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The objective of this commentary is to develop a framework for assessing the rigour of qualitative approaches that identifies and distinguishes between the diverse objectives of qualitative health research, guided by a narrative review of the published literature on qualitative guidelines and standards from peer-reviewed journals and national funding organisations that support health services research, patient-centered outcomes research and other applied health research fields. In this framework, we identify and distinguish three objectives of qualitative studies in applied health research: exploratory, descriptive and comparative. For each objective, we propose methodological standards that may be used to assess and improve rigour across all study phases—from design to reporting. Similar to hierarchies of quality of evidence within quantitative studies, we argue that standards for qualitative rigour differ, appropriately, for studies with different objectives and should be evaluated as such. Distinguishing between different objectives of qualitative health research improves the ability to appreciate variation in qualitative studies and to develop appropriate evaluations of the rigour and success of qualitative studies in meeting their stated objectives. Researchers, funders and journal editors should consider how further developing and adopting the framework for assessing qualitative rigour outlined here may advance the rigour and potential impact of this important mode of inquiry.

BackgroundMoral distress is a state in which a clinician cannot act in accordance with their ethical beliefs because of external constraints. Physician trainees, who work within rigid hierarchies and who lack clinical experience, are particularly vulnerable to moral distress. We examined the dynamics of physician trainee moral distress in end-of-life care by comparing experiences in two different national cultures and healthcare systems.ObjectiveWe investigated cultural factors in the US and the UK that may produce moral distress within their respective healthcare systems, as well as how these factors shape experiences of moral distress among physician trainees.DesignSemi-structured in-depth qualitative interviews about experiences of end-of-life care and moral distress.ParticipantsSixteen internal medicine residents in the US and fourteen junior doctors in the UK.ApproachThe work was analyzed using thematic analysis.Key ResultsSome drivers of moral distress were similar among US and UK trainees, including delivery of potentially inappropriate treatments, a poorly defined care trajectory, and involvement of multiple teams creating different care expectations. For UK trainees, healthcare team hierarchy was common, whereas for US trainees, pressure from families, a lack of guidelines for withholding inappropriate treatments, and distress around physically harming patients were frequently cited. US trainees described how patient autonomy and a fear of lawsuits contributed to moral distress, whereas UK trainees described how societal expectations around resource allocation mitigated it.ConclusionThis research highlights how the differing experiences of moral distress among US and UK physician trainees are influenced by their countries’ healthcare cultures. This research illustrates how experiences of moral distress reflect the broader culture in which it occurs and suggests how trainees may be particularly vulnerable to it. Clinicians and healthcare leaders in both countries can learn from each other about policies and practices that might decrease the moral distress trainees experience.

Drawing on two years of ethnographic fieldwork in two impoverished California communities-one made up of recent immigrants from Mexico, the other of U.S.-born Chicano citizens-this book provides an invaluable comparative perspective on Latino poverty in contemporary America. In northern California's high-tech Silicon Valley, author Daniel Dohan shows how recent immigrants get by on low-wage babysitting and dish-cleaning jobs. In the housing projects of Los Angeles, he documents how families and communities of U.S.-born Mexican Americans manage the social and economic dislocations of persistent poverty. Taking readers into worlds where public assistance, street crime, competition for low-wage jobs, and family, pride, and cross-cultural experiences intermingle,The Price of Povertyoffers vivid portraits of everyday life in these Mexican American communities while addressing urgent policy questions such as: What accounts for joblessness? How can we make sense of crime in poor communities? Does welfare hurt or help?

Background Poor patient‐clinician communication around patient‐reported outcomes (PROs) is a barrier to the effective management of rheumatoid arthritis (RA). We aimed to develop an RA ‘dashboard’ that could facilitate conversations about PROs and that would be acceptable to a wide range of patients, including English and Spanish speakers and patients with adequate or limited health literacy. Methods A diverse group of RA patients along with clinicians from two academic rheumatology clinics joined separate focus groups. We solicited feedback and made iterative changes to mock‐ups of an RA dashboard that visualized PROs using a human‐centred design process. We used the thematic analysis method to identify and characterize themes from the focus groups and used these insights to refine the dashboard. Results We conducted six focus groups involving 25 RA patients and three groups with 11 clinicians. Patients and clinicians agreed that the dashboard could enhance communication about PROs and RA disease activity and could promote patient self‐management. Patients varied in their (a) comprehension, (b) preferences for the display and features of the dashboard, and (c) desired uses for the dashboard. Clinicians expressed significant concerns about the logistics of using the dashboard in clinical practice. Conclusion Using principles of human‐centred design, we created an RA dashboard that was well‐accepted among patients and clinicians. The ability to customize the data display is important for tailoring the dashboard to patients with diverse needs and preferences. Special attention should be given to feasibility concerns voiced by clinicians.

Background Cataract surgery is one of the most common elective outpatient surgeries performed among older adults in the United States. Modern surgical technique makes cataract surgery a relatively quick, low-risk, minimally invasive outpatient procedure that can be performed solely under ophthalmologist-directed local or topical anesthesia. However, in the US, the procedure is routinely performed with additional monitoring and intravenous sedation administered by anesthesia-trained personnel. Given the procedure’s safety profile, we sought to characterize ophthalmologists’ perspectives on barriers preventing the adoption of more individualized approaches to cataract surgery sedation that do not automatically default to employing routine anesthesia care. Methods This study was conducted between December 2022 to January 2024. Using a semi-structured interview guide developed with the Consolidated Framework for Implementation Research (CFIR) framework, we completed interviews with ophthalmologists who performed cataract surgery with or without anesthesia care in hospital outpatient departments, ambulatory surgery centers, minor procedure rooms, and/or office-based surgery suites across the United States. Data were analyzed using an inductive thematic analysis approach to uncover descriptive themes. Results We interviewed 19 ophthalmologists (5 women), including 6 who had experience routinely performing cataract surgery without anesthesia care. Three major themes emerged: (1) inertia, defined as the tendency to continue established practices that serve to maintain the status quo, (2) financial considerations, and (3) the interdependent relationship between ophthalmology and anesthesiology. While some participants supported a more selective approach to the use of anesthesia services, study participants identified multiple barriers to change, including difficulty overcoming the current inertia, decreased reimbursement for office-based surgery, and concerns about implications for patient safety without routine anesthesia involvement. Conclusion Ophthalmologists identified multiple barriers to changing current anesthesia-led sedation models for cataract surgery. Our findings can help inform future efforts to better align anesthesia care with patient and procedural needs in an aging US population.

Sociologists have argued that there is value in incorporating computational tools into qualitative research, including using machine learning to code qualitative data. Yet standard computational approaches do not neatly align with traditional qualitative practices. The authors introduce a hybrid human-machine learning approach (HHMLA) that combines a contemporary iterative approach to qualitative coding with advanced word embedding models that allow contextual interpretation beyond what can be reliably accomplished with conventional computational approaches. The results, drawn from an analysis of 87 human-coded ethnographic interview transcripts, demonstrate that HHMLA can code data sets at a fraction of the effort of human-only strategies, saving hundreds of hours labor in even modestly sized qualitative studies, while improving coding reliability. The authors conclude that HHMLA may provide a promising model for coding data sets where human-only coding would be logistically prohibitive but conventional computational approaches would be inadequate given qualitative foci.

Background Cataract surgery is one of the most common elective surgeries and has been shown to be safe with low adverse event rates. Most cataract patients in the US receive one-to-one intraoperative monitoring and sedation administered by an anesthesiologist or nurse anesthetist, termed “monitored anesthesia care” (MAC). Recent studies have suggested that non-anesthesia-led sedation approaches may safely be used in older adults undergoing cataract surgery. However, it is unknown how individual ophthalmologists perceive the risks of cataract surgery with respect to the need for MAC. We sought to characterize physician beliefs and opinions about the risks of performing cataract surgery when considering potential non-anesthesia-led approaches to cataract surgery sedation. Methods Using a semi-structured interview guide developed with the Consolidated Framework for Implementation Research (CFIR) framework, between December 2022 and May 2023, we conducted virtual interviews with ophthalmologists who routinely performed cataract surgeries in the United States with or without anesthesia care in outpatient clinical settings across the continental US. Data were analyzed from June 2023 through January 2024 using an inductive thematic analysis approach. Results Interviews of 19 ophthalmologists revealed 2 major themes that formed the foundational understanding of how ophthalmologists perceive cataract surgery risk in the context of non-anesthesia-led models of sedation: (1) overall safety of cataract surgery and (2) concerns about assuming sedation responsibilities. Despite conceding that cataract surgery is a low-risk procedure for the vast majority of patients, participants were hesitant to change their current practice and desired an anesthesia “safety net” at all times in case of an unexpected intraoperative event or emergency. Many ophthalmologists’ responses underscored their aversion to any potential loss of routine anesthesia support without an acceptable alternative present. Conclusions Despite acknowledging its low-risk profile, ophthalmologists are wary of making changes to current sedation approaches for routine cataract surgery.

Katherine Possin and colleagues report on the implementation, development, and early findings of the Care Ecosystem, an adaptive, personalized, and scalable dementia care program.Katherine Possin and colleagues report on the implementation, development, and early findings of the Care Ecosystem, an adaptive, personalized, and scalable dementia care program.

Background Many patients with diabetic kidney disease (DKD) do not receive evidence-based, guideline-recommended treatment shown to reduce DKD progression and complications. Proactive electronic consultations (e-consults) are an emerging intervention strategy that could potentially allow nephrologists to provide timely and evidence-based guidance to primary care providers (PCPs) engaged in early DKD care. Methods The objective of this study was to explore perspectives about potential barriers and facilitators associated with a proactive e-consult program to improve DKD care delivery. We conducted semi-structured qualitative interviews with PCPs across three different health systems. Interview transcripts were reviewed in a rapid qualitative analysis approach to iteratively identify, refine, and achieve consensus on a final list of themes and subthemes. Results A total of 18 interviews were conducted. PCPs across all sites identified similar challenges to delivering guideline-recommended DKD care. PCPs were supportive of the proactive e-consult concept. Three major themes emerged surrounding (1) perceived potential benefits of proactive e-consults, including educational value and improved specialist access; (2) concerns about the proactive nature of e-consults, including the potential to increase PCP workload and the possibility that e-consults could be seen as documenting substandard care; and (3) leveraging of care teams to facilitate recommended DKD care, such as engaging clinic-based pharmacists to implement specialist recommendations from e-consults. Conclusion In this pre-implementation qualitative study, PCPs noted potential benefits and identified concerns and implementation barriers for proactive e-consults for DKD care. Strategies that emerged for promoting successful implementation included involving clinic support staff to enact e-consult recommendations and framing e-consults as a system improvement effort to avoid judgmental associations.

United States-based biorepositories are on the cusp of substantial change in regulatory oversight at the same time that they are increasingly including samples and data from large populations, e.g. all patients in healthcare system. It is appropriate to engage stakeholders from these populations in new governance arrangements. We sought to describe community recommendations for biorepository governance and oversight using deliberative community engagement (DCE), a qualitative research method designed to elicit lay perspectives on complex technical issues. We asked for stakeholders to provide input on governance of large biorepositories at the University of California (UC), a public university. We defined state residents as stakeholders and recruited residents from two large metropolitan areas, Los Angeles (LA) and San Francisco (SF). In LA, we recruited English and Spanish speakers; in SF the DCE was conducted in English only. We recruited individuals who had completed the 2009 California Health Interview Survey and were willing to be re-contacted for future studies. Using stratified random sampling (by age, education, race/ethnicity), we contacted 162 potential deliberants of whom 53 agreed to participate and 51 completed the 4-day DCE in June (LA) and September-October (SF), 2013. Each DCE included discussion among deliberants facilitated by a trained staff and simultaneously-translated in LA. Deliberants also received a briefing book describing biorepository operations and regulation. During the final day of the DCE, deliberants voted on governance and oversight recommendations using an audience response system. This paper describes 23 recommendations (of 57 total) that address issues including: educating the public, sharing samples broadly, monitoring researcher behavior, using informative consent procedures, and involving community members in a transparent process of biobank governance. This project demonstrates the feasibility of obtaining meaningful input on biorepository governance from diverse lay stakeholders. Such input should be considered as research institutions respond to changes in biorepository regulation.