Interprofessional education: effects on professional practice and healthcare outcomes (update)

  • Review
  • Intervention

Authors

  • Scott Reeves,

    Corresponding author
    1. University of California, San Francisco, Center of Innovation in Inteprofessional Education, San Francisco, California, USA
    • Scott Reeves, Center of Innovation in Inteprofessional Education, University of California, San Francisco, 521 Parnassus Avenue, CL112, San Francisco, California, 94143, USA. scott.reeves@ucsf.edu.

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  • Laure Perrier,

    1. Li Ka Shing Knowledge Institute of St. Michael's Hospital, Continuing Education and Professional Development, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Joanne Goldman,

    1. Li Ka Shing Knowledge Institute of St. Michael's Hospital, Continuing Education and Professional Development, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Della Freeth,

    1. Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Centre for Medical Education, Institute of Health Sciences Education, London, UK
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  • Merrick Zwarenstein

    1. University of Western Ontario, Department of Family Medicine, London, ON, Canada
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Abstract

Background

The delivery of effective, high-quality patient care is a complex activity. It demands health and social care professionals collaborate in an effective manner. Research continues to suggest that collaboration between these professionals can be problematic. Interprofessional education (IPE) offers a possible way to improve interprofessional collaboration and patient care.

Objectives

To assess the effectiveness of IPE interventions compared to separate, profession-specific education interventions; and to assess the effectiveness of IPE interventions compared to no education intervention.

Search methods

For this update we searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE and CINAHL, for the years 2006 to 2011. We also handsearched the Journal of Interprofessional Care (2006 to 2011), reference lists of all included studies, the proceedings of leading IPE conferences, and websites of IPE organisations. 

Selection criteria

Randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time series (ITS) studies of IPE interventions that reported objectively measured or self reported (validated instrument) patient/client or healthcare process outcomes.

Data collection and analysis

At least two review authors independently assessed the eligibility of potentially relevant studies. For included studies, at least two review authors extracted data and assessed study quality. A meta-analysis of study outcomes was not possible due to heterogeneity in study designs and outcome measures. Consequently, the results are presented in a narrative format.

Main results

This update located nine new studies, which were added to the six studies from our last update in 2008. This review now includes 15 studies (eight RCTs, five CBA and two ITS studies). All of these studies measured the effectiveness of IPE interventions compared to no educational intervention. Seven studies indicated that IPE produced positive outcomes in the following areas: diabetes care, emergency department culture and patient satisfaction; collaborative team behaviour and reduction of clinical error rates for emergency department teams; collaborative team behaviour in operating rooms; management of care delivered in cases of domestic violence; and mental health practitioner competencies related to the delivery of patient care. In addition, four of the studies reported mixed outcomes (positive and neutral) and four studies reported that the IPE interventions had no impact on either professional practice or patient care.

Authors' conclusions

This updated review reports on 15 studies that met the inclusion criteria (nine studies from this update and six studies from the 2008 update). Although these studies reported some positive outcomes, due to the small number of studies and the heterogeneity of interventions and outcome measures, it is not possible to draw generalisable inferences about the key elements of IPE and its effectiveness. To improve the quality of evidence relating to IPE and patient outcomes or healthcare process outcomes, the following three gaps will need to be filled: first, studies that assess the effectiveness of IPE interventions compared to separate, profession-specific interventions; second, RCT, CBA or ITS studies with qualitative strands examining processes relating to the IPE and practice changes; third, cost-benefit analyses.

Resumo

Educação interprofissional: efeitos na prática profissional e na saúde (atualização)

Introdução

O cuidado efetivo e de alta qualidade para pacientes é uma atividade complexa que exige colaboração efetiva entre profissionais de saúde e da área social. Pesquisas continuam a sugerir que a colaboração entre esses profissionais pode ser problemática. A educação interprofissional oferece um caminho possível para melhorar a colaboração interprofissional e o cuidado com o paciente.

Objetivos

Avaliar a efetividade da educação interprofissional comparada com intervenções educacionais específicas para cada área profissional e avaliar a efetividade da educação interprofissional comparada com nenhuma intervenção educacional.

Métodos de busca

Para esta atualização, fizemos buscas na Cochrane Effective Practice and Organisation of Care Group Specialised Register, no MEDLINE e na CINAHL, abrangendo os anos de 2006 a 2011.Nós também fizemos buscas manuais no Journal of Interprofessional Care (2006 a 2011), na lista de referências de todos os estudos incluídos, em anais dos principais congressos sobre educação interprofissional e em websites de organizações de educação interprofissional.

Critério de seleção

Incluímos ensaios clínicos randomizados (RCTs), ensaios clínicos do tipo antes e depois (CBA) e estudos de série interrompida (ITS) de intervenções educacionais interprofissionais que apresentaram desfechos de pacientes/clientes ou de processos medidos de forma objetiva ou usando instrumentos validados de autoavaliação.

Coleta dos dados e análises

Pelo menos dois autores, de forma independente, avaliaram a elegibilidade de estudos potencialmente relevantes.Pelo menos dois autores extraíram os dados  e avaliaram a qualidade dos estudos incluídos. Não foi possível fazer uma metanálise dos desfechos dos estudos devido à heterogeneidade dos desenhos dos estudos e das medidas dos desfechos. Consequentemente, os resultados são apresentados de forma narrativa.

Principais resultados

Esta atualização encontrou 9 estudos que foram adicionados aos 6 estudos da última atualização de 2008. Esta revisão agora inclui 15 estudos (8 RCTs, 5 CBA e 2 ITS). Todos esses estudos avaliaram a efetividade da intervenção educacional interprofissional comparada com nenhuma intervenção educacional. Sete estudos indicaram que a educação interprofissional produziu desfechos positivos nas seguintes áreas: cuidados com o diabetes, cultura do setor de emergência e satisfação do paciente; comportamento colaborativo e redução das taxas de erros das equipes do setor de emergência; comportamento colaborativo das equipes cirúrgicas; atendimento aos casos de violência doméstica; e competências dos profissionais de saúde mental no atendimento dos pacientes. Quatro estudos concluíram que a intervenção educacional interprofissional teve resultados mistos (positivos e neutros) e quatro relataram que essa intervenção educacional não teve impacto na prática profissional nem no cuidado ao paciente.

Conclusão dos autores

Esta atualização de revisão incluiu 15 estudos (9 estudos desta atualização e 6 estudos da atualização de 2008). Apesar dos estudos relatarem desfechos positivos, devido ao pequeno número de estudos e à heterogeneidade das intervenções e medidas dos desfechos, não é possível chegar à inferências que possam ser generalizadas sobre os elementos-chave da educação interprofissional e sua efetividade. Para melhorar a qualidade da evidência sobre a educação interprofissional para desfechos relacionados aos pacientes ou processos de saúde, as seguintes lacunas precisarão ser preenchidas: primeiro, estudos que avaliem a efetividade da educação interprofissional comparada com educação específica para cada profissão; segundo, ECRs, CBAs e ITSs com análises qualitativas que examinem processos relacionados à educação interprofissional e mudanças de prática; terceiro, análises de custo-benefício.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Carolina de Oliveira Cruz)

Plain language summary

Training health and social care professionals to work together effectively

Interprofessional education (IPE) is defined as an intervention where the members of more than one health or social care profession, or both, learn interactively together, for the explicit purpose of improving interprofessional collaboration or the health/well being of patients/clients, or both. This review evaluated the effectiveness of IPE compared to educational interventions in which different professional groups were learning separately from one another and IPE compared with interventions in which no IPE was offered to a comparison group. This review was restricted to studies that measured patient outcomes or healthcare processes. This excluded qualitative studies and quantitative studies that reported on the impact that IPE can have on participants' attitudes, knowledge and skills of collaboration. This does not imply that qualitative studies and those focused on attitudes, knowledge and skills do not offer useful insights for certain purposes; simply that they are not the focus of this review.

Nine studies met the inclusion criteria for the review. These studies were added to the six that we found the last time we updated the review, bringing the total to 15 studies. Seven of these studies reported positive outcomes for healthcare processes or patient outcomes, or both, four studies reported mixed outcomes (positive and neutral) and four reported no effects of IPE. The studies differed in many respects. They were conducted in different areas of clinical practice and included different IPE interventions. The study designs and outcome measures were also different. All 15 studies compared outcomes following an IPE intervention to outcomes, either in similar clinical settings that did not receive the IPE intervention, or in the same clinical setting before the intervention was made. Because no studies compared an interprofessional intervention to a profession-specific intervention, our understanding of interprofessional interventions is limited. The small number of studies included in this review, and their varied nature, limit our understanding of the key components of IPE and its effectiveness. More studies are needed to allow sound conclusions to be reached about the effectiveness of IPE, as well as to inform IPE policy development. In particular, these should include: first, studies that assess the effectiveness of IPE interventions compared to separate, profession-specific interventions; second, RCT, CBA or ITS studies with qualitative strands examining processes relating to the IPE and practice changes; third, cost-benefit analyses.

Laički sažetak

Izobrazba zdravstvenih profesionalaca i radnika socijalne skrbi za učinkovit zajednički rad

Međuprofesijska edukacija (MPE) je definirana kao intervencija pri kojoj članovi više od jedne zdravstvene ili profesije socijalne skrbi, ili obiju, interaktivno uče zajedno, i to s eksplicitnom namjerom poboljšanja međuprofesijske suradnje ili zdravlja / osjećanja pacijenata / klijenata, ili oboje. Ovaj sustavni pregled procjenjuje učinkovitost MPE-a u usporedbi s pedagoškim posredovanjima u kojima su različite strukovne skupine učile odvojeno jedne od drugih te sa posredovanjima u kojima MPE nije bila na raspolaganju usporednoj skupini. Ovaj sustavni pregled je ograničen na istraživanja koja su mjerila rezultate kod pacijenata i procese zdravstvene skrbi.To je isključilo kvalitativna i kvantitativna istraživanja koja su izvještavala o utjecaju koji MPE može imati na sudionikove stavove, znanje i sposobnost suradnje. To ne implicira da kvalitativna istraživanja i ona usredotočena na stavove, znanje i sposobnosti ne nude korisne uvide u određene svrhe; ona jednostavno nisu fokus ovog sustavnog pregleda.

Devet istraživanja je zadovoljilo kriterije uključenja za sustavni pregled. Ova istraživanja su dodana onim šest koja su pronađena kada je zadnji put ažuriran sustavni pregled, što znači da je u trenutnu verziju sustavnog pregleda uključeno 15 istraživanja.Sedam od tih istraživanja je opisalo pozitivne posljedice za procese zdravstvene skrbi ili rezultate kod pacijenata, ili oboje, četiri su istraživanja opisala miješane posljedice (pozitivne i neutralne), a daljnja četiri nisu našla nikakav utjecaj MPE-a. Istraživanja su se razlikovala u mnogim aspektima.Provedena su u različitim područjima kliničke prakse te su uključivala različite MPE intervencije. Vrste istraživanja i mjere ishoda su također bili različiti.Svih 15 istraživanja je uspoređivalo podatke nakon MPE intervencije ili s onim podacima iz sličnih kliničkih okvira koji nisu primili MPE posredovanje, ili sa podacima iz istog kliničkog okvira prije nego što je poduzeta intervencija.S obzirom da nijedno istraživanje nije usporedilo međuprofesijsko posredovanje sa posredovanjem u specifičnoj struci, naše razumijevanje međuprofesijskih posredovanja je ograničeno. Malen broj istraživanja uključenih u ovu recenziju te njihova raznolikost ograničavaju naše shvaćanje ključnih komponenata MPE-a te njezine učinkovitosti. Potrebno je više istraživanja kako bi se dobili smisleni zaključci o učinkovitosti MPE-a i informacije koje će utjecati na razvoj smjernica o MPE-u. Osobito bi trebala biti uključena: prvo, istraživanja koja ocjenjuju učinkovitost MPE posredovanja u usporedbi s odvojenim posredovanjima u specifičnoj struci; drugo, potrebni su randomizirani kontrolirani pokusi, kontrolirane studije s analizama „prije i poslije“ (engl. controlled before and after studies – CBA) ili pokusi s isprekidanim vremenskim slijedom (engl. interrupted time series – ITS) s kvalitativnim komponentama koji ispituju procese koji se odnose na MPE i promjene prakse; treće, analize isplativosti takve intervencije.

Bilješke prijevoda

Cochrane Hrvatska
Preveo: Marin Popović
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Resumo para leigos

Treinando profissionais de saúde e da área social para um trabalho em conjunto mais efetivo

A educação interprofissional é uma forma de treinamento em que pessoas de diversas áreas da saúde ou da assistência social, ou ambas, aprendem juntos de forma interativa. O objetivo desse tipo de educação é melhorar a colaboração interprofissional ou a saúde/bem-estar de pacientes/clientes, ou ambos. Esta revisão avaliou a efetividade da educação interprofissional comparada com intervenções educacionais em que diferentes grupos profissionais aprendiam separadamente uns dos outros. Avaliou também a educação interprofissional comparada com intervenções em que nenhuma educação interprofissional foi oferecida a um grupo de comparação. Esta revisão incluiu somente estudos que mediram desfechos em pacientes ou processos de saúde. A revisão excluiu estudos qualitativos e estudos quantitativos que falavam do impacto que a educação interprofissional pode ter nas atitudes de seus participantes, seu conhecimento e habilidades de colaboração. Isso não significa que estudos qualitativos e estudos focados em atitudes, conhecimento e habilidades não sejam úteis para certos propósitos; simplesmente não foram o foco desta revisão.

Nove estudos novos foram incluídos nesta atualização desta revisão, que, somados aos seis estudos anteriores, deram um total de 15 estudos. Sete deles relataram resultados positivos para processos de saúde ou desfechos relevantes para os pacientes, ou ambos. Quatro estudos tiveram resultados heterogêneos (positivos e neutros) e quatro relataram que a intervenção educacional interprofissional não produziu efeitos. Os estudos eram diferentes em muitos aspectos. Foram conduzidos em diferentes áreas clínicas e incluíram diferentes tipos da intervenção educacional interprofissional. Os desenhos dos estudos e seus desfechos também eram diferentes.Os 15 estudos compararam os desfechos após a intervenção educacional interprofissional com os desfechos em locais semelhantes que não receberam a educação interprofissional ou então os estudos compararam os desfechos no mesmo local, antes e depois da intervenção educacional interprofissional. Como nenhum estudo comparou uma intervenção interprofissional com uma intervenção específica para apenas uma profissão, isso limitou nosso entendimento sobre intervenções interprofissionais. O pequeno número de estudos incluídos nesta revisão e suas naturezas variadas limitaram nosso entendimento de componentes-chave da educação interprofissional e sua efetividade. É preciso realizar mais estudos para que possamos chegar a conclusões mais concretas sobre a efetividade da educação interprofissional e para o desenvolvimento de políticas de educação interprofissional. Em particular, são necessários: primeiro, estudos que avaliem a efetividade da intervenção educação interprofissional comparada com intervenções específicas para cada profissão; segundo, ensaios clínicos randomizados, ensaios clínicos do tipo antes e depois ou estudos de série interrompida com análises qualitativas que examinem processos relacionados à educação interprofissional e mudanças de prática; terceiro, análises de custo-benefício.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Carolina de Oliveira Cruz)

Laienverständliche Zusammenfassung

Schulungen in Gesundheits- und Sozialberufen für effektivere Zusammenarbeit

Interprofessionelle Ausbildung (interprofessional education, IPE) ist definiert als eine Maßnahme, in der Mitglieder aus mehr als einer Berufsgruppe des Gesundheits- und/oder Sozialwesens interaktiv miteinander lernen. Das ausdrückliche Ziel dabei besteht darin, die Zusammenarbeit zwischen den Berufsgruppen und/oder die Gesundheit bzw. das Wohlbefinden von Patienten/Klienten zu verbessern. In diesem Review bewerteten wir die Wirksamkeit von IPE im Vergleich zu Bildungsmaßnahmen, in denen unterschiedliche Berufsgruppen getrennt voneinander lernten, sowie im Vergleich zu Maßnahmen, in denen einer Kontrollgruppe keine IPE angeboten wurde. Dieser Review beschränkte sich auf Studien, die Patienten-Endpunkte oder Prozesse im Gesundheitswesen auswertete. Aus diesem Grund waren qualitative und quantitative Studien ausgeschlossen, die über den möglichen Einfluss von IPE auf Einstellung, Wissen und Kollaborationsfähigkeit der Teilnehmer berichteten. Das bedeutet nicht, dass qualitative Studien und solche, die sich auf Einstellung, Wissen und Fertigkeiten konzentrieren, für bestimmte Zwecke keine nützlichen Einsichten liefern würden, sondern nur, dass sie in diesem Review nicht im Mittelpunkt standen.

9 Studien erfüllten die Einschlusskriterien für den Review. Diese Studien wurden zu den 6 Studien hinzugefügt, die wir im Zuge der letzten Aktualisierung des Reviews fanden, sodass wir insgesamt 15 Studien auswerten konnten. 7 dieser Studien berichteten über positive Ergebnisse für Prozesse im Gesundheitswesen und/oder Patienten-Endpunkte, 4 Studien zeigten gemischte Ergebnisse (positiv und neutral) und 4 konnten keine Wirkungen der IPE nachweisen. Die Studien unterschieden sich in vielerlei Hinsicht voneinander. Sie wurden in unterschiedlichen Bereichen der klinischen Praxis durchgeführt und beinhalteten verschiedene IPE-Maßnahmen. Auch beim Studienaufbau und der Bestimmung der Endpunkte gab es Unterschiede. Alle 15 Studien verglichen Endpunkte nach einer IPE-Maßnahme mit Endpunkten entweder unter ähnlichen klinischen Bedingungen ohne IPE-Maßnahme oder in derselben klinischen Umgebung vor Durchführung der Maßnahme. Da keine Studie eine interprofessionelle Maßnahme mit einer berufsspezifischen Maßnahme verglich, ist unser Einblick in interprofessionelle Maßnahmen beschränkt. Die geringe Anzahl der Studien in diesem Review und ihre Verschiedenheit schränken unser Verständnis der Hauptbestandteile einer IPE und ihrer Wirksamkeit ein. Es werden weitere Studien benötigt, um fundierte Rückschlüsse über die Wirksamkeit von IPE ziehen sowie die Entwicklung von IPE-Strategien beeinflussen zu können. Insbesondere sollte es sich dabei um folgende Arten von Studien handeln: 1. Studien, die die Wirksamkeit von IPE-Maßnahmen mit separaten berufsspezifischen Maßnahmen vergleichen, 2. randomisierte kontrollierte Studien, Kosten-Nutzen-Analysen oder unterbrochene Zeitreihen mit qualitativen Bestandteilen, die Prozesse im Zusammenhang mit IPE und Praxisänderungen untersuchen, 3. Kosten-Nutzen-Analysen.

Anmerkungen zur Übersetzung

S. Schmidt-Wussow, freigegeben durch Cochrane Schweiz.

Summary of findings(Explanation)

Summary of findings for the main comparison. 
Interprofessional education to improve professional practices

Patient or population: professionals or patients involved in interprofessional education intervention

Settings: primarily USA and the UK

Intervention: use of interprofessional education to improve collaboration and patient care

Comparison: separate, profession-specific education interventions; or no education intervention

OutcomesImpactsNo of studiesQuality of the evidence
(GRADE)*
Patient outcomesThe care provided by use of interprofessional education may lead to improved outcomes for patients6

⊕⊕⊖⊖

Low

Adherence ratesThe use of interprofessional education may lead to changes in the use of guidelines or standards (e.g. adherence to clinical guidelines) among different professions3

⊕⊕⊖⊖

Low

Patient satisfactionPatients may be more satisfied with care provided by professionals who have participated in an interprofessional education intervention2

⊕⊕⊖⊖

Low

Clinical process outcomesChanges in clinical processes (e.g. shared decisions on surgical incisions) may be linked to the use of interprofessional education1

⊕⊕⊖⊖

Low

Collaborative behaviourWe are unable to assess adequately the extent to which different professions behave collaboratively in the delivery of care to patients3

⊕⊖⊖⊖

Very low

Error ratesWe are unable to assess adequately the reduction of error due to improved interprofessional education1

⊕⊖⊖⊖

Very low

Practitioner competenciesWe are unable to assess adequately the competencies (e.g. skills, knowledge) of professionals to work together in the delivery of care1

⊕⊖⊖⊖

Very low

 
*GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Background

This review is an update to a previous Cochrane interprofessional education (IPE) review wherein four of the six included studies reported a range of positive outcomes (Reeves 2008). While that review was an improvement from the original Cochrane IPE review that identified no studies for inclusion (Zwarenstein 2000), it marked only a small step forward in establishing the evidence base for IPE due to the small number of studies, methodological limitations, and the heterogeneity of IPE interventions. This updated review is timely not only due to the passage of time but also given the continued interest and investment in IPE by policymakers, educators, healthcare professionals and researchers worldwide. 

IPE occurs when members of more than one health or social care profession (or both) learn interactively together, for the explicit purpose of improving interprofessional collaboration or the health/well being of patients/clients (or both). The widespread advocacy and implementation of IPE reflects the premise that IPE will contribute to developing healthcare providers with the skills and knowledge needed to work in a collaborative manner (CIHC 2010; Interprofessional Educ Collab Expert Panel 2011; WHO 2010). Interprofessional collaboration, in turn, is identified as critical to the provision of effective and efficient health care, given the complexity of patients' healthcare needs and the range of health-care providers and organisations. Interprofessional collaboration has been linked to a range of outcomes, including improvements in patient safety and case management, the optimal use of the skills of each healthcare team member and the provision of better health services (Berridge 2010; Reeves 2010; Suter 2012; Zwarenstein 2000).

Professional and academic leaders from diverse countries have developed a shared vision and strategy for postsecondary education in medicine, nursing and public health. This commission called for, among other recommendations, IPE that breaks down professional silos while promoting collaborative relationships (Frenk 2010). Similarly, the World Health Organization (WHO) published a report that outlined the role of IPE in preparing healthcare providers to enter the workplace as a member of the collaborative practice team (WHO 2010). National organisations have created core competencies for interprofessional collaborative practice, positioning IPE as fundamental to practice improvement (CIHC 2010; Interprofessional Educ Collab Expert Panel 2011).

Ideally, IPE should begin in the early training period and extend throughout a person's professional career (Barr 2005). Many examples of IPE at different stages of professional development continue to be published. From this work, it is possible to see that IPE can have an impact on learners' attitudes, knowledge and skills of collaboration (e.g. Charles Campion-Smith 2011; Makowsky 2009; Sargeant 2011). These are important educational outcomes, but not the focus of the current review.

Given the ongoing emphasis on the importance of IPE to collaborative practice and ultimately to healthcare processes and outcomes, ongoing attention is needed to advancing the research evidence related to IPE. It is timely to undertake this updating review to identify whether there are additional studies with research designs that meet the criteria of this Cochrane review, which can further inform the evidence of IPE.

 The definition of an IPE intervention used in this review is the following:

  • An IPE intervention occurs when members of more than one health or social care (or both) profession learn interactively together, for the explicit purpose of improving interprofessional collaboration or the health/well being (or both) of patients/clients. Interactive learning requires active learner participation, and active exchange between learners from different professions.

Objectives

The two objectives of this review are:

  1. to assess the effectiveness of IPE interventions compared to separate, profession-specific education interventions in which the same professions were learning separately from one another;

  2. to assess the effectiveness of IPE interventions compared with control groups which received no education intervention.

In the first objective we are seeking to understand the effects of IPE better in relation to the current dominant uniprofessional education model, where ideally the control group should receive the same education in a uniprofessional manner. We included the second objective as there was a lack of studies addressing the first objective. Our rationale for doing so was that while studies that do not meet the first objective are not as rigorous as those that do, such studies do nevertheless have value in providing some indication of the effects of IPE.

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time series (ITS) studies.

Types of participants

Health and social care professionals (e.g. chiropodists/podiatrists, complementary therapists, dentists, dieticians, doctors/physicians, hygienists, psychologists, psychotherapists, midwives, nurses, pharmacists, physiotherapists, occupational therapists, radiographers, speech therapists and social workers).

Types of interventions

All types of educational, training, learning or teaching initiatives, involving more than one profession in joint, interactive learning, as described in the IPE definition above.

Types of outcome measures

1. Objectively measured or self reported (validated instrument) patient/client outcomes in the following areas: health status measures; disease incidence, duration or cure rates; mortality; complication rates; readmission rates; adherence rates; satisfaction; continuity of care; use of resources (e.g. cost-benefit analyses).

2. Objectively measured or self reported (validated instrument) healthcare process measures (e.g. skills development, changes in practice style, interprofessional collaboration, teamwork).

Search methods for identification of studies

See: Cochrane Effective Practice and Organisation of Care Group methods used in reviews.

Effective Practice and Organisation of Care Group (EPOC) specialized register (epoc.cochrane.org/epoc-register-studies), July 2006 to 2 August 2011.

The search strategy from the previous IPE Cochrane review was adapted for each of the following databases searched: 

  • MEDLINE August week 4 2006 to July week 3 2011;

  • CINAHL, July 2006 to 2 August 2011.

See Appendix 1 and Appendix 2 for the search strategies

No language restrictions were placed on the search strategy.

We also handsearched the Journal of Interprofessional Care (2006 to 2011), proceedings from key interprofessional conferences - 'All Together Better Health' (Sydney, April 2010) and 'Collaborating Across Borders' (Minneapolis, October 2007 and Halifax, May 2008) and the grey literature contained on the websites of the UK Centre for the Advancement of Interprofessional Education (date accessed: 15 September 2011) and the Canadian Interprofessional Health Collaborative (date accessed 16 September 2011). In addition, we drew on our international networks to ensure that all relevant published and unpublished work in the field would be identified. These searches generated 76 abstracts. See Figure 1.

Figure 1.

Flow diagram.

(*Total refers to sum of 1999 review and updates in 2008 and 2012).

A total of 3069 abstracts were found: 1248 from CINAHL, 285 from EPOC, 1460 from MEDLINE, 76 from handsearching and conference abstracts. After duplicates were removed, 2733 abstracts remained. While the abstract search was sensitive to identifying a high proportion of relevant IPE intervention studies, it exhibited low specificity in relation to differentiating between IPE interventions and other interprofessional teamwork interventions without IPE components, such as continuous quality improvement and total quality improvement initiatives. See Figure 1 for further information.

Data collection and analysis

Three review authors (SR, LP and JG) independently reviewed the 2733 abstracts retrieved by the searches to identify all those that suggested that: 

  1. there was an intervention where interprofessional exchange occurred;

  2. education took place;

  3. professional practice, patient care processes or health or patient satisfaction outcomes were reported;

  4. the intervention was evaluated using an RCT, CBA or ITS design.

Twenty-eight studies were identified from this abstract search as potentially meeting these criteria. The full text of these articles was obtained. These three review authors independently assessed each full-text article to examine whether it met all of the criteria further. Any disagreements and uncertainties were resolved by discussion, and the input of a fourth review author (MZ), who reviewed all of the final papers as a further quality check for inclusion in the review. Nine studies met the outlined criteria; these nine studies were added to the six studies from the previous review for a total of 15 studies.

Assessment of the risk of bias in included studies

Two review authors (SR and LP) assessed the risk of bias for each study using a form with the standard criteria described in EPOC (2002). The 'Risk of bias' assessments are displayed in Figure 2 and Figure 3. The 'Risk of bias' summary is in Figure 4.

Figure 2.
Figure 3.
Figure 4.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

We did not exclude studies on the grounds of risk of bias, but sources of bias are reported when presenting the results of studies.  

Data extraction

Three review authors (SR, LP and JG) extracted the following information from included studies:

  1. type of study (RCT, CBA, ITS);

  2. study setting (country, healthcare setting);

  3. types of study participants;

  4. description of education programme;

  5. description of any other interventions in addition to the education;

  6. main outcome measures;

  7. results for the main outcome measures;

  8. any additional information that potentially affected the results.

Analysis

Ideally, a meta-analysis of study outcomes would have been conducted for this review. However, this was not possible due to heterogeneity of study designs, interventions and outcome measures among the small number of included studies (n = 15). Consequently, the results are presented in a narrative format.

Results

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

All 15 studies addressed objective number two – to assess the effectiveness of IPE interventions compared with control groups that received no education intervention. Given the major differences between the included studies, a description of each is provided below. A formal calculation of the evidence, including the creation of a 'Summary of findings' table, was not feasible given the lack of overlap among the outcomes reported. The included studies are presented in three sections according to the type of research design they employed.

Randomised controlled trials

Barcelo 2010 described an RCT that aimed to improve the quality of diabetes care in primary healthcare centres using the chronic care model. Forty-three primary care teams based in 10 public health centres participated in this study. Teams were made up mainly of physicians and nurses with other professionals, such as nutritionists and psychologists also participating in some teams. All 10 health centres implemented a clinical information system and provided the opportunity for patients to participate in peer support groups. Beyond this, five health centres were randomly assigned to receive the intervention, and five received no intervention. The intervention consisted of a multifaceted quality improvement initiative during which teams and patients participated in three interprofessional learning sessions within a period of 18 months. These included a structured patient diabetes education programme, training in foot care and in-service training. In each of the three learning sessions, the teams selected specific objectives for 'plan-do-study-act' (PDSA) improvement cycles. The objectives were based on problems identified in the practice of each health centre (e.g. organisation of care, decision support, information sharing). Other aspects of the multifaceted quality improvement programme included support from hospital specialists and a case management advisor. Reported outcome measures included clinical observations (e.g. metabolic control and cholesterol) and adherence to clinical protocols (e.g. conducting periodic foot and eye examinations). The authors reported that multilevel logistic regression models were adjusted for the clustering of participants within health centres.

Brown 1999 undertook an RCT that aimed to examine whether an interprofessional communication skills training programme for physicians, physician assistants, nurse practitioners and optometrists increased participants' ratings of clinicians' communication skills. The healthcare professionals worked for a 'not for profit' group-model health maintenance organisation (HMO) in the US. The IPE intervention, led by two physicians, consisted of two four-hour workshops delivered one month apart with two hours of homework and a telephone call from an instructor inbetween. The intervention involved didactic components, role playing and interactive dialogue. Of the 69 participants (75% of whom were physicians), 37 were randomly assigned to receive the intervention and 32 were assigned to the control group (which received the IPE intervention after the study). Pre- and post-intervention patient satisfaction scores were drawn from routine data collection, which yielded clinician-specific patient satisfaction ratings every six months. The HMO contracted out the routine data collection. The contractor randomly sampled clinical consultations and mailed a questionnaire to the relevant participants within 10 days of each consultation in the sample.

Campbell 2001 described an RCT that evaluated an interprofessional training programme for emergency department (ED) physicians, nurses, social workers, hospital administrators and representatives from local domestic violence service organisations. The intervention aimed to increase the identification of acutely abused women in EDs, and improve staff and institutional responses. The two-day programme, developed and implemented by violence prevention organisations, involved didactic instruction, role play, team planning and team work to develop a written action plan. Participants from each ED were asked to meet before and after the training. The programme addressed systems change and coalition building as well as provider attitudes and skill building. The attendees were expected to collaborate in order to implement system changes in their respective EDs, including implementing training for ED staff. The instructors were available for telephone assistance during the implementation phase. Six EDs were randomly assigned to receive either the IPE intervention (three hospitals) or to be in a control group that received no intervention (three hospitals). Follow-up data were collected at nine to 12 months and 18 to 24 months. 

Helitzer 2011 reported an RCT that evaluated the effects of an intervention aimed at improving patient-centred communication skills and proficiency in discussing patients' health risks. Twenty-six primary care professionals (physicians, physician assistants and nurse practitioners) based in a single academic setting participated in the intervention.  A total of 12 professionals were allocated to the intervention group and 14 to the control group. The intervention consisted of training focused on patient-centred communication about behavioural risk factors and included a full day of IPE, individualised feedback on video-taped interactions with simulated patients, and optional workshops to reinforce strategies for engaging the patient. Data were gathered from patients on professionals' patient-centred communication behaviour during two clinic visits that were held at six and 18 months following the intervention.

Nielsen 2007 described a cluster RCT study to evaluate the effectiveness of a teamwork training intervention in reducing adverse outcomes and improving the process of care in hospital labour and delivery units. Fifteen hospitals took part in this study, seven as intervention sites and eight as control sites. Participants included labour and delivery room personnel from obstetrics, anaesthesiology and nursing (n = 1307). The intervention consisted of a three-day instructor training session comprising four hours of didactic lessons, video scenarios and interactive training covering team structure and processes, planning and problem solving, communication, workload management and team skills. The intervention also included assistance with creation and structure of interprofessional teams at each intervention site, which entailed facilitators conducting onsite training sessions to structure each unit into core interprofessional teams. In addition, a contingency team, a group of physicians and nurses drawn from practitioners that were on call during a 24-hour period, were trained to respond in a co-ordinated way to obstetric emergencies. Data were gathered on adverse maternal or neonatal outcomes as well as clinical process data from 28,536 deliveries.

Strasser 2008 described a cluster RCT aimed at evaluating the effects of an IPE intervention on team functioning in stroke rehabilitation units. A total of 227 staff on 14 intervention teams and 237 clinical staff on 15 control teams participated in this study. All teams had representatives from medicine, nursing, occupational therapy, speech-language pathology, physiotherapy and social work. The team training intervention consisted of a multi-phase IPE programme delivered over six months, including: an interactive workshop emphasising team dynamics, problem solving, the use of performance feedback data and the creation of action plans for process improvement. The intervention also included follow-up telephone and video-conference consultations. Patient outcomes data (functional improvement, community discharge, length of stay) were gathered from 579 stroke patients treated by these teams before and after the intervention.

Thompson 2000a described a group RCT aimed at evaluating the effectiveness of IPE and a clinical practice guideline aimed at improving the recognition and improvement of depression in primary care practices. A primary care physician, practice nurse and community mental health nurse delivered the four-hour IPE seminars to general practitioners and practice nurses in groups of two or three practices when convenient. Teaching was supplemented by video-tape recordings, small-group discussion of cases and role play. The educators were available for nine months after the seminars to facilitate guideline implementation and promote use of teamwork. Fifty-nine primary care practices were assigned to the intervention group (29 practices) or control group (30 practices). Practices in the control group received the IPE intervention after the study had been completed. Data were collected six weeks and six months after patient visits.

Thompson 2000b undertook a cluster RCT to examine the effectiveness of a one-year intervention linked to improving identification of domestic violence and the collaborative management of primary care clinics. The intervention for teams of physicians, nurse practitioners, physician assistants, registered nurses, practical nurses and medical assistants, consisted of two half-day IPE sessions, a bimonthly newsletter, clinic educational rounds, system support (posters, cue cards, questionnaires) and feedback of results. Five primary care clinics were randomly assigned to receive the intervention (two clinics) or to the control group (three clinics). Data were collected at baseline, nine to 10 months, and 21 to 23 months.

Controlled before and after studies

Janson 2009 reported a CBA study aimed at improving the care and outcomes of people with type 2 diabetes by improving the care delivered by interprofessional teams. Participants consisted of interprofessional teams of 120 learners (56 second/third-year medicine residents, 29 second-year nurse practitioner students and 35 fourth-year pharmacy students) who delivered team-based diabetes care to 221 people. The control group consisted of 28 traditional-track internal medicine residents who provided usual care to 163 people. The study was undertaken in two general medicine clinics. The intervention involved weekly didactic presentations, clinical discussions and clinic visits with participants. A quality improvement approach was offered by planning and implementing projects using the plan-do-study-act model. The intervention group also received quarterly patient panel reports on process of care benchmarks and clinical status markers.

Morey 2002 presented a CBA study to evaluate the effectiveness of a programme aimed at improving collaborative behaviour of hospital ED staff (physicians, nurses, technicians and clerks). The intervention consisted of an emergency team co-ordination education course as well as implementation of formal teamwork structures and processes. A physician-nurse pair from each ED was involved in developing and implementing the curriculum. The course consisted of eight hours of instruction in one day. The format was lectures, discussion of behaviours, practical exercises and discussion of video-segments. Teamwork implementation involved forming teams by shift and delivering care in a team structure. Each staff member completed a four-hour practicum in which teamwork behaviours were practised and critiqued by an instructor. Staff supported the adoption of collaborative behaviour during normal shifts. This teamwork implementation phase lasted six months. Nine hospital EDs self selected to receive either the IPE intervention (six EDs, 684 clinicians) or act as a control (three EDs, 374 clinicians). Control group departments received the intervention at a later date. Data were collected at two four-month intervals following the training.

Rask 2007 presented a CBA study that aimed to evaluate an interprofessional fall management quality improvement project in nursing homes. Participants consisted of 19 interprofessional falls teams (made up of a nurse, physiotherapist or occupational therapist, certified nursing assistants, a member of maintenance staff). The control group comprised 23 falls teams. The intervention consisted of a full-day interprofessional workshop and a second workshop approximately one month later to address arising challenges. Organisational interventions were also provided in the form of seeking leadership buy-in and support, providing a designated facility-based falls co-ordinator, and ongoing consultation and oversight by advanced practice nurses with expertise in falls management. Data were gathered on process of care documentation, trends in fall rates and changes in physical restraint use.

Weaver 2010 described a CBA study that evaluated an intervention aimed at improving teamwork for operating room staff based at two community-based hospitals. In total, 55 professionals participated in the intervention: 29 in the intervention group (three surgeons, nine nurses, three surgical technicians, 12 anaesthesiologists, two physician assistants); and 26 in the control group (two surgeons, 18 nurses, three surgical technicians, three anaesthesiologists). The intervention consisted of one four-hour session that included didactic presentations and interactive role-playing activities between participants aimed at improving their knowledge and skills of teamwork and collaboration. Data were gathered by observed changes in collaborative behaviour (frequency of team briefings in which information was shared among team members and patient care was planned).

Young 2005 presented a CBA study that evaluated effects of a consumer-led innovation aimed at improving the competence of mental health practitioners working in community mental health provider organisations. The practitioner intervention for psychiatrists, nurses, therapists, case managers, residential staff, mental health workers, and administrative support involved six educational components held over a one-year period that included presentations, discussions, small groups and role-playing techniques, as well as three or four full-day follow-up visits to sites. An additional 16 hours was also spent with staff at the sites. The intervention was developed and delivered by two people who were consumers of mental health services. The innovation also involved a consumer-focused intervention. The study was conducted at five organisations in two states; one organisation in each state received the intervention (total of 269 mental health practitioners, 151 in intervention groups and 118 in control groups). Data were collected at baseline and one year.

Time interrupted series studies

Hanbury 2009 described an ITS study that aimed to test the effectiveness of a theory of planned behaviour intervention to increase community mental health professionals' adherence to a national suicide prevention guideline. The intervention was delivered to 49 participants. The intervention comprised three components designed to target normative beliefs. First, a presentation that contained factual statements, statistics and graphs taken from key government publications highlighting and supporting the guideline evidence base. Second, an interprofessional group discussion was facilitated to ensure that positive normative beliefs were emphasised and any negative normative beliefs challenged. Third, interprofessional group work based on two real life vignettes was undertaken by participants. Data in the form of aggregated, monthly audit adherence data were collected for nearly four years (28 months before the intervention and 18 months afterwards) to evaluate patterns of adherence to using the national suicide prevention guideline. Data from a control site was also included to evaluate the level of adherence.

Taylor 2007 presented an ITS study that assessed the effects an intervention designed to improve the delivery of standard diabetes services and patient care. Professionals based in a single primary care clinic participated in the study. An eight-hour intervention was delivered to participants. The intervention consisted of a range of interactive activities (task redistribution, standardised communication methods and decision-support tool development) that aimed to improve interprofessional communication, teamwork, workflow organisation and information exchange in order to enhance the care of 619 people with diabetes. Data were collected from medical records. Using 1805 clinic visits completed during the study period (160 pre-intervention clinic days and 122 post-intervention clinic days), diabetic services and associated patient outcomes were evaluated for adherence to the American Diabetes Association periodicity recommendations and treatment targets: quarterly blood sugar; quarterly blood pressure; annual low-density lipoprotein; annual urine microalbumin; and annual lower extremity amputation prevention check.

Risk of bias in included studies

The risk of bias in studies was variable. Data are presented for RCTs and CBA studies (Figure 2), and separately for ITS studies (Figure 3). 

All studies

For the eight studies that were RCTs, four met five of the nine EPOC 'Risk of bias' criteria (Brown 1999; Nielsen 2007; Thompson 2000a; Thompson 2000b). Three of the five CBA studies met five of the nine EPOC 'Risk of bias' criteria (Janson 2009; Morey 2002; Young 2005). The EPOC 'Risk of bias' criteria have seven elements for ITS studies and one of the two studies met four of the seven EPOC 'Risk of bias' criteria (Hanbury 2009).

Randomised controlled trials

Four of the eight RCTs reported adequately protecting against contamination (Campbell 2001; Strasser 2008; Thompson 2000a; Thompson 2000b). All of the RCTS demonstrated adequate similar baseline outcome measurements. Only one study was inadequate with regards to baseline characteristics being similar (Campbell 2001). Inadequate allocation concealment was an issue in four of the RCTs, with studies either failing to conceal allocation or not making this clear (Barcelo 2010; Campbell 2001; Helitzer 2011; Thompson 2000b). The same four RCTs were unclear or failed in their reporting of adequate sequence generation (Barcelo 2010; Campbell 2001; Helitzer 2011; Thompson 2000b). Four RCTs were unclear or inadequate with regards to the adequacy of blinding in the assessment of outcomes (Barcelo 2010; Helitzer 2011; Nielsen 2007; Strasser 2008). Three RCTs were unclear or had evidence of selective outcome reporting (Barcelo 2010; Brown 1999; Thompson 2000a). All RCTs had evidence of other bias.

Controlled before and after studies

Allocation concealment was an issue for all CBA studies. Four of the CBA studies did not address incomplete outcome data (Janson 2009; Rask 2007; Weaver 2010; Young 2005). Two of the studies did not demonstrate adequate sequence generation (Janson 2009; Weaver 2010); or selective outcome reporting and adequate blinding (Rask 2007; Weaver 2010). All CBA studies ensured baseline outcome measurements were similar with the exception of one (Weaver 2010). Two studies did not report similar baseline characteristics (Weaver 2010; Young 2005); or that the study was adequately protected against contamination (Rask 2007; Weaver 2010). Only two studies were free of other bias (Janson 2009; Morey 2002) (see Figure 2).

Interrupted time series studies

Both ITS studies were adequate for pre-specifying the shape of the intervention effect and for the intervention to be unlikely to affect data collection. Taylor 2007 was unclear in their reporting of whether the intervention was independent of other changes, and were inadequate with regards to selective outcome reporting. Hanbury 2009 did not address all incomplete outcome data. Both ITS studies were not free of other bias (see Figure 3).

Effects of interventions

See: Summary of findings for the main comparison

Effects of IPE interventions reported in each of the studies are presented by the research design each employed.

Randomised controlled trials

The results of the study by Barcelo 2010 indicated that the proportion of people with good glycaemic control (glycosylated haemoglobin (HbA1c) < 7% (53 mmol/mol)) among those in the intervention group increased from 28% to 39% after the intervention (p value < 0.05). The proportion of people achieving three or more quality improvement goals increased from 16.6% to 69.7% (p value < 0.001) among the intervention group while the control group experienced a non-significant decrease from 12.4% to 5.9% (p value = 0.118).

In the study by Brown 1999, the communication skills training programme did not improve patient satisfaction scores. Based on an average of 81 responses for each of the 69 participating clinicians, there was no significant difference in the mean satisfaction scores for the intervention and control groups: each group showed a very small increase in mean scores on 9-point scales (intervention group 0.03 points and control group 0.05). 

The results in Campbell 2001 study indicated that the EDs that received the intervention to improve responses to acutely abused women recorded significantly higher levels on all components of the "culture of the emergency department" system-change indicator (e.g. appropriate protocols; materials such as posters, brochures, medical record intervention checklists and referral information available to staff; and staff training) (F = 5.72, p value = 0.04) and higher levels of patient satisfaction (F = 15.43, p value < 0.001) than the EDs in the control group. 

Helitzer 2011 reported that the intervention generated significant and persistent changes in patient-centred communication in the intervention group. After six months, a significant difference was found in scores for patient-centredness, which favoured the intervention group (F(1, 20.59) = 8.43, p value < 0.01). After 18 months, the intervention group's significantly higher patient-centredness scores were sustained (F(1, 17.16) = 5.48, p value = 0..032).

Nielsen 2007 found overall no statistically significant differences between the intervention and control groups. Data on adverse outcome prevalence were similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). However, the time from the decision to the incision for an immediate caesarean delivery was significantly shorter in the intervention group (p value = 0.03). In addition, one process measure, the time from the decision to perform an immediate caesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, p value = 0.03).

Strasser 2008 reported a significant difference in improvement in motor score between the intervention group and the control group (13.6% of people in the intervention gained more than 23 points, p value = 0.038). There was no significant difference for the other two outcome measures (p value = 0.1) for both. The proportion of people who had had a stroke making greater than the median functional gain increased by 4.4% in the intervention group, whereas it decreased by 9.2% in the control group, lending further support to the effect of the intervention. At the same time, the intervention had no measurable effect on participants' length of stay.

Thompson 2000a reported no differences between the intervention and control groups in relation to the recognition of depressive symptoms in their evaluation of the effectiveness of an IPE and clinical practice guideline intervention. The outcome for people diagnosed with depression did not significantly improve at six weeks or six months after the intervention. 

Thompson 2000b reported that following the intervention, documentation of domestic violence incidents increased by 14.3%. It is also stated that there was a 3.9-fold relative increase of documentation at nine months in intervention clinics compared to the control sites. Overall case finding increased by 30%, but this was not statistically significant. Recorded quality of domestic violence patient assistance did not change. 

Controlled before and after studies

Janson 2009 reported that, at study completion, intervention group participants more frequently received assessments of HbA1c (79% versus 67%; p value = 0.01), low-density-lipoprotein cholesterol (69% versus 55%; p value = 0..009), blood pressure (86% versus 79%; p value = 0.08), microalbuminuria (40% versus 30%; p value = 0.05), smoking status (43% versus 31%; p value = 0.02), and foot examinations (38% versus 20%; p value = 0.0005). It was also reported that intervention group participants had more planned general medicine visits (7.9 = 6.2 versus 6.2 = 5.7; p value = 0.006) than did control group participants.

The results of Morey 2002 evaluation of the effectiveness of an interprofessional teamwork training programme on collaborative behaviour in EDs, showed a statistically significant improvement in quality of observed team behaviours between the intervention and control groups following training (p value = 0.012). The clinical error rate significantly decreased from 30.9% to 4.4% in the intervention group (p value = 0.039). 

Rask 2007 reported that several key areas of documentation regarding assessment and management of fall risk factors improved. All except two were statistically significant for the intervention teams. Fall rates were not significantly different for the intervention nursing homes (p value = 0.92) and were significantly positive (p value = 0.008) for the control sites. Restraint use decreased substantially during the project period, from 7.9% to 4.4% in the intervention nursing homes (a relative reduction of 44%) and from 7.0% to 4.9% at the control sites (a relative reduction of 30%).

Weaver 2010 reported that intervention participants engaged in significantly more team pre-case briefings after attending training (F [1, 147] = 35.01, p value < 0.001). There was also a significant increase in the proportion of information sharing (e.g. intervention team members were more willing to speak up and participate during briefings) (F [1,128] = 11.47, p value < 0.001). This pattern was also present in the frequency of care plan discussions (F [1,145] = 5.00, p value < 0.05).

Young 2005 reported that in comparison to mental health practitioners in the control group, practitioners in the intervention group reported significantly higher scores in relation to the following competencies: teamwork (r = 0.28, p value = 0.003); holistic approaches (r = 0.17, p value = 0.06); education about care (r = 0.22, p value = 0.03); rehabilitation methods (r = 0.25, p value = 0.007) and overall competency (r = 0.21, p value = 0.02).

Time interrupted series studies

Hanbury 2009 reported that the intervention did not significantly increase adherence to the national guideline. Multiple regression was used to calculate the proportion of variance in intention accounted for by the predictors, and identify the most significant predictor. The intervention was found to account for 58% of the variance (adjusted R2 = 0.58) in intention to adhere to the guideline, a statistically significant finding (F = 23.586, 3 degrees of freedom (df), p value = 0.0001).  

Taylor 2007 found that the intervention achieved improvements in microalbumin testing (+7.40%, p value = 0.001) and HbA1c testing (+3.80%, p value = 0.029). A significant increase in microalbumin levels that were at target (+3.87%, p value = 0.018), and a significant decrease in HbA1c levels that were also at target (–3.81%, p value = 0.011). It is unclear in the reporting if the intervention is independent of other changes. In addition, outcomes were not assessed blindly.

Discussion

In total, this review included 15 studies, locating nine new studies, which were added to the six studies from the previous update (Reeves 2008). This small growth of eligible studies marks continued development of the IPE field, as the first IPE review found no eligible studies (Zwarenstein 2000).

Seven of the studies reported positive outcomes in the following areas: improvements in diabetes clinical outcomes and healthcare quality improvement goals (Barcelo 2010); improvements in patient-centred communication (Helitzer 2011); improved clinical outcomes for people with diabetes (Janson 2009); collaborative team behaviour and reduction of clinical error rates for ED teams (Morey 2002); increased rates of diabetes testing and improved patient outcomes (Taylor 2007); improved mental health practitioner competencies related to the delivery of patient care (Young 2005); and improved team behaviours and information sharing for operating room teams (Weaver 2010). Three of the studies also reported that the gains attributed to IPE were sustained over time: eight months (Morey 2002) and 18 months (Barcelo 2010; Helitzer 2011).

In addition, four studies (Campbell 2001; Rask 2007; Strasser 2008; Thompson 2000b) reported a mixed set of outcomes. As well as reporting positive outcomes in relation to changes in professional practice and patient satisfaction, Campbell 2001 found no differences in the identification rates of victims of domestic violence between their intervention and control groups. While Rask 2007 reported improvements in care documentation and decreases in the use of restraint for people in nursing homes, they found no change in fall rates. Despite reporting functional gains for patients, Strasser 2008 also reported no significant difference in length of stay or rates of community discharge for stroke rehabilitation patients. Thompson 2000b found that documented asking about domestic violence significantly increased, yet the increase in case finding was not significant.  

Four studies reported that the IPE interventions had no impact on either healthcare processes or patient health care or outcomes: Brown 1999 found no significant difference in the improvement of routinely collected patient satisfaction scores between intervention and control groups; Hanbury 2009 reported that the intervention did not significantly increase adherence among participants; Nielsen 2007 reported no statistically significant differences between the intervention and control groups; and Thompson 2000a reported that there were no differences between the intervention and control groups in relation to the recognition or treatment of patients with depression.

Although overall the results indicate some positive outcomes related to IPE, its effectiveness remains unclear at this time due to the heterogeneity among the 15 studies as well as their methodological limitations, as outlined above. The studies were heterogeneous in relation to the objectives and format of the educational intervention, the existence of other interventions in addition to the education, and the clinical areas and settings. The IPE component in these studies ranged from a few hours, to a few days, to longitudinal programmes that were delivered over one year or more. The professional mix of participants also varied from surgeons, nurses, surgical technicians, anaesthesiologists and physician assistants (Weaver 2010), to nurses, physiotherapists, occupational therapists, nursing assistants and maintenance staff (Rask 2007). The aims of the interventions also varied. For example in studies by Brown 1999 and Helitzer 2011, the emphasis was on communication between clinicians and participants, whereas other studies explicitly focused on interprofessional team work in the context of particular settings (ED, operation room) (e.g. Morey 2002; Weaver 2010).

Despite three studies sharing a focus on improving diabetes care (Barcelo 2010; Janson 2009; Taylor 2007), each employed a different research design: an RCT (Barcelo 2010), a CBA (Janson 2009) and an ITS (Taylor 2007). The interventions were different: from a single eight-hour IPE session (Barcelo 2010), to three workshops (Taylor 2007), to weekly seminars (Janson 2009). The participants also varied, from physicians, nurses, nutritionists and psychologists based at 10 public health centres (Barcelo 2010), to 120 students (medical residents, senior nurse practitioner and pharmacy students) (Janson 2009), to an existing team of professionals (who were not identified) based in a single clinic (Taylor 2007). These few examples are some indication of the degrees of heterogeneity and why it is difficult to summarise and identify key elements of successful IPE.

Eight of the studies (Barcelo 2010; Campbell 2001; Janson 2009; Morey 2002; Nielsen 2007; Rask 2007; Thompson 2000b; Young 2005) contained multi-faceted interventions, of which the IPE was only one component. The other interventions included team restructuring, tools such as posters and questionnaires, measurement and feedback, and consumer-directed interventions. In these studies, the authors commented on the importance of system change and the time and resources required to facilitate it (Campbell 2001), the need for leaders who support teamwork within organisations (Morey 2002; Rask 2007) and the use of quality improvement projects (Barcelo 2010; Janson 2009).

Methodologically, the studies shared a common key limitation. All comparative studies (RCTs and CBAs, n = 13) compared the effects of the IPE interventions with control groups that received no educational intervention. As a result, it is difficult to assess the effects of the IPE. Furthermore, most of the included studies involved small samples (defined as fewer than 100 individually randomised practitioners or fewer than 20 randomised clusters), which limited their ability to provide a convincing level of generalisable evidence for the effects of the IPE interventions.

It is also worth noting that there was little evidence of preliminary studies to optimise the IPE interventions and evaluation strategies. IPE interventions are complex, multifaceted interventions in which the components may act both independently and interdependently. Guidance on the development and testing of complex interventions stresses the importance of stepwise work to understand the context for the intervention fully, and optimise the design and implementation of the intervention and evaluation before proceeding to a trial (Craig 2008). 

When planning future trials of IPE, thought should be given to the following dimensions: better randomisation procedures, allocation concealment, larger sample sizes and more appropriate control groups. Importantly, studies should include at least one common outcome for measurement of teamwork to enable a formal weighing up of the evidence; in addition, the remainder of the outcomes should include a clear patient health outcome rather than only process measures. Given that IPE is delivered by two or more providers, future trials should have cluster randomised designs, and researchers are advised to be thoughtful about their unit of analysis. In addition, given a lack of evidence on the impact of IPE on resources (e.g. costs and benefits), attention is needed in this area.

While uniprofessional education remains the dominant model for delivering education for health and social care professionals, IPE is increasingly becoming common. Advocacy and implementation of IPE reflects the premise that IPE will contribute to developing healthcare providers with the skills and knowledge needed to work in a collaborative manner (Barr 2005; CIHC 2010; Interprofessional Educ Collab Expert Panel 2011; WHO 2010). Interprofessional collaboration, in turn, is identified as critical to the provision of effective and efficient health care, given the complexity of patients' healthcare needs and the range of healthcare providers and organisations. In relation to implementing IPE at differing stages of the professional development continuum, it is worth remembering that pre-qualification IPE can be regarded as an investment in the future and, in general, studies with short periods of follow-up would not be expected to detect effects on patient outcomes or healthcare processes, which would be difficult to pinpoint, due to a wide variety of potentially confounding variables. Measuring patient outcomes or care process outcomes arising from IPE after qualification (e.g. during continuing professional development and quality improvement initiatives) is more feasible. But it still presents methodological challenges, particularly identifying the influence of IPE within multifaceted interventions and, further, identifying key attributes of effective IPE.

Although this review located nine new IPE studies (which were added to the six studies from the last update) their heterogeneity limits the conclusions we can draw from this work. Nevertheless, a continued increase in eligible studies represents a further positive step forward in establishing a robust evidence base for the effects of IPE on professional practice and healthcare outcomes.

Authors' conclusions

Implications for practice

Our first IPE review published in 1999 found no eligible studies, our 2008 update located six studies, and this update located a further nine studies. At 15 eligible studies, this demonstrates that the IPE field is growing steadily in terms of publishing rigorous IPE research (those employing RCTs, CBA or ITS designs). Although these studies reported a range of positive outcomes, the heterogeneity of IPE interventions means it is not possible to draw generalisable inferences for the effects of IPE. Despite marking a step forward in beginning to establish an evidence base for IPE, more rigorous IPE research (those employing RCTs, CBA or ITS designs) is needed to demonstrate evidence of the impact of this type of intervention on professional practice or healthcare outcomes, or both.

Implications for research

Despite a growth of IPE studies in the past few years, most of this research does not employ rigorous designs. Future RCTs explicitly focused on IPE with rigorous randomisation procedures and allocation concealment, larger sample sizes and more appropriate control groups would improve the evidence base of IPE. A focus on understanding the use of IPE in relation to resources is also needed. These studies should also include data collection strategies that provide insight into how IPE affects changes in healthcare processes and patient outcomes as research to date has not sufficiently addressed this critical issue.  

To improve the quality of evidence relating to IPE and patient outcomes or healthcare process outcomes, the following three gaps will need to be filled: studies that assess the effectiveness of IPE interventions compared to separate, profession-specific interventions; RCT, CBA or ITS studies with qualitative strands examining processes relating to the IPE and practice changes; and cost-benefit analyses.

What’s new

We completed a substantive update of review from 2008 to 2011. Nine new studies were found and added to the six studies located from the previous update.

Acknowledgements

Amber Fitzsimmons, doctoral student at University of California, San Francisco, for her help with preliminary abstraction notes of some of the included studies.

Data and analyses

Download statistical data

This review has no analyses.

Appendices

Appendix 1. MEDLINE search strategy

MEDLINE search strategy
1 (interprofession$ or inter-profession$).tw.

2 (interdisciplin$ or inter-disciplin$).tw.

3 (interoccupation$ or inter-occupation$).tw.

4 (interinstitut$ or inter-institut$).tw.

5 (interagen$ or inter-agen$).tw.

6 (intersector$ or inter-sector$).tw.

7 (interdepartment$ or inter-department$).tw.

8 (interorgani?ation$ or inter-organi?ation$).tw.

9 interprofessional relations/

10 team$.tw.

11 (multiprofession$ or multi-profession$).tw.

12 (multidisciplin$ or multi-disciplin$).tw.

13 (multiinstitution$ or multi-institution$).tw.

14 (multioccupation$ or multi-occupation$).tw.

15 (multiagenc$ or multi-agenc$).tw.

16 (multisector$ or multi-sector$).tw.

17 (multiorgani?ation$ or multi-organi?ation$).tw.

18 exp professional-patient relations/

19 (transprofession$ or trans-profession$).tw.

20 (transdisciplin$ or trans-disciplin$).tw

21 or/1-20

22 (education$ or train$ or learn$ or teach$ or course$).tw.

23 exp education, continuing/

24 exp education, graduate/

25 or/22-24

26 21 and 25

27 program evaluation/

28 "health care outcome?".tw.

29 (education$ adj outcome?).tw.

30 or/27-29

31 26 and 30

 

Appendix 2. CINAHL search strategy

CINAHL search strategy

(TX interprofession*) or (TX inter-profession*) or (TX interdisciplin*) or (TX inter-disciplin*) or (TX interoccupation*) or (TX inter-occupation*) or (TX interinstitut*) or (TX inter-institut*) or (TX interagen*) or (TX inter-agen*) or (TX intersector*) or (TX inter-sector*) or (TX interdepartment*) or (TX inter-department*) or (TX interorgani?ation*) or (TX inter-organi?ation*) or (MH interprofessional relations) or (TX team*) or (TX multiprofession*) or (TX multi-profession*) or (TX multidisciplin*) or (TX multi-disciplin*) or (TX multiinstitution*) or (TX multi-institution*) or (TX multioccupation*) or (TX multi-occupation*) or (TX multiagenc*) or (TX multi-agenc*) or (TX multisector*) or (TX multi-sector*) or (TX multiorgani?ation*) or (TX multi-organi?ation*) or (MH "Professional-Patient Relations+") or (TX transprofession*) or (TX trans-profession*) or (TX transdisciplin*) or (TX trans-disciplin*) AND (TX education*) or (TX train*) or (TX learn*) or (TX teach*) or (TX course*) or (MH "education, continuing+") or (MH "education, graduate+") AND (MH "student performance appraisal+") or (MH "course evaluation") or (MH "program evaluation") or (MH "evaluation research+") or (MH "health care outcome*") or (education* N1 outcome*)

Feedback

Lack of Evidence

Summary

Received 20/04/2003 13:47:02

I am assuming this excellent work is a follow up from earlier published material from 1999 (J. Int. Care 13 (4)417-4). What I cannot understand is why, therefore is IPE still 'flavour of the month'? We wouldn't push ideas forward without adequate evidence of effectiveness first! Isn't anyone else out there brave enough to concur with the authors? I certify that I have no affiliations with or involvement in any organisation or entity with a direct financial interest in the subject matter of my criticisms.

Reply

Thank you for your positive comment. The article to which you refer is indeed a print version of this Cochrane review, and we will note that in the review. We would like to stress that the 'absence of evidence of effect is not evidence of absence of effect' (Cochrane Reviewers' Handbook 4.1.5, section 9.7). We therefore suggest that interprofessional education (IPE) interventions ought to be implemented widely, but ONLY in the context of rigorous evaluations, ideally randomised controlled trials of their effects. This is not as difficult as it might at first seem, and we would encourage those who are interested enough in IPE to want to subject it to reliable test to contact us or other groups of researchers with randomised controlled trial experience for advice and help.

Merrick Zwarenstein [on behalf of the reviewers.]

The most recent update to this review is published in Issue 1, 2008. The update now has 6 studies. However, it still remains very difficult to draw conclusions about the effectiveness of this intervention and we continue to require further research in the area.

Alain Mayhew [on behalf of the authors and the editorial staff and team]

Contributors

Jane Warner, Practice Nurse

What's new

DateEventDescription
28 February 2013New search has been performedSubstantive amendment, search up to Aug 2011, nine additonal studies
28 February 2013New citation required but conclusions have not changedNine new studies, but no change in conclusions

History

Protocol first published: Issue 3, 2000
Review first published: Issue 1, 2001

DateEventDescription
29 July 2008AmendedConverted to new review format.
12 November 2007New citation required and conclusions have changedSubstantive amendment

Contributions of authors

SR, LP and JG searched and reviewed the literature and extracted data with input from MZ. SR interpreted the data and wrote the main draft of the review with input from LP, JG, DF and MZ. MZ Is guarantor for the review.

Declarations of interest

None known.

Sources of support

Internal sources

  • Center for Innovation in Interprofessional Education, University of California, San Francisco, USA.

  • Li Ka Shing Knowledge Institute of St Michael's Hospital, Canada.

  • Continuing Education and Professional Development, Faculty of Medicine, University of Toronto, Canada.

  • Institute of Health Sciences Education, Queen Mary University London, UK.

  • Institute for Clinical Effectiveness, Toronto, Canada.

External sources

  • No sources of support supplied

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Barcelo 2010

MethodsRCT where teams based in 10 public health centers were randomised to intervention project to improve the quality of diabetes care (n = 5) or control group (n = 5)
ParticipantsPhysicians, nurses, patients, nutritionists and psychologists
InterventionsThe intervention group received learning sessions focused on the implementation of strategies to improve quality of diabetes care
OutcomesClinical outcomes, healthcare process quality improvement goals
NotesNone
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Describes that health centres were "

randomly selected" (p. 146) but random component in the sequence generation process is not described

Allocation concealment (selection bias)Unclear riskNot specified
Baseline outcome measurements similar
All outcomes
Low riskReported in Table 5 (p. 150)
Baseline characteristics similarLow riskReported in Table 1 (p. 148)
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported
ContaminationHigh riskQuote "…avoiding the contamination' of centers that acted as controls…was not possible" (p. 151)
Selective reporting (reporting bias)High riskQuote "…did not collect data on intermediate process variables" (p. 151)
Other biasHigh riskShort follow-up (p. 151)

Brown 1999

MethodsRCT where clinicians were randomly assigned to attend immediate (intervention) or later sessions of the programme (control group)
ParticipantsPhysicians, nurse practitioners, physician assistants, optometrists
Interventions2 physicians gave a communication skills training programme consisting of a 4-hour interactive workshop and a 4-hour follow-up workshop 1 month later. Between workshops participants were asked to audio record and review at least 2 consultations, and an instructor made an encouraging telephone call to each participant
OutcomesRoutinely collected patient satisfaction scores, self reported ratings of communication skills
NotesReported increases in patient satisfaction were not significant. However baseline scores were high in both groups, leaving little room for increase. The study authors state that longer and more intensive training, performance incentives, ongoing feedback and possibly practice restructuring may be needed to improve general patient satisfaction. They also note that the content of the routinely conducted patient satisfaction survey was not well-aligned to the particular focus of the communication skills training. The Art of Medicine survey used in this study is not a validated instrument
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk

Quote "…we used a random-number table" (p. 823)

 

Allocation concealment (selection bias)Low riskQuote "we used a random-number table to assign persons to the intervention or control group" (p. 823)
Baseline outcome measurements similar
All outcomes
Low riskReported in Table 2 (p. 826)
Baseline characteristics similarLow riskQuote "Table 1 compares the characteristics of the intervention and control groups at study entry. No statistically significant differences were seen…" (p. 825)
Incomplete outcome data (attrition bias)
All outcomes
Low riskReported and intention-to-treat analysis was modified (p. 825)
Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcomes were obtained from quote "an anonymous questionnaire that was mailed to patients by a contractor to the HMO" (p. 823)
ContaminationUnclear riskNot specified if control group could have received similar training through other educational opportunities
Selective reporting (reporting bias)Unclear riskInsufficient information to make an assessment
Other biasHigh riskSurvey not validated (p. 824)

Campbell 2001

MethodsRCT with baseline (pre-test), immediate (9-12 months), and long-term (18-24 months) post assessments. Hospitals randomly assigned to experimental and control groups
ParticipantsEmergency department teams (physicians, nurses, social workers, administrators) and local domestic violence advocates
Interventions2-day information and team planning intervention
OutcomesRates of reported domestic violence, patient satisfaction, audit of clinical documentation
NotesOnly 1 hospital sent a complete team as requested; 2 hospitals did not send a physician; social worker sent from 5 of 6 hospitals. Limited institutional support for IPE noted as a possibility for poor outcomes in this study. The components of the culture of emergency department system-change indicator instrument used in this study is not a validated tool
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot specified
Allocation concealment (selection bias)Unclear riskNot specified
Baseline outcome measurements similar
All outcomes
Low riskQuote "This evaluation used an experimental design with baseline (pretest), immediate (9–12 months), and long-term (18–24 months) post-assessments…" (p. 132)
Baseline characteristics similarHigh riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Low riskResponse rates reported (p. 134)
Blinding of outcome assessment (detection bias)
All outcomes
Low riskReviewers had "no knowledge of an individual woman's responses to acute abuse" (p. 136)
ContaminationLow riskSites geographically spread across California and Pennsylvania (p. 132)
Selective reporting (reporting bias)Low riskAll relevant outcomes in the methods section are reported in results
Other biasHigh riskOnly 1 intervention hospital sent a complete team for training (p. 134); insufficient sample size (p. 136); external events may have impacted treatment of battered women at California hospitals (OJ Simpson trial) (p. 136)

Hanbury 2009

MethodsITS study to test the effectiveness of an intervention to increase adherence to a national suicide prevention guideline at a single trust hospital
ParticipantsCommunity mental health professionals (individual professions not specified)
InterventionsA didactic presentation, an interprofessional group discussion stressing positive normative beliefs, interactive group work based on 2 real-life vignettes
OutcomesAdherence rates to guideline use
NotesNeeds assessment data (interviews and questionnaires) were gathered in 2 earlier phases of the study to inform the design of the intervention. The impact of 2 extraneous events was also included – the national introduction of the guideline, and a local change in the system for monitoring service-user discharges
Risk of bias
BiasAuthors' judgementSupport for judgement
Incomplete outcome data (attrition bias)
All outcomes
High riskQuote "...discontinuity occurred between those who returned the questionnaire and those who attended the intervention" (p. 516)
Blinding of outcome assessment (detection bias)
All outcomes
Low riskRoutinely collected audit adherence data used (p. 505)
Selective reporting (reporting bias)Low riskRoutinely collected audit adherence data used (p. 505)
Other biasHigh riskHigh staff turnover at intervention site (p. 516). Discontinuities in the samples
Intervention independent of other changesLow risk2 events were identified and 6 separate analyses were done in order to accommodate the events (p. 509)
Shape of intervention effect pre-specifiedLow riskPoint of analysis is the point of intervention
Intervention unlikely to affect data collectionLow riskRoutinely collected audit adherence data used (p. 505)

Helitzer 2011

MethodsAn RCT of an IPE intervention aimed to improve patient-centred care with follow-up data gathered at 6 and 18 months. Individual professionals were randomised to receive the intervention (n = 13) or act as a control group (n = 14)
ParticipantsPhysicians, physician assistants and nurse practitioners
InterventionsA full-day interprofessional training, individualised feedback on video-taped interactions with simulated patients, and optional workshops to reinforce strategies for engaging the patient
OutcomesObservations of patient-centred communication
NotesData were also gathered on simulated professional-patient interactions to detect the efficacy of the intervention
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot reported
Allocation concealment (selection bias)Unclear riskNot reported
Baseline outcome measurements similar
All outcomes
Low riskPatient-centredness summary score reported for training and medical visits (Tables 4 and 5)
Baseline characteristics similarLow riskQuote "…no significant differences between the groups in terms of sex or practice type, either at baseline or at the final medical visit"
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs indicated in Figure 1. Adjusted for in analysis
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote "The simulated patients were blind to the provider group assignment", however no statement is made about whether coders were blinded
ContaminationUnclear riskSample size is small and recruited from departments of General Internal Medicine and Family Practice of 1 university medical system
Selective reporting (reporting bias)Low riskSee Tables 4 and 5
Other biasHigh riskSampling bias

Janson 2009

MethodsA CBA study that aimed to evaluate interprofessional team-based diabetes care. 120 clinical students received the intervention, while 28 medical residents acted as the control group
ParticipantsMedicine residents, nurse practitioner students, pharmacy students
InterventionsWeekly intervention consisting of didactic presentations, clinical discussions and clinic visits with patients. Quality improvement projects were also developed and implemented. Quarterly patient panel reports also received
OutcomesClinical outcomes, planned visits
NotesAs intervention team members were clinical learners enrolled in different training programmes, they had different rotational schedules, which resulted in a changing team membership
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High risk

Quote "This study was designed as a

nonrandomized, parallel-group clinical trial" (p. 1541)

Allocation concealment (selection bias)High riskEPOC indicates: CBA studies should be scored ‘high risk’
Baseline outcome measurements similar
All outcomes
Low riskReported in Tables 3 and 4 (p. 1544-1545)
Baseline characteristics similarLow riskQuote "Table 2 shows the demographic characteristics of the two cohorts; there were no significant differences between them" (p. 1543)
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskTable 2 has data missing for 1 participant
Blinding of outcome assessment (detection bias)
All outcomes
Low riskData came in from clinical info system directly and loaded into SPSS (p. 1543). Aggregate data stripped of identifiers was analysed (p. 1541)
ContaminationHigh risk1 institution, team members from intervention group could readily interact with control group
Selective reporting (reporting bias)Low riskAll relevant outcomes in the methods section are reported in results
Other biasLow riskStudy patients were pre-assigned to the medicine residents in both groups and were not randomised (p. 1546)

Morey 2002

MethodsCBA study with data gathered 8 months after the intervention. 6 emergency departments received the intervention, while 3 emergency departments acted as the control group
ParticipantsPhysicians, nurses, technicians, and clerks based in 9 teaching and community hospital emergency departments
InterventionsAn 8-hour intervention delivered to groups of physicians, nurses, technicians and clerks involving lectures, discussion of video-taped segments of teamwork and clinical vignettes and interactive teamwork exercises
OutcomesCollaborative behaviour, clinical error rates
NotesAlso gathered survey data which indicated no change in attitudes for participants following the delivery of the IPE intervention
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote "A prospective investigation using a quasi-experimental, untreated control group design" (p. 1556)
Allocation concealment (selection bias)High riskEPOC indicates: CBA studies should be scored ‘high risk’
Baseline outcome measurements similar
All outcomes
Low riskReported in Tables 3 and 4 (pp. 1569-1570)
Baseline characteristics similarLow risk

Quote "The control and experimental group patients who participated in the study

were similar in both Period 1 and Period 2…"

(p. 1563)

Incomplete outcome data (attrition bias)
All outcomes
Low riskMissing data was minimal, amounting to 8.1% or less for each of the outcome measures (p. 1563)
Blinding of outcome assessment (detection bias)
All outcomes
Low riskReported use of "blinded raters…" (p. 1566)
ContaminationLow risk9 separate teaching and community hospital sites (p. 1553)
Selective reporting (reporting bias)Low riskReported in Table 2 (pp. 1555-1556)
Other biasLow risk

Quote "91 percent agreement rate of observed errors that was significantly above chance,

we feel that the lack of blinding was unlikely to introduce appreciable bias into the observed error results" (p. 1575)

Nielsen 2007

MethodsA cluster RCT to evaluate the effectiveness of an interprofessional intervention aimed at reducing adverse outcomes and improving processes of care in labour and delivery units. Fifteen hospitals were randomised to either receive the intervention (n = 7) or act as the control (n = 8)
ParticipantsObstetricians, anaesthesiologists and nurses
InterventionsA 3-day intervention consisting of 4 hours of didactic lessons, video scenarios, and interactive training covering team structure and processes, planning and problem solving, communication, workload management and team skills, assistance with creation of interprofessional teams by use of onsite training sessions, and an on-call contingency team to respond to obstetric emergencies
OutcomesAdverse maternal/neonatal outcomes, clinical process outcomes
NotesExplanations for lack of significant impact include training not effective, teamwork that results in a detectable impact may require more than a 4-hour training session and more than 4 months to practice behaviours regularly
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk

Quote "…a table of random numbers

was used to simulate the toss of a coin" (p. 49)

Allocation concealment (selection bias)Low riskQuote "A balanced, masked randomization scheme at the hospital (cluster) level was implemented by the project biostatistician" (p. 49)
Baseline outcome measurements similar
All outcomes
Low riskReported in Table 3 (p. 52)
Baseline characteristics similarLow riskReported in Table 3 (p. 52)
Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote "All analyses were by intention to treat" (p. 51)
Blinding of outcome assessment (detection bias)
All outcomes
High riskQuote "The trial was not blinded, with personnel at each site aware of their assignment to either the intervention or control arm" (p. 49)
ContaminationUnclear riskHospitals are in different US states but unclear if some personnel may be in contact (e.g. if they are in the military)
Selective reporting (reporting bias)Low riskSee Table 4 (p. 53)
Other biasUnclear riskUnclear if data were collected independently by co-ordinators that were not hospital personnel

Rask 2007

Methods

A CBA study aimed to evaluate an interprofessional fall management quality improvement project in nursing homes

19 nursing homes received the intervention while 23 acted as the control

ParticipantsNurses, physiotherapists, occupational therapists, nursing assistants, maintenance staff
InterventionsA full-day interprofessional workshop and a second follow-up workshop approximately 1 month later to address arising challenges, organisational leadership buy-in and support , a facility-based falls coordinator, ongoing consultation by advanced practice nurses with expertise in falls management
OutcomesCare documentation, fall rates, restraint use
NotesNone
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskConvenience sample of 19 nursing homes (p. 342)
Allocation concealment (selection bias)High riskEPOC indicates: CBA studies should be scored ‘high risk’
Baseline outcome measurements similar
All outcomes
Low riskReported in Table 2 (p. 347)
Baseline characteristics similarLow riskTable 1 indicates no statistically significant differences (p. 346)
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskTable 2 reports results of care processes for 14 of 19 nursing homes – no explanation of missing data on 5 nursing homes
Blinding of outcome assessment (detection bias)
All outcomes
High riskChart audits done by individuals who quote "were not blind to the intervention status of the facilities" (p. 345)
ContaminationHigh riskNursing homes owned and operated by a single non-profit organisation (p. 342)
Selective reporting (reporting bias)High riskChart audits only done on 14 out of 19 intervention nursing homes
Other biasHigh riskNot randomised, chart audit incomplete

Strasser 2008

MethodsCluster RCT involving 31 stroke rehabilitation clinics that were randomised to either receive an IPE intervention designed to improve the care of people who had had a stroke (n = 15) or act as a control group (n = 16)
ParticipantsPhysicians, nurses, occupational therapists, speech-language pathologists, physiotherapists and social workers
InterventionsA 6-month intervention consisting of an interactive workshop emphasising team dynamics, problem solving, and the use of performance feedback data and action plans for process improvement. Follow-up telephone and video-conference consultations were also offered
OutcomesFunctional gains, length of stay, rates of community discharge
NotesNone
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote "…randomized sites to either intervention or control group using a computer…" (pp. 11-12)
Allocation concealment (selection bias)Low riskQuote "…randomized sites to either intervention or control group using a computer…" (pp. 11-12)
Baseline outcome measurements similar
All outcomes
Low riskReported in Table 2
Baseline characteristics similarLow riskReported in Table 1. Description of adjustments in analyses (pp. 12-13)
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAcknowledge sites dropped out but do not discuss if necessary to adjust analyses (p. 12)
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported if data collectors and assessors were blinded
ContaminationLow riskSites randomised across US
Selective reporting (reporting bias)Unclear riskLack of reporting on sites that dropped out of study
Other biasUnclear riskLack of reporting on sites that dropped out of study

Taylor 2007

MethodsAn ITS study to assess the effects of an IPE intervention on the delivery of standard diabetes services and clinical outcomes for patients based at 1 site
ParticipantsHealthcare professionals based in a single primary care clinic
InterventionsAn education intervention that aimed to improve communication, teamwork, workflow to improve diabetes care and patient outcomes. The intervention included task redistribution, standardised communication and decision-support tool development
OutcomesRates of diabetes testing, clinical outcomes
NotesParticipants are reported as a "team" but different professional groups are not described. Clinicians and staff revised existing diabetes care protocols and processes using the American Diabetes Association clinical guidelines. The new process and diabetes checklist were implemented
Risk of bias
BiasAuthors' judgementSupport for judgement
Incomplete outcome data (attrition bias)
All outcomes
Low riskPre-intervention visit and post-intervention visit reported for 277 individuals (p. 246)
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported
Selective reporting (reporting bias)High riskTable 2 analyses reported inconsistently for 3 months or 12 months (p. 246)
Other biasHigh riskLack of a control group (p. 247)
Intervention independent of other changesUnclear riskLack of a comparator as no control group in the study
Shape of intervention effect pre-specifiedLow riskPoint of analysis is the point of intervention
Intervention unlikely to affect data collectionUnclear riskNot reported

Thompson 2000a

MethodsRCT involving 59 primary care practices which were randomly assigned to an intervention group (29 practices) or a control group (30 practices)
ParticipantsPhysician and nursing teams from the participating primary care practices
Interventions4-hour seminar delivered to the primary healthcare teams. The seminars included video-tapes, small group discussion of cases, and role play
OutcomesRecognition and treatment of patient depression
NotesWhile actual number of physicians is reported (n = 152), actual number of nurses is not recorded. Qualitative data relating to participants' views of the intervention were also gathered
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote "Practices were randomly assigned by computer" (p. 186)
Allocation concealment (selection bias)Low riskQuote "Practices were randomly assigned by computer" (p. 186)
Baseline outcome measurements similar
All outcomes
Low riskQuote "Analyses controlled for ... baseline differences in outcome measures between groups" (p. 187)
Baseline characteristics similarLow riskQuote "Randomisation produced adequate matching between the intervention and control groups" (p. 188).  Also reported in Table 2
Incomplete outcome data (attrition bias)
All outcomes
High riskAn intention-to-treat analysis was reported (p. 187)
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported
ContaminationLow riskSites were geographically spread across county of Hampshire
Selective reporting (reporting bias)Low riskReported in Tables 4 and 5
Other biasHigh riskLarge drop-out rates reported in the control group

Thompson 2000b

MethodsRCT involving 5 clinics which were randomly assigned to 2 intervention groups and 3 control groups. Follow-up data were gathered at 9-10 months and 21-23 months
ParticipantsPrimary care practice teams of physicians, nurse practitioners, physician assistants, registered nurses, licensed practical nurses, medical assistants
Interventions2 half-day training sessions based on Precede/Proceed model for behaviour change; 3 extra training sessions for opinion leaders, newsletter, 4 additional educational sessions to teams, system support (e.g. posters in waiting areas, cue cards for providers)
OutcomesProvider knowledge, attitudes and beliefs, rates of asking, case finding, quality of assistance
NotesUnvalidated survey and qualitative data on provider views of the intervention were gathered
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot specified
Allocation concealment (selection bias)Unclear riskNot specified
Baseline outcome measurements similar
All outcomes
Low riskReported in Table 2 (p. 258)
Baseline characteristics similarLow risk"Intervention and control groups at baseline did not differ…" (p. 256)
Incomplete outcome data (attrition bias)
All outcomes
Low riskAdjustments in analysis made for this (p. 256)
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "Chart abstractors, blinded to intervention status, ascertained any mention of possible DV in the records" (p. 256)
ContaminationLow riskClinics spread across large metropolitan area (p 254)
Selective reporting (reporting bias)Low riskReported in Table 2 (p. 258)
Other biasHigh riskSmall number of clinics (p. 260)

Weaver 2010

MethodsA CBA study to evaluate an interprofessional intervention designed to improve team-based collaboration for operating room clinicians. Staff at 1 hospital site received the intervention, while staff based at 1 other site acted as a control
ParticipantsSurgeons, nurses, surgical technicians, anaesthesiologists, physician assistants
InterventionsThe intervention consisted of a 4-hour session which included interactive role-playing activities between participants
OutcomesObserved collaborative behaviour between participants
NotesOther outcomes reported included changes in perceptions and attitudes from the use of the Hospital Survey on Patient Safety Culture and Operating Room Management Attitudes Questionnaire
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskQuote "teams...volunteered to participate in the training and evaluation efforts" (p. 135)
Allocation concealment (selection bias)High riskEPOC indicates: CBA studies should be scored ‘high risk’
Baseline outcome measurements similar
All outcomes
High riskReported in Tables 3 and 4 (p. 136-137)
Baseline characteristics similarUnclear riskNot reported (p. 135)
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskFor example, analyses not conducted for initial observations with regards to debriefing (p. 139)
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported if observers were blinded (p. 137)
ContaminationLow riskGroups located at separate campuses (p. 133)
Selective reporting (reporting bias)Unclear riskFor example, analyses not conducted for initial observations with regards to debriefing (p. 139)
Other biasUnclear riskObservation tool not validated (p. 137). Small sample size of volunteers used in the study. Attrition of control group (p. 139)

Young 2005

  1. a

    CBA: controlled before and after; EPOC: Effective Practice and Organisation of Care; IPE: interprofessional education; ITS: interrupted time series; RCT: randomised controlled trial.

MethodsCBA study involving 2 mental health provider organisations which received the intervention, while 3 acted as the control group
ParticipantsPsychiatrists, mental health nurses, therapists, case managers
Interventions

6 educational components delivered over 1 year involving presentations, small group discussions, role play and 3- to 4-day detailing visits

16 hours of follow-up discussions to monitor progress

OutcomesPractitioner professional competencies
NotesSemi-structured interviews were gathered to qualitatively explore the effects of the intervention in more detail
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk

Quote "This study used a quasi-experimental

design" (p. 968)

Allocation concealment (selection bias)High riskEPOC describes that CBAs should be scored high for first 2 items
Baseline outcome measurements similar
All outcomes
Low riskReported in Tables 4 and 5
Baseline characteristics similarHigh riskSite selection based on clinics which "served a large population with severe and persistent mental illness, and provided similar types of services" (p. 986)
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAnalyses undertaken "using multiple imputation to replace missing data" (p. 970)
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported
ContaminationLow riskSites based in 2 US states – Quote "each state included both intervention and control organizations, ensuring that external events would not be confounded with the intervention" (p. 986)
Selective reporting (reporting bias)Low riskSee Tables 4 and 5
Other biasHigh riskSmall sample size, authors did not measure change in the appropriateness of care or client outcomes (p. 974)

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
  1. a

    CBA: controlled before and after; IPE: interprofessional education; ITS: interrupted time series; RCT: randomised controlled trial.

Ammentorp 2007Not an IPE intervention
Anderson 2009Not an RCT, CBA or ITS
Antunez 2003Post-intervention study design
Armitage 2009Not an RCT, CBA or ITS
Barrett 2001Description of IPE intervention that reports no outcomes
Barton 2006Not an IPE intervention. 1 group pre-/post-test study design
Bashir 2000Not an IPE intervention
Bauer 2009Not an IPE intervention
Beal 2006Not an IPE intervention
Belardi 2004Not an IPE intervention
Bell 2000Not an IPE intervention
Bellamy 20061 group pre-/post-test study design
Benjamin 1999Not an IPE intervention
Berg 2009Not an RCT, CBA or ITS
Berggren 2008Not an IPE intervention
Birch 2007Not an RCT, CBA or ITS
Bluespruce 20011 group pre-/post-test study design
Boyle 20041 group pre-/post-test study design
Bradshaw 2011Not an IPE intervention
Buck 1999Post-intervention study design
Burns 2003Not an IPE intervention
Buxton 2004Not an IPE intervention
Cameron 2009Not an IPE intervention
Carew 2001Post-intervention study design
Cobia 1995Before and after study with no controls
Coggrave 2001Not an IPE intervention
Connolly 1995Post-intervention study with no controls
Cooper 2005A CBA study that gathered self report data related to attitudes and knowledge change
Corso 20061 group post-intervention study design
Crutcher 2004A clinical controlled trial of an IPE intervention. Reports outcomes related to self reported knowledge change
Dacey 2010Not an RCT, CBA or ITS
Dalton 1999Not an IPE intervention
DeVita 20051 group post-intervention study design
Dienst 1981CBA study. Failed to meet comparison group criteria
Dobson 20021 group pre-/post-test study design
Falconer 1993Post-intervention study with control group. Failed to meet comparison group criteria
Fields 2005Not an IPE intervention
Gandara 2010Not an IPE intervention
Hanson 2005Not an IPE intervention
Harmon 19985-year longitudinal study with no controls
Hayward 1996Before and after study with no controls
Hien 2008Not an IPE intervention
Hook 20031 group post-intervention study design
Hope 20051 group pre-/post-intervention study design
Horbar 2001Not an IPE intervention
Hughes 2000Descriptive study
James 20051 group pre-/post-intervention study design
Jones 2006Not an IPE intervention
Jordan-Marsh 20041 group pre-/post-test study with follow-up data collection points
Kenward 2009Not an RCT, CBA or ITS
Ketola 2000Not an IPE intervention
Kwan 2006Outcomes did not meet inclusion criteria
Landon 2004Not an IPE intervention
Lawrence 2002Not an IPE intervention
Lia-Hoagberg 1997Before and after study with no controls
Llewellyn-Jones 1999Not an IPE intervention
McBride 2000Not an IPE intervention
Monette 2008Not an IPE intervention
Nash 1993Before and after study with no controls
O'Boyle 1995Before and after study with no controls
Olivecrona 2010Not an RCT, CBA or ITS
Ouslander 2001Not an IPE intervention
Phillips 2002Not an IPE intervention
Price 2005Not an IPE intervention
Rogowski 2001Not an IPE intervention
Rubenstein 1999Not an IPE intervention
Ryan 2002Not an IPE intervention
Sauer 2010Not an IPE intervention
Smarr 2003Not an IPE intervention
Smith 20051 group pre-/post-intervention study design
Stewart 2010Not an IPE intervention
Taylor 2002Not an IPE intervention
Thomas 2007Not an IPE intervention
Trummer 2006No control group
Tschopp 20051 group pre-/post-intervention study design
Umble 2003Not an IPE intervention
Unutzer 2001Not an IPE intervention
Ward 2004Not an IPE intervention
Wells 2000Not an IPE intervention
Westfelt 2010Not an RCT, CBA or ITS
Wisborg 2009Not an RCT, CBA or ITS

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