http://orcid.org/0000-0001-8856-6970
Figures
Abstract
Introduction
If interprofessional collaborative practice is to be an important component of healthcare reform, then an evidentiary base connecting interprofessional education to interprofessional practice with significantly improved health and healthcare outcomes is an unconditional necessity. This study is a scoping review of the current peer reviewed literature linking interprofessional collaborative care and interprofessional collaborative practice to clearly identified healthcare and/or patient health-related outcomes. The research question for this review was: What does the evidence from the past decade reveal about the impact of Interprofessional collaborative practice on patient-related outcomes in the US healthcare system?
Materials and methods
A modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was followed.
Results
Of an initial 375 articles retrieved 20 met review criteria. The most common professions represented in the studies reviewed were physicians, pharmacists and nurses. Primary care was the most common care delivery setting and measures related to chronic disease the most commonly measured outcomes. No study identified negative impacts of interprofessional collaborative practice. Eight outcome categories emerged from a content analysis of the findings of the reviewed studies.
Conclusions
The results suggest a need for more research on the measurable impact of interprofessional collaborative practice and/or care on patient health-related outcomes to further document its benefits and to explore the models, systems and nature of collaborations that best improve population health, increase patient satisfaction, and reduce cost of care.
Citation: Lutfiyya MN, Chang LF, McGrath C, Dana C, Lipsky MS (2019) The state of the science of interprofessional collaborative practice: A scoping review of the patient health-related outcomes based literature published between 2010 and 2018. PLoS ONE 14(6): e0218578. https://doi.org/10.1371/journal.pone.0218578
Editor: Nelly Oelke, University of British Columbia, CANADA
Received: March 5, 2019; Accepted: June 3, 2019; Published: June 26, 2019
Copyright: © 2019 Lutfiyya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Stimulated by a multitude of factors, including a heightened commitment to reforming healthcare delivery, attention to interprofessional practice and education has grown exponentially over the past decade. [1, 2]. [2–4] In 2008 Berwick et al., published their seminal article on the triple aim, offering a roadmap for healthcare delivery reform. [5] Along with the Institute of Medicine’s (IOM) 2001 report, Crossing the Quality Chasm,[6] and the World Health Organization’s (WHO) 2013 report Transforming and scaling up health professionals’ education and training,[7] these articles galvanized a renewed interest in interprofessional practice and education. Conceptually, these three works explicitly promoted interprofessional healthcare teams as a strategy to improve health services and outcomes. The IOM and WHO reports charged health professions’ programs to incorporate interprofessional education (IPE) into their training with the conviction that these efforts would lead to enhanced communication and care coordination to advance population health, reduce healthcare costs, and improve patient health-related outcomes.
Ultimately, if interprofessional practice is to be an important component of healthcare reform, then an evidentiary base connecting interprofessional collaborative practice (IPCP) with significantly improved health and healthcare outcomes is an unconditional necessity. [2, 3, 8] The 2013 WHO report gave a conditional recommendation of IPE, suggesting rigorous research be included in its implementation. Continued interprofessional education endeavors can only be justified if the return on investment from an IPCP model yields a positive impact on measurable patient health-related outcomes.
A 2014 scoping review [3] noted that despite its multi-decade history, interprofessional practice and education-related research focused mainly on short-term changes such as improved knowledge, skills and attitudes of learners or on intermediate policy changes in either education or clinical settings, but not on patient health and/or healthcare related outcomes.[3] As Brandt et.al. concluded “… little of the literature reviewed focused on population health or patient health outcomes, and none on the reduction in the cost of healthcare.” [3] A 2016 editorial, [4] describing the key findings of the 2015 IOM’s report on interprofessional practice and education, concluded that whether or not interprofessional practice and education improves clinical outcomes remains uncertain since few studies explicitly map interprofessional practice and education to health related outcome measures. [4]
Since most health professions programs, including pharmacy, medicine, public health, nursing and dentistry, [9–12] mandate IPE it is understandable that most research focused primarily on educational methods and learner outcomes. However, this leaves a gap in the evidence linking interprofessional practice and/or care to patient health-related outcomes. As embedded as interprofessional education is in health professions training, for justify these efforts, research must extend to include health-related patient outcomes. Yet despite the mandate for IPE, as John Gilbert notes it remains, “a great truth awaiting scientific confirmation.” An updated WHO report also supported the need for more evidence connecting IPE training to improved health outcomes.
This study is a scoping review [13] of the current peer-reviewed literature that connects interprofessional collaborative care and IPCP to clearly identified patient health-related outcomes. Scoping reviews are a process of mapping an existing literature or evidence base to answer a question. [13] For this study we explored the question: What does the evidence over the past decade reveal about the effectiveness of interprofessional collaborative care and/or interprofessional collaborative practice in the US healthcare system on patient related outcomes? In addition, the study also sought to identify gaps in the existing literature to help guide future research.
Materials and methods
For this review interprofessional collaborative care was defined as: the provision of comprehensive health services to patients by multiple caregivers from different professions (e.g., medicine, nursing, pharmacy, dentistry) who work collaboratively to deliver quality care within and across settings (e.g., hospital, primary care, dental clinics, hospice care). Interprofessional collaborative practice occurs when healthcare providers work with people from within their own profession, with people outside their profession and with patients and their families. When healthcare providers work collaboratively, they seek common goals and can analyze and address any problems that arise. Care is coordinated according to patients’ needs and patient outcomes are explicitly tied to how care is provided (although without exception the influences on patient outcomes are multifactorial).
The review followed a modified preferred approach for reporting items for systematic reviews and meta-analyses (PRISMA). [14] The PRISMA approach is organized by five distinct elements or steps: beginning with a clearly formulated question, using the question to develop clear inclusion criteria to identify relevant studies, an approach to appraise the studies or a subset of the studies, a summary of the evidence using an explicit methodology, and interpreting the findings of the review.
The literature search was limited to peer-reviewed articles, from the time span of 2010–2018. The choice of the year 2010 as the floor was grounded in the historical fact that the US Affordable Care Act [15] became law during that year and 2018 chosen as the ceiling year because that was the last full year that had ended when the review commenced. Unpublished/grey literature, opinion pieces/essays, letters to the editor, and review papers were excluded from this review. The literature search was further limited to papers written in English and based in the US. The rationale to focus solely on US based literature is that the US-based health care system of practice and reimbursement infrastructure are unique compared to other industrialized nations. Until the enactment of the Affordable Care Act, many low to moderate-income families didn’t have access to medical home. The U.S. healthcare team is also more specialty based and focuses more primarily on clinician/patient model and not on team-based health care or universal insurance. This review aims to assess the impact of IPCP within the US healthcare system on patient related outcomes.
PubMed and Google Scholar were systematically searched to identify potentially relevant literature. Google Scholar was included because there is a growing literature [16, 17] assessing the value of Google Scholar in relationship to other indexing databases such as PubMed. Current recommendations suggest including Google Scholar and PubMed for comprehensive health-related systematic review searches [18]. We decided to use both MeSH and broader terms in our search to capture all relevant studies. The initial search terms used for the review entailed the following:
- Interprofessional Collaborative Care in the US Healthcare;
- Interprofessional Collaborative Practice in the US Healthcare;
- Patient Outcomes and Interprofessional Collaborative Care in the US; and
- Patient Outcomes and Interprofessional Collaborative Practice in the US.
In keeping with the PRISMA approach the following five steps were adhered to.
Step 1: The initial research question for this review was:
What does the outcome-derived evidence indicate about interprofessional collaborative care and/or interprofessional collaborative practice in the US healthcare system?
As the review of the literature was underway, two additional questions were formulated to guide the analyses. These were:
- What patient health-related outcomes were measured in the literature reviewed?
- What were the data-driven findings derived from the reviewed literature?
Step 2: The initial question directed the process for identifying the relevant work reviewed. The subsequent questions guided the analysis of the reviewed literature. The inclusion criteria the review proposed emerged directly from the question guiding the review.
Step 3: A systematic approach to appraise the studies was used. To assess the selected papers a comprehensive table that included the full paper citation and complete abstract along with the following five components comprising a checklist was developed and used: 1) Interprofessional Collaborative Care OR Interprofessional Collaborative Practice (yes/no), 2) United States (yes/no), 3) Practice Setting (e.g., acute, primary, hospice), 4) Peer-Reviewed (yes/no), 5) study design specified (yes/no), and 6) Data analyzed (identify specific outcomes) (yes/no). For a paper to be included in the review all of the criteria had to be met. Table 1 displays the definitions used for the inclusion criteria. Once the articles gleaned from the literature search were reviewed, the reasons for exclusion were determined by all of the study authors and recorded for depiction in a flowchart (see Fig 1) for discussion in the results section.
Step 4: The evidence presented in the articles reviewed was organized by study design (observational, randomized controlled trial, etc.), the type(s) of data analyzed, the study outcomes, and study results or findings. Organizing the information in this manner allowed for a comprehensive assessment of the reviewed articles. This information is displayed in Table 2 and is discussed in the results section. From this information (now data) categories were derived from the patient outcomes and findings of the included studies. Using a qualitative content analysis approach, study findings were also analyzed and organized into outcome categories by the group consensus of the authors. [18] The process/methodology used to derive categories is depicted in Fig 2 and the categories discussed in the results section.
Step 5: interpreting the findings. In the Discussion section of this paper, the findings of this review were interpreted in light of the contemporary manifestation of interprofessional collaborative practice and/or care in the US.
Results
Fig 1 illustrates the article selection process for this review. The search conducted in PubMed and Google Scholar yielded 375 papers—249 of which focused on interprofessional collaborative practice and 126 focused on interprofessional collaborative care. After an initial review by one of the study’s authors (MNL), 129 articles tentatively met the study criteria and were then reviewed by the remaining authors. After full examination, a total of 355 articles failed to meet the inclusion criteria. Forty papers were excluded because they were review pieces, 113 papers were not US based, 92 papers did not have patient health-related outcomes, 21 papers did not address interprofessional collaborative practice or interprofessional collaborative care, 54 papers were opinion/commentary or program description papers, 31 papers were duplications, one paper was not peer-reviewed, and three papers were not available from any source. Ultimately, 20 papers [19–38] met the inclusion criteria for review.
Table 2 displays the included papers summarized by study design, study setting, data analyzed and sample size, outcomes studied, and study findings. The selected studies utilized a variety of study designs including clinical trials, quality improvement and pre/post intervention studies. Ten studies were pre/post intervention studies, some of which were quality improvement studies. [20–25, 29, 30, 32, 35, 38] Two studies were clinical trials, [19, 34] one of which was a randomized control trial. [34] Two studies were retrospective cohort studies [23, 37] and one a prospective cohort study. [25] Two studies were cross-sectional, [28, 35] one sequential mixed methods, [33] one a case study,[27] and one a case/control study. [31] In addition to the wide variety of study designs employed, sample sizes ranged widely from one paper reporting two case studies to a sample size [27] of 322,408 patients. [31] The case study project was difficult to assess since each case (two were included in the paper) entailed both a patient along with unspecified multiple healthcare providers as well as family members. [27]
The specific outcomes measured in the studies reviewed varied greatly although some outcomes overlapped among studies. In aggregate, there were 22 distinct outcomes. Among the overlap outcomes displayed in Table 2 are: hospital length of stay, [20, 29] hospital readmission rates, [20, 29] direct cost of care, [20, 21, 31] A1c, [22, 29, 30, 33, 35, 36] blood pressure, [19, 23, 30, 33, 36, 37] and number of office visits. [28, 31, 32] While none of the studies reviewed detected any negative impacts of interprofessional collaborative care or interprofessional collaborative practice, not all findings favored a positive impact of interprofessional care or interprofessional practice.
While study analyses included quantitative, qualitative and mixed methods, descriptive statistical analysis was the most frequently used analytical technique. In all the reviewed studies, at least two professions were engaged with the most frequently engaged professions being physicians (medicine) included in 18 of the 20 studies and pharmacy in 15 of the 20 reviewed studies. Nursing was included in 6 of the reviewed studies. Other engaged professions (e.g., social work, occupational therapy, physical therapy) were represented in one or at most two studies.
The abstracted studies reported on research in six distinct settings: primary care, [19, 23–25, 28, 30–33, 35–37] hospital care, [19, 29, 34] specialty clinic care, [26, 38] nursing home care, [21] home health care, [27] and prison clinic (in and out patient care). [22] The most frequent study setting was primary care followed by hospital care as a distant second.
Finally, an examination of the reviewed studies’ outcomes and findings revealed eight distinct outcome categories. Fig 2 depicts the analysis process and Tables 3 and 4 describe the research outcomes and key study characteristics. The eight categories identified were: 1) Impact of interprofessional collaborative practice on chronic diseases with well-defined management measures [19, 22–24, 28–30, 33–35]; 2) Impact of interprofessional collaborative practice on specialty care outcomes with well-defined management measures [20, 26, 38]; 3) Impact of interprofessional collaborative practice on direct cost of care [20, 29, 31]; 4) Impact of interprofessional collaborative practice on prescribing practices and/or patient adherence [25, 32]; 5) Impact of interprofessional collaborative practice on dental care [27]; 6) interprofessional collaborative practice impact on falls [21]; 7) impact of interprofessional collaborative practice on health services utilization [31, 32]; 8) impact of interprofessional collaborative practice on patient satisfaction. [34]
Discussion
Interprofessional education is firmly entrenched as an essential component to prepare health professions for a complex and evolving healthcare environment. The Health Profession Accreditors Collaborative states that the need for health professions to work together is unprecedented. [39] However, the merit of interprofessional education is inextricably linked to the value of interprofessional collaboration, making evidence related to the value added proposition of collaborative care critically important. Surprisingly, this scoping review yielded only twenty studies that examined clinically relevant outcomes related to interprofessional collaborative care and interprofessional collaborative practice. Of an original yield of 375 studies published between 2010 and 2018, most studies focused on educational endeavors or provider impressions and not on outcomes documenting clinical impact.
In 2008 Berwick, et al. published their seminal triple aim article [5] which argued that healthcare reform should address patient satisfaction, population health improvement, and rising healthcare costs. Both Berwick’s paper [31] and the US Affordable Care Act, [15] cite interprofessional collaborative care and interprofessional collaborative practice as important components of that reform. However, a 2014 interprofessional practice and education review [3] and 2015 IOM report [1] both noted that few studies examined the impact of interprofessional practice and education on triple aim outcomes—most notably patient health outcomes (or population health). Despite limited evidence, policy makers recommend practitioners develop the knowledge, attitudes, skills and behaviors to work collaboratively. [40] What is encouraging is that while the body of evidence is sparse, most studies examining interprofessional care found it positively impacts care.
Of the 20 research studies reviewed, [19–38] all had at least one patient health-related outcome that could be mapped to a triple aim outcome. Several studies examined patient health condition outcomes (e.g., diabetes, asthma, hypertension) but only three explicitly studied whether the intervention reduced healthcare costs [20, 29, 31] and only one examined the effect on patient satisfaction. [34] No study measured outcomes relevant to all three of Berwick, et al.’s, triple aims.
The reviewed studies investigated outcomes across multiple settings, healthcare professions and study designs. The majority found interprofessional collaborative care and/or interprofessional collaborative practice improved health related outcomes such as A1c in patients with diabetes, polypharmacy for pain management in patients with lower back pain, and blood pressure outcomes for patients with hypertension. Healthcare cost savings were documented for chronically ill patients such as those with pancreatitis. The studies reviewed provide blueprints for others wishing to examine the impact of interprofessional collaborative practice or interprofessional collaborative care on appropriate health outcomes. Of note, while not all studies documented benefit, no study found a negative outcome related to interprofessional collaborative care and/or interprofessional collaborative practice,
The majority of the studies included in this review researched outcomes in primary care settings [19, 23–25, 28, 30–33, 35–37] and addressed clearly defined chronic diseases with well-defined management measures. [19, 22–24, 28–30, 33–36] In these instances the challenge of defining, operationalizing, and measuring patient health-related outcomes is minimized.
Of the 20 studies, almost all included medicine and 11 included pharmacy. Surprisingly, no study reviewed included public health professionals, social workers, behavioral health providers or physician assistants and few studies engaged nurses. Only one study included dentists even though their accreditation standards advocate the importance of oral health to overall health and training that links oral health to colleagues in other professions. [41] Addressing these identified gaps in future research will strengthen the evidentiary base of interprofessional collaborative practice. Furthermore, clear articulations of the elements of interprofessional collaborative practice approaches, such as coordination, communication, cooperation, shared decision making and practice [42,43] need to be included in future research.
Limitations
A number of limitations to this review bear noting. First, the study used very specific definitions for our inclusion criteria. Because the field of interprofessional practice and education has yet to standardize the lexicon of its concepts, the definitions used may have been too restrictive and as a result missed some relevant research. For example, the Cochrane review identified studies with positive patient outcomes from integrated behavioral health care team but the terminology “Collaborative Care” used was differed from the IPCP definition used in this review. Therefore, this review paper was not identified in our initial literature search. While this might affect identification of public health and this work IPCP research studies, we do not believe this substantially changes our review.
In addition, while the US healthcare system is unique, by focusing solely on the US healthcare environment, this review could have potentially missed studies from other developed countries that may have documented pertinent data-driven findings. Finally, the review only used the PubMed and Google Scholar search engines. There is always a possibility that an additional search engine might have yielded additional relevant articles.
Conclusions
The goal of interprofessional practice and education is to foster care collaboration that optimizes patient outcomes. Although advocates promote the benefits of removing silos among health professionals, there is surprisingly little evidence documenting the health-related outcome benefits of interprofessional collaborative practice and/or care. In addition, our review found inconsistency in use of terminology to describe health care team work and this might have resulted in difficulties identifying all relevant literature. [44] Continued effort to develop common and meaningful terminology and research on the measurable impact of interprofessional collaborative practice and/or care on patient health-related outcomes is needed to document its benefits and to explore the models, systems and nature of collaborations that best improve population health, increase patient satisfaction, and reduce cost of care.
Dedication: Dr. Nawal Lutfiyya unexpectedly passed away before completing the final revisions of this paper. Her co-authors would like to acknowledge her leadership in developing this review and to dedicate this paper in her memory.
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