Multiple Case Research Articles

Transition to adulthood of youth with disabilities: Mapping declared practices to recommended practices

AbstractPositive transition to adulthood of youth with disabilities is influenced by the type of support they receive. This study aims to analyse current transition to adulthood practices in the province of Quebec to map them to recommended practices and present an overview of the situation and needs. A multiple case study methodology included focus groups in six schools with 65 participants as well as internet searches and interviews with experts. A thematic analysis within and across cases was used. Results underscore the best practices in place concerning student‐focused planning, student development, interagency collaboration and family engagement. They also highlight youths' and parents' opinions about strategies to better support transition. While inspiring practices are present, further efforts with regards to programme structures are required to ensure adequate support for transition to adulthood.

Cultural Heritage Service Design and Experience Innovation: A Case Study of Taiwan

This paper delves into the evolving landscape of community engagement, exploring innovative methods to enhance the involvement and awareness of young individuals. Employing a comprehensive content analysis through a multiple case study approach, this research investigates cultural heritage initiatives in Taiwan, emphasizing the pivotal role of technology and digital platforms in engaging young audiences. The study utilizes theoretical sampling and triangulation methods, incorporating semi-structured interviews, secondary sources, and participant observation. The findings underscore the significance of digital experiences as supplements to physical presence, offering a gateway to cultural heritage. The practical implications advocate for heritage sites to leverage digital platforms, collaborating with external partners to enrich visitor experiences. The paper furnishes valuable recommendations for enhancing customer engagement and communication with the younger demographic, contributing to the field of cultural heritage in Asia. This research marks a transition from physical to online service design, harnessing technology to inspire and engage, ultimately attracting diverse generations and retaining the interest of existing visitors.

Soft and Hard Skills to Be Developed By a Pre-Service Teacher under Distance Learning: Case Study

This article reflects on the development of soft and hard skills and their importance within the academic and educational course of students who study a degree in English as a foreign language under the distance modality. At the center of this study, the opinions of 46 students from various semesters underscore the fundamental role that the cultivation of these competencies plays in distance education. The qualitative approach and NVIVO software were used in a multiple case study to carry out axial coding. In this way, the information was classified into 6 categories, supported by the opinions provided by the survey participants: Personal Growth, Assertive Communication, Professional Enrichment, Digital Management, Pedagogical Confrontation, and English Proficiency. By analyzing the perspectives of these students, the research concludes that pre-service teachers have a valuable perspective on the development of competencies and recognize the integration of these competencies in their distance learning path, promoting personal and professional growth for their future roles.

Does anesthesia duration or number of cases per patient predict safety events?

The need for dental rehabilitation under general anesthesia is increasing, with varying needs between patients. Mortality has been found to be a rare event in these patients; however other perioperative events can and do occur. Previous studies have established increased incidence of perioperative events with younger, sicker children, and longer anesthetics, however, no studies to date have evaluated if the incidence of perioperative events is more closely associated with one long anesthetic or multiple anesthetics per patient. To evaluate the association of perioperative events related to single anesthetic duration or number of anesthetics per patient for dental rehabilitation. After Children's Wisconsin Human Research Protection Program determined this quality activity did not meet the definition of human subjects research, we performed an epidemiologic observational evaluation by extracting all dental related cases (dental alone or with oral surgeon vs. dental with other specialties) with an associated general anesthesia encounter from Children's Wisconsin electronic data warehouse from June 1, 2015 to December 31, 2021. These cases occurred at a free-standing children's hospital or associated pediatric-only ambulatory surgery center. The risk of perioperative safety events was analyzed for previously identified risk groups such as American Society of Anesthesiologists Physical Status (ASA-PS), patient age, anesthesia case time with the addition of number of dental cases per patient. In this study, 8468 procedures were performed on 8082 patients. Of this cohort, 7765 patients underwent one procedure for dental care while 317 patients underwent a total of 703 dental-related procedures, ranging from two to five procedures per patient. Multivariable logistic regression identified increased risk of perioperative events in patients with ASA-PS 3 (n = 1459, rate 1.78%, p value .001, OR 5.7, CI 2.1-15.5) and ASA-PS 4 (n = 86, rate 5.8%, p < .001, OR 17.2, CI 4.4-67.3), anesthesia duration (p < .001, OR 1.46, CI 1.21-1.76), but no increased risk with number of anesthetics per patient (p value .54, OR 0.81, CI 0.4-1.61). Limiting dental care under general anesthesia to multiple short cases may decrease the risk of perioperative events when compared to completing all treatment in one long operative session.

Three‐Phase Unbalance Reduction and Energy Optimization for Active Distribution Network Using Flexible Multi‐State Switch

Active distribution network is integrated with a large number of renewable energy sources and flexible loads such as electric vehicles(EVs). The unstable output of distributed generation and the random access to different phases cause three phase unbalance in the distribution network, which increase the energy loss and carbon emissions. Three phase unbalance reduction requires high real‐time dispatch and optimization of the power flow. This paper attempts to reduce the energy loss and carbon emission by using flexible multi‐state switch (FMSS) with optimal energy dispatch strategy. A multi‐objective optimization model is established based on second‐order cone relaxation to reduce the three‐phase unbalance and energy loss. EVs regulation strategy is proposed by analyzing their charging flexibility. A fast solution method is brought up based on second‐order cone model transformation. The effectiveness and rapidity of the method is verified by multiple cases. © 2024 Institute of Electrical Engineer of Japan and Wiley Periodicals LLC.

Using External Information for More Precise Inferences in General Regression Models.

Empirical research usually takes place in a space of available external information, like results from single studies, meta-analyses, official statistics or subjective (expert) knowledge. The available information ranges from simple means and proportions to known relations between a multitude of variables or estimated distributions. In psychological research, external information derived from the named sources may be used to build a theory and derive hypotheses. In addition, techniques do exist that use external information in the estimation process, for example prior distributions in Bayesian statistics. In this paper, we discuss the benefits of adopting generalized method of moments with external moments, as another example for such a technique. Analytical formulas for estimators and their variances in the multiple linear regression case are derived. An R function that implements these formulas is provided in the supplementary material for general applied use. The effects of various practically relevant moments are analyzed and tested in a simulation study. A new approach to robustify the estimators against misspecification of the external moments based on the concept of imprecise probabilities is introduced. Finally, the resulting externally informed model is applied to a dataset to investigate the predictability of the premorbid intelligence quotient based on lexical tasks, leading to a reduction of variances and thus to narrower confidence intervals.

Teacher language awareness in CLIL teacher education in Argentina, Colombia, and Ecuador: a multiple case study

This multiple case study-based investigation examined teacher language awareness (TLA) for content and language integrated learning (CLIL). This study was carried out in three teacher education programmes in Argentina, Colombia, and Ecuador during two consecutive academic years (2019–2020, 2020–2021), and it sought to explore teacher educators’ (n = 5) and student-teachers’ (n = 58) understanding and practice of (teacher) language awareness for CLIL settings. Data were collected through interviews, online forums, teaching resources (e.g. slides, lesson plans, assignments) and classroom observations (online and face-to-face), and analysed following an interpretivist and inductive approach. Findings show that the participants approached TLA as explicit knowledge about language, and associated it to notions of basic interpersonal skills, general academic language, and subject-­specific terminology when TLA was embedded in CLIL. Based on Morton’s (2018) construct of language knowledge for content learning, the paper puts forward a data-driven model of teacher language awareness for CLIL teacher education. RESUMEN Esta investigación basada en un estudio de casos múltiples examinó la conciencia lingüística de los docentes (TLA por sigla en inglés) para el aprendizaje integrado de contenidos y lenguas extranjeras (AICLE por su sigla en español). Este estudio se llevó a cabo en tres programas de formación del profesorado en Argentina, Colombia y Ecuador durante dos años académicos consecutivos (2019–2020, 2020–2021), y buscó explorar las actitudes de los formadores de profesores (n = 5) y de los educadores en formación (n = 58) sobre la comprensión y práctica de la conciencia lingüística en entornos AICLE. Los datos se recopilaron a través de entrevistas, foros en línea, así como recursos didácticos (por ejemplo, diapositivas, planificaciones de clases, tareas), y observaciones en aula (en línea y de forma presencial), y se analizaron siguiendo un enfoque interpretativista e inductivo. Los hallazgos muestran que los participantes abordaron el TLA como conocimiento explícito sobre el lenguaje y lo asociaron con nociones de habilidades interpersonales básicas, lenguaje académico general y terminología específica de sus especialidades cuando el TLA estaba integrado en AICLE. Basado en el concepto de conocimiento lingüístico para el aprendizaje de contenidos de Morton (2018), el artículo presenta un modelo basado en datos de conciencia lingüística de los docentes para la formación del profesorado AICLE.

Unfolding language awareness in a plurilingual context: A study of metalinguistic, practical, and critical language awareness

AbstractAs part of a larger project investigating language awareness in plurilingual settings across educational levels through a multiple case study, this article zooms in on students’ language awareness as it unfolds in a classroom in a Danish upper secondary school, in the context of a compulsory, plurilingual general language awareness course. Considering language awareness as a sociocognitive phenomenon that may meaningfully be observed through students’ engagement with language in the classroom, qualitative data were collected through observation, interviews, and collections of student work, and analyzed using an abductive form of qualitative content analysis. The initial deductive analysis is based on a theoretical model of language awareness; additional, inductive analyses lead to more nuanced descriptions of students’ metalinguistic, practical, and critical language awareness. Finally, a contextualized analysis of one example is given to illustrate the collaborative unfolding of language awareness in this context, leading to the conclusion that the different forms of language awareness studied are often interlinked and that they should be viewed as such both in research and teaching practice.

Describing Engagement in the Collegiate Concert Band Rehearsal

The purpose of this multiple case study was to investigate engagement in the collegiate concert band setting. Research questions were: (1) How do collegiate band students describe their engagement in large ensemble rehearsals? (2) How do collegiate band directors describe engagement in large ensemble rehearsals? and (3) What does rehearsal engagement look like in action? Cross-case analysis suggested that student engagement is related to personal/temporal factors, the repertoire and instructional strategies, and interpersonal factors among students and between the student and director. Directors spoke of the responsibility and pressure they felt to encourage independence and the challenges of establishing a collaborative, agentic environment. Observation field notes reflected variety in body language, liveliness, and hands-on interactions and technology distractions.

Linkage and association of rs3110045 and rs28499085 variants in the thyrotropin-releasing hormone receptor (TRHR) gene with the risk of familial type 2 diabetes

Type 2 diabetes (T2D) is a chronic and prevalent multisystemic disease that significantly increases morbidity and mortality. Dysfunction of the thyroid hormone system is common in patients with T2D, increasing their risk of both hyperthyroidism and hypothyroidism. Several components of the thyroid system are candidate risk genes for T2D. The thyrotropin-releasing hormone receptor (TRHR) gene encoding for TRHR is of particular interest since it is expressed by the dorsomedial hypothalamus neurons, which are known to regulate food intake. In humans, a variant in the TRHR gene has been previously reported in T2D patients in a population-based case-control study but not in familial T2D. We recruited 212 multigenerational families with T2D originated from the Italian peninsula with multiple cases of T2D and tested, via Pseudomarker 9 single nucleotide polymorphisms (SNPs) in the TRHR gene for linkage and linkage disequilibrium (i.e., linkage plus association) to/with T2D. We identified 2 novel risk variants (rs3110045 and rs28499085) significantly linked to and associated with the risk of T2D in the Italian families across several inheritance models. Our study is the first to confirm the previously reported association of TRHR gene with T2D and extends the risk to familial inheritance. However, functional and replication studies are still needed to confirm these results.

Sustaining the collaborative chronic care model in outpatient mental health: a matrixed multiple case study.

Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying factors related to sustainability are critically needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that influence implementation. We applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM) at nine Department of Veterans Affairs (VA) outpatient mental health clinics, 3-4years after implementation support had concluded. We conducted a directed content analysis of 30 provider interviews, using 6 CCM elements and 4 Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors for each site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed sustainability-related cross-site trends. CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-five factors were identified from the i-PARIHS code summaries, of which 3 exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): "Collaborativeness/Teamwork [Recipients]," "Staff/Leadership turnover [Recipients]," and "Having a consistent/strong internal facilitator [Facilitation]" during and after active implementation. At most high-sustainability sites only, (i) "Having a knowledgeable/helpful external facilitator [Facilitation]" was variably present and enabled sustainability when present, while (ii) "Clarity about what CCM comprises [Innovation]," "Interdisciplinary coordination [Recipients]," and "Adequate clinic space for CCM team members [Context]" were somewhat or less present with mixed influences on sustainability. MMCS revealed that CCM sustainability in VA outpatient mental health clinics may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators. These findings have informed a subsequent CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. MMCS is a systematic approach to multi-site examination that can be used to investigate sustainability-related factors applicable to other EBPs and across multiple contexts.

The effect of visitation restrictions on ED error.

EDs restricted visitors during the COVID-19 pandemic on the assumption that the risks of disease spread outweighed the psychological benefits of liberal visitation. But data suggest that beyond providing emotional support, family and caregivers can clarify history, improve patient monitoring, and advocate for patients-actions that can improve quality of care. Our objective was to assess whether removing visitors from the bedside contributed to errors in emergency care. We reviewed a database of medical errors covering visits from 11/15/17 to 7/30/22 at an urban, tertiary-care, academic ED for five types of error amenable to visitor intervention: inadequate history gathering, inadequate monitoring, falls, giving a medication to which a patient is allergic, and inappropriate medication dosing. These records were reviewed by two investigators to determine the likelihood visitor presence could have prevented the error. For those errors judged susceptible to visitor intercession, the number in each category was compared for the period before and after strict restrictions took effect. Our review found 27/781 (3.5%) errors in the pre-pandemic period and 27/568 (4.8%) errors in the pandemic period fell into one of these five categories (p = 0.29). Visitors prevented harm from reaching the patient in three of 27 pre-pandemic errors (11.1%), compared to 0 out of 27 peri-pandemic errors (p = 0.23). On review by two attendings, 17/24 (70.8%) errors that reached the patient in the pre-pandemic period were judged amenable to visitor intervention, compared to 25/27 (92.6%) in the pandemic period (p = 0.09). There were no statistically significant differences in the categories of error between the two groups; monitoring errors came the closest: 1/17 (5.9%) pre-COVID errors amenable to visitor intervention in these categories were monitoring related, whereas 7/25 (28.0%) post-COVID errors were (p = 0.16). While this study did not demonstrate a statistically significant difference in error between lenient and restrictive visitation eras, we did find multiple cases in the pre-COVID era in which family presence prevented error, and qualitative review of post-COVID errors suggested many could have been prevented by family presence. Larger trials are needed to determine how frequent and consequential such errors are and how to balance the public health imperative of curbing disease spread with the harm caused by restricting visitation.

Multiple case study of processes used by hospitals to select performance indicators: do they align with best practices?

Several health policy institutes recommend reducing the number of indicators monitored by hospitals to better focus on indicators most relevant to local contexts. To determine which indicators are the most appropriate to eliminate, one must understand how indicator selection processes are undertaken. This study classifies hospital indicator selection processes and analyzes how they align with practices outlined in the 5-P Indicator Selection Process Framework. This qualitative, multiple case study examined indicator selection processes used by four large acute care hospitals in Ontario, Canada. Data were collected through 13 semistructured interviews and document analysis. A thematic analysis compared processes to the 5-P Indicator Selection Process Framework. Two types of hospital indicator selection processes were identified. Hospitals deployed most elements found within the 5-P Indicator Selection Process Framework including setting clear aims, having governance structures, considering indicators required by health agencies, and categorizing indicators into strategic themes. Framework elements largely absent included: adopting evidence-based selection criteria; incorporating finance and human resources indicators; considering if indicators measure structures, processes, or outcomes; and engaging a broader set of end users in the selection process. Hospitals have difficulty in balancing how to monitor government-mandated indicators with indicators more relevant to local operations. Hospitals often do not involve frontline managers in indicator selection processes. Not engaging frontline managers in selecting indicators may risk hospitals only choosing government-mandated indicators that are not reflective of frontline operations or valued by those managers accountable for improving unit-level performance.

Gas Kinetic Scheme Coupled with High-Speed Modifications for Hypersonic Transition Flow Simulations.

The issue of hypersonic boundary layer transition prediction is a critical aerodynamic concern that must be addressed during the aerodynamic design process of high-speed vehicles. In this context, we propose an advanced mesoscopic method that couples the gas kinetic scheme (GKS) with the Langtry-Menter transition model, including its three high-speed modification methods, tailored for accurate predictions of high-speed transition flows. The new method incorporates the turbulent kinetic energy term into the Maxwellian velocity distribution function, and it couples the effects of high-speed modifications on turbulent kinetic energy within the computational framework of the GKS solver. This integration elevates both the transition model and its high-speed enhancements to the mesoscopic level, enhancing the method's predictive capability. The GKS-coupled mesoscopic method is validated through a series of test cases, including supersonic flat plate simulation, multiple hypersonic cone cases, the Hypersonic International Flight Research Experimentation (HIFiRE)-1 flight test, and the HIFiRE-5 case. The computational results obtained from these cases exhibit favorable agreement with experimental data. In comparison with the conventional Godunov method, the new approach encompasses a broader range of physical mechanisms, yielding computational results that closely align with the true physical phenomena and marking a notable elevation in computational fidelity and accuracy. This innovative method potentially satisfies the compelling demand for developing a precise and rapid method for predicting hypersonic boundary layer transition, which can be readily used in engineering applications.

Maturity of e-government in Brazilian municipalities: analysis of the dissemination of information and knowledge about the Covid-19 pandemic to Society

Electronic government (e-gov) is a reality already experienced by citizens and organizations of different countries around the world. Governments of different levels can provide information and knowledge available through electronic channels in order to provide a better relationship between their institutions and society. This research aims to identify and classify the maturity of electronic portals of municipal governments in the five largest cities in Brazil regarding the dissemination of information and knowledge about the Covid-19 pandemic to society, classifying them according to the stages of maturity of electronic government proposed by Lechakoski and Tsunoda (2015). To acchieve this goal, a descriptive research of multiple cases was carried out, with the application of a documentary research protocol on the websites of the following Brazilian municipal governments: São Paulo (SP), Rio de Janeiro (RJ), Salvador (BA), Belo Horizonte (MG) and Fortaleza (CE). The results showed that the municipalities of São Paulo (SP) and Rio de Janeiro (RJ) showed greater compliance with the criteria analyzed in the model considered, being classified in the 'integrated' stage, the most developed level. The municipalities of Salvador, Belo Horizonte, and Fortaleza were classified in the transactional stage.

Experimental investigation of a novel high performance multi-walled carbon nano-polyvinylpyrrolidone/silicon-based shear thickening fluid damper

A novel high performance multi-walled carbon nano-polyvinylpyrrolidone/silicon-based shear thickening fluid (MWCNTs-PVP/SiO2-STF), abbreviated and subsequently referred to as MPS-STF, is developed in this paper. The rheological properties of the MPS-STF are investigated, and the viscosity model of MPS-STF is established. Furthermore, the MPS-STF based viscous fluid damper (MPS-STF-VFD) is designed according to the rheological characteristics of the novel fluid. The impact of loading frequencies, displacement amplitudes and the numbers of piston holes on the dynamic performance of the damper is studied through sophisticated multiple cases loading tests using MTS facility. The test results show that the loading frequency, displacement amplitudes and the number of piston holes have great influence on the rheological properties of MPS-STF. This directly affects the maximum damping force and heat dissipation capacity of MPS-STF-VFD. Finally, the mechanical model of the damper is established based on the principle of fluid mechanics. The simulation results agree well with the experimental data. The high damping performance of the MPS-STF-VFD can be achieved based on the characteristics of the modified fluid. Relevant results reported in this paper can provide an important solution for the development and application of damping technology in engineering structures.

Operation Car Wash: Uncovering Corruption Pathways in the Brazilian Construction Industry Through Bid Law Blind Spots

We carried out this study in the construction industry, one of the sectors that contributes significantly to the economic growth of most countries and maintains a strong relationship with the government in infrastructure projects, making it susceptible to corruption. Our objective was to identify the characteristics of the Brazilian Public Administration’s bidding processes for awarding contracts for works that may facilitate corrupt practices. Through a multiple case study, we researched investigations and audits of public works under Operation Car Wash to identify the main mechanisms used to circumvent the law. The results were obtained using an iterative explanation construction technique. With results that contribute to the development of public policies and anti-corruption and project management literature, we conclude that corruption will persist until adequate measures are implemented to combat overpricing and other underlying causes.

A Standardized Benchmarking Framework to Assess Downscaled Precipitation Simulations

Abstract Presently, there is no standardized framework or metrics identified to assess regional climate model precipitation output. Because of this, it can be difficult to make a one-to-one comparison of their performance between regions or studies, or against coarser-resolution global climate models. To address this, we introduce the first steps toward establishing a dynamic, yet standardized, benchmarking framework that can be used to assess model skill in simulating various characteristics of rainfall. Benchmarking differs from typical model evaluation in that it requires that performance expectations are set a priori. This framework has innumerable applications to underpin scientific studies that assess model performance, inform model development priorities, and aid stakeholder decision-making by providing a structured methodology to identify fit-for-purpose model simulations for climate risk assessments and adaptation strategies. While this framework can be applied to regional climate model simulations at any spatial domain, we demonstrate its effectiveness over Australia using high-resolution, 0.5° × 0.5° simulations from the CORDEX-Australasia ensemble. We provide recommendations for selecting metrics and pragmatic benchmarking thresholds depending on the application of the framework. This includes a top tier of minimum standard metrics to establish a minimum benchmarking standard for ongoing climate model assessment. We present multiple applications of the framework using feedback received from potential user communities and encourage the scientific and user community to build on this framework by tailoring benchmarks and incorporating additional metrics specific to their application. Significance Statement We introduce a standardized benchmarking framework for assessing the skill of regional climate models in simulating precipitation. This framework addresses the lack of a uniform approach in the scientific community and has diverse applications in scientific research, model development, and societal decision-making. We define a set of minimum standard metrics to underpin ongoing climate model assessments that quantify model skill in simulating fundamental characteristics of rainfall. We provide guidance for selecting metrics and defining benchmarking thresholds, demonstrated using multiple case studies over Australia. This framework has broad applications for numerous user communities and provides a structured methodology for the assessment of model performance.

Perceived and received social support functions among UEFA B licensed women football coaches

ABSTRACT Literature that focuses on women coaches indicates frequent experiences of difficult social environments in the coaching community. Individuals who are more socially integrated and satisfied with their social network are likely to overcome these demanding situations more effectively and have higher levels of well-being. Therefore, this study explored perceived and received social support functions among UEFA B licensed women football coaches. An exploratory, multiple case study approach was used to collect data from three white British women football coaches (Mage = 26.6, SD = 1.2 years, Mexperience = 7.6, SD = 3.7 years). Each coach engaged in two semi-structured interviews that were conducted three or four months apart. We analysed the interview data using abductive thematic analysis. The coaches reported receiving social support that they perceived as unhelpful such as a tutor giving them easier drills to coach on coaching courses. However, they also received positive exchanges of social support resources (e.g., emotional support or providing a lift to coaching), which predominantly came from friends and family. The women coaches generally felt supported by the social networks that they had access to. However, there was an overall perception that the coaches would like support to be more easily accessible (e.g., via formal coaching networks). Given the pertinence of social support functions for performance and psychological well-being, applied implications that aim to better support women coaches are discussed.

Design organization and clinical processes around patient characteristics: Evidence from a multiple case study of Hemophilia.

Background: There is growing evidence of the relevance of designing organization of care around patient characteristics; this is especially true in the case of complex chronic diseases.Purpose: The goal of the paper - that focuses on the analysis of the clinical condition hemophilia in three different centers - is to address two different research questions:1. How can we define, within the same clinical condition, different patient profiles homogeneous in terms of intensity of service required (e.g. number of visits or diagnostics)? 2. What are the conditions to re-organize care around these patient profiles in a multidisciplinary and coordinated manner?Research design: The authors have used a multiple case study approach combining both qualitative and quantitative methodologies; in particularly the semi-structured interviews and the direct observation were aimed to map the process in order to come up with an estimate of the cost of the full cycle of care.Study sample: The research methodology has been applied consistently in three different centers. The selection of the structures has been based on two main different criteria: (i) high standards regarding both organizational and clinical aspects and (ii) willingness from management, nurses and physicians to provide data.Results: The study clearly shows that different patient profiles - within the same clinical condition - trigger a different set of diagnostic and therapeutic activities. It is, thus, important considering patient characteristics in the development and implementation of clinical pathways and this will imply relevant differences in terms of organizational and economic impact.Conclusions: These process-based analyses are very much critical especially if we want to move to a bundled and integrated payment system but, as shown by this study itself, require a lot of time and efforts since our healthcare information systems are still fragmented and vertically designed.