September, 2009 - SUPPORT Summary of a systematic review | print this article |

Does interprofessional education improve professional practice and health care outcomes?

Patient care is a complex activity which demands that health and social care professionals rendering services work together in an effective manner. Prior research suggests that health professionals may not communicate or collaborate well together in providing health care. Interprofessional education (IPE) is seen as an opportunity to enhance communication and collaboration between professionals to ultimately improve professional practice and health care outcomes.

Key messages

Studies conducted in high income countries provide low quality evidence on the effects of interprofessional education (IPE).
IPE may improve departmental culture, collaborative team behaviour, and health professional competencies, as well as reduce clinical error rates.
The effect of IPE on patient satisfaction, the quality of care and clinical outcomes is uncertain.
Factors that may need to be considered in the applicability of IPE in LMIC settings include resource and time requirements to implement such interventions.
Further rigorous research is needed to demonstrate evidence of the impact of this type of intervention on professional practice and/or healthcare outcomes.

Who is this summary for?

People making decisions about education of health professionals

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, Koppel I. Interprofessinal education: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD 002213. See in Cochrane Library

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Interprofessional education (IPE) has generated a great deal of interest amongst policy makers, educators and researchers as a means to cultivate collaborative practice and enhance patient care. Despite the need for good interprofessional communication and collaboration to help coordinate patient care in an effective manner, research has found that achieving this is problematic.

This summary is based on a systematic review published in 2008 by Reeves and colleagues on the effectivness of IPE in improving interprofessional collaboration and patient care. A previous review in 2000 by the same authors found no IPE studies employing randomised control trials (RCTs), controlled before and after studies (CBA), or interrupted time series studies (ITS) to provide good quality evidence. Numerous studies with a broader methodological approach have since been undertaken. The 2008 review therefore provides an update on the available evidence on IPE.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

/	What the review authors searched for	What the review authors found
Review Objectives: To assess the effectiveness of interprofessional education (IPE) interventions in improving professional practice and patient outcomes
Interventions	RCTs, CBAs and ITS studies assessing IPE interventions where two or more health and/or social care professions learn interactively together to achieve improved interprofessional collaboration and patient care	4 RCTs and 2 CBAs which assessed IPE interventions such as communication skills training, teamwork and team planning interventions, behaviour change training and support. These were implemented over different time periods ranging from four hours to one year.
Participants	Health and social care professionals	Health and social care professionals including physicians, nurses, optometrists, social workers, health administrators, clerks, physician assistants, psychiatrists, and mental health workers amongst others
Settings	Not specified	Hospital emergency departments, community mental health provider organisations, primary care clinics , and a health maintenance organisation in the US (5) and the UK (1)
Outcomes	Objectively measured or self reported healthcare process measures and patient outcomes	A range of outcomes including system change indicators, observed team behaviours, changes in professional practice, patient satisfaction and clinical care outcomes
Date of most recent search: September 2006
Limitations: This is a good quality systematic review

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

The review included six studies which compared the effectiveness of IPE interventions to control groups which received no interventions. All the studies focused on workplace or postqualification education interventions. The IPE interventions, study designs and outcomes measured differed widely and the review was unable to do a meta-analysis of the results. As few common outcomes measures were used in the six studies, a summary of the results is therefore limited to the broad categories of professional practices and patient outcomes. Where positive outcomes were found, these gains were sustained over time, ranging from eight to 21 months.

Six studies assessed the effects of IPE on various aspects of professional practice such as departmental culture and systems changes (e.g. appropriate protocols, checklists, availability of referral information, staff training), collaborative team behaviour, clinical error rates, case recognition or finding, management of care, and professional competencies. Two studies assessed the effects of IPE on patient satisfaction and one assessed its impact on clinical outcomes. These studies show that:

Interprofessional education may improve professional practice
The effect of Interprofessional education on patient satisfaction is uncertain
The effect of interprofessional education on clinical outcomes is uncertain

Professional practise, clinical outcomes and patient satisfaction
Patient or population: Health and social care professionals Settings: Health service providers in US (5) and UK (1) Intervention: Interprofessional education interventions Comparison: No education intervention
Outcomes	Impact	Number of Participants (studies)	Quality of the evidence (GRADE)
Professional practice	4 studies reported a positive outcome in at least one aspect of professional practice, and 2 studies found no significant effect on any of the outcomes. There was a lot of heterogeneity in the outcomes studies and the results.	6 studies
Clinical Outcomes	No significant effect on clinical outcomes	1 study
Patient Satisfaction	One study found that IPE significantly improved patient satisfaction scores (P<0.0001); and the other that it did not improve patient satisfaction scores.	2 studies
p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
The studies settings were in the United States and United Kingdom ranging from hospital emergency departments, health maintenance organisations, community mental health provider organisations, to primary care practices.	Differences in the health system contexts, gender relationships and comparable social status of different health professions may influence the effectiveness of IPE in different settings. Further rigorous studies of IPE are needed in low- and middle-income countries before widescale implementation.
EQUITY
Studies found that IPE required systems changes , facilitated by additional resources, time and supportive leadership within organisations.	The additional resource requirements, as well as reorientation and reorganisation of work processes and professional development systems, may be a barrier in poorly resourced settings in low- and middle-income countries.
ECONOMIC CONSIDERATIONS
Economic evaluations were not included in any of the studies	The cost of IPE is likely to be highly variable and must be estimated based on specific local conditions.Further studies of IPE should also include economic evaluations.
MONITORING & EVALUATION
Evidence of effectiveness is not available in resource poor settings.	The impact and cost-effectiveness of IPE inresource-poor settings should be monitored using objective measures of professional practice and healthcare outcomes, to ensure that intended improvements in practice are achieved.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://supportsummaries.org/support-summaries/how-support-summaries-are-prepared/

Additional information

Related literature

Barr H, Koppel I, Reeves S, Hammick M, Freeth D. Effective inter-professional education: assumption, argument and evidence. London: Blackwell, 2005.

Cooper H, Carlisle C, Gibbs T,Watkins C. Developing an evidencebase for interdisciplinary learning: a systematic review. Journal of Advanced Nursing 2001;35(2):228–37.

Freeth D, Hammick M, Reeves S, Koppel I, Barr H. Effective inter-professional education: development, delivery and evaluation. London: Blackwell, 2005.

Hammick M, Freeth D, Koppel I, Reeves S, Barr H.A best evidence systematic review of interprofessional education.Best Evidence Medical Evaluation Review Guide www.bemecollaboration.org/beme/pages/reviews/(2007).

Reeves S.A review of the effects of interprofessional education on staffinvolved in the care of adults with mental health problems. Journalof Psychiatric and Mental Health Nursing 2001;8:533–42.

Reeves S, Lewin S. Hospital-based interprofessional collaboration:strategies and mean-ings. Journal of Health Services Research and Policy2004;9:218–25.

Skjorshammer M. Co-operation and conflicts in a hospital: interprofessionaldifferences in perception and management of conflicts.Journal of Interprofessional Care 2001;15:7–18.

Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I,Atkins J. Interprofessional education: effects on professionalpractice and health care outcomes. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002213.DOI: 10.1002/14651858.CD002213.Art. No.: CD002213. DOI:10.1002/14651858.CD002213.pub2. See in Cochrane Library

Zwarenstein M, Reeves S, Perrier L. Effectiveness of pre-licensure interprofessionaledu-cation and post-licensure collaborative interventions. Journal of Interprofessional Care 2005;19:S148–65.

Reeves S et al: (2007) Key factors in planning and implementing interprofessional education in health care settings. Journal of Allied Health 36(4), 231-235.

Wakefield A, et al: (2009) Patient safety investigations: the need for interprofessional learning. Learning in Health & Social Care 8(1), 22-32.

Oandasan I, Reeves S (2005) Key elements for interprofessional education. Part 1: the learner, the educator and the learning context. Journal of Interprofessional Care 19(Supp.1), 21-38

This summary was prepared by

Dudley L & Wiysonge CS, South African Cochrane Centre, South Africa

Conflict of interest

None. For details, see: Conflicts of interest

Acknowledgements

This summary has been peer reviewed by:Katherine Pollard, UK, Rukhsana Gazi, Bangladesh

This summary should be cited as

Dudley L, Wiysonge CS.Does interprofessional education improve professional practice and health care outcomes? A SUPPORT Summary of a systematic review. August2008

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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