]. The contributory group of LTCI is the group participating in social health insurance, whether retired or not. The LTCI financing parameter \(premiu{m_{{t_0}}}\) is based on a fixed amount of premiums in Jiaxing, of which the standard is 90 CNY/person/year [ 41 ].

Chinese government proposed a model of elderly care named “9073” model: 90% of older people receive home-based care, 7% receive community care and 3% receive institutional care [ 67 ]. “9073” model represents the prospects of China’s elderly care and is therefore suitable for the long-term simulation in this study [ 29 , 62 ]. Specifically, proportion of HBDC ( \({\alpha _{\text{1}}}\) ), institutional care ( \({\alpha _2}\) ), and combination of HBDMC and nursing hospital care ( \({\alpha _3}\) + \({\alpha _4}\) ) are set at 90%, 3% and 7%, respectively. Disabled older people can choose to receive HBDMC at home or receive nursing hospital care at medical institutions when facing medical care needs. It is free to choose the locations for these two LTC services, and it is quite similar to receiving community care in nature, as it also allows the option of receiving services at home or at community centers. Additionally, the LTCI benefits of these two LTC services in Jiaxing are equal. Therefore, we grouped them together when determining the beneficiaries’ choice of LTC services type ( \({\alpha _3}\) + \({\alpha _4}\) ). We set the interest rate of LTCI fund at 2.5% based on current interest rate of 5-year time deposit in China’s banks [ 68 ]. The sources of each parameter for simulation framework of the study are demonstrated in Additional Fig.  1 (see Additional File 1 ).

The mortality pattern and life expectancy of Zhejiang

The estimated mortality of Zhejiang from 1990 to 2020 is demonstrated in Fig.  1 based on adjusted DCMD model. Overall, the mortality for male and female presents a declining trend. Specially, the child mortality had a continued decline during the estimation period, but the adult mortality and old-age mortality had a slight increase between 1990 and 2000, then with a sharp decline between 2000 and 2020 afterwards.

We further predict the life expectancy at birth with 95% confidential interval under the LC_ER model from 2020 to 2080. The estimated and predicted life expectancy is demonstrated in Fig.  2 . Life expectancy of female had a stable increase from 1990 to 2020. While there was a slight decline of life expectancy of male from 1990 to 2000, then there was a rapid increase until 2020. The model results based on historical information show that life expectancy of both female and male will have an upward trend from 2020 to 2080. Besides, the gender difference in life expectancy will remain relatively stable in the future. In 2020, life expectancy was 80.46 years for male, 84.66 years for female. In 2080, the life expectancy will reach 89.39 [86.61, 91.74] years for male, 91.24 [88.90, 93.25] years for female. Besides, the age-specific rates of mortality decline of Zhejiang from 2021 to 2080 estimated by LC_ER are illustrated in Additional Fig.  2 (see Additional File 1 ).

Mortality pattern of Zhejiang in 1990–2020 based on adjusted DCMD model

Estimated and predicted life expectancy of Zhejiang in 1990–2080

The simulation of long-term care demand and expenditures in Zhejiang

Based on CCP method, the study has projected the number of older people and the number of severely disabled older people with different scenarios of disability in Zhejiang from 2020 to 2080 (shown in Table  1 ). It is illustrated that the population aged 60 and above in Zhejiang will firstly expand to around 2060 and then shrink until 2080. The number of older people with disabilities, especially those with severe disability, reflects the long-term care demand from a demographic perspective. We found that the number of older people with severe disability will continue to increase to 2080 under both medium and high disability scenarios. However, the number of older people with different degrees of disability will increase before 2060, and then decline slightly in the following 20 years under the low disability scenario. We also found that the number of severely and moderately disabled older people will be of little difference before 2050, which means that severe and moderate LTC demand is roughly equal.

Besides, the results of LTC demand under the high and low life expectancy scenarios are illustrated in Additional Table  2 and Additional Table  3 (see Additional file 1 ). It can be seen that Zhejiang Province will have a higher LTC demand under the scenario of higher life expectancy. The number of older people with severe disability under 95% upper interval of life expectancy in 2080 is 154 thousands higher than that under the predicted mean of life expectancy. And the number of older people with severe disability under 95% lower interval of life expectancy in 2080 is 169 thousands lower than that under the predicted mean of life expectancy. This result demonstrates the importance of mortality level prediction for assessing LTC demand.

Our study further calculated the LTCI expenditure paid by insurance fund every year from 2020 to 2080 to analyze the future long-term care demand in our case area from a financial perspective. The expenditure from LTCI illustrates an upward trend from 2023 to 2080 (see Fig. 3 ), with the higher price of long-term care services and increasing number of severe disabled older people. The LTCI expenditure is still increasing although there will be a slight decline in severe disabled older people under low disability scenario.

Projection of Long-term care insurance expenditure in Zhejiang, 2024–2080. Notes Results are based on the predicted mean of life expectancy

The simulation of LTCI fund under diverse disability and financing scenarios

The accumulated balance of LTCI fund from 2022 to 2080 is simulated on different dynamic financing growth scenarios in order to test how to make LTCI achieve actuarial balance in the long run. The accumulated balance and current balance of LTCI fund in Zhejiang are shown in Figs.  4 and 5 . When we set the annual premium growth rate at 2.25% which is equal to the average increase of healthcare CPI, there will be a deficit of current balance before 2028. As a result, the accumulated balance will become negative in 2032 under medium disability scenario, under high disability scenario in 2030 and under low disability scenario in 2036. This result shows that LTCI fund can only be sustainable within 12 years if the financing level grows at a low pace from 2024.

Accumulated balance of LTCI fund under different financing and disability scenarios. Notes Results are based on the predicted mean of life expectancy

Current balance of LTCI fund under different financing and disability scenarios. Notes Results are based on the predicted mean of life expectancy

The minimum annual premium growth is further tested to achieve the positive accumulated balance of LTCI fund under various scenarios from 2022 to 2080. We found that when the annual premium growth rate equals to 4.20%, LTCI fund will realize the long-term sustainable under low disability scenario, which means that the 4.20% financing growth standard is effective to make LTCI sustainable at a relatively low premium level under low disability scenario; however, it will still face the risk of the shortage of financing with 4.20% annual premium growth under the medium and high disability scenarios after 2039 and 2033.

Furthermore, the accumulate balance of LTCI fund remains at a moderate surplus and will not face a shortage until 2080 under the medium disability scenario when the annual premium growth rate equals 5.25%. Although the current balance of LTC fund will be negative in 2043 to 2058 under 5.25% annual premium growth (see Fig.  5 ), the accumulated surplus before 2042 and continuous interest will still realize the accumulated surplus of LTCI fund (5.83 billion CNY) in 2058. Overall, the annual premium growth rate at 5.25% is the best parameter choice if the age-specific prevalence rate of disability in Zhejiang Province is projected to remain stable. Finally, LTCI will be sustainable under all disability scenarios when the premium increases by 6.25% per year. However, this level will put a heavy payment burden on the residents, and there will be a large amount of fund redundancy if the disability does not continue to increase.

The simulation of LTCI fund under diverse life expectancy and financing scenarios

The impact of different life expectancy trend on the sustainability of LTCI schemes is further discussed. The simulation results of accumulated balance of LTCI fund under predicted mean, 95% upper confidential interval and lower confidential interval of life expectancy scenarios are demonstrated in Fig.  6 . It is learned that the sustainability of the LTCI fund will face a completely different situation in the long-term because of the difference trends in life expectancy even under the same disability level and financing level. Under the 5.25% annual premium growth rate and medium disability scenario, LTCI fund will become accumulated deficit under 95% upper interval of life expectancy after 2045. However, the LTCI fund will always remain in surplus before 2080 with the predicted mean or lower 95% interval of life expectancy. Therefore, the balance of LTCI fund is sensitive to life expectancy. In addition to affecting LTC expenditures when other conditions are the same, life expectancy is also related the total amount of financing by the number of contributors, thereby influencing the sustainability of LTCI fund.

Current and accumulated balance of LTCI under different life expectancy scenarios. Notes Results are based on the 5.25% annual premium growth rate scenario and medium disability scenario

This study shows two novel contributions to the existing literature. The first contribution is that we have found an important but often overlooked point that LTCI financing is sensitive to the variability of life expectancy in the long-term. In 2080, the 95% upper interval of the life expectancy in Zhejiang Province will be 2.01 years for female (2.35 years for male) higher than the predicted mean, and its cumulative impact will make LTCI unsustainable 35 years in advance. This finding shows that the accurate estimation of life expectancy is critical for assessing the sustainability of social insurance schemes like LTCI [ 69 , 70 ], and also reveals the significance of life expectancy analysis in this study, because health factors can be dynamically monitored through the evaluation and reimbursement records within the LTCI system [ 34 , 71 ], but life expectancy estimation will become difficult due to the lack of timely statistical data. Besides, the study also finds that LTCI financing is also sensitive to the variability of prevalence rate of disability in the long-term. Only 4.20% annual growth of premium can make Zhejiang’s LTCI sustainable under a disability compression assumption. However, the 6.25% annual growth of premium is necessary for Zhejiang’s LTCI sustainability under disability expansion assumption. The results are consistent with some existing research with various disability scenarios [ 28 , 72 ]. The overall incidence of disability will face a growing trend with population aging [ 17 ]. Therefore, proposing health promotion and postponing disability actions to reduce the incidence and duration of severe disability among older people will mitigate the pressure of LTCI funding [ 73 ].

The second contribution is that Zhejiang’s LTCI financing needs to grow at a relative high speed annually (5.25% under the medium scenario) to achieve sustainability in the long-term. It should be noticed that the LTCI financing parameters to achieve short-term and long-term fund equilibrium are different, and it is clear that long-term fund balance is a necessary condition to ensure the sustainability of the system [ 22 , 29 ]. If the accumulated surplus of the LTCI fund in Zhejiang Province before 2050 is used as a criterion for determining sustainability, as many studies have done [ 19 , 74 ], our results indicate that Zhejiang LTCI fund is projected to experience an accumulating deficit for over 20 years after 2050. Like Zhejiang, there are also several pilot cities in China that have adopted the fixed amount of premium model without premium adjustment [ 32 ]. LTCI funds in these regions will run the risk of accumulating deficits in the short term [ 43 ]. China and other countries adopting social LTCI need to adjust the scale of premium in a timely and dynamic manner to cope with the long-term LTCI financing pressure since China’s aging plateau will continue after 2060 [ 47 ].

Our simulation results can also be used as a reference for countries and regions that adopt a fixed percentage of income model of LTCI financing although we focus on the fixed amount model of LTCI financing. The study finds that LTCI premium in Zhejiang needs to increase by 5.25% per year to ensure sustainability to 2080 under the assumption of disability with dynamic equilibrium. However, the growth rate may exceed the income growth rate of some countries in the context of declining global economic growth [ 75 ]. Therefore, even those countries based on a fixed percentage of income model need adjust financing parameters dynamically [ 1 ]. In LTCI fund management, China and other countries can learn from Germany’s experience to deal with the long-term impact of population aging, which has established a demographic reserve fund which saves 0.1% of premium every year for payment in the future [ 25 ].

Reasonable coverage and benefits are also important factors to achieve sustainable LTCI. Like developed countries, the LTCI pilot cities in Zhejiang Province cover all urban and rural residents. However, most of the LTCI pilot cities in China only cover urban employees [ 35 ]. Therefore, the analysis of LTCI in Zhejiang Province in this paper provides implications for other LTCI pilot cities in China to expand the coverage and promote the equity of receiving LTC. Besides, it should be noted that this study only considers the older adults with severe disabilities according to the rules when estimating LTC needs in Zhejiang Province [ 36 ]. Whereas, it is not only the families of severely disabled groups that face the burden of long-term care [ 17 ]. Moderately disabled people in some developed countries and pilot cities in China are also covered by LTCI [ 76 , 77 ]. Even considering only severe disability, our simulation results show that only a high premium growth rate can make the system sustainable in the long run. Therefore, LTCI policymakers need to comprehensively weigh residents’ payment pressure and long-term care benefits, and make a balance between expanding coverage and increasing financing with the aim of protecting the most vulnerable groups.

This study has explored and built a long-term care insurance system that can be a reference for China and other developing countries to provide LTC services for the disabled older adults in the future. The strength of this study is that a more accurate life expectancy estimation based on the DCMD model is adopted when estimating dynamic financing of LTCI. However, this paper still has some limitations. Firstly, the paper only considers the activities of daily living when estimating the prevalence rate of disability of older people in Zhejiang Province, but does not consider cognitive function, perception and communication function due to the lack of data. Secondly, this study only considers the expenditure cost of LTC in the simulation analysis, but does not consider the operating cost of the LTCI system. Thirdly, this study only considers the total amount of financing for LTCI, but does not discuss the financing structure including individual contributions, government subsidies, and pooling funds. Finally, this study focuses only on the case in Zhejiang, but does not simulate the LTCI financing standard for actuarial equilibrium in other LTCI pilot areas in China.

In summary, this study estimates and predicts the mortality rate in Zhejiang Province from 1990 to 2080 through the DCMD model and LC model, and further evaluates the increasing LTC need in Zhejiang Province in the future. The LTCI dynamic financing in Zhejiang Province under different disability scenarios and life expectancy scenarios is simulated on the LTCI expenditure forecast results, and it is found that only by maintaining a relatively high level (5.25% under medium scenario) of premium growth can Zhejiang’s LTCI be sustainable in the long run. Our empirical case in Zhejiang offers implications for developing countries and LTCI pilot areas that lack high-quality mortality information to establish and dynamically optimize LTCI financing. Therefore, policy makers are called upon to assess the sustainability of LTCI from a long-term perspective, and regularly monitor changes in residents’ health and life expectancy to ensure that LTCI fund can meet LTCI expenditure and control the financing burden.

Data availability

In this study, all the data sources are publicly available. The data calculated in this study is available upon request to the corresponding author.

Abbreviations

Long-term care

• Long-term care insurance

China Health and Retirement Longitudinal Study

Center for Disease Control and Prevention

Consumer Price Index

Developing Country Mortality Database

Lee-Carter method extended with rotation

Cohort-component projection

Chinese Yuan

Home-based daily living care

Home-based daily living & medical care

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Acknowledgements

We would like to thank Professor Xiangming Fang from Zhejiang University, Professor Guangdi Chen from Zhejiang University and Chengxu Long from King’s College London for their constructive advice during the research process of the paper. We would also like to appreciate any comments from the 34th REVES meeting.

This work was supported by the Major Project of Zhejiang Provincial Natural Science Foundation of China (LD21G030001).

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Xu, X., Li, Y. & Mi, H. Life expectancy, long-term care demand and dynamic financing mechanism simulation: an empirical study of Zhejiang Pilot, China. BMC Health Serv Res 24 , 469 (2024). https://doi.org/10.1186/s12913-024-10875-7

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Bridging the gap: understanding Belgian anesthesiologists’ proficiency and training demands in gastric point-of-care ultrasound, a case-based survey

• Adrien Maseri 1 ,
• Quentin Delhez 1 ,
• Anne-Sophie Dincq 1 &
• Dominique Lacrosse 1  

BMC Medical Education volume  24 , Article number:  383 ( 2024 ) Cite this article

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Pulmonary aspiration syndrome remains a significant complication of general anesthesia, particularly in unfasted patients. Gastric point-of-care ultrasound (POCUS) allows for both qualitative and quantitative assessment of gastric content, providing a safe and reliable method to assess gastric emptying and reduce the risk of aspiration during general anesthesia.

The survey was distributed to Belgian certified anesthesiologists and trainees between April 2020 and June 2021. Participants received a simulated clinical case of a patient at risk of gastric aspiration, created and approved by two certified anesthesiologists trained to perform gastric POCUS. The objectives of this study were to assess recognition of high-risk clinical situations for gastric aspiration, awareness of the gastric POCUS and its indications, and knowledge of the technical and practical conditions of the procedure among respondents trained in the technique. Furthermore, the study assessed the state of training in gastric POCUS, the desire for education, and the practical availability of ultrasound equipment. The survey used conditional branching to ensure unbiased responses to POCUS-related questions. It included multiple-choice questions, quantitative variables, and 5-point Likert scales. The margin of error was calculated using Daniel’s formula, corrected for a finite population.

The survey was conducted among 323 anesthesiologists. Only 20.8% (27) recognized the risk of a full stomach based on the patient’s history. Anesthesiologists who recognized the indication for gastric POCUS and were trained in the procedure demonstrated good recall of the practical conditions for performing the procedure and interpreting the results. Only 13.08% (31) of all respondents had received training in gastric POCUS, while 72.57% (172) expressed interest in future training. Furthermore, 80.17% (190) of participants had access to adequate ultrasound equipment and 78.90% (187) supported teaching gastric POCUS to anesthesia trainees.

Conclusions

This survey offers insight into the epidemiology, clinical recognition, knowledge, and utilization of gastric POCUS among Belgian anesthesia professionals. The results emphasize the significance of proper equipment and training to ensure the safe and effective implementation of gastric POCUS in anesthesia practice. Additional efforts should focus on improving training and promoting the integration of gastric POCUS into daily clinical practice.

Peer Review reports

Pulmonary aspiration of gastric contents is a serious complication of general anesthesia, with a prevalence ranging from 1:3000 to 1:6000 in elective surgery and 1:600 in emergency surgery in adults [ 1 ]. It is also associated with a mortality rate of up to 27.8% [ 2 ].

To prevent the flow of stomach contents into the upper airway, it is crucial to ensure gastric emptying by allowing sufficient fasting time. However, various factors such as failure to fast, bowel obstruction, pregnancy, pathologic delayed gastric emptying [ 3 ], or medications such as GLP1 agonists [ 4 ] may render this time insufficient. Chronic respiratory failure can also be a lesser known risk factor, probably due to pathologic changes associated with chronic hypoxemia, COPD therapy, and autonomic dysregulation [ 5 , 6 , 7 ].

Since 1980, gastric ultrasound has been developed as a noninvasive method to assess gastric emptying [ 8 ]. This technique was refined by teams led by Bouvet, Perlas, and Van de Putte [ 9 , 10 , 11 , 12 ], resulting in a common technique called gastric point-of-care ultrasound (gastric POCUS). This technique is highly effective and reliable in assessing gastric content and volume [ 13 ].

The method allows for both qualitative (solid, liquid, or empty) and quantitative assessment of gastric filling status [ 14 ]. To measure the cross-section of the antral surface, a 3.5-5 MHz curved ultrasound probe is used while the patient is in the supine position and then in the right lateral decubitus position for fluid analysis. The left lobe of the liver, pancreas, abdominal aorta, and superior mesenteric artery serve as anatomical landmarks for precise measurement of this area. This section provides a method for calculating the gastric residual volume based on the patient’s age, with a recommended limit of less than 1.5 ml/kg [ 12 ].

The Perlas grading system [ 15 ] is a reliable method for qualitative assessment. This system categorizes patients into three distinct grades based on the amount of fluid detectable in the antrum: Grade 0 (empty antrum), Grade 1 (minimal fluid detectable only in the right lateral decubitus position), and Grade 2 (markedly distended antrum with visible fluid in both supine and lateral positions).

The incorporation of Point-of-Care Ultrasound (POCUS), including Gastric POCUS, into anesthesiologist basic training has gained international support. Canada [ 16 ] and the United States [ 17 ] have already integrated POCUS education, with a specific emphasis on Gastric POCUS, into their core anesthesiology training programs. In 2020, a panel of experts in Belgium convened to develop recommendations for integrating Gastric POCUS into the basic training curriculum for anesthesiologists [ 18 ]. The focus was on proposing a comprehensive framework for seamlessly integrating this technique into educational pathways. Although initiatives have been taken, current research in Belgium has not yet explored the extent of interest among anesthesiologists regarding Gastric POCUS training and its integration into formal educational programs.

This study examines the clinical recognition of high-risk situations associated with a full stomach, awareness of gastric POCUS, understanding of the technical and practical aspects of the technique, and its potential impact on the induction plan.

Materials and methods

To address the aforementioned areas, we created a conditional branching survey that enables participants to be directed to specific sections based on their previous responses. Please refer to Table  1 for the questionnaire items and their corresponding conditional branches.

Questionnaire and variables

The study targeted all clinically active anesthesiologists in Belgium, including 3023 certified anesthesiologists and 638 anesthesiology trainees, as reported by the National Institute for Health and Disability Insurance (NIHDI) [ 19 ]. Participation in the survey was voluntary, and respondents were not compensated. No participants were excluded based on any criteria. By completing the questionnaire, participants provided their consent for the analysis and use of their responses.

The survey sample size was confidently determined using the corrected Daniel formula for a finite population of 3661 anesthesiologists in Belgium. A confidence level of 95% and an acceptable margin of error of 0.05 were assertively considered, resulting in a formula-calculated requirement of 348 participants for the study, assuming a sample proportion of 0.50.

A cross-sectional survey was administered on a computer-based platform with a total of 22 questions. It included multiple-choice questions (MCQs), quantitative variable questions, and Likert scale questions. The text adhered to conventional academic structure and style guidelines. It avoided biased, emotional, or ornamental language and opted for clear, objective, and value-neutral language with a passive tone and impersonal construction. The writing maintained a formal register and avoided contractions, colloquial words, informal expressions, and unnecessary jargon. The structure was clear and progressive, and the writing was free from grammatical errors, spelling mistakes, and punctuation errors. Technical terms were used consistently throughout the text, and abbreviations were explained upon first usage. The survey was designed with a non-linear structure to improve data accuracy, requiring respondents to answer all questions without revisiting previous answers. Additionally, conditional branching was incorporated to prevent specific questions related to Gastric POCUS from being imposed on respondents who primarily rely on clinical judgment to induce anesthesia. Additionally, technical questions about gastric POCUS were directed only to those who had received formal training. Table  1 presents a comprehensive diagram of the survey’s sequential process.

The initial questions (Q1-Q6) gathered epidemiological data such as gender, age, education level, practice type, and clinical practice location. Question 7 assessed participants’ ability to identify situations with a high risk of a full stomach by presenting a clinical scenario of a patient undergoing colonoscopy prior to lung transplantation [see Additional file 1 ]. Question 12 evaluated participants’ interest in obtaining additional information about the case and their desire to perform gastric POCUS while determining their training status. Trained participants then answered questions 13–15, which assessed the technical and anatomical prerequisites for performing gastric POCUS.

Additionally, an image of gastric POCUS was presented to the participants (Q16-Q19), which provided information on the ultrasound-derived gastric volume measurements. The survey inquired about the participants’ anesthesia induction method, the availability of ultrasound equipment, and their views on incorporating POCUS training into the academic curriculum for anesthesia trainees. Please see [Additional file 1 ] for a comprehensive survey content.

The authors confidently pretested the survey at their institution and collected 11 responses. The primary objective was to confidently identify potential problems with understanding the questionnaire. The sample included certified anesthesiologists, some of whom practiced exclusively in clinical settings, while others were also involved in academic research.

Data collection

The SurveyMonkey® survey was electronically distributed to active certified anesthesiologists and trainees working in hospitals throughout Belgium from April 2020 to June 2021. To target this specific group, a comprehensive list of surgical hospitals compiled by the FPS Public Health [ 20 ] was used. A total of 117 anesthesia departments were contacted either through a contact form or direct mail to the anesthesia department secretary.

To increase the reach and participation of the survey, it was also made easily accessible on the authoritative websites of renowned professional associations, specifically the Belgian Society of Anesthesiology, Intensive Care, Perioperative Medicine and Pain Management and the Belgian Association for Regional Anesthesia. The survey aimed to gather a diverse and inclusive group of anesthesiologists from all regions of Belgium by utilizing established digital platforms.

The email distributing the survey clearly stated that individuals who had already completed it should not participate. This was done to prevent duplicate responses from those who may have already participated or received the survey through other channels. By prohibiting multiple responses, the goal was to collect distinct and unique feedback from each participant.

Statistical analysis

Demographic characteristics, such as age (in years), sex (male/female), credentials (certified/trainee), practice type (university/public/private/mixed), and region, were analyzed using descriptive statistics. Numerical variables were presented as means and standard deviations, while categorical variables were presented as percentages. The same method was used to summarize categorical variables in the rest of the survey.

The survey used a Likert scale to measure respondents’ agreement or disagreement, ranging from 1 (strongly disagree) to 5 (strongly agree). The weighted Likert score (WLS) was calculated by averaging the responses. This method enables a comprehensive understanding of the level of agreement or disagreement among respondents. However, detailed analysis of individual responses is not possible with this approach. To offer a more complete analysis, the numerical summary is complemented by a graphical representation that displays the distribution of responses.

The survey study received 323 responses, with 223 from certified anesthesiologists and 100 from trainees. To calculate the final margin of error, we used the Daniel formula corrected for a finite population, resulting in a margin of error of 5.21%. This margin of error was then used throughout the remainder of the article.

Participant flow

A flowchart of the participant distribution across the survey section is shown in Fig.  1 .

Flowchart for participant distribution across survey Sect. 8

Among the respondents, 170 individuals chose direct induction of anesthesia. Of these, 158 participants continued the survey and specified their chosen induction type. Furthermore, 112 respondents requested additional information about the clinical case, with 111 providing specific details of their inquiries. Among them, 22 respondents had prior training in gastric POCUS and were asked about its practical performance and interpretation. Finally, 237 respondents completed the survey, indicating their training preferences and whether they had the required ultrasound equipment available.

Descriptive results

The survey had a final completion rate of 69%, with an average completion time of 4 min and 39 s. To comply with the General Data Protection Regulation (GDPR) and ensure anonymity, only the IP addresses of the participants were retained by the computer system. No matches were found when pooling responses and IP addresses. The reappearance of certain IP addresses may be due to the use of shared computers in different anesthesia departments. However, there is no guarantee that the same person did not respond twice from two different IP addresses.

Main findings

Question 1 to 5: epidemiology.

The sociodemographic characteristics of the participants are described in Table  2 .

Question 7 for clinical recognition of “At-risk” Situation

The clinical recognition of an “at-risk” situation is detailed in Table  3 .

Out of the 323 responses obtained, 170 participants chose direct induction of anesthesia. Among them, 158 specified the type of induction used. Rapid sequence induction and intubation (RSII) was chosen by 13.29% ( n  = 21) of the participants. Furthermore, among the 112 individuals who requested further testing, 41.07% ( n  = 46) inquired about gastric emptying, while 24.11% ( n  = 27) specifically requested gastric point-of-care ultrasound (POCUS). Overall, only 25.81% ( n  = 67) of participants identified the risk of a full stomach based on clinical symptoms and patient risk factors.

Question 12: knowledge of the indications for gastric POCUS

Of the 111 participants who responded to the Q12 survey on fasting assessment, 85.6% ( n  = 95) recognized the indication for gastric ultrasound. Of these, 25.2% ( n  = 28) reported having received training in gastric ultrasound and specifically recognized the indication, while 60.4% ( n  = 67) reported recognizing the indication despite having no specific training in this area. Despite this, 14.4% ( n  = 16) of participants stated that gastric ultrasound was not necessary.

Question 13: realization of the technique

The following results were obtained from the responses of the 22 trained participants. Our study used a WLS ranging from 1 to 5, and the results are shown in Fig.  2 .

Representation of Likert scale responses regarding the clinical context of performing gastric point-of-care ultrasound (POCUS) 10

Technical aspects

A mean WLS of 4.32 was observed for the use of the low-frequency curvilinear probe, indicating strong overall agreement with its use. In contrast, the high-frequency linear probe yielded a mean WLS of 1.71 and is perceived to have limited effectiveness in adult subjects.

Patient positioning aspect

Examination in the supine position followed by the right lateral decubitus position yielded a mean WLS of 4.27, suggesting strong overall agreement with this approach. The other positions showed strong overall disagreement, with a mean WLS of 1.82 for the dorsal position only and a mean WLS of 1.73 for the supine position followed by the left lateral decubitus position.

Anatomical landmarks

Using anatomic landmarks such as the left hepatic lobe, pancreas, abdominal aorta, and superior mesenteric artery to divide the gastric antrum resulted in a mean WLS of 4.41, demonstrating strong overall agreement with this approach. However, the use of anatomic landmarks such as the left hepatic lobe, pancreas, inferior vena cava, and left renal vein resulted in a mean WLS of 1.86, indicating overall robustness.

Questions 14 and 15: interpreting the results of gastric POCUS

Qualitative analysis of the results.

Among respondents, 63.64% ( n  = 14) identified the stomach as full based on the image provided and the question title. However, 31.82% ( n  = 7) of participants required additional information and chose to measure the antral surface to accurately assess gastric fullness, while 4.6% ( n  = 1) considered the stomach empty. Notably, among those seeking further details, 57.1% ( n  = 4) specifically requested an antral surface measurement or Perlas grading system assessment. Upon receiving additional information, participants were apprised of the measured gastric fluid volume, which totaled 3.3 ml/kg, indicative of a high-risk scenario surpassing the 1.5 ml/kg threshold of an empty stomach.

Question 16 to 19: clinical decision according to POCUS

The majority of respondents were in favor of delaying the procedure until later in the day (mean WLS 3.91). However, they were less inclined to delay the procedure until the next day (mean WLS 2.30). If the procedure could not be postponed, 70.93% ( n  = 61) of the respondents opted for rapid RSII, while 11.63% ( n  = 10) opted for general anesthesia with endotracheal intubation without RSII. A total of 1.16% ( n  = 1) preferred the use of a laryngeal mask, and 16.7% ( n  = 14) performed procedural sedation despite the risk of inhalation.

Questions 20 to 22: field conditions for performing a gastric POCUS

A total of 237 respondents answered the questions in this section, for a margin of error of 6.16%. The results are shown in Table  4 .

State of training in gastric POCUS

Among the respondents, 13.08% ( n  = 31) had been trained in gastric POCUS. Conversely, 72.57% ( n  = 172) of the respondents were not trained but would like to be trained, while 14.35% ( n  = 34) were not trained and did not want to be trained.

Availability of the correct US probe

Regarding the availability of the appropriate ultrasound probe, 80.17% ( n  = 190) of participants had access to a low-frequency curved ultrasound probe. However, 10.97% ( n  = 26) of participants did not have this probe, and 8.86% ( n  = 21) were unsure of its availability.

Training of future specialists

Regarding the training of future specialists, a majority of the 78.90% ( n  = 187) of respondents were in favor of teaching gastric POCUS to trainees, while only 4.22% ( n  = 10) were opposed and 16.88% ( n  = 40) were neutral.

The survey study received 323 responses from 223 certified anesthesiologists and 100 trainees. Certified anesthesiologists had an average age of 45 years, while trainees had an average age of 30 years. Practice settings were evenly distributed among university-affiliated, public, and private practices. Notably, only 26% of respondents identified the risk of a full stomach. Respondents trained in gastric POCUS demonstrated a proficient understanding of the technical requirements and interpretation of gastric POCUS, along with its implications for general anesthesia induction. It is worth noting that demand for gastric POCUS training was high among both certified anesthesiologists and trainees, and the majority of anesthesia services were equipped with abdominal ultrasound probes. A significant number of certified anesthesiologists and trainees support the inclusion of gastric POCUS in the basic anesthesia training curriculum.

Interpretations

Clinical recognition of a “high risk” situation for the full stomach.

Our study found that only 20.8% of respondents were able to detect a full stomach situation. This was identified through rapid sequence induction or additional examination targeting gastric filling status. Surprisingly, frequent nausea and early satiety, which may indicate gastric fullness, appear to be clinically under-recognized by the respondents. This study emphasizes the significance of increased awareness and education on clinical signs, as prompt identification of gastric fullness is essential for patient safety and perioperative management. Additionally, the results suggest that chronic respiratory insufficiency is a significantly under-recognized risk factor among anesthesiologists. Efforts to improve clinicians’ awareness and understanding of these important but subtle symptoms are warranted to improve patient outcomes and reduce perioperative complications.

Indications, technical aspects and interpretations of gastric POCUS

The vast majority of respondents who suspected delayed gastric emptying recognized the relevance of gastric POCUS in our clinical situation. However, only 13.1% of respondents had received prior training in the technique.

Among the trained individuals, there was unanimous agreement on the use of a low-frequency curved ultrasound probe and the supine position followed by lateral testing, indicating a clear understanding of the technical standards for performing gastric POCUS. The participants demonstrated a high level of proficiency in identifying the necessary anatomical landmarks required for performing the technique. Nearly all respondents were able to identify the presence of fluid in the stomach while interpreting the ultrasound image. Additionally, approximately one-third of the participants requested that the antral cross-sectional area be measured to determine whether the fluid was abnormal. A considerable number of participants reported abnormal fluid volume based on images without measurements, which may be related to the large amount of fluid present in the image. An experienced echographer may be able to estimate the gastric volume based on their experience.

It was generally agreed that the procedure should be postponed until later in the day, but not until the following day. When faced with the need to proceed quickly, most respondents with gastric ultrasound training either performed RSII or administered general anesthesia with intubation. Despite the disclosure of a volume of gastric fluid that exceeded the high-risk threshold by more than twofold, 17% of respondents still administered procedural sedation without securing the airway.

State of training and environmental conditions in gastric POCUS

Few respondents have received training in performing gastric POCUS, yet there is a high demand for training, particularly among trainees. Additionally, most users have access to adequate ultrasound equipment. 79% of respondents were convinced that Gastric POCUS should be more present in future specialists’ training.

The American Society of Anesthesiologists [ 14 , 17 ] has developed a certifying program in point-of-care ultrasound (Diagnostic POCUS Certificate Program) following the integration of POCUS ultrasound examinations into the APPLIED Exam Objective Structured Clinical Examination (OSCE) by the American Board of Anesthesiology. There are also recommendations from the European Union of Medical Specialists regarding Gastric POCUS education [ 21 ]. Training courses are currently being developed and delivered at both European and Belgian levels by the European Society of Anesthesia and Intensive Care (EUROPoCUS program) and UZLeuven (BePOCUS program), respectively.

The Belgian Society of Anesthesiology, Resuscitation, Perioperative Medicine and Pain Management (BeSARPP) has raised concerns about the implementation of training due to the medico-legal implications of certification in Gastric POCUS [ 21 ]. Nevertheless, they are willing to be involved in this project, in accordance with their mission to promote and improve education in perioperative medicine.

Limitations

Although the calculated sample size was initially set at 348 respondents to achieve a 5% error margin, only 323 responses were received. To address this discrepancy, we used the corrected Daniel formula for a finite population and applied reverse calculation, resulting in a final margin of error of 5.21%. Although the response rate among certified anesthesiologists may raise concerns about representativeness, we conducted a subgroup analysis to assess the issue. The subgroup calculation resulted in a final margin of error of 6.32% based on the 223 responses out of 3023 active certified anesthesiologists. The interpretation of the results remains robust despite this slightly increased margin of error due to the strong and conclusive findings obtained.

In Belgium, Dutch and French are the two predominant languages. To prevent potential translation errors, the authors chose to use English. However, some practitioners may find this discouraging, which could limit the response rate. Additionally, the number of survey dropouts may be due to the survey’s potential length, despite the mean completion time being 4 min and 39 s.

There may be other potential influences to take into account, such as the potential effect of frequent mailbox congestion on the visibility of the electronic survey or on participants’ desire to engage. However, using professional email addresses and working with anesthesia departments can help to mitigate this possibility of bias. Despite the measures implemented at the outset of the study, it is not possible to guarantee that no participant completed the survey more than once. It is important to consider the potential consequences of study dropouts, as they may lead to greater imprecision of responses as the questionnaire progresses. The margin of error percentage had to be revised upward as the survey progressed. Inaccuracies could also have been created due to survey question design and the inclusion of decoy questions to avoid response bias on our research topic.

Generalizability

The generalization of the study’s findings may be limited by several factors. Firstly, Belgium operates within a distinct educational framework that differs from neighboring countries. The intricacies of Belgium’s training system, coupled with regional disparities and legislative nuances, may impede the direct extrapolation of the results to other nations. Therefore, while our study provides valuable insights into the perceptions and practices of anesthesiologists in Belgium, it is important to exercise caution when attempting to generalize these findings to healthcare settings in other countries.

Our survey-based study provides insight into the clinical practice and educational needs of certified anesthesiologists and trainees in Belgium regarding gastric POCUS. The study highlights a concerning lack of clinical recognition among Belgian anesthesiologists regarding the risk of pulmonary aspiration. It is worth noting that although most respondents who suspected gastric fullness recognized the indication for gastric point-of-care ultrasound (POCUS), very few had received formal training in its execution. Proficiency in performing and interpreting gastric POCUS examinations appears to be well integrated among those who have been trained in the technique. Additionally, our findings indicate that the required equipment to perform gastric POCUS is readily available in the majority of anesthesia services surveyed. The strong interest in training for gastric POCUS techniques, expressed by both trainees and certified professionals, emphasizes its perceived importance in clinical practice. Overall, the respondents support the implementation of gastric POCUS training as a basic component of anesthesia training, highlighting its potential benefits. These insights offer valuable guidance for developing curricula and professional training initiatives to improve patient safety and procedural competency in anesthesia practice.

Data availability

The data that support the findings of this study are not openly available due to the presence of personal information and the nature of the survey related to practice quality. Data is available from the corresponding author upon reasonable request. Data are located in controlled access data storage at CHU UCL Namur.

Abbreviations

National Institute for Health and Disability Insurance

Point-of-care ultrasound

Rapid sequence induction and intubation

Weighted Likert scale

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Acknowledgements

The authors of the study received rigorous training in conducting gastric point-of-care ultrasound (POCUS) under the supervision of Professor Peter Van de Putte (Imeldaziekenhuis Bonheiden, Belgium), a specialist in the technique. The training covered both theoretical and practical aspects and was completed at CHU UCL Namur. To maintain regular education, the authors regularly practiced Gastric POCUS and sought updated information and resources from the website of Gastricultrasound.org.

The SurveyMonkey® subscription was paid for by Dr. Adrien Maseri’s personal funds. No other source of funding is reported.

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A.M, D.L. and AS.D. wrote the main manuscript text and A.M. prepared Figs. 1 and 2; Table 1. A.M. and D.L designed the survey content and distributed the survey. A.M., D.L., AS.D. and Q.D., have drafted the work or substantively revised it. All authors reviewed and approved the submitted version.

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Correspondence to Adrien Maseri .

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The content of the survey was submitted to and approved by the Comité d’éthique du CHU UCL Namur, site Godinne. The Ethics Committee (NUB reference number: B0392022000065) considered that answering the survey was equivalent to implicit consent.

The survey prioritized confidentiality and data privacy by excluding questions or variables that could directly identify participants. Personalized or identifying information was not utilized during the distribution of the survey. Electronic communication via email or contact forms was utilized to disseminate the survey to anesthesiologists in Belgian hospitals. The survey was distributed by scientific societies that utilized their own distribution lists, which could not be accessed by the authors.

The data were collected through the secure web link provided by SurveyMonkey®, which retained only participants’ IP addresses; these data were deleted after 13 months. Momentive™, the parent company of SurveyMonkey®, offers a Data Processing Agreement (DPA) compliant with the European Union General Data Protection Regulations and EU and UK standard contractual clauses. The Momentive™ Customer Data Processing Agreement was accessed at the following link: [ https://fr.surveymonkey.com/mp/legal/data-processing-agreement/ ].

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Maseri, A., Delhez, Q., Dincq, AS. et al. Bridging the gap: understanding Belgian anesthesiologists’ proficiency and training demands in gastric point-of-care ultrasound, a case-based survey. BMC Med Educ 24 , 383 (2024). https://doi.org/10.1186/s12909-024-05359-5

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Received : 07 December 2023

Accepted : 27 March 2024

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DOI : https://doi.org/10.1186/s12909-024-05359-5

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