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Interprofessional collaboration to improve professional practice and

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 Cochrane Database of Systematic Reviews

Interprofessional collaboration to improve professional

practice and healthcare outcomes (Review)

Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M

Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M.

Interprofessional collaboration to improve professional practice and healthcare outcomes.
Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD000072.
DOI: 10.1002/14651858.CD000072.pub3.

www.cochranelibrary.com

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review)

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 18
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 47
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) i

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Interprofessional collaboration to improve professional

practice and healthcare outcomes

Scott Reeves1 , Ferruccio Pelone1 , Reema Harrison2 , Joanne Goldman3 , Merrick Zwarenstein4

1 Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, London, UK. 2 University of
Sydney, Sydney, Australia. 3 Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Canada. 4 Department
of Family Medicine, University of Western Ontario, London, Canada

Contact address: Scott Reeves, Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London,
St George’s Hospital, Grosvenor Wing, Cranmer Terrace, London, Greater London, SW17 0BE, UK. [email protected].

Editorial group: Cochrane Effective Practice and Organisation of Care Group.

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 6, 2017.

Citation: Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve profes-
sional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD000072. DOI:
10.1002/14651858.CD000072.pub3.

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background

Poor interprofessional collaboration (IPC) can adversely affect the delivery of health services and patient care. Interventions that address
IPC problems have the potential to improve professional practice and healthcare outcomes.

Objectives

To assess the impact of practice-based interventions designed to improve interprofessional collaboration (IPC) amongst health and
social care professionals, compared to usual care or to an alternative intervention, on at least one of the following primary outcomes:
patient health outcomes, clinical process or efficiency outcomes or secondary outcomes (collaborative behaviour).

Search methods

We searched CENTRAL (2015, issue 11), MEDLINE, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry
Platform to November 2015. We handsearched relevant interprofessional journals to November 2015, and reviewed the reference lists
of the included studies.

Selection criteria

We included randomised trials of practice-based IPC interventions involving health and social care professionals compared to usual
care or to an alternative intervention.

Data collection and analysis

Two review authors independently assessed the eligibility of each potentially relevant study. We extracted data from the included studies
and assessed the risk of bias of each study. We were unable to perform a meta-analysis of study outcomes, given the small number of
included studies and their heterogeneity in clinical settings, interventions and outcomes. Consequently, we summarised the study data
and presented the results in a narrative format to report study methods, outcomes, impact and certainty of the evidence.
Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 1
Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
We included nine studies in total (6540 participants); six cluster-randomised trials and three individual randomised trials (1 study
randomised clinicians, 1 randomised patients, and 1 randomised clinicians and patients). All studies were conducted in high-income
countries (Australia, Belgium, Sweden, UK and USA) across primary, secondary, tertiary and community care settings and had a
follow-up of up to 12 months. Eight studies compared an IPC intervention with usual care and evaluated the effects of different
practice-based IPC interventions: externally facilitated interprofessional activities (e.g. team action planning; 4 studies), interprofessional
rounds (2 studies), interprofessional meetings (1 study), and interprofessional checklists (1 study). One study compared one type of
interprofessional meeting with another type of interprofessional meeting. We assessed four studies to be at high risk of attrition bias
and an equal number of studies to be at high risk of detection bias.
For studies comparing an IPC intervention with usual care, functional status in stroke patients may be slightly improved by externally
facilitated interprofessional activities (1 study, 464 participants, low-certainty evidence). We are uncertain whether patient-assessed
quality of care (1 study, 1185 participants), continuity of care (1 study, 464 participants) or collaborative working (4 studies, 1936
participants) are improved by externally facilitated interprofessional activities, as we graded the evidence as very low-certainty for
these outcomes. Healthcare professionals’ adherence to recommended practices may be slightly improved with externally facilitated
interprofessional activities or interprofessional meetings (3 studies, 2576 participants, low certainty evidence). The use of healthcare
resources may be slightly improved by externally facilitated interprofessional activities, interprofessional checklists and rounds (4 studies,
1679 participants, low-certainty evidence). None of the included studies reported on patient mortality, morbidity or complication
rates.
Compared to multidisciplinary audio conferencing, multidisciplinary video conferencing may reduce the average length of treatment
and may reduce the number of multidisciplinary conferences needed per patient and the patient length of stay. There was little or no
difference between these interventions in the number of communications between health professionals (1 study, 100 participants; low-
certainty evidence).
Authors’ conclusions
Given that the certainty of evidence from the included studies was judged to be low to very low, there is not sufficient evidence to
draw clear conclusions on the effects of IPC interventions. Neverthess, due to the difficulties health professionals encounter when
collaborating in clinical practice, it is encouraging that research on the number of interventions to improve IPC has increased since
this review was last updated. While this field is developing, further rigorous, mixed-method studies are required. Future studies should
focus on longer acclimatisation periods before evaluating newly implemented IPC interventions, and use longer follow-up to generate
a more informed understanding of the effects of IPC on clinical practice.

PLAIN LANGUAGE SUMMARY

How effective are strategies to improve the way health and social care professional groups work together?
What is the aim of this review?
The aim of this Cochrane Review was to find out whether strategies to improve interprofessional collaboration (the process by which
different health and social care professional groups work together), can positively impact the delivery of care to patients. Cochrane
researchers collected and analysed all relevant studies to answer this question, and found nine studies with 5540 participants.
Key messages
Strategies to improve interprofessional collaboration between health and social care professionals may slightly improve patient functional
status, professionals’ adherence to recommended practices, and the use of healthcare resources. Due to the lack of clear evidence, we
are uncertain whether the strategies improved patient-assessed quality of care, continuity of care, or collaborative working.
What was studied in this review?
The extent to which different health and social care professionals work well together affects the quality of the care that they provide.
If there are problems in how these professionals communicate and interact with each other, this can lead to problems in patient
care. Interprofessional collaboration practice-based interventions are strategies that are put into place in healthcare settings to improve
interactions and work processes between two or more types of healthcare professionals. This review studied different interprofessional
collaboration interventions, compared to usual care or an alternative intervention, to see if they improved patient care or collaboration.
Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 2
Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
What are the main results of the review?
The review authors found nine relevant studies across primary, secondary, tertiary and community care settings. All studies were
conducted in high-income countries (Australia, Belgium, Sweden, UK and USA) and lasted for up to 12 months. Most of the studies
were well conducted, although some studies reported that many participants dropped out. The studies evaluated different methods of
interprofessional collaboration, namely externally facilitated interprofessional activities (e.g. collaborative planning/reflection activities
led by an individual who is not part of the group/team), interprofessional rounds, interprofessional meetings, and interprofessional
checklists.
Externally facilitated interprofessional activities may slightly improve patient functional status and health care professionals’ adherence
to recommended practices, and may slightly improve use of healthcare resources. We are uncertain whether externally facilitated
interprofessional activities improve patient-assessed quality of care, continuity of care, or collaborative working behaviours. The use of
interprofessional rounds and interprofessional checklists may slightly improve the use of healthcare resources. Interprofessional meetings
may slightly improve adherence to recommended practices, and may slightly improve use of healthcare resources.
Further research is needed, including studies testing the interventions at scale to develop a better understanding of the range of possible
interventions and their effectiveness, how they affect interprofessional collaboration and lead to changes in care and patient health
outcomes, and in what circumstances such interventions may be most useful.
How up to date is this review?
The review authors searched for studies that had been published to November 2015.

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 3

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Effects of practice- based interprofessional collaboration (IPC) interventions on professional practice and healthcare
outcomes compared to usual care

Patient or population: health and social care prof essionals involved in the delivery of health services and patient care
Settings: prim ary, secondary, tertiary and com m unity care settings, prim arily in the USA and the UK
Intervention: practice-based interprof essional collaboration (IPC) interventions with an explicit objective of im proving
collaboration between two or m ore health or social care prof essionals
Comparison: usual care

Outcomes Impacts No. of studies (participants) Certainty of the evidence

(GRADE)

Patient health outcomes

Patient f unctional status Externally f acilitated inter- 1 ⊕⊕

prof essional activities m ay (464) Lowa
slightly im prove stroke pa-
tients’ f unctional status (
Strasser 2008).

Patient-assessed quality of It is uncertain if externally f a- 1 ⊕

care cilitated interprof essional ac- (1185) Very lowb
tivities increases patient-as-
sessed quality of care be-
cause the certainty of this evi-
dence is very low (Black 2013)
.

Patient m ortality, m orbidity or None of the included stud- -- --

com plication rates ies reported patient m ortal-
ity, m orbidity or com plication
rates

Clinical process or efficiency outcomes

Adherence to recom m ended The use of interprof essional 3 ⊕⊕

practices activities with an external f a- (2576) Lowc
cilitator or interprof essional
m eetings m ay slightly im -
prove adherence to recom -
m ended practices and pre-
scription of drugs (Cheater
2005; Deneckere 2013;
Schm idt 1998).

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 4

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Continuity of care It is uncertain if externally f a- 1 ⊕
cilitated interprof essional ac- (464) Very lowd
tivities im proves continuity of
care because the certainty
of this evidence is very low
(Strasser 2008).

d Use of healthcare resources Interprof essional checklists 4 ⊕⊕

(Calland 2011), interprof es- (1679) Lowe
sional rounds (Curley 1998;
Wild 2004) or externally f a-
cilitated interprof essional ac-
tivities (Strasser 2008), m ay
slightly im prove overall use of
resources, length of hospital
stay, or costs

Collaborative behaviour outcomes

Collaborative working; team It is uncertain whether exter- 4 ⊕

com m unication; team co-ordi- nally f acilitated interprof es- (1936) Very lowf
nation sional activities (Black 2013;
Calland 2011; Cheater 2005;
Deneckere 2013) im prove col-
laborative working, team com -
m unication, and co-ordination
because the certainty of this
evidence is very low

GRADE Working Group grades of evidence

High- certainty: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate- certainty: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and
m ay change the estim ate.
Low- certainty: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is
likely to change the estim ate.
Very- certainty: We are very uncertain about the estim ate.

a We assessed the certainty of the evidence as low because of high risk of bias (no blinding of outcom e assessm ent).
b We assessed the certainty of the evidence as very low because of the risk of bias (high risk of attrition and detection bias;
details about allocation sequence generation and concealm ent were not reported).
c We assessed the certainty of the evidence as low due to potential indirectness (both studies were conducted in one country

and the outcom es m ay not be transf erable to other settings), and risk of bias (high risk of attrition, unclear selection and
reporting risk).
d We assessed the certainty of the evidence as very low because of risk of bias (high risk of attrition and detection bias, and

unclear risk of selection bias).

e
We assessed the certainty of evidence as low because of high risk of bias (attrition and detection), and unclear risk of bias
(selection, reporting, and contam ination).

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 5

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
f
We assessed the certainty of the evidence as very low due to high risk of bias (selection, attrition, and detection) or unclear
risk of bias (reporting and contam ination).

BACKGROUND of interventions used in the interprofessional field found three

main types: education-based interventions, practice-based inter-
ventions, and organisationally-based interventions (Reeves 2011).
Description of the condition This review focuses on interprofessional practice-based interven-
Interprofessional collaboration (IPC) is the process by which dif- tions, also called practice-based IPC interventions. An interprofes-
ferent health and social care professional groups work together to sional practice-based intervention involves the deployment in the
positively impact care. IPC involves regular negotiation and inter- workplace of a tool or routine to improve IPC; examples include
action between professionals, which values the expertise and con- communication tools, interprofessional meetings, and checklists.
tributions that various healthcare professionals bring to patient A review focusing solely on interprofessional education (an edu-
care. However, IPC can be affected by problems linked to imbal- cation-based intervention) was recently updated (Reeves 2013).
ances of authority, limited understanding of others’ roles and re- In this review, an interprofessional education intervention was de-
sponsibilities, and professional boundary friction when delivering fined as ’members of more than one health or social care profes-
patient care (Baker 2011; Reeves 2010). sion learning interactively together, for the explicit purpose of im-
Research has repeatedly documented the impact of collaboration proving interprofessional collaboration, the health and well-being
problems on work processes and patient safety (Lillebo 2015; Van of patients, or both.’ Interactive learning requires active learner
Leijen-Zeelenberg 2015). For example, failures of collaboration participation and active exchange between learners from different
were found to be at the centre of a number of care failures across professions.
the globe (Francis 2013; The Joint Commission 2016). There- An interprofessional organisationally-based intervention involves
fore, professionals must ensure that they collaborate in an effective a change at an organisational level to improve interprofessional col-
manner to deliver safe, high-quality patient care. laboration; examples include policy and staffing changes (Reeves
Different health policy makers across the globe have repeatedly 2010). A review of the effects of this type of intervention still needs
called for the use of IPC as a key approach to improve the quality to be undertaken, to generate a more holistic understanding of the
and safety of patient care (Department of Health 1997; Health nature of these different, but complementary, interventions.
Canada 2003; Institute of Medicine 2000; Institute of Medicine
2013; WHO 1976; WHO 2010). During the past 10 years in
particular, IPC has been at the forefront of much curricular, re- How the intervention might work
search, policy, and regulatory activity at national and international A practice-based IPC intervention might work by incorporating a
levels. The promotion of IPC stems from the complexity and mul- tool, routine, or activity to improve interprofessional interaction
tifaceted nature of patients’ health and care needs and the health (e.g. communication, co-ordination) into clinical practice. In turn,
system, and research that suggests that improved collaboration be- this may improve how healthcare professionals work together and
tween multiple professionals may be essential for the provision of deliver health care, leading to improved health outcomes.
effective and comprehensive care.
Research in the area of IPC is complicated by the use of varied
terms (interdisciplinary collaboration, multidisciplinary co-ordi- Why it is important to do this review
nation, transprofessional teamwork), which has resulted in con-
Research identifying various problems with IPC, and the delivery
ceptual confusion within the field (Reeves 2010). As a result, one
of care and patient outcomes, continues to accumulate (Körner
must take care when evaluating such studies, to ensure one under-
2016; Van Leijen-Zeelenberg 2015). Therefore, It is important to
stands the nature and key activities of the intervention, whatever
understand the effectiveness of interventions aimed at improving
it may be named.
IPC on health and social care. Governments around the globe
continue to institute major changes and invest significant resources
to improve IPC. Ideally, these policy decisions should be based on
Description of the intervention evidence of the effectiveness of these approaches. The aim of this
An IPC intervention involves members of more than one health review is to update a previous review, and synthesise evidence from
or social care profession interacting together with the explicit pur- randomised trials of practice-based IPC interventions, to inform
pose of improving IPC. A scoping review examining the nature such decision-making (Zwarenstein 2009).
Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 6
Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
OBJECTIVES • Patient health outcomes (objectively measured or self-
reported, using a validated instrument)
To assess the impact of practice-based interventions designed to
◦ mortality
improve IPC amongst health and social care professionals, com-
◦ morbidity
pared to usual care or to an alternative intervention, on at least one
◦ disease incidence
of the following primary outcomes: patient health outcomes, clin-
◦ disease duration
ical process or efficiency outcomes or secondary outcomes (col-
◦ cure rates
laborative behaviour).
◦ quality of life measures
◦ functional status
◦ complication rate
METHODS ◦ patient-assessed quality of care
• Clinical process or efficiency outcomes
◦ readmission rates
Criteria for considering studies for this review ◦ adherence to recommended practices (by healthcare
providers)
◦ continuity of care
Types of studies ◦ use of healthcare resources (i.e. cost-benefit analysis)
We only considered individual or cluster-randomised, which pro- ◦ participant satisfaction
vide the most reliable evidence for the effects of practice-based
interprofessional collaboration (IPC).
Secondary outcomes

Types of participants • Collaborative behaviour (objective or self-reported

outcomes, using a validated instrument)
We included interventions that targeted any type of health and so-
cial care professional (e.g. chiropodists or podiatrists, complemen- We excluded interprofessional learning (interprofessional educa-
tary therapists, dentists, dietitians, doctors or physicians, hygien- tion) as a secondary outcome. Whilst interprofessional education
ists, midwives, nurses, occupational therapists, pharmacists, phys- can support IPC in the workplace, these are distinct activities and
iotherapists, psychologists, psychotherapists, radiographers, social our focus was the latter.
workers, or speech therapists).

Types of interventions
Search methods for identification of studies
We included any practice-based intervention with an explicit ob-
jective of improving collaboration between two or more health or
social care professionals. We used the following criterion to in-
clude interventions. Electronic searches
• Evaluations of a practice-based IPC intervention, where the
We searched the following sources.
study explicitly noted an objective to improve collaboration
1. Cochrane Central Register of Controlled Trials
amongst two or more types of health or social care professionals. (CENTRAL; 2015, issue 11) in the Cochrane Library (searched
Other terms besides IPC could have been used, and were on 24 November 2015; full strategy available in Appendix 1).
accepted as equivalent to IPC, such as communication, co- 2. MEDLINE Ovid: 2007 to 2015 (searched on 10
ordination, and teamwork. November 2015; full strategy available in Appendix 2).
The comparator was usual care or an alternative intervention, We 3. CINAHL EBSCO: 2007 to 2015 (searched on 10
placed no restrictions on interventions or settings (e.g. hospitals, November 2015; full strategy available in Appendix 3).
primary care, community-based care). 4. ClinicalTrials.gov and WHO International Clinical Trials
Registry Platform (ICTRP): 2007 to 2015 (searched on 24
November 2015; full strategy available in Appendix 4).
Types of outcome measures We placed no language restrictions on the search strategy. We did
not search Embase, as a review of the studies included previously
showed that none were indexed in this database. We included
Primary outcomes all the trials identified by the previous version of the review (
Zwarenstein 2009).

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 7

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Searching other resources for each outcome (across criteria) within and across studies, using
We handsearched the Journal of Interprofessional Care (2007 to the approach suggested by EPOC 2016.
November 2015), and reviewed the reference lists of included stud-
ies.
Measures of treatment effect
We had initially planned to conduct a meta-analysis, however, this
was not possible due to differences in populations and interven-
Data collection and analysis
tions (see Results). Therefore, we presented a narrative summary
of the results.

Selection of studies
At least two review authors (SR, FP) independently reviewed each Unit of analysis issues
of the titles and abstracts retrieved in the searches, to identify those We critically examined the methods of analysis of all study types.
that met the review’s inclusion criteria. We identified cluster-randomised trials, and where appropriate,
We obtained the full-text of all potentially relevant articles. At commented on unit of analysis errors in the results and discussion.
least two review authors (SR, FP) independently assessed each full-
text article to determine if it met all of the criteria. We resolved
disagreements by consultation with another review author (MZ). Dealing with missing data
As a further quality check, this additional review author reviewed It was not possible to undertake a meta-analysis of the included
all included articles. studies due to heterogeneity and therefore the issue of missing data
in statistical analysis did not arise.

Data extraction and management

Two review authors (SR, FP) independently extracted the follow- Assessment of heterogeneity
ing information from included studies. We did not assess heterogeneity statistically. Our narrative of ran-
1. Study setting (country, healthcare setting). domised trials compared the characteristics of the study popula-
2. Types of study participants. tions, interventions, and outcomes (see Data synthesis).
3. Description of IPC intervention.
4. Description of any other interventions.
5. Outcomes (primary and secondary). Assessment of reporting biases
6. Data for the main outcomes. We attempted to reduce the risk of reporting bias by undertaking
comprehensive searches of multiple databases and trial registers.
We found too few studies reporting the primary outcomes to allow
Assessment of risk of bias in included studies any assessment of reporting bias.
We used the suggested criteria recommended by Cochrane Effec-
tive Practice and Organisation of Care (EPOC) to assess risk of
bias in all studies included in the review (EPOC 2016), an ap- Data synthesis
proach that assessed the key areas of: We could not complete a meta-analysis of study outcomes for
1. selection bias; this review due to the small number of included studies, and the
2. performance bias; differences in IPC subtypes, settings, participants, and outcomes
3. detection bias; across the studies. Consequently, we presented the results in a nar-
4. attrition bias; rative format. In producing this narrative, we grouped (or cate-
5. reporting bias; and gorised) the following types of practice-based IPC interventions as:
6. any other potential sources of bias. externally facilitated interprofessional activities, interprofessional
For each criterion, we described the relevant information provided rounds, interprofessional meetings, and interprofessional check-
by the trial authors, and judged each item as being at: 1) high lists.
risk of bias (plausible bias that seriously weakens confidence in Two review authors (SR, MZ) independently assessed the certainty
the results); 2) low risk of bias (plausible bias unlikely to seriously of the evidence (high, moderate, low, and very low) as it related to
alter the results); or 3) unclear risk of bias (lack of information or the main outcomes, using the five GRADE considerations (risk of
uncertainty over the potential for bias). bias, consistency of effect, imprecision, indirectness, and publica-
We reported all included studies in the Risk of bias in included tion bias) Guyatt 2008.
studies section below. We did not exclude studies on the basis of We developed two ’Summary of findings’ tables for the compar-
their risk of bias. We made an overall assessment of the risk of bias isons: (1) practice-based IPC compared with usual care and; (2)

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 8

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
practice-based IPC compared with an alternative practice-based We had planned to perform a sensitivity analysis for pooled results
IPC. We included the following outcomes. based on the risk of bias information recorded from the included
• Patient health outcomes: patient functional status; patient- studies. However, a meta-analysis was not possible, due to a vari-
assessed quality of care; patient mortality, morbidity or ation in the intervention and study methods used in the included
complication rates. studies.
• Clinical process or efficiency outcomes: adherence to
recommended practices; continuity of care; use of healthcare
resources.
• Collaborative behaviour outcomes: collaborative working; RESULTS
team communication or co-ordination.

We applied the methods and recommendations described in Sec-

tion 8.5 and Chapter 12 of the Cochrane Handbook of Systematic Description of studies
Reviews of Interventions (Higgins 2011), and the EPOC worksheets See: Characteristics of included studies; Characteristics of excluded
(EPOC 2013). We justified all decisions to downgrade or upgrade studies.
the certainty of the evidence using footnotes, and made comments
to aid readers’ understanding of the review where necessary.
Results of the search
Our searches generated a total of 2493 abstracts. Once duplicate
Subgroup analysis and investigation of heterogeneity
abstracts were removed (N = 1083), the total number of abstracts
As we did not undertake a meta-analysis, we could not conduct a reviewed was 1410 (see Figure 1). The handsearch did not produce
subgroup analysis. any additional articles. Following assessment of each of the ab-
stracts, we identified 34 studies that potentially met our inclusion
criteria (1 from EPOC, 1 from CENTRAL, 29 from MEDLINE,
Sensitivity analysis
and 3 from CINAHL).

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 9

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Figure 1. Flow diagram of study selection

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Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
We included nine studies (N = 6540), all conducted in high-
income countries (Australia, Belgium, Sweden, UK, and USA). collaborative audit (the specific focus of these audits was not iden-
We identified four studies for this update (Black 2013; Calland tified) and submit an audit report. Control teams provided usual
2011; Deneckere 2013; Strasser 2008). care at their institution .
Eight studies compared an interprofessional collaboration (IPC) Deneckere 2013 evaluated an interprofessional intervention for
intervention to a control group, which received usual care (Black 30 teams caring for patients with chronic obstructive pulmonary
2013; Calland 2011; Cheater 2005; Curley 1998; Deneckere disease and proximal femur fracture. Seventeen intervention teams
2013; Schmidt 1998; Strasser 2008; Wild 2004); one study com- and 13 control teams based in Belgian hospitals were involved in
pared two different IPC interventions (Wilson 2004). the study (N = 581), the aim of which was to examine effects of the
All of the studies reported an objectively measured, or self-reported use of care pathways on interprofessional teamwork, in an acute
(using a validated instrument), patient, clinical process or effi- care setting. The intervention involved three facilitated compo-
ciency outcome. The secondary outcome, collaborative behaviour, nents. To promote IPC the intervention included: feedback on
was only evaluated in four of the studies (see below). the team’s performance before the implementation of care path-
ways; receipt of evidence-based key indicators for implementing
care pathways in practice; and review and training in the devel-
Included studies
opment and implementation of care pathways. The teams ran-
domised to the control group provided usual care (i.e. did not im-
Externally facilitated interprofessional activities plement care pathways). The intervention teams were given nine
months to implement the intervention. After this time period, a
Black 2013 evaluated the effectiveness of an externally facilitated
summative evaluation was performed, in which the performance
IPC intervention, based in primary care practices, to support
nurses, administrative staff, practice managers, and receptionists on team indicators was compared between the intervention and
control groups.
to work collaboratively with general practitioners (GPs) to en-
Strasser 2008 evaluated the effects of an externally facilitated inter-
hance the delivery of patient care when implementing practice sys-
vention aimed at improving collaboration to support better care
tems that supported chronic disease care. Sixty primary care prac-
delivered to patients following a stroke. Thirty-one teams from
tices, involving 1185 participants based across Australia, took part
different Veteran Affairs’ rehabilitation units based in the USA par-
in the study. The intervention included the following activities:
structured appointment systems; patient disease registers; patient ticipated in the study. Participants included physicians, nurses, oc-
cupational therapists, speech-language pathologists, physical ther-
recall systems with reminders; patient education; planned care;
apists, case managers, or social workers (N = 464). Intervention
definition of roles, responsibilities and job descriptions for each
teams received the following activities, delivered in three phases:
professional or staff member; communication and meetings; prac-
phase 1) an off-site facilitated workshop emphasising team dynam-
tice billing; record keeping; and quality improvement. Before the
ics, problem-solving, the use of performance feedback data, and
intervention, facilitators conducted workshops with primary care
staff, followed by practice visits. Staff were provided with resource the development of action plans (specific team performance pro-
files with recommendations) for process improvement; phase 2)
manuals and workbooks for each of the different elements of the
development of written action plans to address team process prob-
intervention. Facilitators routinely followed up practices by tele-
lems, based on discussions at the earlier workshop; and phase 3)
phone and email. All control teams received the IPC intervention
telephone and video conference consultation on advice for imple-
after the 12-month follow-up data collection in each intervention
mentation of action plans, and facilitation of team process skills.
practice.
Cheater 2005 evaluated an externally facilitated programme aimed Control teams continued with usual care (i.e. specific team per-
formance profile information).
at improving IPC by the use of a multidisciplinary audit in a sec-
For further details on these studies: see Characteristics of included
ondary care setting. Twenty-two multidisciplinary teams from five
studies
acute care hospitals in the UK participated. Each team consisted
of nurses and physicians, and a representative from one or more of
other health professional groups (e.g. pharmacist, social worker,
physiotherapist), service support staff (e.g. ward clerk, care assis- Interprofessional rounds
tant), and managers (N = 141). A range of specialties were repre- Curley 1998 examined the effects of daily interdisciplinary rounds
sented. After participating in a two-day skills workshop, external in inpatient medical wards at an acute care hospital in the USA.
facilitators facilitated five meetings over a period of six months, The intervention group consisted of three ward services that im-
for each of the multidisciplinary teams randomised to the inter- plemented interdisciplinary work rounds; the control group con-
vention group. Intervention teams were required to undertake a sisted of three other ward services that continued usual care (i.e.

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Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
traditional work rounds) (N = 1102). Team members included: speech pathologist, occupational therapists, a social worker, and
medical interns and residents, staff nurses, nursing supervisors, medical students. Patients were randomly assigned to the audio
respirologists, pharmacists, nutritionists, and social workers. To conferencing or video conferencing (N = 100). At each conference
reduce baseline variability the authors used a process of random session, the audio conferences were conducted before the video
allocation of patient and clinical staff to either intervention wards conferences, with the same multidisciplinary team.
or control wards. For further details on these studies: see Characteristics of included
Wild 2004 studied the effects of daily interdisciplinary rounds studies.
in a telemetry unit of a community hospital in the USA. In this
study, patients were randomised to a medical team that performed
daily interdisciplinary rounds, and patients were randomised to a Interprofessional checklists
medical team that provided usual care (N = 84). During the inter- Calland 2011 studied the effects of a procedure checklist for inter-
disciplinary rounds, the resident physicians, nurses, a case man- professional surgical teams during laparoscopic cholecystectomies.
ager, pharmacist, dietitian, and physical therapist spent two to five Ten USA-based general surgery teams were randomly assigned to
minutes discussing each patient, and identifying and addressing an intervention or a control group (N = 29). The intervention
possible discharge problems. No information on the duration of consisted of preoperative steps: a briefing with introductions from
the intervention was provided. all operating team members (surgeons, anaesthetists and nurses), a
For further details on these studies: see Characteristics of included review of the patient’s history, laboratory and radiographic studies,
studies. and a discussion of any unusual care circumstances. Surgeons in
the intervention group received instructions on using the check-
list and reminders before each surgery. In addition, a checklist
Interprofessional meetings
copy was posted on the anaesthesia monitor in the operating room
Schmidt 1998 evaluated the impact of multidisciplinary team during cases, and team members were encouraged to use a call-
meetings on the quality and quantity of psychotropic drug pre- and-repeat method to ensure that key steps of the checklist were
scribing in Swedish nursing homes. Thirty-six nursing homes were neither omitted nor performed in a suboptimal manner. Control
randomised to either receive the intervention or were randomised teams performed the laparoscopic cholecystectomy procedure in
to the control group (N = 1854). In the experimental nursing their normal fashion, without the use of a checklist.
homes, the pharmacist in the homes helped organise team meet- For further details on this study: see Characteristics of included
ings that occurred approximately once a month, over a period of studies.
12 months. The nursing home pharmacists attended two train-
ing sessions prior to, and three sessions during, the programme.
The team meeting participants in the nursing homes included Excluded studies
the pharmacist, a physician, and selected nurses and nursing assis- We excluded 30 studies. The main reason for exclusion was that
tants. All participants were encouraged to take part in the meet- the intervention was not practice-based interprofessional collabo-
ing discussions about the drug use of individual residents. Usual ration (IPC). See: Characteristics of excluded studies.
care continued to be used in the control homes. Nursing home
residents’ prescriptions were recorded one month before, and one
month after, the 12-month intervention.
Risk of bias in included studies
Wilson 2004 compared two forms of multidisciplinary virtual The risk of bias in the nine included studies varied. A brief sum-
team conferencing: usual care (audio conferencing) with video mary is presented below. Further information for each included
conferencing (including audio). Participating team members con- study is presented in the Characteristics of included studies tables;
sisted of medical staff specialists, medical registrars, nurses, a Figure 2 and Figure 3 provide further overviews.

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Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Figure 2. ’Risk of bias’ graph: review authors’ judgements about each risk of bias item presented as
percentages across all included studies, based on EPOC methods.

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 13

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Figure 3. ’Risk of bias’ summary: review authors’ judgements about each risk of bias item for each included
study, based on EPOC methods.

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 14

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Allocation
Selective reporting
We classified the sequence generation for six studies as ’low risk’. In Two of the more recently completed studies published re-
Cheater 2005 and Strasser 2008, randomisation was determined search protocols prior to study commencement (Deneckere 2013;
by computer; in Wild 2004, randomisation was performed with Strasser 2008). We judged seven studies at ’unclear risk’ for this
random numerical assignments in pre-sealed envelopes; Curley bias, due to the difficulty in establishing what outcomes may have
1998 randomised with a firm system; Wilson 2004 used a table of been planned in the protocol and collected, but not reported in
random numbers, while Deneckere 2013 used stratified randomi- the final published study report.
sation to render intervention and control interprofessional teams
comparable. We assessed the sequence generation for three stud-
ies as ’unclear risk’, as there was insufficient information reported Other potential sources of bias
about the sequence generation process (Black 2013; Calland 2011; We assessed two of the studies as being at ’unclear risk’ for contam-
Schmidt 1998). ination bias (Calland 2011; Wilson 2004). In both trials, some
For allocation concealment, we classified five of the studies as measures were taken to prevent contamination, but some of the
’low risk’ (Cheater 2005; Curley 1998; Deneckere 2013; Schmidt subjects crossed over from one arm of the study to the other (and
1998; Wilson 2004). In these studies, participating professionals were involved in both interventions), thereby, potentially con-
or investigators enrolled participants. They could not foresee as- taminating the initial randomisation process. We recorded studies
signment because allocation took place in a location separate from at ’unclear risk’ for baseline outcome measurements and baseline
recruitment; a sequentially numbered, blind or pre-sealed enve- characteristics due to lack of information presented in the pub-
lope was used for allocation concealment, or both. We classified lished paper.
four studies at ’unclear risk’, since there was insufficient informa-
tion provided to assess this criteria (Black 2013; Calland 2011;
Effects of interventions
Schmidt 1998; Wild 2004) .
See: Summary of findings for the main comparison Effects of
practice-based interprofessional collaboration (IPC) interventions
Blinding on professional practice and healthcare outcomes compared
to usual care; Summary of findings 2 Effects of practice-
We considered four studies to represent ’high risk’ for blinding of
based interprofessional collaboration (IPC) interventions on
outcome assessment (Black 2013; Calland 2011; Deneckere 2013;
professional practice and healthcare outcomes compared with
Strasser 2008). These studies did not prevent knowledge of the
alternative IPC intervention
allocated interventions, as no blinding was performed, and the
This section reports on primary and secondary outcomes from
outcome measurement was likely to be affected by lack of blinding.
the nine included studies. Data presented below are taken directly
We classed detection bias as ’low risk’ in five studies (Cheater 2005;
from the published articles of the included studies. We report point
Curley 1998; Schmidt 1998; Wild 2004; Wilson 2004).
estimates and confidence intervals whenever reported by the study
authors. For further detailed information see Summary of findings
Incomplete outcome data for the main comparison and Summary of findings 2.

We assessed four studies as being at ’low risk’ of attrition bias

(Curley 1998; Deneckere 2013; Schmidt 1998; Wild 2004). Practice-based interprofessional collaboration (IPC)
These studies provided an adequate description of participant flow interventions compared with usual care
through the study, with missing outcome data relatively balanced Eight studies compared IPC interventions with usual care.
between groups, and judged to be unlikely to be related to the
outcomes of interest. We assessed four studies as having ’high risk’
of attrition bias for the following reasons: they acknowledged that Externally facilitated interprofessional activities
sites dropped out but intention-to-treat analysis was not men-
tioned in the text; there were differences in characteristics related
to study outcomes between completers and non-completers (Black Patient health outcomes
2013; Calland 2011; Cheater 2005; Strasser 2008). We judged
attrition bias at ’unclear risk’ in one study, as the study authors
did not report sufficient information about attrition and missing
Patient functional status
data (Wilson 2004).

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 15

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Externally facilitated interprofessional activities may slightly im- Use of healthcare resources
prove stroke patients’ motor function (low-certainty evidence, 1 While Strasser 2008 reported that externally facilitated interpro-
study, N = 464). Strasser 2008 reported a difference between the fessional activities may improve use of resources (low-certainty ev-
intervention and control groups in patient health, with changes idence, 1 study, N = 464), Strasser 2008 also reported that there
from admission to discharge in the motor skills component of the was little or no difference between the intervention and control
Functional Independence Measure (FIM) score. For the patients groups for length of stay or discharge disposition.
with stroke, 13.6% more of those in the intervention group gained
in excess of the median gain, 23 points, when compared to the
control group (P = 0.032). Collaborative behaviour outcomes

Patient-assessed quality of care Collaborative working, team communication and team co-
ordination
It is uncertain if externally facilitated interprofessional activities
It is uncertain whether externally facilitated interprofessional ac-
increase patient-assessed quality of care at 12-month follow-up
tivities improve collaborative working, team communication, and
(very low-certainty evidence, 1 study, N = 1185) (Black 2013).
co-ordination (very low-certainty evidence, 3 studies, N = 1907).
Black 2013 reported differences between the intervention and con-
trol groups in the mean change from baseline to follow-up in staff
Patient mortality, morbidity or complication rates role scores assessed using the Chronic Care Team Profile (CCTP).
These differences were in the non-GP clinical staff function (P
None of the included studies reported patient mortality, morbidity
= 0.023), the administrative staff function (P < 0.001), and the
or complication rates.
total score (P = 0.03). These changes included, for example, the
creation of a diabetes care co-ordinator to perform tasks such as
managing the recall and reminder system for patients with dia-
Clinical process or efficiency outcomes
betes, and organising staff meetings to improve communication
and practice systems.
Cheater 2005 report that Collaborative Practice Scale (CPS) scores
on co-operation went from 83.5 at baseline to 88.5 after the inter-
Adherence to recommended practices
vention in the intervention group, compared to 84.5 at baseline
The use of interprofessional activities with an external facilitator to 84.5 after the intervention in the control group. These differ-
may slightly improve adherence to recommended practices and ences are presented with no measures of variability and the change
prescription of drugs (low-certainty evidence, 2 studies, N = 722). appears small in relation to the value at baseline.
Cheater 2005 reported an increase in collaborative audit activity, Deneckere 2013 found little effect of the intervention on relational
with six of the 11 intervention teams completing the full audit co-ordination, which assessed the process of communication and
cycle. Only three control teams undertook any audit (first data relationship between team members in order to complete the task.
collection).
Deneckere 2013 reported improvements in the following out-
comes: conflict management (slope of difference between inter- Interprofessional rounds
vention and control group (β) 0.30, 95% confidence interval (CI)
0.08 to 0.53); team climate for innovation (β 0.29, 95% CI 0.09
Patient health outcomes
to 0.49); and level of organised care (β 5.56, 95% CI 1.35 to
9.76). Deneckere 2013 also reported that the intervention group None of the included studies reported patient health outcomes.
scored lower in emotional exhaustion (β 0.57, 95% CI 0.14 to
1.00) and higher in level of competence (β 0.39, 95% CI 0.15 to Clinical process or efficiency outcomes
0.64).

Use of healthcare resources

Continuity of care Interprofessional rounds may improve use of healthcare resources
It is uncertain if externally facilitated interprofessional activities (low-certainty evidence, 2 studies, N = 1186).
improve continuity of care (low-certainty evidence, 1 study, N = Curley 1998 found differences in length of stay and costs for pa-
464). tients in the interdisciplinary group compared to the traditional

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 16

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
care group. The mean length of stay for patients in the interdisci- Interprofessional checklists
plinary rounds group was 5.46 days, compared with 6.06 days for
traditional care (P = 0.006). The mean total charges were USD
6681 and USD 8090 for the two groups, respectively (P = 0.002). Patient health outcomes
For respiratory therapy, 91.7% of the nursing and pharmacy or-
ders in the interdisciplinary rounds group were appropriate, com- None of the included studies reported patient health outcomes.
pared with 73.6% for the traditional rounds group (P = 0.075).
Wild 2004 found little or no change in the length of hospital stay,
between the experimental group (3.2 ± 2.7 days), which partic- Clinical process or efficiency outcomes
ipated in interdisciplinary rounds, and the control group (3.2 ±
3.2 days (P = 0.90)).

Use of healthcare resources

Collaborative behaviour outcomes Interprofessional checklists may improve use of healthcare re-
None of the included studies reported collaborative behaviour out- sources (low-certainty evidence, 1 study, N = 29).
comes. In Calland 2011, there was little or no difference between sur-
geons and team members in the intervention group (who received
basic team training and used a pre-procedural checklist), and the
control group (who performed standard laparoscopic cholecystec-
Interprofessional meetings
tomies), in patient outcomes, length of operation, discharge sta-
tus, readmission rates, and technical proficiency. Overall, situa-
tional awareness did not differ between the two groups. Surgeons
Patient health outcomes and team members in the intervention group consistently rated
The included study did not report patient health outcomes. their cases as involving less satisfactory levels of comfort, team ef-
ficiency, and communication compared to the control group.

Clinical process or efficiency outcomes

Collaborative behaviour outcomes

Adherence to recommended practices

Collaborative working, team communication and team co-
Interprofessional meetings may slightly improve adherence to rec- ordination
ommended practices and prescription of drugs (low-certainty ev-
Calland 2011 reported that participants in the intervention
idence, 1 study, N = 1854).
(checklist) group were more likely to introduce team members, as-
Schmidt 1998 found that the change from baseline to end of
sign team roles, give case presentations, devise contingency plans,
study in the proportion of patients receiving drugs was the same
and complete post-case performance reviews. The intervention
in experimental and control homes (1.3% intervention and 1.3%
may make little or no difference to collaborative behaviour.
control). The mean number of psychotropic drugs increased from
2.07 to 2.08 (1%) in the intervention group and from 2.06 to
2.20 (7%) in the control group. The use of non-recommended
Practice-based IPC intervention compared with
hypnotics declined by 37% in the experimental homes versus a
alternative IPC intervention
decrease of only 3% in the control homes. There was little or no
change in the prescribing of non-recommended anxiolytics in the Wilson 2004 compared one type of IPC intervention (video con-
experimental homes, but there was an increase of 7% in the con- ferencing) with a second IPC intervention (audio conferencing).
trol homes. Non-recommended antidepressant drugs decreased by
59% in experimental homes but by only 34% in control homes.
Interprofessional meetings

Collaborative behaviour outcomes

The included study did not report collaborative behaviour out- Patient health outcomes
comes. The included study did not report patient health outcomes.

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Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Clinical process or efficiency outcomes encing may improve process/efficiency outcomes by reducing the
number of multidisciplinary conferences needed per patient and
patient length of stay.

Use of healthcare resources Collaborative behaviour outcomes

Interprofessional meetings may improve use of healthcare re-
sources (low-certainty evidence, 1 study, N = 100). Wilson 2004
reported that the mean number of audio conferences held per pa-
Collaborative working, team communication and team co-
tient (mean 3.3; standard deviation (SD) 4.4) was greater than the
ordination
mean number of video conferences held (mean 1.9; SD 1.3; P =
0.04). Video conferencing may reduce the average length of treat- Wilson 2004 reported little or no difference between the groups in
ment (mean 6.0; SD 4.5 days), compared to audio conferencing the number of communications between health professionals, as
(mean 10.2; SD 12.3 days; P = 0.03). The use of video confer- recorded in the notes (low-certainty evidence, 1 study, N = 100).

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Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]

Effects of practice- based interprofessional collaboration (IPC) interventions on professional practice and healthcare
outcomes compared with alternative IPC intervention

Patient or population: health and social care prof essionals involved in the delivery of health services and patient care
Settings: two hospitals in Australia
Intervention: m ultidisciplinary video conf erencing
Comparison: m ultidisciplinary audio conf erencing

Outcomes Impacts No. of Certainty of the evidence

studies (GRADE)
(participants)

Patient health outcomes The study did not report pa- - -

tient health outcom es.

Clinical process or efficiency Video conf erencing m ay re- 1 (100) ⊕⊕

outcomes duce the average length of Lowa
treatm ent, com pared to au-
dio conf erencing and m ay im -
prove process/ ef f iciency out-
com es by reducing the num -
ber of m ultidisciplinary con-
f erences needed per patient
and patient length of stay

Collaborative behaviour out- There was little or no dif f er- 1 (100) ⊕⊕

comes ence between the interven- Lowa
tions in the num ber of com -
m unications between health
prof essionals

GRADE Working Group grades of evidence

High- certainty: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate- certainty: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and
m ay change the estim ate.
Low- certainty: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is
likely to change the estim ate.
Very low- certainty: We are very uncertain about the estim ate.
a We assessed the certainty of evidence as low because of high risk of bias (attrition and detection) and unclear risk of bias
(selection, reporting, and contam ination).

Summary of main results

Eight studies compared an interprofessional collaboration (IPC)
intervention with usual care (Black 2013; Calland 2011; Cheater
DISCUSSION
Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 19
Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
2005; Curley 1998; Deneckere 2013; Schmidt 1998; Strasser Interprofessional meetings
2008; Wild 2004). One study compared one IPC intervention One study reported the effects of this intervention. Interprofes-
(video/audio conferencing) with another (audio conferencing) ( sional meetings may slightly improve adherence to recommended
Wilson 2004). See Summary of findings for the main comparison practices (low-certainty evidence, 1 study, N = 1854) and may im-
and Summary of findings 2. prove use of resources (low-certainty evidence, 1 study). Schmidt
1998 implemented a collaborative team meeting in nursing homes.

IPC interventions compared with usual care

Interprofessional checklists
Each of the eight included studies in this comparison is discussed One study reported the effects of this intervention. Interprofes-
below in relation to the specific IPC intervention they employed. sional checklists may improve the use of resources (low-certainty
None of the included studies reported on patient mortality, mor- evidence, 1 study, N = 29). Calland 2011 used a pre-procedural
bidity or complication rates. checklist with surgical teams.

IPC intervention compared with alternative IPC

Externally facilitated interprofessional activities
intervention
Four studies reported the effects of this intervention. Externally Wilson 2004 assessed the impacts of interprofessional meetings
facilitated interprofessional activities may slightly improve patient facilitated using two different technologies, and found that video/
functional status (1 study, N = 464) and adherence to recom- audio conferencing may be more efficient than audio conferencing
mended practices (2 studies, N = 722), and may improve use of alone.
resources (1 study, N = 464). There was low-certainty evidence for
all outcomes. It is uncertain whether externally facilitated inter-
professional activities improve patient-assessed quality of care (1
Overall completeness and applicability of
study, N = 1185), continuity of care (1 study, N = 464), or collab-
evidence
orative working (3 studies, N = 1907), as we graded the evidence
as very low-certainty. The included studies covered four types of practice-based IPC in-
The included studies reported varied activities. Strasser 2008 terventions: externally facilitated interprofessional activities, inter-
implemented a multiphase, IPC programme, delivered over six professional rounds, interprofessional meetings, and interprofes-
months, that aimed to enhance the effectiveness of interdisci- sional checklists. We did not find any studies that used other types
plinary stroke rehabilitation teams. Cheater 2005 reported an IPC of practice-based IPC interventions, such as debriefing. Given the
intervention where an external facilitator used strategies to en- range of practice-based interventions aimed at promoting IPC,
courage collaborative working. Deneckere 2013 developed a care and the different types of participants, settings, and clinical areas
pathway for patients hospitalised in an acute hospital setting with addressed in these interventions, further studies are required to
either a proximal femur fracture or an exacerbation of chronic ob- provide better insight into the effectiveness of these interventions
structive pulmonary disease. Black 2013 used a multimodal in- alone or in combination, in a variety of target groups and clinical
tervention involving educational sessions, practice visits, and re- areas.
source manuals and workbooks. Other issues affected the completeness of the evidence. For ex-
ample, Schmidt 1998 acknowledged that their study could not
provide robust evidence about the participating teams’ decision-
making processes, or the strategies used by pharmacists in their
Interprofessional rounds
role as team facilitators.
Two studies reported the effects of this intervention. Overall, inter- Secondary outcomes, focused on examining interprofessional col-
professional rounds may improve use of resources (low-certainty laboration processes, were not well examined in most of the stud-
evidence, 2 studies, N = 1186 participants). The studies imple- ies, with only four studies reporting on this type of outcome (Black
mented the intervention in an acute care hospital and in a com- 2013; Cheater 2005; Deneckere 2013; Wilson 2004).
munity hospital telemetry ward (Curley 1998; Wild 2004). Wild Six of the nine included studies were cluster-randomised trials;
2004 suggested that their finding of little or no change in clinical this was appropriate, given the complex nature of interventions
process outcomes could be because, for many admissions, there and their inherently clustered nature, the difficulty of blinding,
was already a clinical pathway with standardised care for their di- and the consequential threat of contamination.
agnoses, the patients were more stable, at a lower risk for compli- Whilst we identified four new studies for this review, the number
cations, and possibly healthier overall, and so the interdisciplinary of practice-based IPC studies remains small. Some of the studies
rounds provided no additional advantage. offered some evidence that IPC interventions may be effective in

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Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
improving clinical processes/efficiency outcomes, but the small Implications for practice
number of studies and the methodological limitations precluded
The findings from the nine studies included in this review sug-
definitive conclusions. Therefore, we still know little about the
gested that interventions aimed at improving interprofessional col-
processes of collaboration, and how they contribute to changes in
laboration (IPC) through practice changes may slightly improve
clinical process/efficiency and patient outcomes.
clinical process/efficiency and patient health outcomes compared
to usual care or an alternative intervention. Nine randomised tri-
als of four different IPC interventions, in nine different clinical
Certainty of the evidence settings and health conditions provided mixed results. We judged
The review included nine randomised trials; the findings for the the certainty of evidence from these randomised trials to be low
two comparisons are summarised in Summary of findings for to very low. Based on these included studies we do not have suf-
the main comparison and Summary of findings 2. Based on our ficient evidence to draw clear conclusions on the effects of IPC
GRADE assessment, we found the certainty of the evidence from interventions.
the included studies to be low or very low due to risk of bias (at-
trition, detection, selection, reporting, and contamination bias),
and potential indirectness (as outcomes generated in one country Implications for research
or clinical setting may not be transferable to other settings).
Given the problems that health professionals encounter with IPC
A number of other study limitations may also have contributed to
in their clinical practice (e.g. Körner 2016; Van Leijen-Zeelenberg
the risk of bias: Curley 1998 used a non-validated survey to ex-
2015), it is encouraging that research on the effects of IPC in-
amine interdisciplinary communication on the ward. Wild 2004
terventions has increased since the previous Cochrane Review of
used a questionnaire to ask about communication, but this was
this intervention (Zwarenstein 2009). While this research field is
only administered to the experimental group. Similarly, Cheater
developing, further rigorous, mixed-method studies are required.
2005 used a modified Collaborative Practice Scale (CPS), which
It is recommended that future randomised trials have a clear and
was also only completed by the experimental group. Wilson 2004
explicit focus on IPC, longer acclimatisation periods before eval-
used the number of communications between health professionals,
uating newly implemented teamwork interventions, and longer
recorded in the notes, to measure communication, which is a lim-
follow-up.
ited measurement of collaboration. Deneckere 2013 used a post-
test only; as a result, there was no baseline assessment measured
before the intervention. Also, the results were primarily based on Future research should also focus on the conceptualisation and
self-reported outcomes, which caused some limitations, such as measurement of collaboration. While there are some scales that
possible social desirability bias. measure collaboration (e.g. Kenaszchuk 2010), there are limita-
tions with their validity, reliability, the extent to which they could
be used with different professional groups, and how well they ex-
Potential biases in the review process amine issues of collaborative practice.

The searches were sensitive, but some literature may be under-

The studies included in this updated Cochrane Review used a va-
represented. We did not contact authors of the included studies
riety of terms to describe their interventions (e.g. interdisciplinary,
for this review, which may have introduced some bias. In the next
multidisciplinary), which contributes to an on-going confusion
review, Scopus should be added to the databases to be searched,
of terminology. The absence of a consistent approach to termi-
and corresponding authors of included studies should be contacted
nology of these interventions undermines our ability to synthesise
to clarify published information, and to seek unpublished data.
them in order to develop a more informed understanding of their
The limited number of studies reporting data on both primary
effects. Further work is needed to clarify the conceptualisation
and secondary outcomes limited exploration of publication bias
of IPC, interprofessional education, and interprofessional organ-
and sensitivity analyses.
isationally-based interventions to support consistency in the use
and understanding of these terms and their related interventions.
While we have published an initial classification (Reeves 2010;
Agreements and disagreements with other
Reeves 2011), future empirical work could test these conceptuali-
studies or reviews
sations to generate more detailed knowledge related to their imple-
There were no comparable reviews in this area. mentation. Finally, quantitative and qualitative methods should
be used in single studies to improve our understanding of how the
intervention addresses collaboration, the nature of changes that
occur in relation to collaboration, and how they in turn lead to
AUTHORS’ CONCLUSIONS the outcomes achieved.

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 21

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ACKNOWLEDGEMENTS viewers Kunal D Patel and Andreas Xyrichis who generously gave
up their time to provide comments on the review, which helped
The authors would like to acknowledge their respective academic
improve its quality.
institutions for the support in undertaking this updated Cochrane
Review. The authors would also like to thank the following Ef- The National Institute for Health Research (NIHR), via Cochrane
fective Practice and Organisation of Care (EPOC) editors and Infrastructure, funds the Effective Practice and Organisation of
staff for their advice and feedback on the review: Pierre Durieux, Care (EPOC) Group. The views and opinions expressed therein
Daniela Gonçalves Bradley, Simon Lewin, Paul Miller, and Julia are those of the authors and do not necessarily reflect those of the
Worswick. We would like to thank Vicki Pennick for copy-editing Systematic Reviews Programme, NIHR, National Health Service
the review. Finally, the authors would like to thank the peer re- (NHS), or the Department of Health.

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∗
professionals/education/en/. Indicates the major publication for the study

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 25

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Black 2013

Methods Cluster-randomised trial to test the effectiveness of an intervention involving non GP-
staff in GP practices, on the quality of care for patients with diabetes or cardiovascular
disease

Participants Country: Australia

General practitioners, nurses, practice managers, receptionists, and other administrative
staff. 60 general practices were randomised to receive a 6-month teamwork intervention
immediately (intervention, n = 637) or after 12 months (control, n = 548)

Interventions To assist non-GP staff (e.g. nurses, administrative staff (practice managers, receptionists)
) to work as a team with GPs, the intervention included a number of activities including:
the use of structured appointment systems, recall and reminders, planned care, the use
of roles, responsibilities, and job descriptions, as well as communication and meetings

Outcomes Quality of care (12-month follow-up)

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Randomisation is mentioned: “…Follow-

bias) ing baseline-data collection, practices were
stratified according to size (solo, 2 to 4 GPs
or 5+ GPs) and randomised to receive the
6-month teamwork intervention immedi-
ately, or after 12 months…”, but method
not specified

Allocation concealment (selection bias) Unclear risk No description of allocation method.

Baseline outcome measurements similar - Low risk At baseline, the quality of care PACIC out-
All outcomes comes in the intervention group (3.01, SD
0.30) and control group (2.87, SD 0.34)
were similar

Baseline characteristics similar Low risk Intervention and control teams look rea-
sonably similar.
Quote: “Control practices were more likely
to be in an urban location compared with
the intervention practices, have a lower full-
time equivalent level of practice nurses and
were also more likely to have a higher score

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 26

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Black 2013 (Continued)

on the CCTP with more administrative

functions for chronic disease managed by
non-GP staff. There were no key differ-
ences between the control and intervention
practices for total levels of non-GP staffing.
”

Blinding of outcome assessment (detection High risk It did not appear that there was any blind-
bias) - All outcomes ing.

Incomplete outcome data (attrition bias) - High risk Acknowledged sites dropped out, but ITT
All outcomes is not mentioned in the text
Practice level:
Quote: “Of these, 69% (60/87) finally par-
ticipated in the study, and three of these
(3/60) withdrew at follow up…Reasons for
withdrawal of three practices included con-
cern about the extent of data collection and
other reasons not pertaining to the study.”
Patient level:
There were 3349 patients invited to partic-
ipate in the study, with 2642 (79%) provid-
ing informed consent. Of these, 2552 (96.
6%) returned the PACIC questionnaire at
baseline, with 2135 (73.7%) completing all
20 items. To be included in the factor anal-
ysis, at least 17 questions needed to be com-
pleted, and 2438 participants met this cri-
terion. The multilevel regression included
data for which all relevant variables were
available, resulting in a final sample size of
1853 patients

Contamination Low risk Allocation was by practice, and it is unlikely

that the control practices received the in-
tervention

Selective reporting (reporting bias) Unclear risk All relevant outcomes in the method sec-
tion (p B) were reported in the results sec-
tion (p D-E). A study protocol was not
available and there was insufficient infor-
mation to permit judgement of high or low
risk of bias

Other bias Low risk Cluster-randomised trial with appropriate

statistical analysis

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 27

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Calland 2011

Methods A RT of an IPC intervention aimed to determine the effectiveness of procedural checklists

for surgical teams during 47 laparoscopic cholecystectomies. General surgeons were
randomly assigned to an intervention (i.e. the use of the checklist) or a control group

Participants Country: USA

Ten general surgeon teams consisting of surgeons, anaesthetists and nurses. Twenty-
three patients in the control group and 24 in the intervention group. Eighteen patients
dropped out between the randomisation and the analysis

Interventions An intraoperative procedural checklist including preoperative, intraoperative, and post-

operative items

Outcomes Clinical process or efficiency outcomes: length of operation, discharge status, readmission
rates and technical proficiency. Collaborative behavioural outcomes: team behaviours (e.
g. team communication and co-ordination)

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Randomisation was mentioned: “a total of
bias) 65 cases were randomized (by attending
surgeon) to…”, but method not specified

Allocation concealment (selection bias) Unclear risk No description of allocation method.

Baseline outcome measurements similar - Unclear risk Not reported.

All outcomes

Baseline characteristics similar Low risk Quote: “Length of operation, discharge sta-
tus, and readmission rates as indication of
case outcome showed nonstatistical differ-
ences between groups.”

Blinding of outcome assessment (detection High risk It did not appear that there was any blind-
bias) - All outcomes ing.

Incomplete outcome data (attrition bias) - High risk Acknowledged sites dropped out but ITT
All outcomes was not mentioned in the text
Patient level:
Quote: “A total of 65 cases were random-
ized...”
Quote: “Eighteen subjects/cases dropped
out between randomization and analysis:
two in the checklist group declined to use
the checklist or requested that their cases
be withdrawn after videotaping, three cases

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 28

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Calland 2011 (Continued)

were excluded due to the conversion from

laparoscopic to open procedure, procedure
cancellations occurred in four cases, and
scheduling difficulties or mechanical prob-
lems precluded participation for the nine
remaining dropouts.”

Contamination Unclear risk Randomised at the level of surgeon, but as

noted by the authors “there exists the pos-
sibility that residents and other staff par-
ticipated in both control and intervention
cases and this contaminated our results” (p
1137)

Selective reporting (reporting bias) Unclear risk All relevant outcomes in the method sec-
tion (p 1132-3) were reported in the results
section (p 1133-6). A study protocol was
not available and there was insufficient in-
formation to permit judgement of high or
low risk of bias

Other bias Low risk None detected.

Cheater 2005

Methods A RT where 22 multidisciplinary teams from five acute care hospitals were randomised to
an intervention group that participated in a facilitated programme on multidisciplinary
audit or a control group

Participants Country: UK
Nurses, physicians and other professionals (e.g. pharmacist, social worker, physiother-
apist), service support staff (e.g. ward clerk, care assistant), and managers. A range of
specialties (e.g. surgery, medicine, and nephrology) were included. There were 11 teams
with a total of 77 participants in the intervention group and 11 teams with a total of 64
participants in the control group

Interventions Five facilitated meetings over 6 months with activities designed to support multidisci-
plinary teams to undertake an audit

Outcomes Collaborative audit activity.

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 29

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cheater 2005 (Continued)

Random sequence generation (selection Low risk Quote: “Teams within the same hospi-
bias) tal were stratified on mean self-reported
KSA scores, perceived level of team collab-
oration and medical or surgical specialty
before randomisation. The project secre-
tary under the supervision of [a researcher]
randomised 22 teams to intervention or
control groups, using a computer random
number generator

Allocation concealment (selection bias) Low risk Quote: “With the exception of two ac-
cident and emergency teams in different
hospitals, teams from the same organisa-
tion were randomised in pairs. Other re-
searchers were blind to allocation.”

Baseline outcome measurements similar - Low risk At baseline, both groups were equivalent
All outcomes for baseline variables in relation to KSA
scores, and on the scores for the Collabo-
rative Practice Scale

Baseline characteristics similar Low risk Quote: “At baseline, both groups were
equivalent for all outcome variables except
two. In comparison to the intervention
group, the control arm reported higher lev-
els of audit knowledge (median score 32.5
vs 25.0, z = -3.001, P = 0.003) and skills
(median score 32.5 vs. 24.6, z = - 2.990, P =
0.003). Baseline differences were adjusted
for in the analysis. Baseline differences were
not found for WWTs.”

Blinding of outcome assessment (detection Low risk Quote: “Two members of the research team
bias) - All outcomes (RB and HH) independently assessed the
quality of the reports (blind to group alloca-
tion) and the percentage inter-rater agree-
ment did not fall below 82%.”

Incomplete outcome data (attrition bias) - High risk Practice level:

All outcomes Quote: “Participation in the intervention
programme was associated with increased
audit activity, with 9 of the 11 teams re-
porting improvements to care and seven
teams completing the full audit cycle. In
contrast, the majority of teams in the con-
trol group had made no progress with un-
dertaking an audit and only two teams had
undertaken a first data collection and im-
plemented changes.”

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 30

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cheater 2005 (Continued)

Patient level:
Results were provided about the quality of
the audits in relation to their compliance
with the 55 quality criteria, but no further
information was provided in relation to any
patient level outcomes

Contamination Low risk Only intervention teams participated in the

facilitation programme

Selective reporting (reporting bias) Unclear risk All relevant outcomes in the method sec-
tion (p 781-2) were reported in the results
section (p 785-7). A study protocol was not
available and there was insufficient infor-
mation to permit judgement of high or low
risk of bias

Other bias Low risk None detected.

Curley 1998

Methods Randomised trial - Firm trial: patients and staff from inpatient medical wards at an acute
care hospital were randomised to one of six medical wards. Three wards were allocated
to the intervention group that implemented daily interdisciplinary work rounds, and
three wards were allocated to the control group that continued traditional work rounds

Participants Country: USA

Interns and residents in medicine, staff nurses, nursing supervisors, respirologists, phar-
macists, nutritionists, and social workers. There were 567 patients in the intervention
group and 535 patients in the control group

Interventions Daily interdisciplinary work rounds.

Outcomes Length of stay, total charges, orders for administration of aerosols

Notes Unit of analysis error - allocated intervention to wards but analysed patients without
correction for clustering. However, this correction may not substantially change the
conclusion because randomisation of staff and patients limits variation between clusters

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Quote: “The firm system randomization
bias) procedures and their validation have been
reviewed extensively in the literature. Each
inpatient firm has two physician teams or
ward services. For this trial the six ward ser-

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 31

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Curley 1998 (Continued)

vices were divided so that three ward ser-

vices continued traditional work rounds as
usual and the three ward services imple-
mented the CQI designed interdisciplinary
work rounds.”

Allocation concealment (selection bias) Low risk Quote: “The firm system randomization
procedures and their validation have been
reviewed extensively in the literature. Each
inpatient firm has two physician teams or
ward services. For this trial the six ward ser-
vices were divided so that three ward ser-
vices continued traditional work rounds as
usual and the three ward services imple-
mented the CQI designed interdisciplinary
work rounds.”

Baseline outcome measurements similar - Unclear risk Not reported.

All outcomes

Baseline characteristics similar Low risk Quote: “After controlling for baseline dif-
ferences in case-mix using a multivariate
propensity score, the length of stay and to-
tal charges for the hospital stay for the pa-
tients included in the trial were evaluated.
”

Blinding of outcome assessment (detection Low risk Quote: “Patient data were retrieved from
bias) - All outcomes the hospital’s administrative and billing sys-
tem. Thus, patient specific cost and effi-
ciency outcomes were limited to resource
utilization in the form of hospital length of
stay and total charges.”
“...the Respiratory Therapy (RT) Depart-
ment conducted a study of aerosol use
appropriateness, as determined by criteria
previously devised and tested by the RT
Department.”

Incomplete outcome data (attrition bias) - Low risk Practice level:

All outcomes Quote: “The outcome measures reported
in this review were at the patient level. The
study does report results from satisfaction
surveys completed by 19 providers of the
traditional rounds group and 21 providers
of the interdisciplinary rounds group but
provides no information about the total
number of providers in each group.”
Patient level:

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 32

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Curley 1998 (Continued)

Quote: “Study patients included all pa-

tients admitted to the medical inpatient
units between November 8, 1993, and May
31, 1994, who spent at least 50% of their
hospital stay on that unit and were dis-
charged from that unit. If patients were
readmitted during the trial, each admission
was considered separately.” “Patient data
were retrieved from the hospital’s adminis-
trative and billing system.”

Contamination Low risk Quote: “Patients were excluded from anal-

ysis if their hospital stay was not on their as-
signed medical firm because they had been
’de-firmed’ because of excess admissions to
one service or if they were ’boarding’ on
a floor that was not the ward team’s home
floor. Patients were excluded from the trial
if they were transferred from medicine to
another service (e.g. surgery) or if less than
50% of their stay occurred on the medical
floor...”

Selective reporting (reporting bias) Unclear risk All relevant outcomes in the method sec-
tion (AS6) were reported in the results sec-
tion (AS7-9). There was no published pro-
tocol so we cannot be sure all planned anal-
yses were conducted

Other bias Low risk None detected.

Deneckere 2013

Methods A post-test-only cluster-RT of 30 teams caring for patients with COPD and PFF. 17
intervention teams and 13 control teams examined how the use of CPs improved team-
work in an acute hospital setting

Participants Country: Belgium

Doctors (i.e. orthopaedic surgeons or pneumologists), head nurses, nurses, and allied
health professionals (i.e. physiotherapists and social workers). 581 participants: 346 in
the intervention teams (N = 17) and 235 in the control teams (N = 13)

Interventions The intervention involved the development and implementation of CPs including 3
components: 1) feedback on team’s performance before CP implementation; 2) receipt
of evidence-based key-indicators for implementing CPs in practice to review; 3) training
in CP development. Control teams: usual care

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 33

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Deneckere 2013 (Continued)

Outcomes Conflict management, team climate for innovation, level of organised care, emotional
exhaustion, level of competence, relational co-ordination

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Quote: “Stratified randomisation was used
bias) to assign the teams to an intervention
group (using care pathways) and a control
group (usual care). Interprofessional teams
were randomised. COPD/PFF was used as
blocking factor.”

Allocation concealment (selection bias) Low risk Quote: “Before the start of the randomi-
sation process, random numbers were as-
signed to each cluster by a researcher not
involved in the study, using the online
available tool ’Research Randomizer’ www.
randomizer.org). Next, the researcher ran-
domly allocated the coded clusters to the
intervention or control group using the
same online tool.”

Baseline outcome measurements similar - Unclear risk Not reported.

All outcomes

Baseline characteristics similar Low risk Intervention and control teams were rea-
sonably similar.
Quote: “No significant differences in or-
ganizational or team member characteris-
tics were found, except for the number of
years of experience, which was significantly
higher in the control group” (Table 2)

Blinding of outcome assessment (detection High risk It did not appear that there was any blind-
bias) - All outcomes ing.

Incomplete outcome data (attrition bias) - Low risk Practice level ITT was not mentioned. Au-
All outcomes thors acknowledged that sites dropped out
Quote: “A potential weakness of the study
is the dropout of 7 teams and its possible
impact on the results.”

Contamination Low risk Only intervention teams participated in the

development and implementation of CP

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 34

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Deneckere 2013 (Continued)

Selective reporting (reporting bias) Low risk All relevant outcomes in the method sec-
tion (p 100-1) were reported in the re-
sults section (p 102-4). There was also a
published protocol and all planned analy-
ses were conducted

Other bias Low risk Cluster-RT with appropriate statistical

analysis.

Schmidt 1998

Methods A RT of 33 nursing homes, 15 experimental homes and 18 control homes, to examine

the effects of monthly facilitated multidisciplinary rounds on the quality and quantity
of psychotropic drug prescribing.

Participants Country: Sweden

Physician, pharmacists, selected nurses, and nursing assistants
1854 long-term residents: 626 in experimental homes and 1228 in control homes

Interventions Pharmacist led team meetings once a month over a period of 12 months

Outcomes Proportion of patients receiving drugs, number of psychotropic drugs, use of non-rec-
ommended hypnotics, use of non-recommended anxiolytics, use of non-recommended
antidepressant drugs

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not reported.

bias)

Allocation concealment (selection bias) Low risk Quote: “Thirty-six nursing homes, repre-
senting 5% of all nursing homes in Swe-
den, participated in the study. The sam-
pling process consisted of three steps. At the
time of the study, the National Corpora-
tion of Swedish Pharmacies was organized
into 36 regions, 18 of which were randomly
selected for this study. Each regional phar-
macy director then selected two facilities in
his or her region using several criteria....Re-
searchers randomly assigned one home in
each pair to receive the intervention.”

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 35

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Schmidt 1998 (Continued)

Baseline outcome measurements similar - Low risk Quote: “At baseline, we found no signifi-
All outcomes cant differences in the proportion of resi-
dents with scheduled psychotropics (64%
vs 65%), number of drugs among residents
with psychotropics (2.07 vs 2.06).”

Baseline characteristics similar Low risk Quote: “There were no significant differ-
ences in the demographic, functional, or
psychiatric characteristics of residents in ex-
perimental and control homes at baseline.
”
Quote: “The overall level of prescribing was
similar in experimental and control homes
before the intervention (Table 2). At base-
line, we found no significant differences in
the proportion of residents with scheduled
psychotropics (64% vs 65%), number of
drugs among residents with psychotropics
(2.07 vs 2.06), or proportion of residents
with polymedicine (46% vs 47%). Baseline
rates of therapeutic duplication were also
comparable in the experimental and con-
trol homes.”

Blinding of outcome assessment (detection Low risk Quote: “Lists of each resident’s prescrip-
bias) - All outcomes tions were collected 1 month before and
1 month after the 12-month intervention
in both experimental homes and control
homes. Trained coders, supervised by phar-
macists, classified and coded all scheduled
and PRN (pro re nata) orders.”

Incomplete outcome data (attrition bias) - Low risk 3 intervention homes out of 18 became in-
All outcomes eligible.

Contamination Low risk Quote: “Pharmacists assigned to experi-

mental homes had no contact with control
nursing homes. In the control homes, no
efforts were made beyond normal routine
to influence drug prescribing.”

Selective reporting (reporting bias) Unclear risk Insufficient information to permit judge-
ment of high or low risk of bias. There was
no published protocol so we cannot be sure
all planned analyses were conducted

Other bias Low risk None detected.

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 36

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Strasser 2008

Methods RT, in which patients with a stroke were treated by 31 teams from 31 Veteran Affair
rehabilitation units before and after a multifaceted intervention, aimed at improving
interprofessional collaboration

Participants Country: USA

Medical doctors, nurses, occupational therapists, speech-language pathologists, physical
therapists, and case managers or social workers. 464 participants: 227 in the intervention
teams (N = 15) and 237 in the control teams (N = 16). Patients with a stroke were
randomly assigned to each group

Interventions Intervention teams: received the following multifaceted intervention: 1) an off-site work-
shop emphasising team dynamics, problem-solving, and the use of performance feed-
back data; 2) action plans (specific team performance profiles with recommendations)
for process improvement; 3) telephone and video conference consultations to sustain
improvement in collaboration
Control teams only received specific team performance profile Information

Outcomes Functional improvement (as measured by the change in motor items of the FIM instru-
ment), length of stay (LOS), rates of community discharge

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Quote: “... we randomized sites to either
bias) intervention or control group using a com-
puter; each stratum was force randomized
to have 4 sites in 1 arm.”

Allocation concealment (selection bias) Unclear risk Method of concealment was not described.

Baseline outcome measurements similar - Low risk The mean FIM scores at baseline were sim-
All outcomes ilar for the intervention group (52.2 ± 3.9)
and for the control group (52.4 ± 3.8)

Baseline characteristics similar Low risk Quote: “…There were no differences be-
tween study conditions in demographic
characteristics (table 2). Control sites ad-
mitted stroke patients with lower initial
(admission) motor FIM scores during the
pre-intervention periods (P.002); thus, we
adjusted all analyses using FRGs … a clas-
sification based on initial motor FIM and
age.”

Blinding of outcome assessment (detection High risk It did not appear that there was any blind-
bias) - All outcomes ing.

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 37

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Strasser 2008 (Continued)

Incomplete outcome data (attrition bias) - High risk Acknowledged sites dropped out but ITT
All outcomes was not mentioned in the text
Practice level
Quote: “Of 33 eligible sites, a total of 31
sites agreed to participate, initiated the IRB
approval, and were randomized. One con-
trol site was unable to complete the IRB
process and withdrew, and 1 intervention
site did not report data to the FSOD, leav-
ing 15 sites in the control group and 14 in
the intervention group

Contamination Low risk No reason to think contamination had oc-

curred.

Selective reporting (reporting bias) Low risk All relevant outcomes in the methods sec-
tion (p 11) were reported in the results sec-
tion (p 14). There was a published protocol
and all planned analyses were conducted

Other bias Low risk None detected.

Wild 2004

Methods Randomised trial in which patients in inpatient telemetry ward in a community hospital
were randomised to the intervention medical team, which conducted interdisciplinary
rounds or to the control team, which provided standard care

Participants Country: USA

Resident physicians, nurses, a case manager, pharmacist, dietician, and physical therapist.
Eighty-four patients were enrolled: 42 in intervention and 42 in standard care

Interventions Intervention: daily interdisciplinary rounds.

Control group: standard care.

Outcomes Length of hospital stay

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Quote: “Randomization was performed us-
bias) ing random numerical assignments in pre-
sealed envelopes.”

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 38

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wild 2004 (Continued)

Allocation concealment (selection bias) Unclear risk Envelope randomisation.

Baseline outcome measurements similar - Low risk Mean length of stay (days) was similar in
All outcomes the intervention group (3.04 ± 1.8) com-
pared with the control group (2.7 ± 1.8)

Baseline characteristics similar Low risk Quote: “There were no significant differ-
ences between groups for admission diag-
nosis; number of co-morbidities; number
of abnormal laboratory data; ability to per-
form activities of daily living; presence of
dementia or diabetes, or whether there was
a home health aide. In spite of random-
ization, the gender composition between
groups was somewhat different...and the
number of readmissions in the IR Team was
higher than in the non-IR Team (P = 0.
003).”

Blinding of outcome assessment (detection Low risk Quote: “Charts were surveyed to determine
bias) - All outcomes patient characteristics and LOS. LOS was
measured as the difference between dis-
charge and admission date.”

Incomplete outcome data (attrition bias) - Low risk Practice level:

All outcomes Quote: “Questionnaire return was 80%”,
but these results were not reported in this
review because they did not meet outcome
criteria
Patient level:
All participants were accounted for and
none were lost to follow-up

Contamination Low risk Quote: “Patients were randomly assigned

to two medical teams: the intervention
group received IRs and the control subjects
received standard care.”

Selective reporting (reporting bias) Unclear risk All relevant outcomes in the method sec-
tion (p 64) were reported in the results sec-
tion (p 67). There was no published proto-
col so we cannot be sure all planned analy-
ses were conducted

Other bias Low risk None detected.

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 39

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wilson 2004

Methods RT comparing multidisciplinary audio conferencing and multidisciplinary video con-

ferencing with a team that worked at two hospitals

Participants Country: Australia

Medical staff specialists, medical registrars, nurses, speech pathologist, occupational ther-
apists, social worker, medical students. Fifty patients were randomly assigned to each
group

Interventions Multidisciplinary audio conferences and video conferences. At each conference session,
the audio conferences were conducted before the video conferences, with the same mul-
tidisciplinary team

Outcomes Number of audio conferences held per patient, number of video conferences held, length
of treatment

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Quote: ”The random allocation was done
bias) by an independent administrative assistant,
using a table of random numbers.“

Allocation concealment (selection bias) Low risk Quote: ”The random allocation was done
by an independent administrative assistant,
using a table of random numbers.“

Baseline outcome measurements similar - Unclear risk None reported.

All outcomes

Baseline characteristics similar Low risk Quote: ”The two groups were similar in
terms of age, sex and diagnosis (Table 1).“

Blinding of outcome assessment (detection Low risk Quote: ”Conference times were recorded
bias) - All outcomes by an independent observer and files were
reviewed by an independent medical prac-
titioner blinded to the randomization.“

Incomplete outcome data (attrition bias) - Unclear risk Practice level:

All outcomes Quote: ”Only 14 of 29 (including 6 med-
ical students) completed a staff satisfaction
survey. These results are not reported in this
review because they did not meet outcome
criteria.“
Patient level”
Quote: “There were no deaths, and all pa-
tients recruited completed the trial.”

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 40

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wilson 2004 (Continued)

Contamination Unclear risk Quote: “Within each meeting of the mul-

tidisciplinary team, the audioconferences
were conducted before the videoconfer-
ences, to ensure that there was no visual
contact between the two locations until the
latter part of the session.”
“The team remained consistent at either
site for both the audio- and videoconfer-
ences held on each individual day of the
conference, but the team members rotated
between sites over the study period.”
While measures were taken to prevent con-
tamination, the same team members were
involved in both types of conferencing

Selective reporting (reporting bias) Unclear risk All relevant outcomes in the method sec-
tion (p 353-4) were reported in the results
section (p 354). Insufficient information
was provided to permit judgement of high
or low risk of bias. There was no published
protocol so we cannot be sure all planned
analyses were conducted

Other bias Low risk None detected.

CCTP = Chronic care team profile

COPD = chronic obstructive pulmonary disease
CP = care pathway
CQI = Continuous quality improvement
FIM = Functional independence measure
FRG = Functional-related groups
FSOD = Functional status outcomes database
GP = General practitioner
IPC = Interprofessional collaboration
IRs = interdisciplinary rounds
IRB = Institutional Research Board
ITT = Intention-to-treat
KSA = Knowledge, skills, attitudes
LOS = length of stay
PACIC = Patient assessment of chronic illness care
PFF = proximal femur fracture
RT = randomised trial
WWT = Wider ward teams

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 41

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Bekelman 2015 Not a practice-based IPC intervention

Boet 2013 Not a practice-based IPC intervention

Boone 2008 Not a practice-based IPC intervention

Chen 2013 Not a practice-based IPC intervention

Cheng 2013 Not a practice-based IPC intervention

Curtis 2012 Not a RT

Dhalla 2014 Not a practice-based IPC intervention

Döpp 2013 Not a practice-based IPC intervention

Fransen 2012 Not a practice-based IPC intervention

Goud 2009 Not a practice-based IPC intervention

Hallin 2011 Not a practice-based IPC intervention

Hobgood 2010 Not a practice-based IPC intervention

Hoffmann 2014 Not a practice-based IPC intervention

Jankouskas 2011 Not a practice-based IPC intervention

Jenkins 2013 Not a practice-based IPC intervention

Katakam 2012 Not a practice-based IPC intervention

Keller 2012 Not a practice-based IPC intervention

Kemper 2011 Not a RT

Koerner 2014 Not a practice-based IPC intervention

Kunkler 2007 Not a practice-based IPC intervention

Körner 2012 Not a practice-based IPC intervention

Lee 2013 Not a practice-based IPC intervention

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 42

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

Marsteller 2013 Not a practice-based IPC intervention

Mohaupt 2012 Not a practice-based IPC intervention

Musick 2011 Not a practice-based IPC intervention

O’Leary 2010 Not a RT

Rörtgen 2013 Not a practice-based IPC intervention

Van de Ven 2010 Not a RT

Weller 2014 Not a practice-based IPC intervention

Wittenberg-Lyles 2013 Not a practice-based IPC intervention

IPC: interprofessional collaboration

RT: randomised trial

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 43

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES
This review has no analyses.

APPENDICES

Appendix 1. CENTRAL search strategy

#1[mh “Interprofessional Relations”] and (collaborat* or team*)
#2 [mh “Patient Care Team”] and (collaborat* or team*)
#3 ((interprofession* or inter-profession*) next (collaborat* or team*))
#4 ((interdisciplin* or inter-disciplin*) next (collaborat* or team*))
#5 ((interoccupation* or inter-occupation*) next (collaborat* or team*))
#6 ((multiprofession* or multi-profession*) next (collaborat* or team*))
#7 ((multidisciplin* or multi-disciplin*) next (collaborat* or team*))
#8((multioccupation* or multi-occupation*) next (collaborat* or team*))
#9((transdisciplin* or trans-disciplin*) next (collaborat* or team*))
#10(team* next collaborat*)
#11{or #1-#10}

Appendix 2. MEDLINE search strategy

1 exp Interprofessional Relations/ and (collaborat$ or team$).tw. (8220)
2 exp Patient Care Team/ and (collaborat$ or team$).tw. (13439)
3 ((interprofession$ or inter-profession$) adj (collaborat$ or team$)).tw. (853)
4 ((interdisciplin$ or inter-disciplin$) adj (collaborat$ or team$)).tw. (2660)
5 ((interoccupation$ or inter-occupation$) adj (collaborat$ or team$)).tw. (0)
6 ((multiprofession$ or multi-profession$) adj (collaborat$ or team$)).tw. (355)
7 ((multidisciplin$ or multi-disciplin$) adj (collaborat$ or team$)).tw. (7856)
8 ((multioccupation$ or multi-occupation$) adj (collaborat$ or team$)).tw. (0)
9 ((transdisciplin$ or trans-disciplin$) adj (collaborat$ or team$)).tw. (105)
10 (team$ adj collaborat$).tw. (158)
11 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 (26183)
12 randomized controlled trial.pt. (276233)
13 controlled clinical trial.pt. (42446)
14 randomized controlled trials/ (83918)
15 random allocation/ (45887)
16 double blind method/ (80591)
17 single blind method/ (16519)
18 12 or 13 or 14 or 15 or 16 or 17 (452549)
19 animals/ not humans/ (1793680)
20 18 not 19 (410246)
21 11 and 20 (954)
22 limit 21 to yr=“2007 -Current” (595)

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 44

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Appendix 3. CINAHL search strategy
1 (MH “Interprofessional Relations+”) AND TX ((collaborat* or team*))
2 (MH “ Multidisciplinary Care Team+”) AND TX ((collaborat* or team*))
3 TX ((interprofession* or inter-profession*) N1 (collaborat* or team*))
4 TX ((interdisciplin* or inter-disciplin*)) N1 (collaborat* or team*))
5 TX ((interoccupation* or inter-occupation*) N1 (collaborat* or team*))
6 TX ((multiprofession* or multi-profession*) N1 (collaborat* or team*))
7 TX ((multidisciplin* or multi-disciplin*) N1 (collaborat* or team*))
8 TX ((multioccupation* or multi-occupation*) N1 (collaborat* or team*))
9 TX ((multioccupation* or multi-occupation*) N1 (collaborat* or team*))
10 TX ((transdisciplin* or trans-disciplin*) N1 (collaborat* or team*))
11 TX team* N1 collaborat*
12 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11
13 (MH “Clinical Trials+”)
14 PT Clinical trial
15 TX ( (trebl* n1 blind*) or (trebl* n1 mask*) )
16 TX ( (tripl* n1 blind*) or (tripl* n1 mask*) )
17 TX ( (doubl* n1 blind*) or (doubl* n1 mask*) )
18 TX ( (singl* n1 blind*) or (singl* n1 mask*) )
19 TX randomi* control* trial*
20 (MH “Random Assignment”)
21 TX random* allocat*
22 TX placebo*
23 (MH “Placebos”)
24 (MH “Quantitative Studies”)
25 TX allocat* random*
26 S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25
27 S12 AND S26
28 S12 AND S26. Limiters - Publication Year: 2007-2014; Clinical Trial

Appendix 4. ClinicalTrials.gov and ICTRP search strategies

ClinicalTrials.gov search strategy
(collaboration OR team) AND (interdisciplinary OR interprofessional OR multidisciplinary OR multiprofessional)
ICTRP search strategy
#1 collaboration AND interdisciplinary
#2 collaboration AND interprofessional
#3 collaboration AND multidisciplinary
#4 collaboration AND multiprofessional
#5 team AND interdisciplinary
#6 team AND interprofessional
#7 multidisciplinary team
#8 team AND multiprofessional
#9 OR/1-8

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 45

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
WHAT’S NEW
Last assessed as up-to-date: 10 November 2015.

Date Event Description

13 November 2015 New citation required but conclusions have not This update found four new studies. As a result, the
changed review now includes nine studies. While the num-
ber of studies has increased slightly, the main con-
clusions from the previous update remain unchanged
(Zwarenstein 2009). There have been changes to the
author team, with the inclusion of two new authors

10 November 2015 New search has been performed New searches performed to 10 November 2015. Four
new studies identified

HISTORY
Protocol first published: Issue 3, 1996
Review first published: Issue 2, 1997

Date Event Description

13 May 2009 New citation required and conclusions have changed Conclusions changed, based on additional studies. Crite-
ria for included study designs, included participants and
specification of the intervention changed from the 1997
review. This first review included randomised trials, con-
trolled before-after studies and interrupted time series de-
signs, whereas this update included only randomised tri-
als. The types of participants included in the first review
were physicians and nurses, whereas this update included
all types of healthcare professionals. The first review in-
cluded studies in which the interventions may not have
specified their intent to change interprofessional collabo-
ration, whereas this update only included studies with an
explicit focus on collaboration. These changes were in-
tended to increase the validity of the conclusions, and to
widen their applicability to professions other than nurs-
ing and medicine

13 May 2009 New search has been performed New search and four additional studies identified and
included in the review

20 August 2008 New search has been performed Converted to new review format.

11 January 2000 New citation required and conclusions have changed Substantive amendment

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 46

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CONTRIBUTIONS OF AUTHORS
SR and FP undertook the searches and both independently reviewed each of the titles and abstracts located to ensure they met the
inclusion criteria. SR and FP independently assessed each full-text article to ensure they met the criteria. MZ resolved any disagreements
during the screening processes. SR and MZ independently assessed the certainty of evidence for the included studies. All authors (SR,
FP, RH, JG, MZ) analysed and interpreted the data and contributed to writing the review. SR is guarantor for the review.

DECLARATIONS OF INTEREST
Scott Reeves: none known.
Ferruccio Pelone: none known
Reema Harrison: none known
Joanne Goldman: none known
Merrick Zwarenstein: none known.
The authors have no personal or professional interests as to whether this review shows benefits of practice-based interventions on
interprofessional collaboration.

SOURCES OF SUPPORT

Internal sources
• Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, UK.
• Continuing Education and Professional Development, Faculty of Medicine, University of Toronto, Canada.

External sources
• Canadian Institutes of Health Research, Canada.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW

Review authorship changed between protocol and review updates. The title has changed from the protocol: ’The effects on patient
care of interventions to change collaboration between nurses and doctors’ (Zwarenstein 1996). Changes were also made to criteria for
included study designs, included participants, and specification of the intervention between the published protocol and this update.
The protocol planned to include randomised trials, controlled before-after studies, and interrupted time series designs, whereas the
last update (Zwarenstein 2009) and this update included only randomised trials. The protocol planned to include only physicians and
nurses, whereas this update included all types of health and social care professionals. The protocol also planned to include studies in
which the interventions may not have specified their intent to change interprofessional collaboration, whereas this update included
only studies with an explicit focus on collaboration. These changes were made to increase the validity of the conclusions, and to widen
their applicability to professions beyond nursing and medicine.

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 47

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 INDEX TERMS

Medical Subject Headings (MeSH)

∗ CooperativeBehavior; ∗ Health Personnel; ∗ Interprofessional Relations; ∗ Professional Practice; Delivery of Health Care; Quality of
Health Care; Randomized Controlled Trials as Topic; Telecommunications

MeSH check words

Female; Humans

Interprofessional collaboration to improve professional practice and healthcare outcomes (Review) 48

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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