# Method of the month: Coding qualitative data

Once a month we discuss a particular research method that may be of interest to people working in health economics. We’ll consider widely used key methodologies, as well as more novel approaches. Our reviews are not designed to be comprehensive but provide an introduction to the method, its underlying principles, some applied examples, and where to find out more. If you’d like to write a post for this series, get in touch. This month’s method is coding qualitative data.

## Principles

Health economists are increasingly stepping away from quantitative datasets and conducting interviews and focus groups, as well as collecting free text responses. Good qualitative analysis requires thought and rigour. In this blog post, I focus on coding of textual data – a fundamental part of analysis in nearly all qualitative studies. Many textbooks deal with this in detail. I have drawn on three in particular in this blog post (and my research): Coast (2017), Miles and Huberman (1994), and Ritchie and Lewis (2003).

Coding involves tagging segments of the text with salient words or short phrases. This assists the researcher with retrieving the data for further analysis and is, in itself, the first stage of analysing the data. Ultimately, the codes will feed into the final themes or model resulting from the research. So the codes – and the way they are applied – are important!

## Implementation

There is no ‘right way’ to code. However, I have increasingly found it useful to think of two phases of coding. First, ‘open coding’, which refers to the initial exploratory process of identifying pertinent phrases and concepts in the data. Second, formal or ‘axial’ coding, involving the application of a clear, pre-specified coding framework consistently across the source material.

### Open coding

Any qualitative analysis should start with the researcher being very familiar with both the source material (such as interview transcripts) and the study objectives. This sounds obvious, but it is easy, as a researcher, to get drawn into the narrative of an interview and forget what exactly you are trying to get out of the research and, by extension, the coding. Open coding requires the researcher to go through the text, carefully, line-by-line, tagging segments with a code to denote its meaning. It is important to be inquisitive. What is being said? Does this relate to the research question and, if so, how?

Take, for example, the excerpt below from a speech by the Secretary of State for Health, Jeremy Hunt, on safety and efficiency in the NHS in 2015:

Let’s look at those challenges. And I think we have good news and bad news. If I start with the bad news it is that we face a triple whammy of huge financial pressures because of the deficit that we know we have to tackle as a country, of the ageing population that will mean we have a million more over 70s by 2020, and also of rising consumer expectations, the incredible excitement that people feel when they read about immunotherapy in the newspapers that gives a heart attack to me and Simon Stevens but is very very exciting for the country. The desire for 24/7 access to healthcare. These are expectations that we have to recognise in the NHS but all of these add to a massive pressure on the system.

This excerpt may be analysed, for example, as part of a study into demand pressures on the NHS. And, in this case, codes such as “ageing population” “consumer expectations” “immunotherapy” “24/7 access to healthcare” might initially be identified. However, if the study was investigating the nature of ministerial responsibility for the NHS, one might pull out very different codes, such as “tackle as a country”, “public demands vs. government stewardship” and “minister – chief exec shared responsibility”.

Codes can be anything – attitudes, behaviours, viewpoints – so long as they relate to the research question. It is very useful to get (at least) one other person to also code some of the same source material. Comparing codes will provide new ideas for the coding framework, a different perspective of the meaning of the source material and a check that key sections of the source material have not been missed. Researchers shouldn’t aim to code all (or even most) of the text of a transcript – there is always some redundancy. And, in general, initial codes should be as close to the source text as possible – some interpretation is fine but it is important to not get too abstract too quickly!

### Formal or ‘axial’ coding

When the researcher has an initial list of codes, it is a good time to develop a formal coding framework. The aim here is to devise an index of some sort to tag all the data in a logical, systematic and comprehensive way, and in a way that will be useful for further analysis.

One way to start is to chart how the initial codes can be grouped and relate to one another. For example, in analysing NHS demand pressures, a researcher may group “immunotherapy” with other medical innovations mentioned elsewhere in the study. It’s important to avoid having many disconnected codes, and at this stage, many codes will be changed, subdivided, or combined. Much like an index, the resulting codes could be organised into loose chapters (or themes) such as “1. Consumer expectations”, “2. Access” and/or there might be a hierarchical relationship between codes, for example, with codes relating to national and local demand pressures. A proper axial coding framework has categories and sub-categories of codes with interdependencies formally specified.

There is no right number of codes. There could be as few as 10, or as many as 50, or more. It is crucial however that the list of codes are logically organised (not alphabetically listed) and sufficiently concise, so that the researcher can hold them in their head while coding transcripts. Alongside the coding framework itself – which may only be a page – it can be very helpful to put together an explanatory document with more detail on the meaning of each code and possibly some examples.

### Software

Once the formal coding framework is finalised it can be applied to the source material. I find this a good stage to use software like Nvivo. While coding in Nvivo takes a similar amount of time to paper-based methods, it can help speed up the process of retrieving and comparing segments of the text later on. Other software packages are available and some researchers prefer to use computer packages earlier in the process or not all – it is a personal choice.

Again, it is a good idea to involve at least one other person. One possibility is for two researchers to apply the framework separately and code the first, say 5 pages of a transcript. Reliability between coders can then be compared, with any discrepancies discussed and used to adjust the coding framework accordingly. The researchers could then repeat the process. Once reliability is at an acceptable level, a researcher should be able to code the transcripts in a much more reproducible way.

Even at this stage, the formal coding framework does not need to be set in stone. If it is based on a subset of interviews, new issues are likely to emerge in subsequent transcripts and these may need to be incorporated. Additionally, analyses may be conducted with sub-samples of participants or the analysis may move from more descriptive to explanatory work, and therefore the coding needs may change.

## Applications

Published qualitative studies will often mention that transcript data were coded, with few details to discern how this was done. In the study I worked on to develop the ICECAP-A capability measure, we coded to identify influences on quality of life in the first batch of interviews and dimensions of quality of life in later batches of interviews. A recent study into disinvestment decisions highlights how a second rater can be used in coding. Reporting guidelines for qualitative research papers highlight three important items related to coding – number of coders, description of the coding tree (framework), and derivation of the themes – that ought to be included in study write-ups.

Coding qualitative data can feel quite laborious. However, the real benefit of a well organised coding framework comes when reconstituting transcript data under common codes or themes. Codes that relate clearly to the research question, and one another, allow the researcher to reorganise the data with real purpose. Juxtaposing previously unrelated text and quotes sparks the discovery of exciting new links in the data. In turn, this spawns the interpretative work that is the fundamental value of the qualitative analysis. In economics parlance, good coding can improve both the efficiency of retrieving text for analysis and the quality of the analytical output itself.

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# Method of the month: Synthetic control

Once a month we discuss a particular research method that may be of interest to people working in health economics. We’ll consider widely used key methodologies, as well as more novel approaches. Our reviews are not designed to be comprehensive but provide an introduction to the method, its underlying principles, some applied examples, and where to find out more. If you’d like to write a post for this series, get in touch. This month’s method is synthetic control.

## Principles

Health researchers are often interested in estimating the effect of a policy of change at the aggregate level. This might include a change in admissions policies at a particular hospital, or a new public health policy applied to a state or city. A common approach to inference in these settings is difference in differences (DiD) methods. Pre- and post-intervention outcomes in a treated unit are compared with outcomes in the same periods for a control unit. The aim is to estimate a counterfactual outcome for the treated unit in the post-intervention period. To do this, DiD assumes that the trend over time in the outcome is the same for both treated and control units.

It is often the case in practice that we have multiple possible control units and multiple time periods of data. To predict the post-intervention counterfactual outcomes, we can note that there are three sources of information: i) the outcomes in the treated unit prior to the intervention, ii) the behaviour of other time series predictive of that in the treated unit, including outcomes in similar but untreated units and exogenous predictors, and iii) prior knowledge of the effect of the intervention. The latter of these only really comes into play in Bayesian set-ups of this method. With longitudinal data we could just throw all this into a regression model and estimate the parameters. However, generally, this doesn’t allow for unobserved confounders to vary over time. The synthetic control method does.

## Implementation

Abadie, Diamond, and Haimueller motivate the synthetic control method using the following model:

$y_{it} = \delta_t + \theta_t Z_i + \lambda_t \mu_i + \epsilon_{it}$

where $y_{it}$ is the outcome for unit $i$ at time $t$, $\delta_t$ are common time effects, $Z_i$ are observed covariates with time-varying parameters $\theta_t$, $\lambda_t$ are unobserved common factors with $\mu_i$ as unobserved factor loadings, and $\epsilon_{it}$ is an error term. Abadie et al show in this paper that one can derive a set of weights for the outcomes of control units that can be used to estimate the post-intervention counterfactual outcomes in the treated unit. The weights are estimated as those that would minimise the distance between the outcome and covariates in the treated unit and the weighted outcomes and covariates in the control units. Kreif et al (2016) extended this idea to multiple treated units.

Inference is difficult in this framework. So to produce confidence intervals, ‘placebo’ methods are proposed. The essence of this is to re-estimate the models, but using a non-intervention point in time as the intervention date to determine the frequency with which differences of a given order of magnitude are observed.

Brodersen et al take a different approach to motivating these models. They begin with a structural time-series model, which is a form of state-space model:

$y_t = Z'_t \alpha_t + \epsilon_t$

$\alpha_{t+1} = T_t \alpha_t + R_t \eta_t$

where in this case, $y_t$ is the outcome at time $t$, $\alpha_t$ is the state vector and $Z_t$ is an output vector with $\epsilon_t$ as an error term. The second equation is the state equation that governs the evolution of the state vector over time where $T_t$ is a transition matrix, $R_t$ is a diffusion matrix, and $\eta_t$ is the system error.

From this setup, Brodersen et al expand the model to allow for control time series (e.g. $Z_t = X'_t \beta$), local linear time trends, seasonal components, and allowing for dynamic effects of covariates. In this sense the model is perhaps more flexible than that of Abadie et al. Not all of the large number of covariates may be necessary, so they propose a ‘slab and spike’ prior, which combines a point mass at zero with a weakly informative distribution over the non-zero values. This lets the data select the coefficients, as it were.

Inference in this framework is simpler than above. The posterior predictive distribution can be ‘simply’ estimated for the counterfactual time series to give posterior probabilities of differences of various magnitudes.

### Software

#### Stata

• Synth Implements the method of Abadie et al.

#### R

• Synth Implements the method of Abadie et al.
• CausalImpact Implements the method of Brodersen et al.

## Applications

Kreif et al (2016) estimate the effect of pay for performance schemes in hospitals in England and compare the synthetic control method to DiD. Pieters et al (2016) estimate the effects of democratic reform on under-five mortality. We previously covered this paper in a journal round-up and a subsequent post, for which we also used the Brodersen et al method described above. We recently featured a paper by Lépine et al (2017) in a discussion of user fees. The synthetic control method was used to estimate the impact that the removal of user fees had in various districts of Zambia on use of health care.

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# Alastair Canaway’s journal round-up for 28th August 2017

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Valuing health-related quality of life: an EQ-5D-5L value set for England. Health Economics [PubMed] Published 22nd August 2017

With much anticipation, the new EQ-5D-5L value set was officially published. For over 18 months we’ve had access to values via the OHE’s discussion paper but the formal peer-reviewed paper has (I imagine) been in publication purgatory. This paper presents the results of the value-set for the new (ish) EQ-5D-5L measure. The study used the internationally agreed hybrid model combining TTO and DCE data to generate the values for the 3125 health states. It’s worth noting that the official values are marginally different to those in the discussion paper, although in practice this is likely to have little impact on results. Important results of the new value set include fewer health states worse than death (5.1% vs over 33%), and a higher minimum value (-0.285 vs -0.594). I’d always been a bit suspect of the values for worse than death states for the 3L measure, so this if anything is encouraging. This does, however, have important implications, primarily for interventions seeking to improve those in the worst health, where potential gains may be reduced. Many of us are actively using the EQ-5D-5L within trials and have been eagerly awaiting this value set. Perhaps naively, I always anticipated that with more levels and an improved algorithm it would naturally supersede the 3L and the outdated 3L value set upon publication. Unfortunately, to mark the release of the new value set, NICE released a ‘position statement’ [PDF] regarding the choice of measure and value sets for the NICE reference case. NICE specifies that i) the 5L value set is not recommended for use, ii) the EQ-5D-3L with the original UK TTO value set is recommended and if both measures are included then the 3L should be preferred, iii) if the 5L measure is included, then scores should be mapped to the EQ-5D-3L using the van Hout et al algorithm, iv) NICE supports the use of the EQ-5D-5L generally to collect data on quality of life, and v) NICE will review this decision in August 2018 in light of future evidence. So, unfortunately, for the next year at least, we will be either sticking to the original 3L measure or mapping from the 5L. I suspect NICE is buying some time as transitioning to the 5L is going to raise lots of interesting issues e.g. if a measure is cost-effective according to the 3L, but not the 5L, or vice-versa, and comparability of 5L results to old 3L results. Interesting times lie ahead. As a final note, it’s worth reading the OHE blog post outlining the position statement and OHE’s plans to satisfy NICE.

Long-term QALY-weights among spouses of dependent and independent midlife stroke survivors. Quality of Life Research [PubMed] Published 29th June 2017

For many years, spillover impacts were largely being ignored within economic evaluation. There is increased interest in capturing wider impacts, indeed, the NICE reference case recommends including carer impacts where relevant, whilst the US Panel on Cost-Effectiveness in Health and Medicine now advocates the inclusion of other affected parties. This study sought to examine whether the dependency of midlife stroke survivors impacted on their spouses’ HRQL as measured using the SF-6D. An OLS approach was used whilst controlling for covariates (age, sex and education, amongst others). Spouses of dependent stroke survivors had a lower utility (0.69) than those whose spouses were independent (0.77). This has interesting implications for economic evaluation. For example, if a treatment were to prevent dependence, then there could potentially be large QALY gains to spouses. Spillover impacts are clearly important. If we are to broaden the evaluative scope as suggested by NICE and the US Panel to include spillover impacts, then work is vital in terms of identifying relevant contexts, measuring spillover impacts, and understanding the implications of spillover impacts within economic evaluation. This remains an important area for future research.

To finish this week’s round-up I thought it’d be helpful to signpost this article on conducting DCEs, which I feel may be helpful for researchers embarking on their first DCE. The article hasn’t done anything particularly radical or made ground-breaking discoveries. What it does however do is give you a practical guide to walk you through each step of the DCE process following the ISPOR guidelines/checklist. Furthermore, it expands upon the ISPOR checklist to provide researchers with a further resource to consider when conducting DCEs. The case study used relates to measuring patient preferences for type 2 diabetes mellitus medications. For every item on the ISPOR checklist, it explains how they made the choices that they did, and what influenced them. The paper goes through the entire process from identifying the research question all the way through to presenting results and discussion (for those interested in diabetes – it turns out people have a preference for immediate consequences and have a high discount rate for future benefits). For people who are keen to conduct a DCE and find a worked example easier to follow, this paper alongside the ISPOR guidelines is definitely one to add to your reference manager.

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