Quest for Quality and Improved Performance: Quality ......patient care team interventions should...

Quest for Quality and Improved Performance: Quality Enhancing InterventionsPatient Care TeamsMarije Bosch, Marjan Faber, Gerlienke Voerman, Juliëtte Cruijsberg, Professor Richard Grol, Marlies Hulscher, Michel Wensing,

Radboud University Nijmegen Medical Centre

December 2009

Published by:

The Health Foundation90 Long AcreLondon WC2E 9RATelephone: 020 7257 8000Fax: 020 7257 8001

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First published 2009

ISBN 978-1-906461-14-0

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Table of contents

Executive summary 5

Project background 7

Introduction 8Definition of ‘team’ 8Conceptual framework 9

Objectives 11

Methods 12Data sources and searches 12Study selection 12Data extraction procedure 14Quality assessment 15Data synthesis 15

Results 16Identification of evidence 16Description of studies 16Types of team intervention 17Participants and settings 17Methodological quality of the studies 17 1A. Interventions: enhanced clinical expertise (n = 8) 17 1B. Evidence: enhanced clinical expertise 19 2A. Interventions: improved coordination (n = 5) 20 2B. Evidence: improved coordination 22 3A. Interventions: enhanced clinical expertise and coordination (n = 10) 22 3B. Evidence: enhanced clinical expertise and coordination 25 4. Description of interventions and results derived from review studies 27 5. Team characteristics as determinants of effect 28Table 2: Summary of the evidence and intervention characteristics 29Discussion 39Discussion of main findings 39Methodological considerations 40Implications for health policy 41Implications for research 43

Appendix A: Search strategy for QQUIP teams review in PubMed 44

Appendix B: Search strategy and results per database 45

Appendix C: Data collection forms 50

Appendix D: Excluded studies and reason for exclusion 51

Appendix E: Methodological quality studies 54

Appendix F: Results per study 56

References 68

Bosch, Faber, Voerman, Cruijsberg, Grol, Hulscher, Wensing

Quality Enhancing Interventions: Patient Care Teams

5

Executive summary

Executive summary

Introduction

The delivery of healthcare by a coordinated team of health professionals is now assumed to be beneficial, and the concept of ‘teamwork’ has taken firm hold in healthcare. The expectation is that enhanced, more elaborated team approaches in selective circumstances are associated with improved healthcare delivery processes, leading to more appropriate care, better patient outcomes and lowered costs, compared to approaches with less elaborated teamwork. The establishment or enhancement of a patient care team is therefore increasingly considered a key method for improving the quality of healthcare. However, as yet, it is unclear whether teams are as effective as they are supposed to be, and under what conditions team effectiveness is optimal. For decision makers in both health policy and healthcare practice, it is imperative to identify the critical elements for effective teams in order to transform healthcare workplaces into effective team-based environments.

Objective

The authors reviewed the research literature published between 1990 and February 2008, grouping the studies according to the particular objectives of the teams. By aggregating the results to these subgroups, we aimed to draw some headline measures about the effectiveness of different types of teams. In addition, determinants for team effectiveness were collected.

Methods

Twelve literature databases were explored during January and February 2008 following a predefined search strategy. All systematic reviews of original studies or reviews, randomised controlled trials (RCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) written in English were eligible for inclusion. According to the definition of team in this report, original studies or reviews were included that assessed the impact of multidisciplinary (or interdisciplinary) or professional teams. Within these studies, we organised the discussion of the evidence according to three subgroups we identified: 1) teams with enhanced clinical expertise; 2) teams with improved coordination; and 3) teams with both enhanced clinical expertise and coordination. Titles and abstracts of unique studies were assessed by two reviewers (or three in case of disagreement). Two reviewers studied the retrieved full-text articles, extracted information and discussed findings. If no consensus was reached, a third reviewer assisted.

Results

Main findings: enhanced clinical expertise

We identified eight studies in which a team member was added to the care because of his or her additional clinical expertise. Given the consultative character of these interventions, one would expect to find an impact on process measures, such as those reflecting guideline adherence, and thus – ultimately − improved patient outcomes. With respect to the process measures, most of these studies indeed measured such outcomes, and results were at least partly in favour of the intervention groups. However, although at least some positive results were reported in terms of process, studies showed mixed results in relation to patient outcomes.



6

Executive summary

Main findings: improved coordination

Five studies were identified that focused on improving coordination: in three studies, a coordinator was added to the team; and in two studies, improved communication and coordination structures were introduced. Patient outcomes seemed to show some positive results, but given that the main aim was to improve coordination, one would also expect an impact on resource utilisation and efficiency in healthcare delivery. All five studies included such measures. However, overall, there was very little evidence to conclude that resource utilisation and costs reduced as a result of improved coordination in patient care teams, although some studies reported shorter length of stay.

Main findings: enhanced clinical expertise and coordination

Ten studies were identified in which the intervention comprised both clinical expertise and coordination. Process measures were hardly reported, and the studies showed limited effect on patient outcomes and little effect on costs and resource utilisation. We therefore found little evidence to conclude that the combination of enhanced coordination and expertise added value compared to enhanced clinical expertise only or improved coordination only.

Very little information was found on the determinants of team effectiveness, such as the presence or absence of a team leader and task descriptions for team members.

Overall conclusion and implications

From our review of the evidence, enhanced clinical expertise may indeed improve appropriateness of care, although this did not consistently translate into improved patient outcomes. It remained unclear what costs were involved in achieving the improvements. We suggest that putting in additional resources may be acceptable, as they are an investment in better patient outcomes; however, formal evidence on efficiency would be helpful for decision makers. The improvements in processes, if present, did not consistently translate into improved patient outcomes. This finding may be due to many reasons, including methodological problems in the research itself, and needs further exploration in future.

Improved coordination did not show a consistent reduction in resource utilisation or costs, as might have been expected. The effects on patient outcomes were, to some extent, positive. Process measures were hardly mentioned. We suggest that the intended effects of improved coordination, either through adding a human coordinator or through adding more coordination structures, need to be examined. If reduced utilisation and costs are indeed the objective (for example, by shortening hospital stay), the mechanism by which this is achieved should be clarified. Currently, there is limited evidence to suggest to decision makers that adding a team member with a coordination role or more coordination activities has a beneficial effect.

We speculated that enhanced expertise and coordination might add value, as coordination may be most effective when combined with added expertise and integrated into an appropriate organisational context. Unfortunately, the available studies did not provide evidence to support these expectations.

Decision makers who want to know what components contribute to the effectiveness and optimisation of patient care team interventions should plan evaluations alongside programmes to enhance patient care teams. It is important that expectations of enhanced team approaches are clarified. Is the aim to improve patient outcomes or to achieve equivalent patient outcomes with reduced costs and/or higher capacity?



7

Project background

Project background

QQUIP (Quest for Quality and Improved Performance) is a five-year research initiative of the Health Foundation. One of the three main focuses of QQUIP is the Quality Enhancing Interventions (QEI) programme. The QEI programme includes a series of structured evidence-based reviews of the effectiveness of a wide range of interventions designed to improve the quality of healthcare. The six main categories of QEIs for which evidence will be reviewed are shown below. The main category, ‘Organisation interventions’, focuses on improving managerial, professional and institutional behaviours in healthcare (figure 1). Within this category, this report will focus on patient care teams, also called clinical delivery teams.

Healthcare is increasingly provided by formalised teams of health professionals, rather than by doctors in less elaborated team approaches. The expectation is that elaborated and formal team approaches in selective circumstances are associated with improved healthcare delivery processes, leading to more appropriate care, better patient outcomes and lowered costs, compared to less elaborated team approaches. The establishment or enhancement of a patient care team is therefore increasingly considered a key method for improving the quality of healthcare. In this study, we have searched for research evidence to support these claims. Our aim is to provide guidance for decision makers in healthcare regarding patient care teams, and to offer suggestions for research and development in this domain.

Overview of review categories in the QEI programme

Patient focused

Regulatory interventions

Incentives Data driven and IT based

Organisational interventions

Healthcare delivery

Quality enhancing



8

Introduction

Introduction

The delivery of healthcare by a coordinated team of health professionals is now assumed to be beneficial (Wagner, 2001) and the concept of ‘teamwork’ has taken firm hold in healthcare (Baker, Day and Salas, 2006). In 1978, the World Health Organization (WHO) began to put emphasis on the importance of teamwork (WHO, 1978). From that time, teamwork in healthcare has been increasingly recognised and recommended by health policy makers. The expectation is that enhanced, more formalised team approaches in selective circumstances are associated with improved healthcare delivery processes, leading to more appropriate care, better patient outcomes and lowered costs, compared to less elaborated team approaches. In addition, it is considered that specific tasks in patient care are too complex to be performed well by a single professional, and therefore that teamwork is needed. Teamwork may overcome the fragmentation of care caused by professional specialisation. Patients who receive care from a team of carers may benefit from more ‘eyes and ears’, the various insights of different bodies of knowledge (for example, medicine and nursing) and a wider range of skills (Wagner, 2001). Teams satisfy individuals’ needs for social interaction, status, recognition and respect (Cohen and Bailey, 1997). At the same time, teamwork is complex and specific characteristics of teams can require compromise. For example, teamwork means that team members have to sacrifice some of their individual autonomy in the interests of collective decision-making.

The appeal of the potential advantages of teamwork, and the emerging evidence, has meant that policy documents from countries with disparate health systems such as the USA and the UK (Department of Health, 2000; Institute of Medicine, 2000; Institute of Medicine, 2001) reinforce its importance in healthcare. However, despite this pressure, it is as yet unclear whether teams are as effective as they are supposed to be, and under what conditions team effectiveness is optimal.

For decision makers in both health policy and healthcare practice, it is imperative to identify the critical elements for effective teams in order to transform healthcare workplaces into effective team-based environments.

Definition of ‘team’

Despite the often cited indistinctness of the concept of ‘team’ (Oandasan et al, 2006), there seems to be a general consensus in the literature that a team consists of two or more individuals who have specific roles, perform interdependent tasks, are adaptable and share a common goal (Salas et al, 1992; Xyrichis and Ream, 2008). These characteristics are in line with the MeSH definition for a patient care team (first introduced in 1968): ‘Care of patients by a multidisciplinary team usually organised under the leadership of a physician; each member of the team has specific responsibilities and the whole team contributes to the care of the patient.’ ‘Collaboration’ is often used as a synonym for ‘team’; however, these words are not mutually exchangeable (Oandasan et al, 2006). Collaboration can be seen as a prerequisite for teamwork. People may collaborate without being part of a defined team. For example, in primary care, the family physician, a physiotherapist and a dentist may provide care to the same individual, yet they may not see themselves as a team working collaboratively with the patient. Teamwork explicitly requires a decision by team members to cooperate in meeting predefined and collective objectives. So, a collective goal is what distinguishes a team from a group of collaborating people (Firth-Cozens, 1998; Saltman et al, 2007).



9

Introduction

Conceptual framework

From the field of psychology, West et al have been frontrunners in bringing the message that effective team activities are characterised by input, structural factors (such as team composition and skill mix), team processes (such as communication between several team members) and team effectiveness (the output of the team) (West, Borrill and Unsworth, 1998). They proposed a model, based on organisational and management literature, which was mainly applied to non-healthcare settings. In healthcare settings, Oandasan et al (2006) distinguished between two types of team: project teams and care delivery teams. Project teams (or quality improvement teams) are often time-limited, and once their project goal has been achieved they are discontinued (Cohen and Bailey, 1997). Care delivery teams (work teams or patient care teams) are continuing work units responsible for providing services (Cohen and Bailey, 1997). Patient care teams can be further subdivided according to patient populations (such as geriatric teams), disease type (such as stroke teams) or delivery settings (such as primary care, hospital and long-term care).

After the work of West, Borrill and Unsworth (1998), Lemieux-Charles and McGuire (2006), in their review of healthcare team effectiveness, extended the explanatory model for team effectiveness and adapted it to the healthcare situation. Their model integrates both types of teams as distinguished by Oandasan et al (2006). In addition, Lemieux-Charles − and others − identified the team characteristics expected to foster or hinder teamwork in patient care. (Lemieux-Charles and McGuire, 2006; Xyrichis and Lowton, 2008). Field studies showed, for example, that the type and diversity of clinical expertise involved in team decision-making was expected to account for improvements in patient care and organisational effectiveness (Lemieux-Charles and McGuire, 2006; Xyrichis and Lowton, 2008). Also, for teams to be effective, structures were required that outlined team objectives, the different roles and responsibilities of team members, mechanisms for exchanging information, and coordinating mechanisms for team activities and staffing (Oandasan et al, 2006; Xyrichis and Lowton, 2008). Thus, team members may be needed for their specific knowledge or expertise, their coordinating or leadership role, or both.

Considerable numbers of evaluations of teamcare interventions have been published. However, these studies have been criticised for a number of reasons. First, the explicit qualification by type of team, as distinguished by Oandasan, has often not been taken into account. Second, outcome measures have been highly heterogeneous, making comparisons across studies difficult (Lemieux-Charles and McGuire, 2006). Underlying team objectives have been overlooked, despite the need in evaluation studies to select effect measures that closely relate to the intervention objective (Ovretveit and Gustafson, 2002). In addition, many studies have failed to provide insight into the important question of which characteristics of teamwork contribute to effectiveness. In a way, since team characteristics have seldom been measured and/or provided, making it impossible to establish which characteristics have contributed to effectiveness, the intervention has often remained a ‘black box’. In summary, previous evaluations have tended to make overall syntheses of team interventions based on heterogeneous literature.

In this review, we took the above critiques into account. We classified the types of outcome, and grouped the studies according to the underlying objectives of the teams, since different teams may be effective on different outcomes. For our analyses, we slightly redesigned the conceptual model of West et al (Borrill et al, 2000; West, Borrill and Unsworth, 1998) by separating the team objective from other input characteristics and group processes (figure 1).



10

Introduction

Figure 1: Input, process and output model of team effectiveness

INPUTS =>GROUP PROCESSES => OUTPUTS

TEA

M O

BJE

CTI

IVE

Domain

Healthcare environment

Organisational context

Team task

Team composition

Leadership

Clarity of objectives

Participation

Task orientation

Support for innovation

Reflexivity

Decision-making

Communication

Effectiveness (self- and externally rated)

Clinical outcomes and quality of healthcare

Innovation (self- and externally rated)

Cost-effectiveness

Team member mental health

Team member turnover

after West, Borrill and Unsworth, 1998



11

Objectives

Objectives

Our aim was to assess the effectiveness of patient care teams in healthcare settings on outcomes. In this review we focus exclusively on patient care teams according to the MeSH definition, that is, multidisciplinary (or multiprofessional) in nature and contributing to the care of the patient. The evidence was organised according to three subgroups we identified. This classification was derived from the information the authors provided on the objectives of the team and the description of the intervention components. More specifically, we aim:

1. To examine the effects of adding a relevant specialist to a patient care team compared to usual (team) care (‘enhanced clinical expertise’)

2. To examine the effects of adding a coordinating person or system to a patient care team compared to usual (team) care (‘improved coordination’)

3. To examine the effects of patient care teams with both added clinical expertise and enhanced coordination compared to usual (team) care (‘enhanced clinical expertise and coordination’).

In addition, determinants for team effectiveness, such as the characteristics of team members and team processes, were collected.



12

Methods

Methods

Data sources and searches

We searched the following databases for literature: PubMed; PsycINFO; CINAHL; EMBASE; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects (DARE); NHS Economic Evaluation Database (NHS EED); Health Technology Assessment Database (HTA); Web of Science; World Health Organization (WHOLIS); Organisation for Economic Cooperation and Development (OECD); and Sociological Abstracts. All databases were searched from January 1990 to February 2008 inclusive.

Since the outcome measures of patient care teams were rather diverse, searches were not limited to specific outcomes. Instead, based on our experience of initial searches, which included MeSH terms and text word fields, we decided to limit the searches to terms in titles to enable us to find the most relevant studies. To narrow down the number of hits further, while ensuring that we would find the studies that would be most useful for a review on effectiveness, we used a filter that limited our search results to designs considered acceptable for EPOC reviews (www.epoc.cochrane.org). In addition, we limited our searches with healthcare terms in the databases that also contained studies in other sectors. Appendix A shows the PubMed search for studies, which was slightly adapted to meet the specific requirements of the other databases. Appendix B presents the search strategies and results for each database.

Study selection

Types of studies

All systematic reviews of original studies or reviews, randomised controlled trials (RCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) were eligible for inclusion.

Types of interventions

According to the definition of team in this report, original studies or reviews were included that assessed the impact of:

1. Multidisciplinary (or interdisciplinary) teams: active participation of professionals from more than one discipline (for example, geriatrics, cardiologists and general practitioners) in the ongoing management of patients

2. Multiprofessional (or interprofessional) teams: active participation of professionals from more than one profession (for example, medicine, nursing, pharmacy, nutrition) in the ongoing management of patients.

We subsequently categorised the interventions within these studies into three subgroups:

1. Enhanced clinical expertise: First, we identified interventions in which a relevant specialist was added to a patient care team (or formed a new team with a usual care provider) and functioned as more than a conventional consultant by referral. The addition of a team member, such as a pharmacist or nurse with skills in managing behavioural problems, may ensure that critical elements of care that doctors either do not have the training or time to do well are competently performed (Wagner, 2000). Involvement may vary: it may be consultative,



13

Methods

where a specialist advises the usual caregiver on the management of specific patient groups; or patients may be directed to expert services: for example, a population-based expert team such as a diabetes team may visit a primary care practice by invitation to see patients with the primary care team and establish a model for good diabetes care.

2. Improved coordination: While in the first category it seemed that team members were involved for their specific clinical expertise, we also identified interventions that appeared to focus on enhancing coordination and/or communication. These included the introduction of structures through which team goals could be communicated (for example, regular (mandatory) team meetings or the involvement of team members in a patient care team who primarily carried out coordinating functions (for example, case managers, coordinators).

3. Enhanced expertise and coordination: Third, studies were included in which the above elements were combined. These were compared with the usual, non-coordinated (team) care without the specific enhancement of clinical expertise.

Across this classification, information on the determinants of effectiveness related to ‘input’ or ‘group processes’ in the conceptual framework (figure 2) were collected and analysed. Potential determinants included: the professions and disciplines involved; the presence of a team leader or coordinator; characteristics such as team size, age of team members or team tenure; and the presence or absence of explicit task descriptions of team members.

Inclusion criteria

We included studies that: a) compared a patient care team versus (team or non-team) usual care: b) were conducted in healthcare settings: c) used objective outcome measures (or used validated questionnaires to measure subjective outcomes): d) treated the team rather than the team member as a unit of analysis: and e) were published in English. Teamwork could take place in any healthcare setting (inpatient, outpatient, or other, such as community-based or mixed) and it could focus on any clinical domain in prevention, chronic disease management (physical and mental illnesses) and acute care. Inclusion criteria for reviews were: 1) at least a description of the search strategy had to be provided, and 2) inclusion criteria had to be mentioned, and 3) some sort of analysis/integration of the data of the included studies had to be present (no narrative reviews), and 4) the review included at least 50 per cent of studies with an RCT, CBA or ITS design. No additional inclusion criteria for RCT, CBA or ITS designs were adopted.

Exclusion criteria

Articles were excluded if they were not published in English, could not be retrieved, were anecdotal, did not make comparisons with a control group over time, focused on teamwork without linking to outcomes, or were doctoral dissertations, books or book chapters. Studies that evaluated the effectiveness of (Breakthrough) collaboratives or other quality improvement teams were excluded, as were studies in which the intervention was too confounded by other interventions, such as studies on integrated care with a main focus on logistics of care service delivery, or studies that compared similar teams in different care structures. Studies that focused mainly on relocating care, on the inclusion of lay people in teams or primarily on team-based learning were excluded. Outreach team studies in which the ‘consultant(s)’ did not take part in the actual care for patients were also excluded. Reviews that did not fulfil the above inclusion criteria were excluded.

Types of outcome measures

Patient care teams may have impact on many different types of outcomes. Frequently, study outcomes were patient outcomes such as mortality. Outcomes were grouped differently by different authors, and categories are therefore unlikely to be exclusive. For example, the number of prescriptions may be



14

Methods

seen as a resource utilisation measure, while the appropriateness of a prescription may be seen as a process of care (quality) outcome. From the description of the studies it was not always clear which specific outcome had been measured. For the purpose of comparison we grouped outcomes of interest into six categories. The outcomes reported in the included studies were assigned to one of these six categories, although the authors did not necessarily use the same taxonomy. Box 1 shows the taxonomy of outcomes used in this report.

Table 1: Outcomes of interest

Outcome measure Examples

Clinical patient outcomes

MorbidityMortalityPhysical functioning Quality of life

Behavioural patient outcomes

SatisfactionPreferenceKnowledgeCompliance/adherence to treatment

Process of care (ie quality) delivered

Adverse events (eg unscheduled hospital admissions; visit accident and emergency department)Provision of adviceGuideline adherences (eg appropriate prescriptions and management)

Provider outcomes Subjective workload measures such as stress, burn-outSatisfactionAttitudes to teamwork

Resource utilisation Number of prescriptionsNumber of tests and investigationsNumber of consultationsNumber of hospitalisationsLength of hospital stay

Cost-effectiveness and cost outcomes

QUALYsStaff costsCost savings

Data extraction procedure

Abstracts were independently screened for inclusion by two reviewers (MB and JL or MW or MF or MH). Full-text versions were retrieved for the papers that were potentially useful. All studies were reviewed by one reviewer who assessed the text for study quality criteria, study period, number of patients randomised or included in the study, country, setting, clinical domain, type of intervention, control group, professions and disciplines involved, presence of team leader or coordinator, team characteristics, presence of explicit task descriptions of team members, and results in the categories as specified in appendix A. Outcomes within specific patient groups (for example, men) were not included if the overall outcomes were reported. After data collection, a second reviewer assessed the data collection forms for correctness and completeness. Disagreements were solved through discussion, including a third



15

Methods

reviewer. We used a modified version of the EPOC data collection checklist to extract data from the studies in a standardised way (see appendix C).

Quality assessment

For RCT and CBA studies, the EPOC quality criteria were used. These included seven items, six of which applied to both designs: follow-up of professionals (at least 80 per cent); follow-up of patients (at least 80 per cent); blinded assessment of primary outcomes; baseline measurement (measured prior to the intervention and where no substantial differences were present, or where the study was corrected for baseline); reliable primary outcome measures (agreement of 90 per cent, or kappa > 0.8, or outcomes from an automated system, or validated instruments with Chronbach α > 0.7); and protection against contamination (where it was unlikely that the control group received the intervention). For RCTs the additional item was concealment of allocation (randomisation process is explicitly described); and for CBAs it was similar characteristics for studies using second site as control. For reviews, the following criteria were used: search period specified; search terms specified; databases specified; data extraction by at least two reviewers; quality assessment provided; and methodological quality reported. For all studies an overall score out of the total number of criteria was provided.

Data synthesis

The data were considered to be too heterogeneous to allow statistical pooling, so we summarised data narratively according to three subgroups we identified during the review process. For each of these objectives, we grouped the results as follows. Here, we first present the results for the process measures (processes of care and provider outcomes), followed by patient outcomes (clinical and behavioural) and, finally, costs (resource utilisation, costs and cost-effectiveness). This distinction is important, since the aim and components of the intervention have implications for how to assess the outcomes. Ideally, one evaluates the outcomes that are most directly linked to the intervention itself (Eddy, 1998; Ovretveit and Gustafson, 2002). Different aspects of teamwork may impact on different outcomes. For instance, if a hospitalist is added to the team because of their coordinating role, one would expect changes in outcomes such as resource utilisation. If a pharmacist is added to the team because of their clinical expertise, one might expect to see changes in clinical behaviour (process measures). Because both interventions and control conditions were rather heterogeneous, and context is important in interpreting outcomes of a specific study (Oandasan et al, 2006), we start each results section with a description of the intervention and the control conditions of the study.



16

Results

Results

Identification of evidence

We identified 6,807 abstracts. Full-text versions were retrieved for the 118 papers that were potentially useful. After reviewing the full text, we selected 29 articles that provided relevant data. One more paper was excluded since it did not provide original data, which left 28 articles for our review. Appendix D provides a list of excluded studies with reasons for exclusion.

Figure 2: Study flow

Databases:PubMed 2,252PsyclNFO: 750Embase: 1,208

Web of Science 349Cinahl: 2,052

Dare/HTA/NHS EED: 68WHOLIS: 67OECD: 23

Sociological Abstracts32Total n = 6,807

6,689 papers excluded on title/abstract screening

(including doubles)

118 unique papers

29 unique papers

28 unique papers

90 papers excluded on full text screening

1 paper excluded no original data

1 paper additionally identified

Description of studies

A total of 28 papers were included in this review, which presented the results of 25 studies, including two reviews (Malone et al, 2007; Mitchell, Del and Francis, 2002) and two studies with CBA design (Jack et al, 2003; Mudge et al, 2006). All other studies were (quasi) RCTs. Table 2 presents pertinent information



17

Results

on all included studies, including a summary of the evidence and an overview of intervention and control group characteristics. Appendix F provides the results for each study in more detail. A small majority of the studies (56 per cent) were published after 2000.

Types of team intervention

Eight of the single studies we identified were classified as ‘enhanced clinical expertise’, five as ‘improved coordination’. Ten single studies were identified that contained elements of both additional clinical expertise and coordination. The reviews we identified in our search were not categorised, since the single studies they summarised contained a mix of these elements.

Participants and settings

Most of the studies were undertaken in the USA (43 per cent), the UK (22 per cent) or Canada (13 per cent). The majority of the studies were performed in an inpatient setting, six studies were performed in an outpatient setting, three studies examined results of team interventions in community care, and six studies had mixed settings. With respect to the clinical domain, a large number of studies examined patient care teams in psychogeriatrics or palliative care, some examined team interventions in mental health or psychiatry, some studied outcomes in various chronic care conditions such as cardiovascular disease and diabetes mellitus, and some focused on stroke care, rheumatoid arthritis, general or internal medicine, infectious diseases and orthopaedics.

Methodological quality of the studies

Appendix E presents the methodological quality of studies. Overall, methodological quality was rather poor. In particular, protection against contamination was a problem in the studies examined. This might imply that the available research underestimates the effectiveness of team approaches.

1A. Interventions: enhanced clinical expertise (n = 8)

Bogden et al, 1997, 1998 assessed the effect of a programme that encouraged teamwork between physicians and pharmacists on attempts to improve evidence-based care in two groups of patients in an ambulatory primary care centre in the USA. They presented their results in two papers: one on the management of patients with total cholesterol concentrations of 6.2mmol/L or more, and the other on patients with uncontrolled hypertension. In the intervention arm, a pharmacist routinely interacted with and advised patients and physicians on the best course of pharmacological therapy. During such visits, patients met with the pharmacist for half an hour before seeing their physician (resident or intern). At that time, the pharmacist took a medication history, answered questions and encouraged compliance. After meeting the patient, the pharmacist reviewed laboratory data with the physician. The pharmacist attached recommendations for the physician to the patient’s chart. The resident or intern discussed these with the supervising physician in order to accept or reject them as part of the overall treatment plan. The physician was responsible for possible referrals to other health professionals. In the control group, patients received usual care by resident physicians and interns under supervision of the control arm physicians.

Dey et al, 2005 determined the impact on outcome of immediate access to a mobile team. The team attempted to promote clinical and ward staff adherence to guidelines on effective management during the acute phase of stroke in two district general hospitals in the UK that had stroke rehabilitation units but did not have either a direct admissions stroke unit or an acute stroke ward. Three hundred and eight patients were randomly allocated to a mobile stroke team, which supported the clinical team (n = 157/112



18

Results

before/after), or to usual ward-based care (n = 151/116). When patients were allocated to the intervention group, their details were forwarded to the mobile team, which included a consultant with a special interest in stroke and a senior therapist. The team visited patients within 12 hours of randomisation. The responsibility for patients remained with the admitting clinicians and ward staff, but the team advised on acute stroke management using evidence-based guidelines (adherence was also recorded by the team). The team revisited patients as necessary to review progress. Members of the team could visit patients alone, but were expected to meet regularly to discuss the case. Patients in the control group received usual ward-based care during the acute phase of stroke and were referred to the stroke rehabilitation unit at the request of the clinician of care.

Gattis et al, 1999 evaluated the effect of a clinical pharmacist on outcomes in outpatients with heart failure in the USA. For patients in the intervention group, the clinical pharmacist discussed the patient’s case and verbally provided therapeutic recommendations on the optimisation of therapy to the attending physician. The pharmacist then discussed changes made in drug therapy with the patient, the purpose of each drug and the importance of adhering to the regime. Patients were able to ask the pharmacist questions and were provided with a telephone number for the pharmacist should questions arise. The pharmacist provided telephone follow-up at 2, 12 and 24 weeks after the initial clinic visit to identify the occurrence of clinical events. In the case of worsening symptoms, patients were advised to contact their clinician for further evaluation and the pharmacist contacted the physician to discuss these cases. The control group received usual care, in which patient assessment and education were provided by the attending physician and/or physician assistant or nurse practitioner. The pharmacist contacted the control group by telephone at 12 and 24 weeks after the enrolment visit to identify clinical events.

Gums et al, 1999 aimed to identify the financial and outcome benefits of therapeutic intervention by a multidisciplinary antimicrobial treatment team composed of pharmacists, a clinical microbiologist and an infectious disease specialist in a community hospital in the USA. Two hundred and seventy-two patients were randomised to either multidisciplinary care (n = 138/127 before/after) or usual care (134/125). Team members identified eligible patients and prepared a typed consult for the attending physician within two hours of randomisation. The consult contained the rationale, with appropriate references, for changing antimicrobial therapy. It also provided a comparison of advantages of each suggested therapy and information regarding costs. Patients allocated to the control group received usual care by the attending physician.

Jack et al, 2003 evaluated the impact of a hospital palliative care team in patients with a confirmed diagnoses of cancer in a controlled before and after study. The aim was that the palliative care team would transfer the principles of hospice care to the acute setting. The team consisted of four clinical nurse specialists, supported when required by a consultant (who, in addition, had sessional commitments at a local hospice) and a specialist registrar. Medical staff referred patients, who were located on wards distributed throughout the hospital, to the team. Patients received specialist intervention from the team, which focused on individualised assessment, advice, psychological support, symptom control and evaluation in addition to their standard care. Other cancer patients not referred to the palliative care team acted as a standard care control.

Koproski, Pretto and Poretsky, 1997 studied the effects of a diabetes team (a diabetes nurse educator and an endocrinologist) on length of stay and other outcomes of hospitalisation in patients. A total of 179 patients were randomly assigned to receive usual care supplemented with (85/85) or without (94/94) a diabetes team intervention. The diabetes team visited patients on a daily basis. Orders were written by the endocrinologist after discussion had taken place with the primary care physician. Nutrition and social work consultations were requested by the team, based on individual need. The control group received care, usually in medical/surgical units, from physicians, nurses, nutritionists and social workers.



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Results

Rubin et al, 2005 examined the effects of collaboration between an internist and psychiatrists on the processes and costs of care among psychiatric inpatients. Patients in the intervention group met with an internist who participated in their care by communicating with the patients’ primary care physician (PCP), assessing needs, updating appropriate health maintenance services, managing chronic and acute medical problems, and attending hospital work rounds. Patients in the usual care group were cared for by psychiatric house staff who had rotations in the inpatient unit that lasted for a month. They saw patients daily, and their progress was followed by one of the four psychiatric attending physicians who were permanently assigned to the units. Consultations from medical specialists were obtained using the usual hospital services.

Scott et al, 2005 assessed the economic and clinical implications of systematic long-term nutrition team follow-up of patients after percutaneous endoscopic gastronomy. Intervention patients were visited at least weekly by the nutritional support team (NST) nurse and/or dietitian while in the acute hospital and at least monthly after discharge into the community. There was regular liaison between the NST and the ward and PCPs, with advice and help on a proactive basis for any problems or questions that arose. Patients and their carers were counselled, educated and trained in all relevant aspects of nutritional support, and were given a telephone number to contact at any time, if required. Patients in the control group received no specific input from the NST before or after discharge, which is standard practice. This did not exclude referrals to the team if the ward or community team felt this was necessary; however, the level of input was generally limited to advice only. The time and input of ward dietitians (not part of the NST) for setting up home feeding and deliveries from the homecare company were common to both groups.

1B. Evidence: enhanced clinical expertise

Process measures

Some studies evaluated whether clinical guideline adherence improved in intervention patients. Overall, results were mainly in favour of the intervention groups. Bogden et al (1997, 1998) found that, overall, physicians accepted around 90 per cent of the recommendations made by the pharmacist; when physicians declined the recommendations, the success rate for reaching the goals was significantly lower (17 per cent versus 51 per cent) (intervention only). Gattis et al (1999) found that patients in the intervention group were significantly closer to target ACE inhibitor dose at six months follow-up (1.0; 0.5 to 1 (25th to 75th percentile) versus 0.5; 0.19 to 1). However, no difference was found in prescription of ACE inhibitors between groups (78 patients (87 per cent) in intervention versus 72 (79 per cent) in control at follow-up). Significantly more patients in the intervention group received alternative therapy (9 (75 per cent) versus 5 (26 per cent)). Also, Koproski, Pretto and Poretsky (1997) found that significantly more patients in the intervention (diabetes team) group had their blood monitored for glucose levels (98 per cent versus 57 per cent), had insulin administration (69 per cent versus 25 per cent), received education of any kind (87 per cent versus 37 per cent) and received nutritional education (76 per cent versus 40 per cent). However, these results have to be interpreted with care since they were based on post-intervention measures only. In addition, Rubin et al (2005) found positive effects for integrating an internist in the psychiatry team for 12 of 17 processes of care measures, such as better needs assessment (89 per cent ± 1 4 per cent versus 59 per cent ± 20 per cent), better health maintenance (56 per cent ± 34 per cent versus 3 per cent ± 7 per cent) and coordination of care (81 per cent ± 40 per cent versus 40 per cent ± 55 per cent). Scott et al (2005), however, failed to find positive effects on median time to removal of PEGS and time to antibiotics treatment in patients receiving follow-up care by the nutrition team.

Patient outcomes

Effects on patient outcomes were mixed. In their study, Bogden et al (1997, 1998) found that patients in the physician–pharmacist team had a significantly greater reduction in total cholesterol levels (44 ± 47mg/dL (1.1 ± 1.2mmol/L) versus 13 ± 51mg/dL (0.3 ± 1.3mmol/L)), diastolic blood pressure (14 ±11mm Hg versus 3 ± 11mm Hg) and systolic blood pressure (23 ± 22mm Hg versus 11 ± 23mm Hg). In



20

Results

43 per cent of patients in the physician–pharmacist team cholesterol goals were met, compared with 21 per cent in control patients (a significant difference). Also, significantly more intervention patients reached blood pressure goals (55 per cent versus 20 per cent). By contrast, Koproski et al (1997) found no significant difference in blood glucose between hospitalised patients treated by a diabetes team versus usual care patients. Studies that measured all cause mortality or survival generally did not find significant results comparing their intervention with control patients (Dey et al, 2005; Gattis et al, 1999; Gums et al, 1999a; Scott et al, 2005). Other clinical endpoints showed mixed results: Gattis et al (1999) found significantly higher event rates in their control group, such as non-fatal heart failure (11 versus 1; OR = 0.08 (0.004 to 0.40), total non-fatal cardiovascular events (23 versus 8; OR = 0.31; 0.31 to 0.69), and total events (36 versus 29; OR = 0.73, 0.39 to 1.33). One study (Scott et al, 2005) evaluated patient satisfaction with care, and showed no differences between intervention and control group patients.

Resource utilisation and costs

Studies that included resource utilisation and cost reported a wide range of outcome measures and did not show clear effects in favour of the intervention or control groups. Several studies measured hospital length of stay (LoS) and readmission rates. Gums et al (1999) found that antibiotic therapy intervention by a multidisciplinary consult team reduced LoS in the intervention group by 37 per cent (9.0 ± 0.5 days in control patients versus 5.7 ± 0.5 days in intervention patients). By contrast, others (Koproski, Pretto and Poretsky, 1997; Rubin et al, 2005; Scott et al, 2005) did not find effects of the input of a team on LoS of patients. Scott et al (2005) found no difference in readmission of patients with team care compared to patients in their control group, while Koproski, Pretto and Poretsky (1997) found that significantly fewer patients in the intervention group were readmitted (13 per cent versus 30 per cent). Bogden et al (1997) studied the added value of pharmacists working closely with physicians. They did not identify significant differences in medication charges, frequency of emergency department visits, referrals to dietitians and ordered panels, although they did report more clinical visits in the intervention group (12 versus 9; p < 0.05). A mean reduction in medication charges of $6.80 in the intervention group compared to a $6.50 increase in the control group did not reach statistical significance (Bogden et al, 1998). Dey et al (2005) reported that patients treated by a mobile stroke team were transferred significantly earlier to the stroke rehabilitation unit compared to control patients (14.7 versus 24.4 days; CI difference –17.0 to –2.6), although the number of patients transferred to the unit was not different for intervention and control patients. Also, they failed to find significant differences on their other measures: time to uptake of other interventions, and number of patients receiving CT scans or anti-platelet therapy. Gums et al (1999) measured several cost categories (antibiotic, laboratory, radiology, non-ICU, ICU, total room and board costs) and found that geriatric assessment by a team led to lower hospital costs (total costs: $12,207 ± $1,042 versus $9,153 ± $761 for the intervention patients). The implementation costs, however, were $21,000 per year. Scott et al (2005) reported a similar number of referrals in patients treated by the nutrition team compared to control patients, and the same number of contacts. Again, no statistical differences were found in total costs of both groups of patients. Likewise, Rubin et al (2005) found no significant differences in hospital costs as a result of adding an internist to the inpatient psychiatry team. They also found no differences on their other measures in this category, which were hospital services after discharge and emergency department visits.

2A. Interventions: improved coordination (n = 5)

Forster et al, 2005 evaluated whether adding a clinical nurse specialist (CNS) to physician teams in hospitals that already had discharge planning services made a difference. In two teaching hospitals, patients were randomly assigned to regular hospital care or care with a clinical nurse specialist. All four general medicine teams participated in the study. These services primarily treat undifferentiated and acute, multisystem medical illnesses. Each team was supervised by a staff internist with a senior (postgraduate, year 2) medical resident and varying numbers of postgraduate, year 1 residents and medical students. If required, social workers, home care workers and physiotherapists facilitated patient care. In the intervention teams, each of the four CNSs worked closely with their team to facilitate patient care. CNSs prioritised their activities as follows: retrieving information collected by family physicians and



21

Results

consultants before admission; arranging in-hospital imaging, procedures and consultations; facilitating patient discharge by arranging follow-up visits and providing patient education; and telephoning patients early after discharge from hospital to answer questions and address early problems.

Huddleston et al, 2004 determined the impact of providing a collaborative, hospitalist-led* model of care on postoperative outcomes and costs among adult high-risk patients having elective primary or revision total hip or knee arthroplasties in a teaching hospital in the USA. Five hundred and twenty-six patients were randomly assigned to either multidisciplinary collaborative hospitalist–orthopaedic team (HOT) care (n = 251/232 before/after) or standard orthopaedic-managed practice (n = 254/237 before/after). In the standard model of peri-operative care, the orthopaedic surgical team was responsible for postoperative patient issues that required additional diagnostic evaluation or treatment throughout the hospitalisation. The HOT care model was designed to integrate internal medicine faculty hospitalists with the orthopaedic surgical team (largely interfacing with the surgical residents) and the orthopaedic surgery nurses. Unlike standard practice, the hospitalist, rather than the orthopaedic surgeons, provided all indicated postoperative medical care after the surgical team completed initial postoperative orders. Hospitalists saw patients more than once a day and were able to order appropriate diagnostic tests and medications.

Moher et al, 1992 determined the effect of a medical team coordinator (MTC) on the length of stay in a teaching hospital. The MTC was a baccalaureate nurse, and her role was to facilitate administrative tasks such as discharge planning, coordinating tests and procedures, and collecting and collating patient information. Although these duties required the MTC to act as liaison between other members of the clinical team, her primary role was to function as part of the house staff team. Control patients received standard medical care.

Mudge et al, 2006 evaluated the effect of incorporating patient-centred multidisciplinary (MD) teams in a general medicine service in a controlled before and after study. The internal medicine department consisted of eight general medical teams grouped into four clinical units. Newly admitted patients were allocated to a medical team according to a cyclical roster. Each team consisted of one to two consultant general physicians, a registrar and an intern. A total of 1,538 patients entered the study, 792 of whom were included in the intervention group and 746 in the control group. The intervention consisted of several elements: the number of allied health personnel (AHP) was increased, which allowed for a consistent individual member of staff for each discipline in each intervention unit; the MD team was formed for every intervention unit, and comprised medical staff, allied health staff and the unit clinical nurse consultant (CNC). The team provided care to all patients belonging to a unit, wherever their physical location. A structured communication system involving daily team meetings was introduced, with mandatory attendance by all disciplines, at which all patients in the unit were discussed. An explicit planned discharge date and destination were also identified and documented in the team meeting within 24 hours of admission. On the other hand, control units continued their usual practice of medical and/or nursing referral to ward-based AHP, where staffing was frequently inconsistent, leading to interruptions in continuity of care and communication.

Yagura et al, 2005 evaluated the efficacy of a regular interdisciplinary stroke team approach on rehabilitation outcome. A stroke rehab unit (SRU) with weekly regular interdisciplinary (ID) stroke team conferences was compared with general rehab ward (GRW) care without such conferences in the same rehabilitation hospital. On the GRW, ID team conferences were not offered, but patients received daily rehab intervention, including rehab nursing care, physical therapy, occupational therapy and/or speech therapy, and they received discharge planning by medical social workers. In both groups, the

* hospitalists are hospital-based doctors who manage admissions from the primary care doctor. They coordinate all diagnostic tests and processes during the person’s stay, which allows the primary care physician to do more office-based work.



22

Results

rehabilitation programme and the nursing care were identical. For the SRU group, discharge planning was provided to patients by social workers based on the information presented at the weekly ID conferences. However, for the GRW group, discharge planning was provided by the social worker as well, based on the information he or she gathered from various team members. Conferences were held irregularly only for those patients with unsolved medical or social problems.

2B. Evidence: improved coordination

Process measures

In these studies, hardly any processes were measured. One study reported on medical care information provision (Moher et al, 1992). In a subgroup of this study’s population (n = 40), information was provided equally to the control and intervention patients.

Patient outcomes

Some positive results were found in studies reporting on patient outcomes. Huddleston et al (2004) found that most patients in the hospitalist-led team were discharged without complications (61.6 per cent versus 49.8; CI difference 2.8 to 20.7). Also, intervention patients had fewer minor complications (30.2 per cent versus 44.3 per cent; CI difference –22.7 to –5.3), although the frequency of intermediate and major complications was statistically equal. Yagura et al (2005) found no significant differences in functional impairment of intervention and control patients. Mudge et al (2006) reported that significantly fewer patients in the intervention group died (31 (3.9 per cent) versus 48 (6.4 per cent)); however, this was no longer significant after six months. Significantly fewer patients in the intervention group showed functional decline in the hospital (3.2 per cent versus 5.4 per cent), and self-rated health was better in intervention patients (data not provided). In addition, Forster et al (2005) and Moher et al (1992) did not find any significant effects on mortality or occurrence of post-discharge events (Forster et al, 2005).

Three studies evaluated patient satisfaction. Forster et al (2005) found that patients in the clinical nurse specialist group perceived the quality and processes of care to be superior: doctors had sufficient information (70.4 per cent versus 58.1 per cent); patients were contacted by hospital personnel (49.6 per cent versus 18.1 per cent); and overall quality was higher (8.2 ± 2.2 versus 7.6 ± 2.4). In addition, Moher et al (1992) reported that patients in the intervention group were significantly more satisfied (89 per cent versus 62 per cent; CI 2 per cent to 52 per cent), whereas Huddleston et al (2004) found no significant difference in patient satisfaction for their control and intervention patients.


Overall, no clear positive (or negative) effects were identified regarding costs and resource utilisation. Moher et al (1992) reported a significant shorter LoS in their intervention patients compared to control patients (7.43 versus 9.40 days; CI 1.02 to 2.92 days), although they did not find any differences in readmission rates. Foster et al (2005) reported no significant differences in time to discharge, hospital readmissions, time to ER or time to readmission. Huddleston reported patients in hospitalist-led team had shorter adjusted LoS (5.1 versus 5.6 days; CI difference –.8 to –.1). In contrast, Mudge et al (2006) failed to find significant differences in LoS between team care and usual non-team care, as did Yagura et al (2005), who also found no difference in discharge position. In addition, Mudge et al (2006) found no significant differences in six-month readmission, inpatient bed occupancy and discharge to residential care. Huddleston reported that physician costs were significantly higher in the HOT care model ($2,689 versus $2,367; CI difference $175 to $484), although hospital costs and total medical costs were not significantly different. Finally, Yagura et al (2005) did not find significant differences in costs of hospitalisation between intervention and control patients.

3A. Interventions: enhanced clinical expertise and coordination (n = 10)



23

Results

Banerjee et al, 1996 investigated the efficacy of intervention by a psychogeriatric team in the treatment of depression in elderly disabled people receiving home care from their local authority in the UK. Sixty-nine patients were randomly assigned to the psychogeriatric team in the catchment area (n = 33/29 before/after) or usual care (n = 36/32). Each case in the intervention group was presented at a MD team meeting, which included community psychiatric nurses, occupational therapists, senior and junior medical staff, a social worker and a psychologist. The team formulated management plans for each subject on an individual basis, as for any referral to the team. A team member acted as each person’s keyworker. The study population differed in their management only by being assigned a doctor. The control group received GP care. Patients, however, could be referred to the psychogeriatric team as normal (which was the case in 6 per cent of controls).

Germain et al, 1995, in their RCT, aimed to decrease the LoS of hospitalised patients on a waiting list for admission to an inpatient geriatric assessment unit (GAU), and to optimise use of the GAU and other hospital services in an acute hospital in the USA. Experimental subjects received the consultative services of a geriatric assessment and intervention team (GAIT) immediately after qualifying for GAU admission, in place of waiting for GAU services. The GAIT was staffed by a consultant geriatrician, social worker, physical therapist and geriatric nurse. GAIT consultations are initiated by referrals from primary physicians who identify functional deterioration in their elderly inpatients. After completion of comprehensive geriatric assessment, the team physical therapist and geriatric nurse began a variety of therapeutic interventions. Upon referral, the geriatrician qualified patients for the GAIT. Each team member assessed the patient. The geriatrician reviewed the patient’s medical condition and mental status, followed patients regularly, and offered advice to primary care physicians concerning medical management. The social worker visited all patients and families during the discharge planning period for home care services or nursing home placement. The geriatric nurse conducted an initial nursing assessment of all patients, was in contact with the physical therapist (who saw patients every day) on a daily basis and served as liaison with families and nursing homes regarding implementation of aftercare plans. The GAIT met weekly to discuss all assessment results. Control patients, having been accepted by the geriatrician to the GAU waiting list, received a standard consultation, which usually involved a review of medical conditions and screening for cognitive and functional problems by the geriatrician with recommendation to primary care physicians for ad interim changes in therapy. The social worker arranged the transfer. In this arm, several features of GAIT were missing: a) the team approach to diagnosis, care planning and treatment; b) order writing responsibility for patients' geriatric problems prior to their GAU transfer; and c) the early involvement of the geriatric nurse.

Hogan and Fox, 1990 researched the effects of a geriatric consultation team (GCT) in acute care in a Canadian hospital. One hundred and thirty-two patients were allocated to management in the usual manner by their attending physician (n = 66/65) or the services of the GCT (66/66), which comprised a specialist in geriatric medicine, a nurse coordinator, an occupational therapist, a physiotherapist, a social worker, a dietitian and a representative from pastoral care. The only person hired specifically for the programme was the coordinator; the other members were reassigned from other duties. Initial contact by the GCT was through a physician–physician consultation by the coordinator or the physician. Other team members became involved as required. Full-team rounds were held each week. The emphasis of the programme was on addressing functional problems and providing post-discharge follow-up. The attending service decided whether or not to adopt the recommendations from the consulting service.

Lincoln et al, 2004 studied the effectiveness of stroke rehabilitation by a community stroke team. Four hundred and twenty-one patients were randomised to either coordinated multidisciplinary rehabilitation in the community (n = 189/154) or routine rehabilitation services (n = 232/175). The team included occupational therapists, physiotherapists, speech and language therapists and a mental health nurse. It exclusively treated stroke patients, thereby providing a specialist service. All patients were initially seen at home by two team members and were discussed at weekly team meetings. Following these meetings, the team allocated therapists according to the nature of the patients’ problems. All patients were seen at their homes and were treated for as long as they were considered to be benefiting. The control



24

Results

group received services that were available to patients in each area, including day hospitals, outpatient departments and social services occupational therapy. A list of alternative rehabilitation services was provided to the referring agent (physician or patients).

Phelan et al, 2007 assessed the effect of a team of geriatrics specialists (senior resource team (SRT)) on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older in two primary care clinics in Seattle. The team consisted of geriatrically oriented clinicians. These included one full-time fellowship-trained geriatrician, two half-time gerontological advanced registered nurse practitioners and an off-site pharmacist with specialised geriatric training. The team met weekly throughout the intervention period to address team operations and to ensure that they were following a standard approach with each patient. The nurse practitioners first conducted an initial in-clinic assessment and then scheduled a follow-up visit for the patient approximately two weeks after the date of the initial assessment. Before the follow-up visit, the geropharmacist reviewed the patient’s medication list and made recommendations to the nurse practitioner. The geriatrician reviewed the findings of the initial assessment and reached a consensus with the nurse practitioner on clinical priorities for the patient. Through a collaborative process including the patient, a final set of goals and a proposed action plan were written. The team made medication changes and the nurse practitioners provided telephone and face-to-face follow-up for issues each patient was working on, focusing on self-management, support and the barriers assessed.

Rabow et al, 2004 conducted an RCT to evaluate an intervention in which an interdisciplinary team offered palliative medicine consultation and direct services to outpatients, their families and their primary care physicians (PCPs), in addition to the usual primary care. The team, called the comprehensive care team (CCT), comprised a social worker, nurse, chaplain, pharmacist, psychologist, art therapist, volunteer coordinator and three physicians who addressed physical, emotional and spiritual issues. All team members except the volunteer coordinator had expertise in palliative care. The programme integrated PCP consultation, case management, volunteer and group support, chaplaincy consultations and artistic expression. The seven main components of the team were: 1) consultation with PCPs was based on in-depth and follow-up patient assessments conducted by the social worker. Assessments were presented to the entire team at regularly scheduled meetings; 2) the social worker provided case management and offered psychological support in person and by telephone; 3) a nurse provided family caregiver training and support through formal classes and informal individual consultations; 4) a pharmacist performed a medical chart review of patient medications; 5) a chaplain offered spiritual and psychological support; 6) patients and their families were invited to monthly support groups that included discussions about symptom management and advance care planning; and 7) medical and pharmacy students provided volunteer patient support and advocacy through weekly telephone contacts with patients. Control patients received usual primary care only.

Schmidt et al, 1998 evaluated the effect of regular multidisciplinary team interventions on the quantity and quality of psychotropic drug prescribing in Swedish nursing homes. Experimental homes participated in an outreach programme that was designed to influence drug use through improved teamwork among physicians, pharmacists, nurses and nurse assistants. A pharmacist from outside the nursing home was assigned to spend one day a month in the intervention. He or she supported cooperation and organised MD team meetings for nursing home physicians and nursing personnel. Multidisciplinary team meetings were held on a regular basis (one a month) throughout the 12-month study period to discuss the drug use of individual residents and to encourage participation. The aim was to improve drug treatment and reduce the prescription of non-recommended drugs, as defined by guidelines distributed to all physicians at approximately the same time at the start of the study. In the control homes, no efforts were made beyond the normal routine to influence drug prescribing. In Sweden, pharmacists visit nursing homes approximately once a year to supervise drug storage and regulatory issues. Physicians and nurses discuss drug therapy as needed, but they generally have no structured reviews nor meet as a group to discuss drug use with under-nurses and nursing assistants.



25

Results

Schned et al, 1995 determined whether an outpatient team management programme for persons with early chronic inflammatory arthritis would produce improved clinical outcomes and lower costs than traditional, non-team, outpatient rheumatologic care in a clinic setting. The intervention had the following characteristics: 1) the rheumatologist maintained ordinary primary or consultative services and patient contact in a unconstrained manner; 2) a detailed standardised needs assessment interview was conducted by the project director after randomisation; 3) a half-day education and management programme for newly enrolled patients and family members or friends was conducted on site; 4) the team of rheumatologists and allied health professionals met and reviewed all newly enrolled patients monthly and all other patients quarterly; 5) patients were referred to any of the team members for care based on demonstrated need noted by the telephone interviews; 6) standardised telephone interviews were carried out every three months, and a defined formal written arthritis care plan was formulated and updated quarterly by the rheumatologist for the patient and for the primary or referring physician. The control group received traditional care in an unconstrained fashion from their primary care physicians and rheumatologists. There was no standardisation of care in any way, and communication was usually restricted to the office visit, occasional telephone calls, patients’ charts and letters.

Tijhuis et al, 2002, 2003 and van den Hout et al, 2003 compared the long-term effectiveness of care delivered by a clinical nurse specialist (CNS) with inpatient team care and day patient team care in patients with rheumatoid arthritis (RA) and increasing functional limitations. All patients randomised to care provided by a CNS were seen by a nurse specialist attached to the transmural nurse clinics of one of the six participating hospitals. The care provided by the CNS was additional to the usual outpatient care provided by rheumatologists. The CNS provided information about RA and prescribed, in consultation with the rheumatologist, joint splints, adaptive equipment and house adaptations if needed. If indicated, the patient could also be referred to other health professionals such as an occupational therapist, physical therapist or social worker. The MD inpatient team care and day patient team consisted of a rheumatologist, occupational therapist, physical therapist and a social worker. Inpatients and day patients followed a prescribed treatment programme of equal intensity for both groups and tailored to their needs. Treatment goals and modalities were discussed during weekly MD team conferences. Apart from the intervention period in the two team care groups, the decision to change or introduce disease-modifying drugs and injections was left to the rheumatologist at the outpatient clinic in all three study groups.

Vliet Vlieland, Breedveld and Hazes, 1997 compared the long-term effect of a period of 11 days of inpatient multidisciplinary team care, followed by routine outpatient care in 80 patients with rheumatoid arthritis (RA). Inpatient treatment consisted of primary medical and nursing care, daily exercise therapy, occupational therapy and support from a social worker. Treatment goals and modalities were discussed during weekly MD team conferences. During outpatient care, the prescription of medication and paramedical treatment was left to the attending rheumatologist at the outpatient clinic in both groups. There was no attempt to alter the treatment regime normally employed in the outpatient clinic.

3B. Evidence: enhanced clinical expertise and coordination

Process measures

Few studies compared the process measures of usual care providers and team care, and there were no clear effects. Tijhuis et al (2002, 2003) compared the long-term effectiveness of care delivered by a clinical nurse specialist (CNS) with inpatient team care and day patient team care in patients with rheumatoid arthritis (RA). No differences in medical treatment (drug use or injections) were reported between the three arms. Phelan et al (2007) did not identify significant differences in the specialist group versus control patients for primary care physician management, prescription of high-risk medication and proactive screening, and satisfaction or self-efficacy of primary care physicians. One study measured for the intervention group whether the team treatment led to high rates of implementation of proposed interventions (Banerjee et al, 1996). They found that 78 to 100 per cent of the proposed interventions



26

Results

by the psychogeriatric team were completed, except for outreach referral, where 43 per cent of the interventions were completed.

Patient outcomes

Several studies measured patient outcomes. Overall, these studies showed mixed results for a wide range of outcome measures. For survival rates, Germain et al (1995) reported that one-year survival in patients treated by the geriatric assessment and intervention team was not significantly different from survival in control patients. One study (Phelan et al, 2007) reported higher mortality in the intervention group (11.5 per cent versus 7.6 per cent). Hogan and Fox (1990) found significantly longer survival at 180 days in the intervention group, but not at 365 days. In addition, they found significantly higher improvements in Barthel index after 12 months (75 per cent versus 44 per cent). Banerjee et al (1996) found that significantly more patients in the psychogeriatric team group recovered from depression (19 versus 9, or 33 per cent; CI difference 10 per cent to 55 per cent), or improved (27 versus 17, or 35 per cent; CI difference 14 per cent to 56 per cent). Fewer remained the same (2 versus 9, or 19 per cent; CI difference –35 per cent to –3 per cent), or became worse (0 versus 6, or 17 per cent; CI difference –29 per cent to –5 per cent). Also, the change in mean depression rating was greater in intervention patients. Rabow et al (2004) found that the odds for dyspnea in control patients were higher than for the patients who received care from the comprehensive care team (OR = 6.07; CI 1.04 to 35.56). Also, sleep and anxiety improved in intervention patients. However, depression and quality of life scores were similar for both groups. Lincoln et al (2004) failed to find positive effects of the community stroke team on functional independence in activities of daily living (ADL), extended ADL, general health and quality of life. Schned et al (1995), in their study on the effects of team-managed outpatient care, measured a wide range of clinical measures, and found that all 16 were not significantly different for team care and control patients. Vliet Vlieland, Breedveld and Hazes (1997) found that significant changes on a wide range of disease activity outcomes were only present at short-term measures, although the proportion of patients showing clinical improvement was, over the total period, higher in the intervention group than in the outpatient group. In addition, Tijhuis et al (2002, 2003) compared the long-term effectiveness of care delivered by a clinical nurse specialist (CNS) with inpatient team care and day patient team care in patients with RA and increasing functional limitations. No significant differences were found in a comparison of clinical outcomes among the three groups, or among the CNS group versus the two team groups. Finally, Phelan et al (2007) found no differences in functional status and self-rated health for patients treated by the team compared to the control patients, although intervention patients scored higher on psychological well-being.

Some studies evaluated behavioural outcomes. Rabow et al (2004) evaluated patient satisfaction with care and found no differences between intervention and control group patients. Lincoln et al (2004) evaluated patient satisfaction with care (no overall difference) and knowledge of stroke (not significant). They also measured how carers judged their general health (no difference between routine carers and team members: how carers judged the burden of care (lower levels of strain were reported in the intervention group (median 8 versus 10; IQR 5–10 versus 6–12); and how carers judged their satisfaction with care and their satisfaction with knowledge (both higher in intervention group). Finally, Tijhuis et al (2002) reported that patients treated by clinical nurses were slightly less satisfied with their care than patients in the two team groups (the VAS score was 73mm ± 23 for nurse specialists versus 85mm ± 19 in inpatients and 92mm ± 10 in day patients).


Overall, no consistent reduction in costs or resource utilisation was observed in the studies reporting on these outcomes. Several studies included LoS as an endpoint. For example, Germain et al (1995) found that patients receiving team care had significantly lower LoS (42.8 ± 20.8 days versus 65.5 ± 23.5 days) in both high functioning and low functioning patients. However, Rabow et al (2004) did not find effects of the input of a diabetes team in the LoS of patients. Several studies measured rehospitalisation



27

Results

or readmission rates but did not find significant differences on (re)admission between intervention and control patients (Germain et al, 1995; Hogan and Fox, 1990; Schned et al, 1995; Tijhuis et al, 2002, 2003; van den Hout et al, 2003) or hospitalisations (Hogan and Fox, 1990; Phelan et al, 2007; Rabow et al, 2004; Tijhuis et al, 2003). One study (Germain et al, 1995) reported significantly higher percentages of patients discharged to home, especially in high-functioning patients (42 per cent versus 13 per cent in high-functioning patients and 10 per cent versus 7 per cent in low-functioning patients). Finally, Schned et al (1995) reported no differences in health professional visits, number of referrals, medication provided, use of aids and devices, number of surgical procedures or the number of blood tests ordered.

Few studies reported cost categories. Tijhuis et al (2002, 2003) found that QALY differences in the three arms of their study were less than 0.1 year (not significant). Significantly higher costs were reported for the initial assessment and treatment of patients in both team care groups compared to patients in the clinical nurse specialist (CNS) group (€5,000 for inpatient care and €4,100 for outpatient care versus €200 for CNS). Although other healthcare and non-healthcare costs were not significantly different, average total healthcare costs per patient were lower for the nurse group patients compared to the two team group patients (€8,092 versus €16,581 and €13,252 respectively). Costs for society were also significantly lower in CNS group patients versus the other two groups: at least €5,400. Over the two-year follow-up period, no significant differences were found for the aggregate of rheumatoid arthritis quality of life and QALYs based on the four different instruments used. The use of services and the introduction of specific equipment were not significantly different between the three groups, except that, at two-year follow-up, more inpatients than CNS group patients received home help (23 versus 10), and visits to a clinical nurse specialist were more frequent in the CNS group than in the two team groups. Finally, Rabow et al (2004) reported that patients treated by the outpatient palliative medicine team made fewer visits to their GP and urgent care clinics (7.5 ± 4.9 versus 10.6 ± 7.5/0.6 ± 0.9 versus 0.3 ± 0.5), but no differences were found with respect to specialty care clinics or emergency department visits. The mean charge per patient was $4,711 ± $73,009 in intervention patients versus $43,338 ± $69,647 in control patients.

4. Description of interventions and results derived from review studies

Two reviews were included in this category.

Malone et al, 2007 performed a Cochrane review to evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management. Three studies were included, with a total of 587 participants. The CMHTs in each study were involved in multidisciplinary assessments of each person, followed by regular team reviews. Care involved monitoring and prescribing medication and different forms of psychological intervention (including family intervention), with a special focus on continuity of care. Standard care was coordinated from hospital-based staff who assessed and treated people primarily in hospital outpatient and inpatient settings. Care involved psychiatrists, nurses and social workers, but this was not closely coordinated and was not carried out by a single team. Treatment covered the range of psychiatric interventions.

Process measures: No process measures were reported.

Patient outcomes: No conclusions could be drawn for the mental state of the participants. Patients in the team group had more contact with the police (social functioning: RR 2.07; CI 1.1 to 4.0). No differences were reported in death from any cause. Fewer people in the team group were not satisfied with their care compared to usual care (RR = 0.37; CI 0.2 to 0.8).

Costs: Lower admissions to a hospital were reported in team groups (RR 0.81; CI 0.7 to 1.0), whereas no clear evidence was reported on hospital admissions, use of emergency services, contact with primary care and contact with social services.



28

Results



29

Results

Mitchell, Del and Francis, 2002 conducted a systematic review to assess whether primary medical practitioner involvement with a specialist team improved patient outcomes, the behaviour of medical practitioners and the costs of health delivery. Seven studies were included, with 1,862 participants in total. Patient groups included chronic patients (five studies), frail aged (one study) and orthopaedic referrals (one study). They defined organised cooperation between primary medical practitioners and specialists as any formal arrangement that linked the GPs with specialist practitioners in the care of patients. This definition included case conferences between the GP and specialist (n = 1), shared consultations (n = 1), organised consultations by GPs with patients in specialist inpatient units (n = 1), visits by specialist staff to a GP clinic (n = 2), and formal shared care arrangements between the patients’ GPs and specialist clinics (n = 2). The category ‘specialist’ included medical and nursing specialists.

Process measures: Four studies showed improved clinical behaviour for GPs. The three studies that reported retention rates all demonstrated improved rates within programmes involving GPs compared with standard outpatient specialist care of chronic patients.

Patient outcomes: The studies found mixed effects for physical outcomes. With a few exceptions, no intervention group showed worse results. GP involvement in care led to greater patient satisfaction (four studies) and patients felt better prepared for discharge from hospital when the GP was involved in pre-discharge planning (one study).

Costs: Four studies showed improved waiting times. Mixed results were found on cost aspects. The measurement of costs differed too much to allow for making comparisons.

5. Team characteristics as determinants of effect

We attemped to retrieve information on the professions and disciplines involved, the presence of a team leader or coordinator, characteristics such as team size, age of team members or team tenure, and the presence of explicit task descriptions of team members. In general, hardly any information on these topics could be retrieved from the articles. In less than half of the studies, was any description (partly) provided regarding the tasks of the team members. In just a few cases, information was provided about who in the team was to be considered the leader or coordinator. None of our included studies provided information regarding the number of team members, age and gender of team members or tenure of the team.



28

Results



29

Results

Tabl

e 2:

Sum

mar

y of

the

evid

ence

and

inte

rven

tion

char

acte

ristic

s

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Enha

nced

clin

ical

exp

ertis

e

Bog

den

et

al, 1

997,

19

98

RC

T

n =

100

Haw

aii/U

SA

Out

patie

nt

Patie

nts

with

el

evat

ed

chol

este

rol

Patie

nts

with

un

cont

rolle

d hy

perte

nsio

n

Phys

icia

n–ph

arm

acis

t te

amw

ork

vs Usu

al c

are

Phar

mac

ist,

phys

icia

n,

resi

dent

or i

nter

n

vs Phys

icia

n, re

side

nt o

r in

tern

To a

sses

s th

e ef

fect

of a

pr

ogra

mm

e th

at e

ncou

rage

s te

amw

ork

betw

een

phys

icia

ns a

nd

phar

mac

ists

on

atte

mpt

s to

low

er

tota

l cho

lest

erol

leve

ls a

nd to

mee

t re

com

men

ded

goal

s pr

opos

ed b

y th

e N

atio

nal C

hole

ster

ol E

duca

tion

Prog

ram

To a

sses

s th

e ef

fect

of a

phy

sici

an

and

phar

mac

ist t

eam

wor

k ap

proa

ch

to u

ncon

trolle

d hy

perte

nsio

n in

a

med

ical

resi

dent

teac

hing

clin

ic,

for p

atie

nts

who

faile

d to

mee

t th

e re

com

men

ded

goal

s of

the

fifth

Joi

nt N

atio

nal C

omm

issi

on

on D

etec

tion,

Eva

luat

ion

and

Trea

tmen

t of H

igh

Blo

od P

ress

ure

Posi

tive

effe

cts

of te

am

inte

rven

tion

on c

are

deliv

ery

and

inte

rmed

iate

pat

ient

ou

tcom

es, e

spec

ially

fo

r pat

ient

s w

ith C

HD

or

risk

fact

ors

(incr

ease

d ris

k pa

tient

s). E

ffect

of

inte

rven

tion

was

abs

ent i

n pa

tient

s w

ithou

t CH

D a

nd

few

er th

an tw

o ris

k fa

ctor

s

Posi

tive

effe

cts

of te

am

inte

rven

tion

on c

are

deliv

ery

and

inte

rmed

iate

pat

ient

ou

tcom

es

Dey

et a

l, 20

05R

CT

n =

308

UK

Inpa

tient

s

Stro

ke (a

cute

ph

ase)

Org

anis

ed s

troke

ca

re/m

obile

stro

ke

team

vs Usu

al c

are

Stro

ke c

onsu

ltant

and

se

nior

ther

apis

t (te

am)

vs Clin

ical

nur

sing

sta

ff an

d th

erap

ists

To d

eter

min

e th

e im

pact

on

outc

ome

of a

cces

s to

a m

obile

team

du

ring

the

acut

e ph

ase

of s

troke

am

ong

patie

nts

adm

itted

to g

ener

al

war

ds

No

posi

tive

(or n

egat

ive)

ef

fect

of m

obile

stro

ke te

am

Gat

tis e

t al,

1999

RC

T

n =

181

US

A

Out

patie

nts

Hea

rt fa

ilure

pa

tient

s

Add

ition

of c

linic

al

phar

mac

ist t

o he

art

failu

re m

anag

emen

t te

am

vs Usu

al c

are

Phar

mac

ist,

phys

icia

n (a

ssis

tant

s, N

P)

vs Phys

icia

n (a

ssis

tant

s,

NP)

The

obje

ctiv

e of

the

stud

y w

as

to e

valu

ate

the

effe

ct o

f a c

linic

al

phar

mac

ist o

n ou

tcom

es in

ou

tpat

ient

s w

ith h

eart

failu

re

Add

ition

of c

linic

al

phar

mac

ist t

o m

anag

emen

t te

am o

f hea

rt fa

ilure

see

ms

to h

ave

bene

ficia

l effe

ct

on p

atie

nt o

utco

me,

som

e as

pect

s of

car

e de

liver

y an

d re

duct

ion

of e

vent

s



30

Results



31

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Gum

s et

al,

1999

RC

T

n =

252

US

A

Inpa

tient

Infe

ctio

us

dise

ases

Mul

tidis

cipl

inar

y te

am (p

rovi

ding

re

com

men

datio

ns

conc

erni

ng a

ntib

iotic

th

erap

y an

d m

onito

ring

whe

n ne

cess

ary)

vs Usu

al c

are

Clin

ical

mic

robi

olog

ist,

infe

ctio

us d

isea

se

spec

ialis

t

vs Atte

ndin

g ph

ysic

ian

To te

st th

e hy

poth

esis

that

a ti

mel

y co

nsul

t fro

m a

MD

ant

imic

robi

al

ther

apy

team

wou

ld im

prov

e th

e qu

ality

of c

are,

redu

ce p

atie

nt

char

ges,

and

resu

lt in

net

sav

ings

to

the

hosp

ital

Mul

tidis

cipl

inar

y an

timic

robi

al

ther

apy

team

effe

ctiv

e in

im

prov

ing

LoS

and

redu

cing

co

sts

Jack

et a

l, 20

03C

BA

n =

100

UK

Inpa

tient

Palli

ativ

e ca

re

Hos

pita

l-bas

ed

palli

ativ

e ca

re te

ams

vs Sta

ndar

d ca

re

Four

clin

ical

nur

se

spec

ialis

ts, s

uppo

rted

whe

n re

quire

d by

a

cons

ulta

nt (w

ho

addi

tiona

lly h

ad

sess

iona

l com

mitm

ents

at

all

loca

l hos

pice

s) a

nd

a sp

ecia

list r

egis

trar

vs ‘Sta

ndar

d ca

re’ (

not c

lear

)

To d

eter

min

e w

heth

er th

e ho

spita

l-ba

sed

palli

ativ

e ca

re te

am h

ad a

gr

eate

r effe

ct o

n im

prov

ing

canc

er

patie

nts’

sym

ptom

s w

hen

com

pare

d to

sta

ndar

d ca

re a

lone

. (Th

e pa

lliat

ive

care

team

was

mea

nt to

tra

nsfe

r the

prin

cipl

es o

f hos

pice

ca

re to

the

acut

e se

tting

)

Bot

h gr

oups

sig

nific

ant

impr

ovem

ents

in p

atie

nt

outc

omes

whi

ch s

eem

la

rger

in te

am g

roup

, but

st

atis

tical

met

hods

use

d ar

e no

t ade

quat

e fo

r ra

ting

effe

ctiv

enes

s of

the

inte

rven

tion

Kop

rosk

i, Pr

etto

and

Po

rtes

ky,

1997

RC

T

n =

179

US

A

Inpa

tient

s

Dia

bete

s

Dia

bete

s te

am

inte

rven

tion

vs Con

trol g

roup

with

us

ual c

are

Car

e fro

m p

hysi

cian

s,

nurs

es, n

utrit

ioni

sts

and

soci

al w

orke

rs

supp

lem

ente

d w

ith

diab

etes

team

(a d

iabe

tes

nurs

e ed

ucat

or a

nd a

n en

docr

inol

ogis

t) pl

us

nutri

tion

and

soci

al w

ork

cons

ulta

tions

if n

eces

sary

vs Car

e fro

m p

hysi

cian

s,

nurs

es, n

utrit

ioni

sts

and

soci

al w

orke

rs n

orm

ally

re

ceiv

ed in

the

med

ical

/su

rgic

al u

nits

To s

tudy

the

effe

cts

of a

dia

bete

s te

am o

n le

ngth

of s

tay

and

othe

r ou

tcom

es o

f hos

pita

lisat

ion

Gen

eral

ly p

ositi

ve e

ffect

s fo

r di

abet

es te

am in

terv

entio

n on

var

ious

per

form

ance

m

easu

res

(alth

ough

m

easu

red

post

-inte

rven

tion

only

) and

par

tly o

n re

sour

ce

utili

satio

n (re

adm

issi

on ra

tes

at 3

and

6 m

onth

s bu

t not

Lo

S)



30

Results



31

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Rub

in e

t al,

2005

RC

T

n =

139

US

A

Inpa

tient

s

Psy

chia

tric

patie

nts

Add

ition

of i

nter

nist

to

inpa

tient

psy

chia

try

team

vs Usu

al c

are

grou

p

Inte

rnis

t, ps

ychi

atry

ho

use

staf

f, P

CP

vs Psy

chia

try s

taff

(and

us

ual c

onsu

ltatio

ns fr

om

spec

ialis

ts if

nec

essa

ry)

To e

xam

ine

the

effe

cts

of

colla

bora

tion

betw

een

an in

tern

ist

and

psyc

hiat

rists

on

the

proc

esse

s an

d co

st o

f car

e am

ong

psyc

hiat

ric

inpa

tient

s. T

o te

st th

e hy

poth

esis

th

at th

is c

olla

bora

tion

wou

ld

impr

ove

the

proc

esse

s of

car

e w

ithou

t inc

reas

ing

cost

Proc

ess

of c

are

sign

ifica

ntly

be

tter i

n in

terv

entio

n gr

oup,

bu

t no

effe

cts

on re

sour

ce

use

Scot

t et a

l, 20

05R

CT

n =

112

UK

Inpa

tient

/ ou

tpat

ient

/co

mm

unity

Inte

rnal

m

edic

ine

(nut

ritio

n)

Nut

ritio

n te

am a

fter

gast

rono

my

vs Usu

al c

are

Nut

ritio

nal s

uppo

rt te

am

(NST

) nur

se a

nd/o

r di

etiti

an, p

rimar

y ca

re

prof

essi

onal

s, w

ard

team

pr

ofes

sion

als

vs War

d te

am, w

ard

diet

itian

, prim

ary

care

te

am

To te

st th

e hy

poth

esis

that

sy

stem

atic

nut

ritio

n te

am fo

llow

-up

afte

r PEG

inse

rtion

wou

ld le

ad to

a

decr

ease

in th

e co

st o

f car

e an

d m

aint

enan

ce o

f (or

impr

ovem

ent i

n)

clin

ical

out

com

es. (

The

hypo

thes

is

was

that

gen

eral

ists

wou

ld fe

el

unce

rtai

n, s

o sp

ecia

list s

ervi

ces

wou

ld b

e ne

eded

)

No

clea

r effe

cts

of n

utrit

ion

team

Impr

oved

coo

rdin

atio

n

Fors

ter e

t al

, 200

5R

CT

n =

620

Can

ada

Inpa

tient

s

All

kind

s of

pa

tient

s in

ho

spita

l

Car

e w

ith c

linic

al

nurs

e sp

ecia

list

(CN

S) (t

eam

)

vs Reg

ular

car

e

Inte

rnis

ts, r

esid

ents

, m

edic

al s

tude

nts

plus

cl

inic

al n

urse

vs Inte

rnis

ts, r

esid

ents

, m

edic

al s

tude

nts

Sev

eral

rand

omis

ed tr

ials

hav

e fo

und

that

dis

char

ge p

lann

ing

impr

oves

out

com

es fo

r hos

pita

lised

pa

tient

s. W

e do

not

kno

w if

add

ing

a cl

inic

al n

urse

spe

cial

ist t

o ph

ysic

ian

team

s in

hos

pita

ls th

at a

lread

y ha

ve d

isch

arge

pla

nnin

g se

rvic

es

mak

es a

diff

eren

ce. (

Hyp

othe

sis:

th

is is

an

inte

rven

tion

that

may

im

prov

e ei

ther

effi

cien

cy o

r saf

ety

of h

ospi

talis

atio

ns)

CN

S d

oes

not h

ave

a be

nefic

ial e

ffect

on

clin

ical

pat

ient

out

com

es

and

reco

urse

util

isat

ion

mea

sure

s, b

ut in

crea

ses

the

perc

eive

d qu

ality

of c

are

(inpa

tient

sat

isfa

ctio

n)



32

Results



33

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Hud

dles

ton

et a

l, 20

04R

CT

n =

526

US

A

Inpa

tient

s

Patie

nts

need

ing

hip/

knee

ar

thro

plas

ty

Hos

pita

list–

orth

opae

dic

team

(H

OT)

vs Sta

ndar

d or

thop

aedi

c m

anag

ed c

are

Hos

pita

list a

nd

orth

opae

dic

vs Orth

opae

dic

To d

eter

min

e th

e im

pact

of a

co

llabo

rativ

e, h

ospi

talis

t-led

mod

el

of c

are

on p

osto

pera

tive

outc

omes

an

d co

sts

amon

g pa

tient

s ha

ving

hi

p or

kne

e ar

thro

plas

ty

HO

T: fe

wer

min

or

com

plic

atio

ns (b

ut n

ot fo

r m

ore

seve

re o

nes)

, mor

e pa

tient

s di

scha

rged

with

out

com

plic

atio

ns a

nd s

horte

r ad

just

ed L

oS. P

refe

rred

by

prof

essi

onal

s, b

ut h

ighe

r co

sts

and

equa

l pat

ient

sa

tisfa

ctio

n

Moh

er e

t al,

1992

RC

T

n =

267

Can

ada

Inpa

tient

s

Gen

eral

med

ical

cl

inic

al te

achi

ng

units

Med

ical

team

co

ordi

nato

r (M

TC)

vs Usu

al c

are

‘Clin

ical

team

’ (no

t cl

ear),

plu

s M

TC =

ba

ccal

aure

ate

nurs

e

vs ‘Clin

ical

team

’ (no

t cle

ar)

To a

sses

s th

e ef

fect

of a

n M

TC

on th

e le

ngth

of h

ospi

tal s

tay,

the

frequ

ency

of r

eadm

issi

on a

nd th

e sa

tisfa

ctio

n w

ith h

ospi

tal c

are

in a

ge

nera

l med

ical

clin

ical

teac

hing

un

it to

whi

ch p

atie

nts

wer

e ad

mitt

ed

from

the

emer

genc

y de

partm

ent

Gen

eral

ly s

light

pos

itive

ef

fect

, as

LoS

is re

duce

d in

MTC

gro

up, b

ut n

o ef

fect

on

read

mis

sion

s an

d de

ath.

Pat

ient

s w

ere

mor

e po

sitiv

e an

d re

ceiv

ed

mor

e in

form

atio

n (s

ubgr

oup

anal

ysis

)

Mud

ge e

t al

, 200

6C

BA

n =

1538

Aus

tralia

Inpa

tient

s

Inte

rnal

m

edic

ine

Team

inte

rven

tion

(pat

ient

-cen

tred

mul

tidis

cipl

inar

y te

ams

in a

gen

eral

m

edic

ine

serv

ice)

vs Con

trol g

roup

with

us

ual c

are

The

MD

team

was

form

ed

for e

very

inte

rven

tion

unit

and

cons

iste

d of

med

ical

st

aff,

allie

d he

alth

sta

ff an

d th

e un

it cl

inic

al n

urse

co

nsul

tant

(CN

C)

vs Usu

al c

are:

con

trol

units

on

the

othe

r han

d co

ntin

ued

thei

r usu

al

prac

tice

of m

edic

al

and/

or n

ursi

ng re

ferr

al

to w

ard-

base

d A

HP,

w

here

sta

ffing

was

fre

quen

tly in

cons

iste

nt,

lead

ing

to in

terr

uptio

ns

in c

ontin

uity

of c

are

and

com

mun

icat

ion

(not

cle

ar)

To e

valu

ate

the

effe

ct o

f an

enha

nced

mod

el o

f car

e on

hos

pita

l ut

ilisa

tion

and

patie

nt o

utco

mes

Gen

eral

ly p

ositi

ve e

ffect

s of

team

inte

rven

tion

on

patie

nt o

utco

mes

(in-

hosp

ital

mor

talit

y (n

ot s

igni

fican

t at 6

m

onth

s), f

unct

iona

l dec

line,

an

d se

lf-ra

ted

heal

th,

thou

gh n

ot o

n re

stor

atio

n to

pr

evio

us fu

nctio

nal l

evel

1

mon

th a

fter d

isch

arge

), bu

t no

t on

reso

urce

util

isat

ion

(LoS

, 6 m

onth

s re

adm

issi

on,

inpa

tient

bed

occ

upan

cy,

disc

harg

e to

resi

dent

ial c

are;

on

ly a

cces

s to

any

alli

ed

heal

th p

rofe

ssio

nals

gre

ater

in

inte

rven

tion

grou

p)



32

Results



33

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Yagu

ra e

t al

, 200

5(S

emi)

RC

T

n =

178

Japa

n

Inpa

tient

s (h

ospi

tal)

Initi

al s

troke

Stro

ke re

habi

litat

ion

unit

(SR

U) (

= te

am)

vs Gen

eral

reha

bilit

atio

n w

ard

(GR

W)

Clin

ical

psy

chol

ogis

t, ph

ysic

al th

erap

ist,

occu

patio

nal t

hera

pist

an

d/or

spe

ech

ther

apis

t, so

cial

wor

k, re

hab

nurs

e

vs Clin

ical

psy

chol

ogis

t, ph

ysic

al th

erap

ist,

occu

patio

nal t

hera

pist

an

d/or

spe

ech

ther

apis

t, so

cial

wor

k, re

hab

nurs

e

To c

ompa

re th

e fu

nctio

nal o

utco

me

of tw

o ty

pes

of s

troke

reha

bilit

atio

n pr

ogra

mm

es a

t the

ince

ptio

n of

the

SR

U

No

effe

ct o

n tw

o m

easu

res

of fu

nctio

nal i

mpa

irmen

t. N

o ef

fect

on

LoS

or c

ost

of h

ospi

talis

atio

n. O

nly

mar

gina

l pos

itive

effe

ct fo

r S

RU

on

disc

harg

e po

sitio

n,

espe

cial

ly fo

r sev

ere

patie

nts

with

rega

rd to

dis

char

ge to

ho

me

Enha

nced

clin

ical

exp

ertis

e an

d co

ordi

natio

n

Ban

erje

e et

al

, 199

6R

CT

n =

69

UK

Com

mun

ity

Ger

iatri

cs (f

rail

elde

rly)

Psy

chog

eria

tric

team

vs Sta

ndar

d G

P c

are

Sev

eral

dis

cipl

ines

(m

edic

al, O

T, p

sych

olog

y,

soci

al w

ork)

vs GP

To in

vest

igat

e th

e ef

ficac

y of

in

terv

entio

n by

a p

sych

oger

iatri

c te

am in

the

treat

men

t of d

epre

ssio

n in

eld

erly

dis

able

d pe

ople

rece

ivin

g ho

me

care

from

thei

r loc

al a

utho

rity

Team

inte

rven

tion

mor

e ef

fect

ive

com

pare

d to

GP

ca

re w

ith re

spec

t to

reco

very

fro

m d

epre

ssio

n

Ger

mai

n et

al

, 199

5R

CT

n =

108

US

A

Inpa

tient

s

Ger

iatri

cs

Con

sulta

tive

serv

ices

of a

ger

iatri

c as

sess

men

t and

in

terv

entio

n te

am

(GA

IT)

vs Usu

al h

ospi

tal c

are

Con

sulta

nt g

eria

trici

an

Soc

ial w

orke

r

PT

Ger

iatri

c nu

rse

vs Ger

iatri

cian

plu

s w

hoev

er

is n

eces

sary

The

obje

ctiv

e w

as to

dev

elop

an

d ev

alua

te th

e im

pact

of a

ne

w g

eria

tric

asse

ssm

ent a

nd

inte

rven

tion

team

(GA

IT) o

n th

e le

ngth

of s

tay

of h

ospi

talis

ed

patie

nts

on a

wai

ting

list f

or

adm

issi

on to

an

inpa

tient

s ge

riatri

c un

it

Posi

tive

effe

ct fo

r GA

IT o

n Lo

S a

nd d

isch

arge

to h

ome,

bu

t not

on

reho

spita

lisat

ions

, nu

rsin

g ho

me

disc

harg

e an

d 1-

year

sur

viva

l



34

Results



35

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Hog

an a

nd

Fox,

199

0Pr

ospe

ctiv

e,

cont

rolle

d tri

al

(rand

omis

atio

n no

t exp

licitl

y m

entio

ned)

n =

132

US

A

Inpa

tient

s

Ger

iatri

cs

Ger

iatri

c co

nsul

tatio

n te

am (G

CT)

vs Usu

al c

are

by

phys

icia

n

Ger

iatri

c co

nsul

tatio

n te

am (G

CT)

: spe

cial

ist

in g

eria

tric

med

icin

e, a

nu

rse

coor

dina

tor,

an

occu

patio

nal t

hera

pist

, a

phys

ioth

erap

ist,

a so

cial

w

orke

r, a

diet

itian

and

a

repr

esen

tativ

e fro

m

past

oral

car

e

vs Phys

icia

n on

ly?

(not

cl

ear)

To te

st th

e us

eful

ness

of g

eria

tric

cons

ulta

tion

team

s in

an

acut

e ca

re

setti

ng

Posi

tive

effe

ct o

n 18

0-da

y bu

t not

on

365-

day

surv

ival

, an

d on

impr

ovem

ent

in A

DL.

No

effe

cts

on

livin

g ar

rang

emen

ts o

r ho

spita

lisat

ions

Linc

oln

et

al, 2

004

RC

T

n =

428

UK

Com

mun

ity

Stro

ke

Com

mun

ity s

troke

te

am (C

ST)

vs Rou

tine

care

Occ

upat

iona

l the

rapi

sts,

ph

ysio

ther

apis

ts, s

peec

h an

d la

ngua

ge th

erap

ists

an

d a

men

tal h

ealth

nu

rse,

and

trea

ted

excl

usiv

ely

stro

ke

patie

nts

vs Ser

vice

s av

aila

ble

to

patie

nts

in e

ach

area

in

clud

ing

day

hosp

itals

, ou

tpat

ient

dep

artm

ents

, an

d so

cial

ser

vice

s oc

cupa

tiona

l the

rapy

(not

cl

ear)

To a

sses

s w

heth

er re

habi

litat

ion

by a

spe

cial

ist m

ultip

rofe

ssio

nal

team

impr

oved

the

outc

ome

in

term

s of

func

tiona

l abi

litie

s, m

ood,

qu

ality

of l

ife a

nd s

atis

fact

ion

with

ca

re c

ompa

red

to c

onve

ntio

nal

outp

atie

nt re

habi

litat

ion

serv

ices

No

effe

cts

on c

linic

al p

atie

nt

outc

omes

. CST

resu

lts in

so

me

bene

ficia

l asp

ects

for

both

the

patie

nt a

nd th

e ca

rer

on s

atis

fact

ion

leve

l. C

arer

s ex

perie

nced

less

stra

in



34

Results



35

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Phel

an e

t al

, 200

7R

CT

n =

874

US

A

Out

patie

nts

(prim

ary

care

cl

inic

s)

Ger

onto

logy

Sen

ior r

esou

rce

team

(SR

T); t

eam

of

geria

tric

spec

ialis

ts

vs Usu

al G

P c

are

Ger

iatri

cally

orie

nted

cl

inic

ians

, inc

ludi

ng

one

full-

time

fello

wsh

ip-

train

ed g

eria

trici

an, t

wo

half-

time

gero

ntol

ogic

al

adva

nced

regi

ster

ed

nurs

e pr

actit

ione

rs, a

nd

an o

ff-si

te p

harm

acis

t w

ith s

peci

alis

ed g

eria

tric

train

ing

vs GP

To a

sses

s th

e ef

fect

of a

team

of

geria

trics

spe

cial

ists

on

the

prac

tice

styl

e of

prim

ary

care

pro

vide

rs a

nd

the

func

tioni

ng o

f the

ir pa

tient

s ag

ed 7

5 an

d ol

der.

(The

hyp

othe

sis

was

that

, by

inte

ract

ing

with

a

geria

trica

lly tr

aine

d ph

ysic

ian

in re

latio

n to

a s

mal

l num

ber o

f pa

tient

s (ro

ughl

y 10

), a

PC

P’s

kn

owle

dge

abou

t man

agem

ent o

f ol

der a

dults

wou

ld in

crea

se a

nd

thei

r sel

f-effi

cacy

to p

rovi

de c

are

to o

lder

adu

lts w

ould

be

enha

nced

. Th

is m

ight

tran

slat

e in

to im

prov

ed

qual

ity o

f car

e de

liver

ed to

old

er

adul

ts in

the

PS

P’s

pra

ctic

e)

No

or n

egat

ive

effe

cts

in

team

inte

rven

tion:

hig

her

deat

hs a

nd n

o su

perio

r pe

rform

ance

, hos

pita

lisat

ion

rate

s or

oth

er p

atie

nt

outc

omes

Rab

ow e

t al

, 200

4R

CT

n =

90

US

A

Out

patie

nts

(terti

ary

care

)

Palli

ativ

e ca

re

Com

preh

ensi

ve c

are

team

(CC

T); p

allia

tive

outp

atie

nt m

edic

ine

team

s

vs Usu

al P

CP

car

e

Soc

ial w

orke

r, nu

rse,

ch

apla

in, p

harm

acis

t, ps

ycho

logi

st, a

rt th

erap

ist,

volu

ntee

r co

ordi

nato

r and

th

ree

phys

icia

ns w

ho

addr

esse

d ph

ysic

al,

emot

iona

l, an

d sp

iritu

al

issu

es. A

ll te

am

mem

bers

exc

ept t

he

volu

ntee

r coo

rdin

ator

ha

d ex

perti

se in

pal

liativ

e ca

re

vs PC

P

To c

ompa

re p

hysi

cal,

psyc

holo

gica

l, so

cial

and

spi

ritua

l out

com

es

betw

een

an in

terv

entio

n gr

oup

of

patie

nts

rece

ivin

g a

mul

tifac

eted

, ou

tpat

ient

, pal

liativ

e m

edic

ine

cons

ulta

tion

inte

rven

tion

plus

usu

al

prim

ary

care

and

a c

ontro

l gro

up

rece

ivin

g on

ly u

sual

prim

ary

care

Bet

ter r

esul

ts b

y te

am

inte

rven

tion

for d

yspn

oea,

an

xiet

y an

d w

ell-b

eing

, bu

t not

for p

ain

and

depr

essi

on a

nd q

ualit

y of

lif

e. In

terv

entio

n pa

tient

s m

ade

few

er v

isits

to G

P

and

urge

nt c

are

clin

ics,

but

no

diff

eren

ce fo

r spe

cial

ity

care

clin

ics,

em

erge

ncy

depa

rtmen

t vis

its, n

umbe

r of

hosp

italis

atio

ns, n

umbe

r of

days

in h

ospi

tal a

nd c

harg

es

per p

atie

nt



36

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Schm

idt e

t al

, 199

8R

CT

(blo

ck

rand

omis

atio

n)

n =

1854

Sw

eden

Inpa

tient

(n

ursi

ng h

omes

)

Ger

iatri

cs

(psy

chot

ropi

c pr

escr

iptio

ns)

Inte

rven

tion

(team

)

vs Con

trol

Phys

icia

ns, p

harm

acis

ts,

nurs

es a

nd n

urse

s’

assi

stan

ts

vs Phys

icia

ns, n

urse

s an

d nu

rses

’ ass

ista

nts.

To e

valu

ate

the

impa

ct o

f reg

ular

m

ultid

isci

plin

ary

team

inte

rven

tions

on

the

quan

tity

and

qual

ity o

f ps

ycho

tropi

c dr

ug p

resc

ribin

g in

S

wed

ish

nurs

ing

hom

es

Gen

eral

ly, t

eam

wor

k se

emed

to im

prov

e th

e w

ay p

sych

otro

pics

wer

e de

scrib

ed. H

owev

er, n

o di

rect

com

paris

ons

wer

e m

ade

betw

een

both

gro

ups

Schn

ed e

t al

, 199

5R

CT

(no

blin

ding

)

n =

107

US

A

Out

patie

nt

Chr

onic

in

flam

mat

ory

arth

ritis

TEA

MC

AR

E; te

am

man

aged

out

patie

nt

care

vs TRA

DC

AR

E; u

sual

ou

tpat

ient

car

e (c

ontro

l gro

up)

Rhe

umat

olog

ist,

allie

d he

alth

pro

fess

iona

ls

(and

prim

ary

or re

ferr

ing

phys

icia

n?)

vs PC

P a

nd rh

eum

atol

ogis

ts

To d

eter

min

e w

heth

er a

n ou

tpat

ient

te

am m

anag

emen

t pro

gram

me

for p

erso

ns w

ith e

arly

chr

onic

in

flam

mat

ory

arth

ritis

wou

ld

prod

uce

impr

oved

clin

ical

out

com

es

and

low

er c

osts

than

trad

ition

al,

non-

team

, out

patie

nt rh

eum

atol

ogic

ca

re in

a c

linic

set

ting.

It w

as

hypo

thes

ised

that

team

-man

aged

ca

re p

rovi

ded

early

in th

e co

urse

of

chr

onic

infla

mm

ator

y ar

thrit

is

mig

ht a

fford

bet

ter o

utco

mes

than

pr

evio

usly

repo

rted,

and

that

the

bene

fits

of e

arly

inte

rven

tion

mig

ht

also

incl

ude

impr

oved

long

-term

ec

onom

ic o

utco

mes

No

effe

ct fo

und

for p

atie

nt

outc

omes

or r

esou

rce

utili

satio

n



37

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Tijh

uis

et

al, 2

002,

20

03, a

nd

van

den

Hou

t et a

l, 20

03

RC

T

n =

210

Net

herla

nds

Inpa

tient

and

ou

tpat

ient

Rhe

umat

oid

arth

ritis

Clin

ical

nur

se

spec

ialis

t car

e (C

NS

C)

vs Inpa

tient

m

ultid

isci

plin

ary

team

ca

re (I

MTC

)

vs Day

pat

ient

m

ultid

isci

plin

ary

team

ca

re (D

MTC

)

The

care

pro

vide

d by

th

e C

NS

was

add

ition

al

to th

e us

ual o

utpa

tient

ca

re p

rovi

ded

by

rheu

mat

olog

ists

. If

indi

cate

d, th

e pa

tient

co

uld

also

be

refe

rred

to

oth

er h

ealth

pr

ofes

sion

als

vs The

MD

inpa

tient

team

ca

re a

nd d

ay p

atie

nt

team

con

sist

ed o

f a

rheu

mat

olog

ist a

nd

occu

patio

nal t

hera

pist

, a

phys

ical

ther

apis

t and

a

soci

al w

orke

r

To c

ompa

re th

e lo

ng-te

rm (c

linic

al)

effe

ctiv

enes

s of

car

e de

liver

ed

by a

clin

ical

nur

se s

peci

alis

t with

in

patie

nt te

am c

are

and

day

patie

nt

team

car

e in

pat

ient

s w

ith R

A a

nd

incr

easi

ng fu

nctio

nal l

imita

tions

. To

ass

ess

the

rela

tive

cost

ef

fect

iven

ess

of C

NS

car

e, in

patie

nt

team

car

e an

d da

y pa

tient

team

ca

re

CN

SC

is tr

eatm

ent o

f pr

efer

ence

, at l

east

from

he

alth

eco

nom

ic p

oint

of

view

. No

supe

rior t

reat

men

t ra

ted

in te

rms

of c

linic

al

effic

acy

Vlie

t Vl

iela

nd,

Bre

edve

ld

and

Haz

es,

1997

RC

T

n =

80

Net

herla

nds

Inpa

tient

s an

d ou

tpat

ient

s

vs

Out

patie

nts

alon

e

Rhe

umat

oid

arth

ritis

Inpa

tient

MD

team

ca

re

vs Rou

tine

outp

atie

nt

care

For a

ctiv

e R

A

Prim

ary

med

ical

and

nu

rsin

g ca

re, p

hysi

cal

ther

apis

ts, o

ccup

atio

nal

ther

apis

ts, s

ocia

l wor

ker

vs Rhe

umat

olog

ist

To e

valu

ate

whe

ther

the

impr

ovem

ent a

chie

ved

by a

sho

rt in

patie

nt m

ultid

isci

plin

ary

treat

men

t pr

ogra

mm

e co

uld

be m

aint

aine

d ov

er a

2-y

ear p

erio

d

Inte

rven

tion

seem

s to

ha

ve p

ositi

ve e

ffect

s on

di

seas

e ac

tivity

; how

ever

, no

sign

ifica

nt e

ffect

rem

aine

d at

2-

year

follo

w-u

p



38

Results



39

Results

Stud

y an

d de

sign

St

udy

char

acte

rist

ics

Inte

rven

tion

Dis

cipl

ines

and

pr

ofes

sion

als

invo

lved

A

im o

f stu

dy a

nd u

nder

lyin

g hy

poth

eses

(if a

ny)

Key

find

ings

Evid

ence

der

ived

from

revi

ews

Mal

one

et

al, 2

007

Men

tal i

llnes

ses

Com

mun

ity c

are

(Rev

iew

, thr

ee s

tudi

es

incl

uded

)

Com

mun

ity m

enta

l he

alth

team

s

vs Usu

al c

are

Com

mun

ity m

enta

l he

alth

team

s (C

MH

T)

vs Sta

ndar

d ca

re w

as

coor

dina

ted

from

ho

spita

l-bas

ed s

taff

who

as

sess

ed a

nd tr

eate

d pe

ople

prim

arily

in

hosp

ital o

utpa

tient

and

in

patie

nt s

ettin

gs. C

are

invo

lved

psy

chia

trist

s,

nurs

es a

nd s

ocia

l w

orke

rs b

ut th

is w

as n

ot

clos

ely

coor

dina

ted

and

was

not

car

ried

out b

y a

sing

le te

am

To re

view

the

effe

cts

of C

MH

T m

anag

emen

t, w

hen

com

pare

d to

no

n-te

am c

omm

unity

man

agem

ent,

for a

nyon

e w

ith s

erio

us m

enta

l ill

ness

Com

mun

ity m

enta

l hea

lth

team

s ar

e no

t inf

erio

r to

non-

team

sta

ndar

d ca

re a

nd in

so

me

aspe

cts

even

sup

erio

r (a

ccep

tanc

e of

trea

tmen

t, ho

spita

l adm

issi

on, a

void

ing

deat

h by

sui

cide

)

Mitc

hell,

D

el a

nd

Fran

cis,

20

02

Vario

us

Rev

iew

(sev

en

stud

ies

incl

uded

)

Org

anis

ed

coop

erat

ion

betw

een

GP

and

spe

cial

ist

vs Usu

al c

are

Org

anis

ed c

oope

ratio

n be

twee

n pr

imar

y m

edic

al p

ract

ition

ers

and

spec

ialis

ts, a

s an

y fo

rmal

arr

ange

men

t tha

t lin

ked

GP

s w

ith s

peci

alis

t pr

actit

ione

rs in

the

care

of

pat

ient

s

It is

ass

umed

that

GP

s sh

ould

co

ntrib

ute

usef

ully

to th

e m

anag

emen

t of p

atie

nts

who

nee

d sp

ecia

list s

ervi

ces.

To

dete

rmin

e w

hat d

iffer

ence

s, if

any

, clo

se,

form

alis

ed c

oope

ratio

n m

akes

to

the

heal

th o

utco

mes

of p

atie

nts,

the

beha

viou

r of m

edic

al p

ract

ition

ers

and

the

cost

s of

hea

lth d

eliv

ery

Coo

pera

tion

betw

een

GP

an

d sp

ecia

list s

eem

s no

t to

affe

ct th

e ph

ysic

al o

utco

me

but m

ay im

prov

e re

tent

ion

rate

s, p

atie

nt s

atis

fact

ion

and

clin

ical

beh

avio

ur o

f GP

s



38

Results



39

Results

Discussion

This review identified 28 evaluations of patient care teams. Enhanced clinical expertise was demonstrated to have the potential to improve professional performance as measured by appropriateness of care processes, but its impact on patient outcomes was mixed. Costs and resource utilisation − if provided − seemed to remain mainly unchanged. Coordinated teams, as defined by a narrow set of structures, showed some positive effects on patient outcomes but little impact on costs and resource utilisation. Care process measures were infrequently examined in studies on coordinated teams. Finally, enhanced expertise and coordination showed some limited effect on patient outcomes only. We conclude that enhanced clinical expertise seems to be an important component of patient care teams, while the added value of improved coordination remains uncertain.

Discussion of main findings

Enhanced clinical expertise

We identified eight studies in which a team member was added to the care because of his or her added clinical expertise. Given the consultative character of these interventions, one would expect to find impact on care process measures, such as those reflecting guideline adherence, and thus – ultimately − improved patient outcomes. Indeed, most of these studies measured such outcomes, and results were at least partly in favour of the intervention groups. For instance, Gums et al (1999) found improved performance of physicians when a clinical microbiologist and infectious disease specialist provided recommendations on antibiotic therapy and monitoring, leading to shorter length of stay and total hospital costs in the intervention group. Two studies evaluated the effect of programmes that encouraged teamwork between physicians and pharmacists on attempts to improve guideline-compliant care in patients with high cholesterol levels and blood pressure (Bogden et al, 1997, 1998) and heart failure (Gattis et al, 1999). In both studies, positive results were reported for process measures as well as for (intermediate) patient outcomes. These findings are in line with a recent Cochrane review on the expanding role of pharmacists. This review reported that studies that compared pharmacist services targeted at health professionals versus the delivery of no comparable service demonstrated that pharmacist interventions produced the intended effects on physicians’ prescribing practices (Beney, Bero and Bond, 2000).

Although at least partially positive results were reported in terms of process measures, studies showed mixed results regarding patient outcomes. For instance, a relatively well-conducted study found no effect of the advice of a mobile stroke team to the responsible clinical team on mortality and morbidity (Dey et al, 2005). This conclusion is in line with the findings of recent reviews. For instance, a Cochrane review on shared care interventions (across primary and secondary care) in chronic disease management concluded that there is, at present, insufficient evidence to demonstrate significant benefits from shared care apart from improved prescribing (Smith, Allwright and O’Dowd, 2007). There could be several reasons for the absence of a relation between process measures and patient outcomes, including inadequate length of follow-up, inadequate case-mix adjustment or insufficiently responsive outcome measures. Alternatively, the underlying clinical research evidence may be interpreted as being too optimistic in relation to treatment effects. We suggest that further exploration of the link between process and outcomes is needed, but that enhanced expertise is a potentially effective component of patient care teams.

Improved coordination

Five studies were identified that focused on adding a coordinator to the team (three studies) or improved communication and coordination structures (two studies). Patient outcomes seemed to show some positive results, especially on ‘soft’ measures such as patient preferences. But given that



40

Results

mainly coordination was improved, one would expect an impact on resource utilisation and efficiency of healthcare delivery. All five studies included such measures. Huddleston et al (2004), for example, reported shorter adjusted length of stay in patients treated by the collaborative, hospitalist-led model of care. They reported higher physician costs, although hospital and total medical costs were not significantly different. However, overall, there is very little evidence to conclude that resource utilisation and costs reduce as a result of improved coordination in patient care teams, although some studies reported shortened length of stay. These mixed findings are in line with a Cochrane review, which compared the effects of closely coordinated community mental health team treatment with standard non-team management (Malone et al, 2007). They reported that lower admissions to a hospital were reported in the team group, while no clear evidence was reported on admittance to emergency services, contact with primary care and contact with social services. No differences were reported in death from any cause. Fewer people in the team group were not satisfied with their care, compared to usual care.

Enhanced clinical expertise and coordination

Ten studies were identified in which the intervention contained both clinical expertise and coordination. Process measures were hardly reported, and the studies showed mixed results regarding patient outcomes and little effect on costs and resource utilisation. We therefore found little evidence to conclude that the combination of enhanced coordination and expertise added value compared to enhanced clinical expertise only or improved coordination only. It was not possible to disentangle the influence of specific components of these teams with enhanced expertise and coordination because these were not well described and analysed. One study (Tijhuis et al 2002, 2003; van den Hout et al, 2003), which compared care provided by a clinical nurse specialist in addition to the usual outpatient rheumatologist care versus both multidisciplinary inpatient and day patient team care, showed that standard ‘full’ multidisciplinary care may not always be preferable, since the full inpatient and day patient team approach did not lead to better results in terms of clinical efficacy and led to higher costs.

Evidence derived from reviews

Finally, two reviews were identified by our search. Given the fact that the reviews included different interventions (specifically Mitchell, Del and Francis, 2002), we did not classify them under the three categories we used for the description of the single studies. Mitchell et al (2002) concluded that cooperation between GP and specialist did not seem to affect physical outcomes but may have improved retention rates, patient satisfaction and the clinical behaviour of GPs. However, only seven studies were included and conclusions may be based on one study only. Malone et al (2007) concluded that community mental health teams may in some respects be superior to non-team standard care.

Methodological considerations

We encountered difficulties in defining a sensitive search strategy with a feasible number of potential eligible studies. Given the high number of hits when ‘patient care team’, as a MeSH term, was included, or team search terms in the title and abstract were used, ultimately, the search was limited to terms which only appeared in the titles of papers. We therefore realised that relevant studies would be missed. This explains why there was little overlap with selected studies from an earlier review (Lemieux-Charles and McGuire, 2006). We tried to overcome this problem by snowball sampling from the identified studies. For example, Huddleston et al (2004) was not identified in our search, but was later included because we identified a summary of that paper in our search. The sample sizes of the included studies were often small and the methodological quality was often rather poor, therefore limiting our ability to draw firm conclusions on the basis of our sample of included studies. In addition, it was often unclear what the expected effects of enhanced team approaches were, and therefore what scientific hypothesis was tested in the evaluation. We grouped studies to three subgroups of teams rather than according to setting or other factors. In doing so, we may not have paid enough attention to the context in which the



41

Results

care took place (for example, outpatient versus inpatient care (Hearld et al, 2008; Lemieux-Charles and McGuire, 2006)). This limits the external generalisability of our conclusions. Finally, some of the studies included comparisons across different settings, which may also have confounded the effects. Despite our efforts to collect information regarding the impact of potential determinants on team effectiveness, no conclusions could be drawn owing to the limited availability of this type of information. Intervention studies which focus primarily on improving team functioning by altering team characteristics or processes probably include a more comprehensive set of factors.

Despite the possible limitations, this review has a clear strength. In previous studies, outcome measures were highly heterogeneous, thereby making comparisons across studies difficult (Lemieux-Charles and McGuire, 2006). Since different teams may be effective in relation to different outcomes, in this review, we classified the type of outcome and grouped the studies according to the underlying objectives of the teams (enhanced clinical expertise, improved coordination, and a combination of these features). In doing so, we gained insight into the relative importance of these elements. A better understanding of the relevance of mechanisms underlying teamwork is important for both decision makers and for the design of future studies on the impact of clinical delivery teams.

As we based our conclusions on experimental designs only, evidence on the outcomes of patient care teams is strong. Observational designs (including process evaluations, case studies and ethnographic studies) have a high risk of bias with respect to conclusions on effectiveness. However, there is an ongoing debate in the literature whether interventions such as patient care teams and teamwork may be too complex to measure in an RCT (Norman, 2003). For instance, according to Salas et al (2005), teamwork is dynamic, and its manifestation can vary based on a vast number of variables such as team environment, type of task, individual difference and perceived workload. Therefore, it has been argued, to fully understand such a construct it is insufficient to take a single ‘snapshot’ of team performance. Instead, teamwork should be sampled during a variety of conditions and situations, including laboratory and applied research settings (Salas et al, 2005). Thus, other waves of research focus primarily on dynamic processes of collaboration that improve interteam work around patients (Kerosuo and Engeström, 2003; Leonard, Graham and Bonacum, 2004; Salas et al, 1992), using a range of qualitative methodologies such as team performance measures on single teams (Jeffcott and Mackenzie, 2008; Salas et al, 2008), situation analysis (Outhwaite, 2003), ethnographic and interview methods (Hunter et al, 2008) and video feedback (Carroll, Iedema and Kerridge, 2008).These studies may be helpful in building new theory, especially in identifying the process factors that will eventually lead to better outcomes and identifying the conditions under which this will take place. These studies would ideally be complemented by experimental designs to explore whether relationships that are observed in observational studies also hold in experimental designs.

Implications for health policy

Improving quality in healthcare has become a priority for countries worldwide. Figuring out how to achieve this in an evidence-based manner without adding to the already unsustainable cost burden is an imperative. This means that we must go beyond invocations such as ‘we need more teamwork’ to understanding with precision exactly when, in what circumstances and with what properties teamwork contributes to better patient outcomes. For this reason, we specifically tried to examine different team subgroups.

Policy makers can create and optimise stimulating environments and conditions such that workers in diverse healthcare settings are able to perform to the best of their ability. The following conclusions and recommendations for health policy makers may be drawn from our review:



42

Results

1. Enhanced clinical expertise: the available research indicated that adding clinical expertise may indeed improve appropriateness of care, although this did not consistently translate into improved patient outcomes. This may be due to the relatively short follow-up periods of most studies. It remained unclear what investments were made to achieve these improvements. We suggest that putting in additional resources may be acceptable, as they are an investment in better patient outcomes, but that formal evidence on efficiency would be helpful for decision makers.

2. Regarding enhanced coordination, the available research did not show a consistent reduction in resource utilisation or costs, as might have been expected. We suggest that the intended effects of enhanced coordination, either through an added human coordinator or through additional coordination structures, should be examined. If reduced utilisation and costs are indeed the aim (for example, by shortening hospital stay), the mechanism by which this is achieved should be clarified. Currently, there is only limited evidence to suggest to decision makers that adding a team member with coordination tasks or introducing more coordination activities has a beneficial effect.

3. Coordination may be most effective when combined with added expertise and integrated into an appropriate organisational context. Similar results were found for these studies as for those with improved coordination alone.

4. Despite our in-depth analysis of the studies, the amount of detailed information provided on patient care teams in terms of team structure, processes and outcomes was limited. This hinders our ability to make strong recommendations on levels for effective team environments and conditions.

5. Questions regarding cost-effectiveness of team approaches cannot be answered adequately because of the lack of sufficient studies. Additional resources for teamwork may be acceptable, as they are an investment in better patient outcomes, but formal evidence on efficiency is not available. The intended effects of enhanced coordination, either through adding a co-coordinator or through introducing coordination structures, are worthy of further exploration. If reduced utilisation and costs are indeed at the aim (for example, by shortening hospital stay), the mechanism by which this is achieved should be clarified. Currently, there is very limited evidence to suggest to decision makers that enhanced coordination in patient care teams has a beneficial effect.

6. Decision makers wishing to know what components contribute to the success of teams and how patient care team interventions can be optimised should plan evaluations alongside strategic programmes to enhance patient care teams. Careful consideration should be given to how to interpret these programmes. As yet, it is often unclear how the results of these measures should be interpreted. For example, if consumption of nurse-led care is higher than consumption of care provided by physicians, does this mean that nurse-led care is less favourable? Outcomes should therefore be related to cost consequences.

The evidence may be weaker than might be expected by policy makers and managers in supporting a case for investment in resources for coordination, which is often a very high priority for policy and public interest in healthcare. The usual arguments can be made that research methods may be responsible for the weaker than expected findings. Studies did not consistently focus on outcomes where one would expect to see most effect. On the other hand, one might focus on the strength of the finding that enhancement of clinical expertise in teams does, as expected, appear to be associated with improvements in the delivery of healthcare.



43

Results

Implications for research

This review has focused on two potential ingredients of effective teamwork: more clinical expertise and better coordination in patient care. From a research perspective, the challenge in our review was to extract features that contribute to successful teamwork. We formulated the categories from the information provided by authors on the objectives of the teams and from the description of the intervention components. We focused on a team structure attribute (adding expertise) and a team process attribute (adding coordination). From the analysis we make a number of observations:

1. Interventions to enhance patient care teams are not well described in research publications. We strongly recommend that the description of the content, integrity and context of these interventions is improved (or that a link to sources where such information can be found is provided).

2. Reports on studies of patient care teams should follow guidelines for the evaluation of complex interventions in healthcare (Medical Research Council, 2008). Currently, studies do not consistently focus on outcomes where one would expect the most significant results. Only when more information on the interventions and their context is provided can we start to learn about factors associated with effects on performance, patient outcomes and costs.

In addition to robust reviews taking a clinical epidemiology perspective to build theory, more explorative reviews should be conducted including a range of qualitative methodologies.



44

Appendix A: Search strategy for QQUIP teams review in PubMed

Appendix A: Search strategy for QQUIP teams review in PubMed

# Search term Number of hits

12345

Team (TI)Teams (TI)Teamwork (TI)Teamworking (TI)1 OR 2 OR 3 OR 4

9,7571,9091,073

1812,658

67891011121314

Interdisciplinary (TI)Inter disciplinary (TI)Multidisciplinary (TI)Multi disciplinary (TI)Interprofessional (TI)Inter professional (TI)Multiprofessional (TI)Multi professional (TI)6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13

3,42128

4,11824361441

10946

8,579

151617171819

Collaboration (TI)14 AND 155 OR 16Publication Date from 1990, Humans, EnglishEPOC study design criteria 17 AND 18 AND 19

4,328228

11,8285,098,2277,272,377

2,252



45

Appendix B: Search strategy and results per database


Database Source Search terms

Date + number of hits

PubMed University library

#((((((((((((((((((((((((((((((((Randomized Controlled Trial[ptyp]))) OR (((Controlled Clinical Trial[ptyp])))) OR (((Comparative Study[ptyp])))) OR (((Evaluation Studies[ptyp])))) OR ((“comparative study”))) OR ((“effects”))) OR ((“effect”))) OR ((“evaluations”))) OR ((“evaluating”))) OR ((“evaluation”))) OR ((“evaluates”))) OR ((“changing”))) OR ((“changes”))) OR ((“change”))) OR ((“interventions”))) OR ((“intervention”))) OR ((“impact”))) OR ((“random allocation”))) OR ((“post test”))) OR ((“posttest”))) OR ((“pre test”))) OR ((“pretest”))) OR ((“time series”))) OR ((“experimental”))) OR ((“experiments”))) OR ((“experiment”))) OR ((“intervention studies”))) OR ((“intervention study”))) OR ((“controlled clinical trial”))) OR ((“randomised controlled trial”))) OR ((“randomized controlled trial”))

and#Limits:

(“1990”[PDAT]: “3000”[PDAT]) AND “humans”[MeSH Terms] AND English[lang]

and#Interdisciplinary collaboration and team search terms:

((((((((((((“interdisciplinary”[TI])) OR ((“interdisciplinary”[TI]))) OR ((“multidisciplinary”[TI]))) OR ((“multi disciplinary”[TI]))) OR ((“interprofessional”[TI]))) OR ((“interprofessional”[TI]))) OR ((“multiprofessional”[TI]))) OR ((“multi professional”[TI])))) AND ((collaboration[TI])))) OR ((team[TI])) OR ((teams[TI])) OR ((teamwork[TI])) OR ((teamworking[TI]))

25–01–2008

Number of hits: 2,252



46




PsycINFO University library

#(((evaluation studies) or (evaluation study)) or (evaluations) or ((evaluate) or (evaluates) or (evaluation)) or (pretest) or (“pre test”) or (“time series”) or (intervention study) or (intervention studies) or (controlled clinical trial) or (randomised clinical trial) or (randomized clinical trial) or ((change) or (changes) or (changing)) or ((experiment) or (experiments) or (experimental)) or (interventions) or (intervention) or (impact) or (random allocation) or (posttest) or (“post test”) or (comparative study) or ((effect) or (effects))) and (LA:PSYI = ENGLISH) and (PY:PSYI >= 1990)

and# ((((collaboration ) in TI) and (((“inter disciplinary”) in TI) or ((multidisciplinary) in TI) or ((“multi disciplinary”) in TI) or ((interprofessional ) in TI) or ((multiprofessional ) in TI) or ((“inter professional”) in TI) or ((interdisciplinary) in TI) or ((“multi professional”) in TI))) or (((teamworking) in TI) or ((teamwork) in TI) or ((teams) in TI) or ((team ) in TI))) and (LA:PSYI = ENGLISH) and (PY:PSYI >= 1990)

and# ((general practice or medical or physician* or medicine or clinician*) or (patient or patients or inpatient or inpatients or outpatient or outpatients or hospital or hospital* or healthcare or health institution* or primary care or primary practice* or family practice*)) or ((community health) or (clinical) or (nurses) or (mental health) or (care) or (caregivers)) and (LA:PSYI = ENGLISH) and (PY:PSYI >= 1990)

Note: No selection on study type (as done in Pubmed)

15–02–2008

Number of hits: 750

EMBASE University library

#1(((evaluation studies) or (evaluation study)) or (evaluations) or ((evaluate) or (evaluates) or (evaluation)) or (pretest) or (“pre test”) or (“time series”) or (intervention study) or (intervention studies) or (controlled clinical trial) or (randomised clinical trial) or (randomized clinical trial) or ((change) or (changes) or (changing)) or ((experiment) or (experiments) or (experimental)) or (interventions) or (intervention) or (impact) or (random allocation) or (posttest) or (“post test”) or (comparative study) or ((effect) or (effects)))

#2((((collaboration ) in TI) and (((“inter disciplinary”) in TI) or ((multidisciplinary) in TI) or ((“multi disciplinary”) in TI) or ((interprofessional ) in TI) or ((multiprofessional ) in TI) or ((“inter professional”) in TI) or ((interdisciplinary) in TI) or ((“multi professional”) in TI))) or (((teamworking) in TI) or ((teamwork) in TI) or ((teams ) in TI) or ((team ) in TI)))

# (((general practice or medical or physician* or medicine or clinician*) or (patient or patients or inpatient or inpatients or outpatient or outpatients or hospital or hospital* or healthcare or health institution* or primary care or primary practice* or family practice*)) and (LA:EMBV = ENGLISH) and (PY:EMBV >= 1990)) and (#2 and (LA:EMBV = ENGLISH) and (PY:EMBV >= 1990)) and (#1 and (LA:EMBV = ENGLISH) and (PY:EMBV >= 1990))

Note: Limited selection on healthcare

08–02–2008




47




Web of Science

University library

# Topic=(Caregiver* or care or nurse* or “mental health” or “community health” or clinical or ((general practice or medical or physician* or medicine or clinician*) or (patient or patients or inpatient or inpatients or outpatient or outpatients or hospital or hospital* or healthcare or health institution* or primary care or primary practice* or family practice*)))

Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=1990-2008

and# Title=((((collaboration)) and (((“inter disciplinary”)) or ((multidisciplinary)) or ((“multi disciplinary”)) or ((interprofessional)) or ((multiprofessional)) or ((“inter professional”)) or ((interdisciplinary)) or ((“multi professional”)))) or (((teamworking)) or ((teamwork)) or ((teams))) or ((team))))


and# Title=((((evaluation studies) or (evaluation study)) or (evaluations) or ((evaluate) or (evaluates) or (evaluation)) or (pretest) or (“pre test”) or (“time series”) or (intervention study) or (intervention studies) or (controlled clinical trial) or (randomised clinical trial) or (randomized clinical trial) or ((change) or (changes) or (changing)) or ((experiment) or (experiments) or (experimental)) or (interventions) or (intervention) or (impact) or (random allocation) or (posttest) or (“post test”) or (comparative study) or ((effect) or (effects))))


Note: Limited selection on healthcare

15–02–2008

Number of hits: 349



48




Cumulative Index to Nursing & Allied Health Literature (CINAHL)

University library

# (((((collaboration ) in TI) and (((“inter disciplinary”) in TI) or ((multidisciplinary) in TI) or ((“multi disciplinary”) in TI) or ((interprofessional ) in TI) or ((multiprofessional) in TI) or ((“inter professional”) in TI) or ((interdisciplinary) in TI) or ((“multi professional”) in TI))) or (((teamworking) in TI) or ((teamwork) in TI) or ((teams ) in TI) or ((team) in TI))) and (LA:NU = ENGLISH) and (PY:NU >= 1990)) and ((((evaluation studies) or (evaluation study)) or (evaluations) or ((evaluate) or (evaluates) or (evaluation)) or (pretest) or (“pre test”) or (“time series”) or (intervention study) or (intervention studies) or (controlled clinical trial) or (randomised clinical trial) or (randomized clinical trial) or ((change) or (changes) or (changing)) or ((experiment) or (experiments) or (experimental)) or (interventions) or (intervention) or (impact) or (random allocation) or (posttest) or (“post test”) or (comparative study) or ((effect) or (effects))) and (LA:NU = ENGLISH) and (PY:NU >= 1990)) and (LA:NU = ENGLISH) and (PY:NU >= 1990)

and # ((((collaboration) in TI) and (((“inter disciplinary”) in TI) or ((multidisciplinary) in TI) or ((“multi disciplinary”) in TI) or ((interprofessional ) in TI) or ((multiprofessional ) in TI) or ((“inter professional”) in TI) or ((interdisciplinary) in TI) or ((“multi professional”) in TI))) or (((teamworking) in TI) or ((teamwork) in TI) or ((teams ) in TI) or ((team ) in TI))) and (LA:NU = ENGLISH) and (PY:NU >= 1990)

and # (((evaluation studies) or (evaluation study)) or (evaluations) or ((evaluate) or (evaluates) or (evaluation)) or (pretest) or (“pre test”) or (“time series”) or (intervention study) or (intervention studies) or (controlled clinical trial) or (randomised clinical trial) or (randomized clinical trial) or ((change) or( changes) or (changing)) or ((experiment) or (experiments) or (experimental)) or (interventions) or (intervention) or (impact) or (random allocation) or (posttest) or (“post test”) or (comparative study) or ((effect) or (effects))) and (LA:NU = ENGLISH) and (PY:NU >= 1990)

Note: no selection on healthcare

08–02–2008


Database of Abstracts of Reviews of Effects (DARE) + HTA + NHS EED

www.crd.york.ac.uk/crdweb

# (team:ti OR teams:ti OR teamwork:ti OR teamworking:ti)

or # multidisciplinary:ti AND collaboration:ti

or # interdisciplinary:ti AND collaboration:ti

or # multiprofessional:ti AND collaboration:ti

or # interprofessional:ti AND collaboration:ti

15–02–2008

Number of hits: 68



49




Cochrane Database of Systematic Reviews

University library

# “team in Record Title or teams in Record Title or teamwork in Record Title or teamworking in Record Title

or # “multidisciplinary in Record Title and collaboration in Record Title

or # “interdisciplinary in Record Title and collaboration in Record Title

or

# “multiprofessional in Record Title and collaboration in Record Title

or

# “interprofessional in Record Title and collaboration in Record Title

15–02–2008

Number of hits: 6

World Health Organisation Library Database (WHOLIS)

www.who.int

# title “team” OR title “teams” OR title “teamwork” OR title “teamworking”

or #title “multidisciplinary” and “collaboration”

or #title “interdisciplinary” and “collaboration”

or #title “multiprofessional” and “collaboration”

or #title “interprofessional” and “collaboration”

15–02–2008

Number of hits: 67

Organisation for Economic Cooperation and Development (OECD)

www.oecd.org

# (multidisciplinary and (team or teams or teamwork or teamworking) and “healthcare”) and year>=1990 and year<=2008

or # (interdisciplinary and (team or teams or teamwork or teamworking) and “healthcare”) and year>=1990 and year<=2008

or # (interprofessional and (team or teams or teamwork or teamworking) and “healthcare”) and year>=1990 and year<=2008

Note: the number of hits were not useful, because it was not possible to search within title words)

29–02–2008

Number of hits: 23

Sociological Abstracts

University library

# ((TI=(team or teams or teamwork or teamworking)) or (TI=((interprofessional or interdisciplinary or multidisciplinary or multiprofessional) and collaboration))) and (((general practice or medical or physician* or medicine or clinician*) or (patient or patients or inpatient or inpatients or outpatient or outpatients or hospital or hospital* or healthcare or health institution* or primary care or primary practice* or family practice*)) or ((community health) or (clinical) or (nurses) or (mental health) or (care) or (caregivers))) and (((evaluation studies) or (evaluation study)) or (evaluations) or ((evaluate) or (evaluates) or (evaluation)) or (pretest) or (“pre test”) or (“time series”) or (intervention study) or (intervention studies) or (controlled clinical trial) or (randomised clinical trial) or (randomized clinical trial) or ((change) or (changes) or (changing)) or ((experiment) or (experiments) or (experimental)) or (interventions) or (intervention) or (impact) or (random allocation) or (posttest) or (“post test”) or (comparative study) or ((effect) or (effects)))

22–02–2008

Number of hits: 32



50

Appendix C: Data collection forms

Appendix C: Data collection forms

Review

• First author and year

• Type of the review

• Aim of the review

• Search period

• Data sources

• Number of studies

• Included study design

• Procedure study selection and data extraction

• Language (inclusion criteria, and actually included)

• Countries (inclusion criteria, and actually included)

• Brief description of the intervention

• Brief description of the control condition

• Setting

• Clinical domain

• Main outcomes

• Findings per outcome category:

◦ Clinical outcomes

◦ Behavioural patient outcomes

◦ Process of care outcomes

◦ Provider outcomes

◦ Resource utilisation

◦ Cost-effectiveness and cost outcomes

• Conclusions

• Study limitations

• Our comments

Other study design

• First author and year

• Study design

• Aim of the study

• Study period

• Number of participants (randomised, before and after in all groups)

• Country

• Setting

• Clinical domain

• Brief description of the intervention:

◦ Professions and disciplines involved

◦ Presence of team coordinator

◦ Team tenure

◦ Explicit task description team members

• Brief description of the control condition:

◦ Professions and disciplines involved

◦ Presence of coordinator

◦ Usual care provider tenure details

◦ Explicit task description usual care providers

• Findings per outcome category:

◦ Clinical outcomes

◦ Behavioural patient outcomes

◦ Process of care outcomes

◦ Provider outcomes

◦ Resource utilisation

◦ Cost-effectiveness and cost outcomes

• Conclusions

• Our comments

• Study limitations



51

Appendix D: Excluded studies and reason for exclusion


If a study did not meet one of the criteria, it was not further examined whether the other criteria were met

Author, year Design Intervention OtherNaji, 1994 xHSE report, 2002 xBellomo, 2004 xAberg-Wistedt, 1995 xAgius, 2007 x xAneman, 2006 xAnderson, 1999 xBellomo, 2004 xBithoney, 1991 xBaggs, 2004 xBakewell-Sachs, 1991 xBoland, 1996 xBakheit, 1996 xBond, 1991 xBristow, 2000 xDewachter, 2007 xBell, 2005 xBall, 2003 xChaboyer, 2004 xChaboyer, 2004 xChung, 2007 xCohen, 1991 xCorser, 2004 xCostantini, 2003 xBostrom, 2003 x xCowan, 2006 xDacey, 2007 xBritton, 2006 xBuist, 2002 xKing, 2006 xEappen, 2007 xEvans, 2002 xFelton, 1995 xFisher, 1996 xFrancke, 1999 xGales, 1994 xHaig, 1991 xHanks, 2002 x



52


Author, year Design Intervention OtherHassell, 1994 xHearn, 1998 xHigginson, 2001 xHigginson, 2003 xPalmer, 2000 xHillman, 2005 xHughes, 2000 xJack, 2004 xJack, 2006 xJohnson, 2005 xJones, 2005 xJones, 2007 xKarjalainen, 2001 xKarjalainen, 2001 xKhetarpal, 1999 xHultberg, 2006 xKucukarslan, 2003 xLaffel, 2002 xLe, 1998 xJansson, 1992 xLevetan, 1995 xMartin, 1994 xMcCrone, 1994 xMcDonnell, 2002 xMickan, 2005 xMuijen, 1994 xKennedy, 2002 xNaylor, 2004 xKennedy, 2005 xRowley, 1995 xBritton, 2000 xFaulkner, 1999 xSoifer, 1998 xStephens, 2006 xLitaker, 2003 xStroebel, 2000 xSuarez, 2004 xVliet Vlieland, 1997 xWebster, 1999 xNikolaus, 2003 xOvretveit, 1993 xWaldenstrom, 2000 xRichardson, 2000 x



53


Author, year Design Intervention OtherRobinson, 2005 xUpchurch, 2007 xVliet Vlieland, 2004 xTeague, 1995 xVliet Vlieland, 2004 xVos, 2003 xHanson, 1999 xWilliams, 2002 xZiran, 2003 x



54

Appendx E: Methodological quality studies


RCTs

First author, year A B C D E F G

Huddleston et al, 2004 + ? + ? ? ? -

Banerjee et al, 1996 + + + + + + -

Bogden et al, 1997 - + + + + ? -

Dey et al, 2005 + ? + + ? + -

Forster et al, 2005 + ? - + ? + -

Gattis et al, 1999 + ? + + ? ? -

Germain et al, 1995 + ? + ? ? ? -

Gums et al, 1999 ? ? + + ? + -

Hogan and Fox, 1990 - + + - + + -

Koproski, Pretto and Poretsky, 1997 ? ? ? ? + ? -

Lincoln et al, 2004 + ? - - - ? -

Moher et al, 1992 + ? + ? ? ? ?

Phelan et al, 2007 + + + + + + +

Rabow et al, 2004 - ? - + + + ?

Rubin et al, 2005 ? ? + ? ? ? ?

Schmidt et al, 1998 ? + + ? + ? +

Schned et al, 1995 ? ? - - + ? -

Scott et al, 2005 + ? + + ? ? -

Tijhuis et al, 2003 + ? + + + + -

Yagura et al, 2005 - ? + + + ? -

Vliet Vlieland, Breedveld and Hazes, 1997 + ? + + + + -

A = concealment of allocation; B = follow-up of professionals; C = follow-up of patients or episodes of care; D = blinded assessment of primary outcomes; E = baseline measurement; F = reliable primary outcome measures; G = protection against contamination



55


CBAs

First author, year A B C D E F G

Mudge et al, 2006 - + + - + ? -

Mudge et al, 2006 - + + + + ? +

A = baseline measurement; B = characteristics for studies using second site as control; C = blinded assessment of primary outcomes; D = protection against contamination; E = reliable primary outcome measures; F = follow-up of professionals; G = follow-up of patients or episodes of care

Reviews

First author, year A B C D E F

Malone et al, 2007 + + + + + +

Mitchell, Del and Francis, 2002 + + + + + -

A = search period specified; B = databases specified; C = data extraction by at least two reviewers; D = search terms specified; E = quality assessment provided; F = methodological quality reported



56

Appendix F: Results per study



57


App

endi

x F:

Res

ults

per

stu

dy

Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

Bo

gden

et a

l, 19

97RC

Tn

= 10

0Ha

waii /

USA

Out

patie

ntPa

tient

with

el

evat

ed

chol

este

rol

Phys

icia

n–ph

arm

acist

team

work

vs Us

ual c

are

Prim

ary:

1. A

bsol

ute

chan

ge in

to

tal c

hole

ster

ol c

once

ntra

tion

from

ba

selin

e en

rolm

ent

Oth

er: 2

. Ach

ieve

men

t of N

CEP

(Nat

iona

l Cho

lest

erol

Edu

catio

n pr

ogra

m) g

oals

depe

nden

t on

risk

fact

ors

and

coro

nary

hea

rt di

seas

e

1. S

igni

fican

tly la

rger

redu

ctio

n in

tota

l cho

lest

erol

in in

terv

entio

n gr

oup

com

pare

d to

con

trol.

Tota

l cho

lest

erol

leve

ls in

the

inte

rven

tion

arm

dec

lined

44

± 47

mg/

dL

(1.1

± 1

.2m

mol

/L) v

ersu

s 13

± 5

1mg/

dL (0

.3 ±

1.3

mm

ol/L

). Re

duct

ion

in m

en n

ot

signi

fican

tly d

iffer

ent b

etwe

en tw

o gr

oups

(1.5

± 1

.3m

mol

/L in

inte

rven

tion

vs

0.7

± 0.

7mm

ol/L

in c

ontro

l). S

igni

fican

t diff

eren

ce in

wom

en: 1

.0 ±

1.2

mm

ol/L

vs

0.2

± 1.

4mm

ol/L

). No

sta

tistic

al d

iffer

ence

bet

ween

men

and

wom

en in

redu

ctio

n (p

= .1

8)2.

Suc

cess

rate

in in

terv

entio

n gr

oup

43%

vs

21%

in c

ontro

l gro

up, s

tatis

tical

ly sig

nific

ant (

inte

rven

tion

grou

p: w

hen

phys

icia

n de

clin

ed re

com

men

datio

n of

ph

arm

acol

ogist

then

suc

cess

rate

sig

nific

antly

lowe

r, ie

17

vs 5

1%),

also

whe

n st

ratif

ied

for s

ex. E

ffect

of i

nter

vent

ion

signi

fican

tly la

rger

in p

atie

nts

with

CH

D or

≥

2 ris

k fa

ctor

s (1

3/34

or 3

8% v

s 5/

36 o

r 14%

). In

pat

ient

s wi

th fe

wer t

han

2 ris

k fa

ctor

s no

sig

nific

ant e

ffect

(7–1

3 or

54%

vs

5–11

or 4

5%)

3. O

ther

effe

cts:

med

icat

ion

char

ge w

as n

ot s

igni

fican

tly d

iffer

ent b

etwe

en tw

o gr

oups

, nor

wer

e fre

quen

cies

of e

mer

genc

y de

partm

ent v

isits

, ref

erra

ls to

di

etiti

ans

and

orde

red

pane

ls. S

igni

fican

tly m

ore

clin

ical

visi

ts in

inte

rven

tion

grou

p (1

2 vs

9)

Addi

tiona

l: pha

rmac

ist m

ade

186

reco

mm

enda

tions

; 90%

of t

hem

wer

e ad

opte

d by

ph

ysic

ians

(all w

ith re

gard

to p

atie

nt e

duca

tion;

94%

with

rega

rd to

alte

r dos

age,

and

93

% w

ith re

gard

to p

atie

nt m

onito

ring.

19%

of d

rugs

sel

ectio

n re

com

men

datio

ns

were

reje

cted

by

phys

icia

n

Bogd

en e

t al,

1998

RCT

n =

100

Hawa

ii/US

AO

utpa

tient

Patie

nts

with

un

cont

rolle

d hy

perte

nsio

n

Phys

icia

n–ph

arm

acist

team

work

vs Us

ual c

are

Prim

ary:

1. %

pat

ient

s wh

o at

tain

ed b

lood

pre

ssur

e go

als

(sys

tolic

pre

ssur

e be

low

140;

di

asto

lic b

elow

90m

m H

g)Se

cond

ary:

2. A

bsol

ute

chan

ge in

bl

ood

pres

sure

leve

ls (s

ysto

lic a

nd

dias

tolic

)

1.

Sign

ifica

ntly

mor

e pa

tient

s in

inte

rven

tion

grou

p re

ache

d go

als

(55%

vs

20%

)2.

De

clin

e in

dia

stol

ic pr

essu

re in

inte

rven

tion

grou

p is

14 ±

11m

m H

g vs

3 ±

11m

m

Hg in

con

trol g

roup

. Dec

line

in s

ysto

lic p

ress

ure

in in

terv

entio

n gr

oup

is 23

±

22m

m H

g vs

11 ±

23m

m H

g in

con

trol g

roup

Addi

tiona

l: pha

rmac

ist m

ade

162

reco

mm

enda

tions

; 7.4

% w

ere

decl

ined

by

phys

icia

ns

Cost

s: $

6.8

redu

ctio

n in

mea

n m

edic

atio

n ch

arge

s in

inte

rven

tion

grou

p, a

nd $

6.5

incr

ease

in c

ontro

l gro

up (n

o sig

leve

l rep

orte

d)



56




57


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

De

y et

al,

2005

RCT

n =

308

UK

Inpa

tient

sSt

roke

(acu

te

phas

e)

Org

anise

d st

roke

ca

re/m

obile

stro

ke

team

vs Usua

l car

e

Prim

ary:

1. M

orta

lity

Seco

ndar

y: 2

. Dea

th o

r de

pend

ency

; 3. D

eath

or

inst

itutio

nalis

ed c

are

Not f

orm

ally

deno

ted:

Bar

thel

in

dex

for f

unct

iona

l out

com

e an

d Ca

nadi

an n

euro

logi

cal s

cale

(CNS

) fo

r stro

ke s

ever

ity, E

uroQ

ol

1.

No d

iffer

ence

bet

ween

gro

ups

at 6

wee

ks/1

2 m

onth

s2.

an

d 3.

No

diffe

renc

e be

twee

n gr

oups

at 6

wee

ks n

or a

t 12

mon

ths

No s

igni

fican

t diff

eren

ce in

num

ber o

f pat

ient

s re

ceivi

ng C

T sc

ans,

ant

i-pla

tele

t th

erap

y or

in n

umbe

r tra

nsfe

rred

to s

troke

reha

b un

itPa

tient

s in

inte

rven

tion

grou

p tra

nsfe

rred

to s

troke

reha

b un

it sig

nific

antly

ear

lier

than

con

trol g

roup

(14.

7 vs

24.

4 da

ys, C

I diff

eren

ce –

17.0

to –

2.57

), bu

t tim

e to

up

take

of o

ther

inte

rven

tion

was

simila

rNo

diff

eren

ces

in fu

nctio

nal o

utco

me

or q

ualit

y of

life

mea

sure

s (B

arth

el in

dex/

and

CNS,

and

Eur

oQol

)

Gat

tis e

t al,

1999

RCT

n =

181

USA

Out

patie

nts

Hear

t fai

lure

pa

tient

s

Addi

tion

of c

linic

al

phar

mac

ist to

hea

rt fa

ilure

man

agem

ent

team

vs Us

ual c

are

Prim

ary

end

poin

ts: 1

. Eve

nts

(dea

th/m

orta

lity

and

hear

t fai

lure

ev

ent/h

ospi

talis

atio

n/em

erge

ncy

depa

rtmen

t visi

t for

hea

lth fa

ilure

)2.

Cl

inic

al d

ata

1.

All-c

ause

mor

talit

y an

d no

n-fa

tal h

eart

failu

re in

inte

rven

tion

4 an

d in

con

trol

grou

p 16

: OR

= 0.

22 (0

.06–

0.63

) (sig

)

Deat

h/al

l-cau

se m

orta

lity

not s

igni

fican

tly d

iffer

ent b

etwe

en th

e tw

o gr

oups

: th

ree

in in

terv

entio

n an

d fiv

e in

con

trol g

roup

; OR

= 0.

59 (0

.12 to

2.4

9).

No

n-fa

tal h

eart

failu

re s

igni

fican

tly h

ighe

r in

cont

rol g

roup

(11

vs 1

; OR

= 0.

08

(0.0

04 to

0.4

). To

tal n

on-fa

tal c

ardi

ovas

cula

r eve

nts

were

sig

nific

antly

hig

her i

n co

ntro

l gro

up (2

3 vs

8; O

R =

0.31

; 0.3

1 to

0.6

9).

To

tal e

vent

s hi

gher

in c

ontro

l gro

up v

s in

terv

entio

n gr

oup

(36

vs 2

9; O

R =

0.73

, 0.

39 to

1.3

3)

2.

Patie

nts

in in

terv

entio

n gr

oup

were

sig

nific

antly

clo

ser t

o ta

rget

ACE

inhi

bito

r do

se a

t 6 m

onth

s fo

llow-

up (1

.0; 0

.5 to

1 v

s 0.

5; 0

.19 to

1) ,

but

no

diffe

renc

e in

AC

E in

hibi

tor u

se b

etwe

en g

roup

s (7

8 pa

tient

s (8

7%) i

n in

terv

entio

n vs

72

(79%

) in

con

trol a

t fol

low-

up).

Sign

ifica

ntly

mor

e pa

tient

s in

inte

rven

tion

grou

p re

ceive

d al

tern

ative

ther

apy

(9 (7

5%) v

s 5

(26%

))



58




59


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

G

ums

et a

l, 19

99RC

Tn

= 25

2US

AIn

patie

ntIn

fect

ious

di

seas

es

Usua

l car

evs M

ultid

iscip

linar

y te

am (p

rovi

ding

re

com

men

datio

ns

conc

erni

ng a

ntib

iotic

th

erap

y an

d m

onito

ring

when

ne

cess

ary)

Prim

ary:

1. L

engt

h of

sta

y (L

oS)

Seco

ndar

y: 2

. Cha

rges

to p

atie

nts

for a

ntib

iotic

s, la

bora

tory

and

ra

diol

ogy

serv

ices

; 3. R

oom

and

bo

ard;

4. I

CU c

harg

es; 5

. Non

-ICU

char

ges;

6. T

otal

pat

ient

cha

rges

; 7.

Estim

ated

hos

pita

l cos

t;

8. S

urviv

al; 9

. (Co

st o

f im

plem

entin

g in

terd

iscip

linar

y ap

proa

ch);

10. P

hysic

ian

acce

ptan

ce

1.

Leng

th o

f sta

y: m

edia

n Lo

S 3.

3 da

ys (3

7.1%

) sig

nific

antly

sho

rter i

n in

terv

entio

n gr

oup

(9.0

± 0

.5 d

ays

in c

ontro

l vs

5.7

± 0.

8 da

ys)

4.

Med

ian

ICU

days

sta

tistic

ally

equa

l (9.

4 ±

1.1 v

s 7.

3 ±

0.8

days

)5.

Si

gnifi

cant

ly 36

.7%

(3.3

day

s) s

horte

r in

inte

rven

tion

grou

p (9

.0 ±

0.8

vs

5.7

± 0.

5 da

ys)

6.

Tota

l cos

ts s

igni

fican

tly lo

wer i

n in

terv

entio

n gr

oup

12,2

07 ±

1,0

42 v

s 9,

153

± 76

1 do

llars

)7.

Ho

spita

l cos

ts s

igni

fican

tly lo

wer i

n in

terv

entio

n gr

oup.

Med

ian

patie

nt c

harg

es

redu

ced

by 4

,404

/inte

rven

tion;

med

ian

hosp

ital c

ost:

redu

ced

by $

2.64

2/in

terv

entio

n 8.

No

t sta

tistic

ally

signi

fican

t bet

ween

bot

h gr

oups

(int

erve

ntio

n: 6

.3%

of 1

27 v

s co

ntro

l: 12.

0% o

f 125

of t

he p

atie

nts

died

). RR

= 1

.35

(ns)

(bef

ore

excl

usio

ns/

corre

ctio

ns R

R =

1.16)

9.

Impl

emen

tatio

n co

sts:

$21

,000

/yea

r 10

. Sug

gest

ed in

terv

entio

ns re

ject

ed b

y 11

%

Jack

et a

l, 20

03CB

An

= 10

0U

KIn

patie

ntPa

lliativ

e ca

re

Pallia

tive

care

team

vs Us

ual c

are

cont

rol

grou

p

PACA

tool

: 1. P

ain;

2. A

nore

xia;

3. N

ause

a; 4

. Ins

omni

a;

5. C

onst

ipat

ion

Sign

ifica

nt im

prov

emen

t ove

r tim

e in

PC

team

(% im

prov

emen

t): 1

. 56.

9% (m

ean

2.32

–1.4

2–1.

00);

2. 4

4.7%

(mea

n 2.

46–1

.72–

1.36

); 3.

51.

8% (m

ean

2.24

–1.4

2–1.

08);

4. 4

8.9%

(mea

n 1.

80–1

.18–0

.92)

; 5. 4

2.5%

(mea

n 0.

8–0.

74–0

.46)

Si

gnifi

cant

impr

ovem

ent o

ver t

ime

in u

sual

car

e gr

oup

(% im

prov

emen

t): 1

. 16.

3%

(mea

n 2.

08–1

.78–

1.74

); 2.

10.

7% (m

ean

2.24

–2.0

8–2.

00),

3. 1

4.8%

(mea

n 1.

76–

1.56

–1.5

0); 4

. 9.8

% (m

ean1

.22–

1.18–

1.10)

, 26.

4% (m

ean

1.36

–1.2

4–1.

00)

3. 4

. 5. S

igni

fican

t diff

eren

ce b

etwe

en in

terv

entio

ns a

t tim

e 1

(bas

elin

e)1.

2. S

igni

fican

t diff

eren

ce b

etwe

en in

terv

entio

ns a

t tim

e 2

1. 2

. 3. 5

. Sig

nific

ant d

iffer

ence

bet

ween

inte

rven

tions

at t

ime

3

Kopr

oski

, Pr

etto

and

Po

rets

ky, 1

997

RCT

n =

179

USA

Inpa

tient

sDi

abet

es

Diab

etes

team

in

terv

entio

nvs Co

ntro

l gro

up w

ith

usua

l car

e

1. L

engt

h of

sta

y (L

oS);

2. B

lood

gl

ucos

e co

ntro

l; 3. R

eadm

issio

n ra

te; 4

. Ent

ries

for i

nsul

in

adm

inist

ratio

n, g

luco

se m

onito

ring,

an

d nu

tritio

n an

d so

cial

ser

vice

cons

ulta

tions

1.

No s

igni

fican

t diff

eren

ce b

etwe

en th

e tw

o gr

oups

(prim

ary

diag

nosis

7.8

± 6.

7 in

in

terv

entio

n ve

rsus

10.

3 ±

8.5

in c

ontro

l gro

up; a

nd s

econ

dary

dia

gnos

is: 1

2.9

± 10

.0 v

ersu

s 14

.1 ±

11.7

)2.

No

sig

nific

ant d

iffer

ence

bet

ween

the

two

grou

ps (1

54.6

± 6

4.0

in in

terv

entio

n vs

15

3.9

± 59

.7 in

con

trol g

roup

) 3.

Si

gnifi

cant

ly fe

wer p

atie

nts

in in

terv

entio

n gr

oup

read

mitt

ed a

t 3 m

onth

s (1

3 vs

30

, or 1

5% v

s 32

%) a

nd e

ffect

rem

aine

d at

6 m

onth

s [d

ata

not s

hown

]4.

Si

gnifi

cant

ly m

ore

patie

nts

in in

terv

entio

n gr

oup

had

thei

r blo

od m

onito

red

for g

luco

se le

vel (

89%

vs

57%

); id

em fo

r ins

ulin

adm

inist

ratio

n (6

9% v

s 25

%)

Sign

ifica

ntly

mor

e pa

tient

s in

inte

rven

tion

grou

p ha

d ha

d ed

ucat

ion

of a

ny k

ind

(87%

vs

37%

); 76

% v

s 40

% re

ceive

d nu

tritio

nal c

onsu

ltatio

n (s

igni

fican

t)



58




59


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

Ru

bin

et a

l, 20

05RC

Tn

= 13

9US

AIn

patie

nts

Psyc

hiat

ric

patie

nts

Addi

tion

of in

tern

ist to

in

patie

nt p

sych

iatry

te

am

vs Usua

l car

e gr

oup

1. P

roce

sses

of c

are:

func

tions

of a

ge

nera

l inte

rnist

(coo

rdin

atin

g ca

re,

deve

lopi

ng n

eeds

ass

essm

ent/

docu

men

ting

prob

lem

s, u

pdat

ing

heal

th s

ervic

es)

Need

s as

sess

men

t inc

lude

d:

upda

ting

list o

f pro

blem

s, u

pdat

ing

med

icat

ion

list,

look

ing

for p

oten

tial

adve

rse

drug

reac

tions

. Ap

prop

riate

hea

lth m

aint

enan

ce

serv

ices

wer

e ju

dged

on

US

Prev

entiv

e Se

rvic

es T

ask

Forc

e Co

ordi

natio

n of

car

e: c

allin

g pr

imar

y ca

re p

rovi

ders

at a

dmis

sion

and

disc

harg

e2.

Rec

ours

e us

e: L

oS, t

otal

ho

spita

l cos

ts; h

ospi

tal in

patie

nt

days

; em

erge

ncy

visits

(lat

ter 2

for

subg

roup

)

1.

Inte

rven

tion

grou

p ha

d be

tter s

core

s on

pro

cess

of c

are;

12

of 1

7 we

re

signi

fican

t. O

nly

sum

mar

y sc

ores

are

pre

sent

ed h

ere:

nee

ds a

sses

smen

t be

tter i

n in

terv

entio

n gr

oup

(89

± 14

vs

59 ±

20)

; hea

lth m

aint

enan

ce b

ette

r in

inte

rven

tion

grou

p (5

6 ±

34 v

s 3

± 7)

and

coo

rdin

atio

n of

car

e al

so b

ette

r in

inte

rven

tion

grou

p (8

1 ±

40 v

s 40

± 5

5)2.

Lo

S no

t sig

nific

antly

diff

eren

t in

inte

rven

tion

vs c

ontro

l gro

up (1

1.5

± 9

vs 1

0.9

± 7.

3). H

ospi

tal c

osts

not

sig

nific

antly

diff

eren

t bet

ween

two

grou

ps (8

,527

± 6

,512

vs

8,5

58 ±

5,7

03 d

olla

rs).

No d

iffer

ence

s in

hos

pita

l ser

vices

afte

r disc

harg

e (4

.2

± 1

1.3

inpa

tient

day

s vs

4.4

± 1

9.6

or e

mer

genc

y de

partm

ent v

isits

(1.1

± 3

.2 v

s 0.

7 ±

2.2)

Scot

t et a

l, 20

05RC

Tn

= 11

2U

KIn

- out

patie

nt/

com

mun

ityIn

tern

al m

edic

ine

(nut

ritio

n)

Nutri

tion

team

afte

r ga

stro

nom

yvs Us

ual c

are

Prim

ary:

1. T

otal

cos

ts o

f hea

lth

serv

ice

(uni

t cos

t dat

a an

d pa

tient

us

e of

ser

vices

Seco

ndar

y: 2

. Clin

ical

co

mpl

icat

ions

; 3. L

oS;

4. R

eadm

issio

ns; 5

. Nut

ritio

nal

stat

us; 6

. QO

L

1.

Sim

ilar n

umbe

r of r

efer

rals

in b

oth

grou

ps (9

6% v

s 98

%) a

nd s

ame

num

ber o

f co

ntac

ts (5

2% v

s 55

%).

No s

tatis

tical

diff

eren

ce in

tota

l cos

ts (1

6,85

8 ±

16,3

51

in c

ontro

l and

13,

330

± 15

,505

dol

lars

in in

terv

entio

n gr

oups

; 21%

diff

eren

ce).

(Tab

le 5

pro

vide

s de

taile

d su

bdivi

sions

of c

osts

)2.

M

orta

lity

was

simila

r bet

ween

the

two

grou

ps (n

o ad

ditio

nal d

ata

prov

ided

). Cl

inic

al o

utco

mes

wer

e al

l sta

tistic

ally

equa

l bet

ween

the

two

grou

ps (t

ime

to

rem

oval

of P

EG (6

0 (6

–366

) vs

113

(11–

366)

day

s); c

ompl

icat

ions

spe

cifie

d in

ta

ble

2; d

urat

ions

of a

ntib

iotic

use

(8 (0

–43)

vs

11 (0

–158

))3.

Lo

S st

atist

ics

simila

r bet

ween

the

two

grou

ps (d

iffer

ent a

spec

ts o

f len

gth

of s

tay

men

tione

d in

tabl

e 3)

4.

No s

igni

fican

t diff

eren

ce in

read

mis

sions

(18

in in

terv

entio

n, 2

9 in

con

trol)

5.

?6.

Be

tter r

esul

ts o

n so

cial

func

tioni

ng e

lem

ent o

f QoL

at S

F36

(det

ails

not

pres

ente

d) fo

r int

erve

ntio

n gr

oup.

Oth

er e

lem

ents

of S

F36

were

sim

ilar,

as w

ere

care

r/pat

ient

sat

isfac

tion



60




61


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

Fo

rste

r et a

l, 20

05RC

Tn

= 62

0Ca

nada

Inpa

tient

sAl

l kin

ds o

f pa

tient

s in

ho

spita

l

Care

with

clin

ical

nu

rse

spec

ialis

t (C

NS) (

team

)vs Re

gula

r car

e

Prim

ary:

1. I

n-ho

spita

l dea

ths;

2.

Occ

urre

nce

of a

pos

t-disc

harg

e ev

ent (

abou

t 30

days

afte

r di

scha

rge)

incl

udin

g sy

mpt

oms

Seco

ndar

y: 3

. Tim

e to

ER

visit;

4.

Hos

pita

l rea

dmis

sion;

5. D

eath

; 6.

Tim

e to

read

mis

sion;

7. T

ime

to

deat

h; 8

. Inp

atie

nt s

atisf

actio

n

1.–7

. No

signi

fican

t diff

eren

ce b

etwe

en c

ontro

l and

inte

rven

tion

grou

ps8.

Pa

tient

s in

CNS

gro

up p

erce

ived

qual

ity a

nd p

roce

ss o

f car

e to

be

supe

rior:

doct

ors

had

suffi

cien

t inf

orm

atio

n (7

0.4%

[95]

vs

58.1%

[90]

in c

ontro

l gro

up),

and

patie

nts

reca

lled

bein

g co

ntac

ted

by h

ospi

tal p

erso

nnel

(49.

6% [6

7] v

s 18

.1% [2

8]).

Ove

rall q

ualit

y of

car

e wa

s be

tter (

8.2

± 2.

2 in

CNS

vs

7.6

± 2.

4 in

co

ntro

l gro

up),

alth

ough

this

did

not r

each

sig

nific

ance

(p =

0.0

52)

Hudd

lest

on e

t al

, 200

4RC

Tn

= 52

6US

AIn

patie

nts

Patie

nts

need

ing

hip/

knee

ar

thro

plas

ty

Hosp

italis

t–or

thop

aedi

c te

am

(HO

T)

vs Stan

dard

orth

opae

dic

man

aged

car

e

Prim

ary:

1. P

ost-o

pera

tive

com

plic

atio

n ra

te; 2

. LoS

Seco

ndar

y: 3

. Pat

ient

sat

isfac

tion;

4.

Pro

vide

r pre

fere

nce;

5. H

ospi

tal

and

phys

icia

n co

sts

Prim

ary:

1. M

ost f

requ

ent p

osto

pera

tive

com

plic

atio

n ra

te w

ere

elec

troly

te

abno

rmal

ities

(30%

), po

stop

erat

ive fe

ver (

13%

), ur

inar

y tra

ct in

fect

ion

(4%

). M

ost

patie

nts

in H

OT

disc

harg

ed w

ithou

t com

plic

atio

ns (6

1.6%

vs

49.8

; CI d

iffer

ence

2.

8 to

20.

7). H

OT

patie

nts

had

fewe

r min

or c

ompl

icat

ions

(30.

2 vs

44.

3%; C

I di

ffere

nce

–22.

7 to

–5.

3); f

requ

ency

of i

nter

med

iate

and

maj

or c

ompl

icat

ions

st

atist

ical

ly eq

ual (

6.9%

to 4

.6%

; CI d

iffer

ence

–2.

1% to

6.6

% a

nd 1

.3%

to 1

.3%

, CI

diff

eren

ce –

2.3

to 2

.4)

2.

Patie

nts i

n HO

T ha

d sh

orte

r adj

uste

d Lo

S (5

.1 vs

5.6

day

s; C

I diff

eren

ce –

.8 to

–.1)

3.

Patie

nt s

atisf

actio

n di

d no

t diff

er (n

o ab

solu

te v

alue

s pr

ovid

ed, o

nly

grap

h)4.

Nu

rses

and

orth

opae

dics

pre

ferre

d HO

T (n

o ab

solu

te v

alue

s pr

ovid

ed, o

nly

grap

h)5.

Ph

ysic

ian

cost

s: s

igni

fican

tly h

ighe

r in

HOT

($2,

689

vs $

2,36

7, CI

diff

eren

ce

$175

to $

484)

; but

hos

pita

l cos

ts a

nd to

tal m

edic

al c

osts

wer

e no

t sig

nific

antly

di

ffere

nt ($

12,6

84 v

s $1

2,91

6, C

I diff

eren

ce –

1,09

6 to

636

) and

15,

373

vs

15,2

83, C

I diff

eren

ce $

–887

to $

1,06

7)

Moh

er e

t al,

1992

RCT

n =

267

Cana

daIn

patie

nts

Gen

eral

med

ical

cl

inic

al te

achi

ng

units

Med

ical

team

co

ordi

nato

r (M

TC)

vs Usua

l car

e

1. L

oS; 2

. Dea

th; 3

. Rea

dmis

sions

Subg

roup

n =

40:

4. P

atie

nt

satis

fact

ion;

5. M

edic

al c

are

info

rmat

ion

1.

Patie

nts

in M

TC g

roup

had

sig

nific

antly

sho

rter l

engt

h of

sta

y co

mpa

red

to

cont

rol g

roup

(CI 1

.02

to 2

.92

days

). No

sig

nific

ant e

ffect

for s

ex, a

ge a

nd

disc

harg

e de

stin

atio

n ca

tego

ries.

Effe

ct p

ositi

ve fo

r dig

estiv

e di

seas

es a

nd

nega

tive

for c

ircul

ator

y sy

stem

def

icits

. Tab

le 3

pro

vide

s Lo

S st

ratif

ied

for

seve

ral d

iffer

ent v

aria

bles

(age

, sex

, etc)

2.

10 p

atie

nts

(7%

) in

inte

rven

tion

died

bef

ore

disc

harg

e vs

8 (6

%) i

n co

ntro

l (ns

)3.

22

pat

ient

s (1

6%) i

n in

terv

entio

n we

re re

adm

itted

vs

18 (1

4%) i

n co

ntro

l (ns

)4.

Si

gnifi

cant

ly m

ore

patie

nts

in in

terv

entio

n gr

oup

satis

fied

(89%

vs

62%

; CI 2

% to

52

%)

5.

Info

rmat

ion

prov

ided

to 1

00%

of p

atie

nts

in in

terv

entio

n vs

86%

in c

ontro

l (ns

)



60




61


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

M

udge

et a

l, 20

06CB

An

= 15

38Au

stra

liaIn

patie

nts

Inte

rnal

med

icin

e

Team

inte

rven

tion

vs Cont

rol g

roup

with

us

ual c

are

Prim

ary:

1. L

engt

h of

sta

y;

2. D

eath

; 3. M

orta

lity

(in-h

ospi

tal

and

6 m

onth

s); 4

. Fun

ctio

nal

decl

ine

in h

ospi

tal

Seco

ndar

y: 5

. 6 m

onth

s re

adm

issio

n; 6

. Inp

atie

nt b

ed

occu

panc

y; 7.

Disc

harg

e to

re

siden

tial c

are;

8. S

elf-r

ated

hea

lth

chan

ge 1

mon

th a

fter d

ischa

rge;

9.

Res

tora

tion

to p

revi

ous

func

tiona

l le

vel 1

mon

th a

fter d

ischa

rge;

10

. Hea

lth u

tilis

atio

n

1.

No s

igni

fican

t diff

eren

ce2.

Si

gnifi

cant

ly fe

wer p

atie

nts

in in

terv

entio

n gr

oup

died

(exa

mpl

e fro

m c

omm

unity

pa

tient

s: 3

1 (3

.9%

) vs

48 (6

.4%

)), b

ut n

o lo

nger

sig

nific

ant a

t 6 m

onth

s4.

Si

gnifi

cant

ly fe

wer p

atie

nts

in in

terv

entio

n gr

oup

show

ed fu

nctio

nal d

eclin

e in

ho

spita

l (3.

2% v

s 5.

4%)

5.

No d

iffer

ence

in ra

te o

f rea

dmis

sion

6.

No s

igni

fican

t diff

eren

ce b

etwe

en th

e gr

oups

7.

7.4%

vs

5.4%

(not

sig

nific

ant)

8.

Self-

rate

d he

alth

bet

ter i

n pa

tient

s fro

m in

terv

entio

n gr

oup

(dat

a no

t pro

vide

d)9.

81

.1% v

s 80

.9%

(not

sig

nific

ant)

10. S

igni

fican

tly g

reat

er a

cces

s to

hea

lth s

ervic

es; e

g 53

.2%

vs

63.9

% (o

r 397

vs

506

patie

nts)

for a

ny a

llied

heal

th s

ervic

e. O

T, s

ocia

l wor

k, n

utrit

ion,

spe

ech

ther

apy

and

disc

harg

e lia

ison

also

bet

ter e

ffect

for i

nter

vent

ion

grou

pO

vera

ll add

ition

al c

ost p

er p

atie

nt fo

r int

erve

ntio

n gr

oup

$184

Yagu

ra e

t al,

2005

(Sem

i) RC

Tn=

178

Japa

nIn

patie

nts

hosp

ital

Initi

al s

troke

Stro

ke re

habi

litat

ion

unit

(SRU

) (=

team

)vs G

ener

al re

habi

litat

ion

ward

(GRW

)

Prim

ary:

1. F

unct

iona

l impa

irmen

t m

easu

re (F

IM);

2. D

ischa

rge

disp

ositi

onSe

cond

ary:

3. S

troke

impa

irmen

t as

sess

men

t set

(SIA

S); 4

Len

gth

of h

ospi

tal s

tay;

5. C

ost o

f ho

spita

lisat

ion

per d

ay

1.

No s

igni

fican

t diff

eren

ce, a

lso n

ot w

hen

stra

tifie

d fo

r sev

erity

2.

No s

igni

fican

t diff

eren

ce; s

tratif

ying

for s

ever

ity s

howe

d sig

nific

antly

mor

e se

vere

pat

ient

s di

scha

rged

to h

ome

in S

RU th

an in

GRW

(47.

4% v

s 0%

)3.

No

sig

nific

ant d

iffer

ence

, also

not

whe

n st

ratif

ied

for s

ever

ity4.

No

sig

nific

ant d

iffer

ence

, also

not

whe

n st

ratif

ied

for s

ever

ity5.

No

sig

nific

ant d

iffer

ence

, also

not

whe

n st

ratif

ied

for s

ever

ity

Bane

rjee

et a

l, 19

96RC

Tn

= 69

UK

Com

mun

ityG

eria

trics

(fra

il el

derly

)

Psyc

hoge

riatri

c te

am

vs Stan

dard

GP

care

1. R

ecov

ery

from

dep

ress

ion

(AG

ECAT

sco

re a

nd M

ontg

omer

y As

berg

dep

ress

ion

ratin

g sc

ale,

M

ADRS

)2.

Upt

ake

prop

osed

man

agem

ent

plan

s (in

terv

entio

n on

ly!)

Not r

epor

ted

in m

etho

ds s

ectio

n:

3. m

anag

emen

t of d

epre

ssio

n 4.

Ref

erra

l to

psyc

hiat

ric te

am/

adm

ittan

ce to

psy

chia

tric

unit

1.

AGEC

AT: s

igni

fican

tly m

ore

patie

nts

in in

terv

entio

n gr

oup

reco

vere

d (1

9 vs

9, o

r 33

%; C

I diff

eren

ce 1

0 to

55)

, sig

nific

antly

mor

e pa

tient

s im

prov

ed (2

7 vs

17,

or

35%

; CI d

iffer

ence

14

to 5

6) a

nd fe

wer r

emai

ned

the

sam

e (2

vs

9, o

r –19

%; C

I di

ffere

nce

–35

to –

3) o

r bec

ame

wors

e (0

vs

6 or

–17

%, C

I diff

eren

ce –

29 to

–5)

1.

MAD

RS c

hang

e wa

s gr

eate

r in

inte

rven

tion

grou

p th

an in

con

trol g

roup

; –8.

3 ±

6.5

vs 11

.6 ±

6.4

(CI d

iffer

ence

in p

oint

s –1

0 to

–3)

1.

ORa

dj fo

r effe

ct o

f ant

idep

ress

ants

was

0.3

(0.0

–1.9

), ns

2.

78–1

00%

of p

ropo

sed

inte

rven

tions

wer

e co

mpl

eted

, exc

ept f

or o

utre

ach

refe

rral

(43%

)3.

16

% o

f con

trol p

atie

nts

vs 6

9% o

f int

erve

ntio

n pa

tient

s re

ceive

d an

tidep

ress

ants

(h

owev

er, n

o sig

nific

ant l

evel

s pr

ovid

ed)

4.

2 an

d 1

patie

nts

in c

ontro

l gro

up v

s 3

and

0 in

inte

rven

tion

grou

p (h

owev

er, n

o sig

nific

ant l

evel

s pr

ovid

ed)



62




63


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

G

erm

ain

et a

l, 19

95RC

Tn

= 10

8US

AIn

patie

nts

Ger

iatri

cs

Cons

ulta

tive

serv

ices

of a

ger

iatri

c as

sess

men

t and

in

terv

entio

n te

am

(GAI

T)vs Us

ual h

ospi

tal c

are

1. L

engt

h of

sta

y (L

oS);

2.

Disc

harg

e to

hom

e;

3. R

ehos

pita

lisat

ion;

4. S

urviv

al

rate

; 5. N

ursin

g ho

me

disc

harg

e

1.

Sign

ifica

ntly

lowe

r in

GAI

T (4

2.8

± 20

.8 v

s 65

.5 ±

23.

5), b

oth

in h

igh

func

tioni

ng

and

low

func

tioni

ng p

atie

nts

2.

Sign

ifica

ntly

high

er in

GAI

T, e

spec

ially

in h

igh

func

tioni

ng p

atie

nts

(42%

vs

13%

in

hig

h an

d 10

% v

s 7%

in lo

w fu

nctio

ning

pat

ient

s)3.

Re

hosp

italis

atio

n 1

year

afte

r disc

harg

e st

atist

ical

ly eq

ual b

etwe

en b

oth

grou

ps

(48%

vs

46%

)4.

O

ne-y

ear s

urviv

al s

tatis

tical

ly eq

ual in

bot

h gr

oups

(75%

vs

64%

)5.

No

diff

eren

ce

Hoga

n an

d Fo

x,

1990

Pros

pect

ive,

cont

rolle

d tri

al

(rand

omis

atio

n no

t exp

licitl

y m

entio

ned)

n =

132

USA

Inpa

tient

s G

eria

trics

Ger

iatri

c co

nsul

tatio

n te

am (G

CT)

vs Usua

l car

e by

ph

ysic

ian

1. S

urviv

al s

tatu

s;

2. L

iving

arra

ngem

ents

; 3.

Sub

sequ

ent h

ospi

talis

atio

n;

4. B

arth

el in

dex

1.

Sign

ifica

ntly

larg

er s

urviv

al a

t 180

day

s in

GCT

gro

up, b

ut n

ot a

t 365

day

s (n

o ab

solu

te n

umbe

rs g

iven,

% in

gra

ph, n

ot a

ccur

ate)

2.

Equa

l adm

ittan

ce to

nur

sing

hom

e (1

4% v

s 19

%) a

nd fr

om n

ursin

g ho

me

to

gene

ral c

omm

unity

(25%

vs

8%)

3.

Equa

l hos

pita

l rea

dmitt

ance

afte

r 3, 6

and

12

mon

ths

(at 1

2 m

onth

s 41

% v

s 57

%)

4.

Sign

ifica

ntly

high

er im

prov

emen

t in

Barth

el in

dex

in G

CT (7

5% v

s 44

% o

f the

pa

tient

s) a

fter 1

2 m

onth

s. N

ot a

fter 3

and

6 m

onth

s (6

9% v

s 52

% a

nd 7

7% v

s 69

% re

spec

tivel

y)

Linc

oln

et a

l, 20

04RC

T [N

o ba

selin

e m

easu

rem

ent!

Asse

ssm

ent o

nly

at 6

mon

ths]

n =

428

UK

Com

mun

itySt

roke

Com

mun

ity s

troke

te

am (C

ST)

vs Rout

ine

care

Patie

nt: 1

. Bar

thel

inde

x (B

I);

2. E

xten

ded

ADL;

3. G

ener

al h

ealth

qu

estio

nnai

re –

12 (G

HQ-1

2);

4. E

uroQ

ol; 5

. Sat

isfac

tion

with

ca

re (4

-poi

nt L

ikert

scal

e, p

ract

ical

, em

otio

nal,

over

all);

6. K

nowl

edge

of

stro

keCa

rer:

7. G

HQ-1

2 ; 8

. Car

er s

train

in

dex

(CSI

) ; 9

. Eur

oQol

_car

er;

10. S

atisf

actio

n wi

th c

are

(kno

wled

ge o

f stro

ke; p

ract

ical

su

ppor

t; em

otio

nal h

elp,

ove

rall

satis

fact

ion)

1. 2

. 3. 4

. 5 (P

ract

ical

/ove

rall)

; no

signi

fican

t diff

eren

ces

betw

een

grou

ps a

t 6 m

onth

s po

st-s

troke

6:

No s

igni

fican

t diff

eren

ces

5.

CST

gro

up m

ore

satis

fied

with

em

otio

nal h

elp

they

rece

ived

(med

ian

3 vs

2)

7. 9.

10.

(Pra

ctic

al h

elp

and

emot

iona

l sup

port)

no

diffe

renc

e be

twee

n gr

oups

8.

Lowe

r lev

els

of s

train

in C

ST g

roup

(med

ian

8 vs

10;

IQR

5–10

vs

6–12

)10

. Hig

her s

atisf

actio

n wi

th k

nowl

edge

(med

ian

2 vs

2; I

QR

2–3

vs 1

-3) a

nd o

vera

ll sa

tisfa

ctio

n (m

edia

n 2

vs 2

; IQ

R 2–

3 vs

1–3

) in

CST

gro

up



62




63


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

Ph

elan

et a

l, 20

07RC

Tn

= 87

4US

AO

utpa

tient

s (p

rimar

y ca

re

clin

ics)

Ger

onto

logy

Seni

or re

sour

ce

team

(SRT

); te

am o

f ge

riatri

c sp

ecia

lists

vs Usua

l GP

care

Prim

ary:

1. P

CP c

are

(man

agem

ent,

pres

crip

tion,

pr

oact

ive s

cree

ning

);

2. P

hysic

al a

nd a

ffect

sub

scal

es o

f fu

nctio

nal s

tatu

s (a

rthrit

is im

pact

m

easu

rem

ent s

cale

2 –

sho

rt fo

rm

(AIM

S-2S

F)Se

cond

ary:

3. P

CP s

atisf

actio

n;

4. P

rovi

der s

elf-e

ffica

cy;

5. P

rovi

der s

atisf

actio

n; 6

. New

di

sabi

litie

s in

ADL

; 7. S

elf-r

ated

he

alth

; 8. P

sych

olog

ical

wel

l-bei

ng,

men

tal h

ealth

inde

x (M

HI);

9.

Hos

pita

lisat

ions

10. V

ital s

tatu

s (d

eath

)

1.

PCP

man

agem

ent i

mpr

oved

at 1

2 m

onth

s in

con

trol b

ut n

ot in

inte

rven

tion;

at

24 m

onth

s no

sta

tistic

al d

iffer

ence

bet

ween

the

two

grou

ps (6

4% in

inte

rven

tion

vs 6

1% in

con

trol g

roup

at b

asel

ine;

65%

vs

69%

at 1

2 m

onth

s; 6

1% v

s 62

% a

t 24

mon

ths)

; no

chan

ge in

pre

scrip

tion

over

follo

w-up

(hig

h-ris

k m

edic

atio

n: 3

4%

vs 4

0%; 3

8% v

s 39

%; 3

6% v

s 39

%);

high

er p

ropo

rtion

s of

pat

ient

s sc

reen

ed in

in

terv

entio

n gr

oup

durin

g fir

st y

ear,

not a

t 24

mon

ths

follo

w-up

(diff

eren

tiate

d be

twee

n de

pres

sion,

cog

nitiv

e im

pairm

ent a

nd fa

lls in

tabl

e 2)

2.

No e

ffect

s on

AIM

S-2S

F, n

o gr

oup

diffe

renc

es (p

hysic

al s

ubsc

ale:

1.2

7 vs

1.2

8;

1.53

vs

1.51

; 1.6

8 vs

1.5

9) (a

ffect

sub

scal

e: 2

.39

vs 2

.47;

2.5

3 vs

2.6

0; 2

.60

vs

2.66

) (sd

not

repo

rted)

3.

Sa

tisfa

ctio

n wi

th in

terv

entio

n wa

s hi

gh4.

M

ean

self-

effic

acy

of p

rovi

der w

as h

igh

in b

oth

grou

ps, n

o ch

ange

or d

iffer

ence

5.

Rath

er lo

w sa

tisfa

ctio

n of

pro

vide

r; no

diff

eren

ce b

etwe

en g

roup

s6.

Lo

wer r

ate

of d

isab

ility

in in

terv

entio

n gr

oup

at 1

2 m

onth

s, n

ot a

t 24

mon

ths

(12

mon

ths:

10

vs 1

5; 2

4 m

onth

s: 1

4 vs

16)

7.

No d

iffer

ence

s in

sel

f-rat

ed h

ealth

ove

r tim

e or

bet

ween

inte

rven

tion

grou

ps

(70%

vs

75%

; 69%

vs

70%

; 67%

vs

71%

)8.

Hi

gher

MHI

sco

re in

inte

rven

tion

grou

p at

24

mon

ths

only

(78.

8 vs

78.

5; 7

7.1 v

s 76

.9; 7

7.6

vs 7

5.5)

(no

sd re

porte

d)9.

Ho

spita

lisat

ion

not s

igni

fican

tly d

iffer

ent o

ver t

ime

nor b

etwe

en in

terv

entio

ns

(11.

5% v

s 12

.3%

; 19.

4% v

s 16

.2%

; 18.

2% v

s 16

.4%

)10

. Hig

her m

orta

lity

in in

terv

entio

n gr

oup

(11.

5% v

s 7.

6%)



64


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

Ra

bow

et a

l, 20

04RC

Tn

= 90

USA

Out

patie

nts

(terti

ary

care

)Pa

lliativ

e ca

re

Com

preh

ensiv

e ca

re

team

(CCT

); pa

lliativ

e ou

tpat

ient

med

icin

e te

ams

vs Usua

l PCP

car

e

1. P

hysic

al fu

nctio

ning

and

sy

mpt

oms:

rapi

d di

sabi

lity

ratin

g sc

ale;

2. D

yspn

ea (U

nive

rsity

of

Califo

rnia

, San

Die

go s

hortn

ess

of

brea

th q

uest

ionn

aire

); 3.

Brie

f pai

n in

vent

ory

and

pain

med

icat

ions

and

tre

atm

ent;

4. 6

item

s fro

m M

edic

al

Out

com

es S

tudy

Psyc

hoso

cial

and

spi

ritua

l we

llbei

ng: 5

. Pro

file

of m

ood

stat

es;

6. C

entre

of E

pide

mio

logy

Stu

dies

de

pres

sion

scal

e; 7.

Spi

ritua

l we

llbei

ng s

cale

; 8. Q

oL s

cale

–

canc

er v

ersio

n; 9

. Car

e sa

tisfa

ctio

n:

Gro

up H

ealth

Ass

ocia

tion

of

Amer

ican

Con

sum

er S

atisf

actio

n Su

rvey

Ad

vanc

e ca

re p

lann

ing

(sev

eral

sin

gle

ques

tions

)

1.

?2.

In

crea

sed

odds

for d

yspn

ea a

t tim

e 2

for c

ontro

l gro

up c

ompa

red

to in

terv

entio

n (O

R =

6.07

; CI 1

.04

to 3

5.56

), lo

wer i

nter

fere

nce

with

dai

ly ac

tiviti

es d

ue to

dy

spne

a in

inte

rven

tion

grou

p bu

t hig

h in

con

trol g

roup

. (6.

5 at

T2

vs 7.

1 at

T3

in

cont

rol g

roup

and

5.8

vs

3.6

in in

terv

entio

n)3.

No

cha

nges

and

diff

eren

ces

in p

ain

scor

es (i

nter

fere

nce

with

act

ivitie

s: 3

9.9

vs

40.8

and

43.

1 vs

36.

4).

4.

Impr

ovem

ent i

n sle

ep in

inte

rven

tion

grou

p bu

t not

diff

eren

t gro

up x

tim

e in

tera

ctio

n (q

ualit

y: 1

0 vs

11 a

nd 11

.9 v

s 12

.5)

5.

Anxi

ety

impr

oved

in th

e in

terv

entio

n gr

oup

and

dete

riora

ted

in th

e co

ntro

l gro

up

(5.5

at T

2 vs

5.9

at T

3; 6

.8 a

t T2

vs 5

.3 a

t T3)

6.

No s

igni

fican

t diff

eren

ce fo

r dep

ress

ion

scor

es b

etwe

en c

ontro

l and

inte

rven

tion

(17.

5 at

T2

vs 1

5.3

at T

32; 1

6.5

at T

2 vs

12.

4 at

T3)

7.

In

terv

entio

n gr

oup

pt s

howe

d sig

nific

antly

incr

ease

d le

vel o

f spi

ritua

l wel

lbei

ng

but c

ontro

l gro

up u

ncha

nged

(91.

2 at

T2

vs 9

2.4

at T

3 in

con

trol g

roup

; 98.

0 at

T2

vs

105.

5 at

T3)

8.

No d

iffer

ence

in Q

oL (6

5.4

at T

2 vs

67.7

at T

3 in

con

trol g

roup

; 69.

7 vs

69.

3 at

T3

in in

terv

entio

n)9.

No

diff

eren

ces/

impr

ovem

ents

(74.

5 at

T2

vs 7

2.4

at T

3; 6

9.6

at T

2 vs

70.

1 at

T3)

Adva

nced

car

e pl

anni

ng: s

igni

fican

tly m

ore

pt in

inte

rven

tion

grou

p ha

d co

mpl

eted

fu

nera

l arra

ngem

ents

at e

nd o

f fol

low-

up (3

5% v

s 5%

in c

ontro

l gro

up)

Heal

thca

re u

tilis

atio

n: in

terv

entio

n pa

tient

s m

ade

fewe

r visi

ts to

thei

r GP

and

the

urge

nt c

are

clin

ics

(7.5

± 4

.9 v

s 10

.6 ±

7.5/

0.6

± 0.

9 vs

0.3

± 0

.5),

but n

o di

ffere

nces

wi

th re

gard

to s

peci

alty

car

e cl

inic

s, e

mer

genc

y de

partm

ent v

isits

, num

ber o

f ho

spita

lisat

ions

, num

ber o

f day

s in

hos

pita

l (se

e al

so ta

ble

5). M

ean

char

ge p

er

patie

nt w

as 4

7,21

1 ±

73,0

09 d

olla

rs in

inte

rven

tion

vs 4

3,33

8 ±

69,6

47 in

con

trol

grou

p (n

ot s

igni

fican

t)



65


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

Sc

hmid

t et a

l, 19

98RC

T (b

lock

ra

ndom

isat

ion)

n =

1854

Swed

enIn

patie

nt (n

ursin

g ho

mes

)G

eria

trics

(p

sych

otro

pic

pres

crip

tions

)

Inte

rven

tion

(team

)vs Co

ntro

l

1. D

rugs

pre

scrip

tion

in fo

ur

clas

ses:

ant

ipsy

chot

ics,

hyp

notic

s,

anxi

olyt

ics,

ant

idep

ress

ants

Num

ber o

f dru

gs: 2

. % w

ith

psyc

hotro

pic

drug

s; 3

. % w

ith

polym

edic

ine;

4. %

with

ther

apeu

tic

dupl

icat

ion;

5. N

umbe

r of d

rugs

pr

escr

ibed

; 6. %

with

non

-re

com

men

ded

drug

s pr

escr

ibed

; 7.

% w

ith a

ccep

tabl

e dr

ugs

in e

ach

clas

sSe

lect

ivity

of d

rugs

: 8. C

lass

ified

ac

cord

ing

to S

MPA

gui

delin

es

1. 2

. 3. 4

. No

signi

fican

t diff

eren

ce b

efor

e an

d af

ter i

n ex

perim

enta

l hom

es1.

4. S

igni

fican

t inc

reas

e be

fore

and

afte

r in

cont

rol h

omes

: (m

ean

num

ber o

f dru

gs

incr

ease

d fro

m 2

.06

to 2

.2; u

se o

f ≥ 2

dru

gs in

crea

sed

from

20.

7 to

24.

2)1.

19

%, s

igni

fican

t red

uctio

n in

ant

ipsy

chot

ics

desc

riptio

n in

exp

erim

enta

l gro

up

only

(con

trol g

roup

7%

dec

reas

e)1.

Hy

pnot

ics

desc

riptio

n ch

ange

d in

exp

erim

enta

l gro

up o

nly:

non

-reco

mm

ende

d hy

pnot

ics

desc

riptio

n de

clin

ed w

ith 3

7% (a

ccep

tabl

e hy

pnot

ics

incr

ease

d fro

m

9% to

15%

and

ove

rall r

ate

of h

ypno

tic p

resc

riptio

ns d

eclin

ed b

y 16

%)

1.

No c

hang

e in

pre

scrip

tion

of n

on-re

com

men

ded

anxi

olyt

ics

(bot

h gr

oups

), bu

t in

crea

se in

pre

scrip

tion

of a

ccep

tabl

e an

xiol

ytic

s in

exp

erim

enta

l hom

es (1

3.9%

vs

20.

8%) a

nd o

vera

ll inc

reas

e in

anx

ioly

tics

pres

crip

tion

in e

xper

imen

tal h

omes

(2

9%)

Schn

ed e

t al,

1995

RCT

(no

blin

ding

)n

= 10

7US

AO

utpa

tient

Chro

nic

infla

mm

ator

y ar

thrit

is

TEAM

CARE

vs TRAD

CARE

(con

trol

grou

p)

Phys

ical

: 1. J

oint

infla

mm

atio

n m

easu

red

with

the

Ritc

hie

artic

ular

in

dex;

2. D

urat

ion

of m

orni

ng

stiff

ness

Seve

rity

mea

sure

s: 3

. Pre

senc

e of

no

dule

s; 4

. Fat

igue

; 5. V

ascu

litis;

6.

Fel

ty’s

synd

rom

e Se

lf-re

port

s: 7.

Mod

ified

hea

lth

asse

ssm

ent q

uest

ionn

aire

(mH

AQ);

8. A

rthrit

is he

lple

ssne

ss in

dex

(AHI

); 9.

VAS

for p

ain;

10.

Arth

ritis

impa

ct m

easu

rem

ent s

cale

s (A

IMS)

; 11.

Bec

k de

pres

sion

inve

ntor

y (B

DI)

Cost

s: 1

2. C

ost p

art o

f HAQ

; 13

. Med

icat

ion;

14.

Num

ber o

f re

ferra

ls; 1

5. U

se o

f aid

s an

d de

vices

; 16.

Arth

ritis

-rela

ted

proc

edur

esLa

bora

tory

: irre

gula

rly! e

ryth

rocy

te

sedi

men

tatio

n ra

te; h

emog

lobi

n;

hand

radi

ogra

phs;

late

x fix

atio

n

**Da

ta 1

yea

r afte

r int

erve

ntio

n st

arte

d**

1.–1

6. N

o sig

nific

ant d

iffer

ence

bet

ween

the

two

grou

psDa

ta c

olle

ctio

n fo

r lab

orat

ory

mea

sure

s wa

s de

scrib

ed a

s be

ing

inad

equa

te a

nd

outc

omes

wer

e no

t rep

orte

d



66




67


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

Ti

jhui

s et

al,

2003

van

den

Hout

et

al, 2

003

Tijh

uis

et a

l, 20

02

RCT

n =

210

Neth

erla

nds

In-p

atie

nt a

nd

outp

atie

ntRh

eum

atoi

d ar

thrit

is

Clin

ical

nur

se

spec

ialis

t car

e (C

NSC)

vs Inpa

tient

m

ultid

iscip

linar

y te

am

care

(IM

TC)

vs Day

patie

nt

mul

tidisc

iplin

ary

team

ca

re (D

MTC

)

(#98

; #11

3) P

rimar

y: fu

nctio

nal

stat

us m

easu

red

with

1. H

ealth

as

sess

men

t que

stio

nnai

re (H

AQ),

and

2. M

acM

aste

r Tor

onto

arth

ritis

patie

nt p

refe

renc

e in

terv

iew

(#98

, 99)

Oth

er: Q

ALYs

mea

sure

d wi

th: 3

. Qua

lity

of lif

e as

sess

ed w

ith

RA-

spec

ific

QoL

que

stio

nnai

re

(RAQ

oL),

and

4. R

and-

36(#

99) 5

. Rat

ing

scal

e on

cur

rent

he

alth

(TRS

)(#

99) 6

. Tim

e tra

de-o

ff (T

TO) f

or

pref

eren

ce o

f cur

rent

hea

lth(#

99) 7

. Cos

ts fo

r hos

pita

lisat

ion

(cos

t-pric

e da

ta) a

nd

(#99

) 8. S

ocie

tal c

osts

(for

CEA

)(#

98) 9

. Dise

ase

activ

ity s

core

(D

AS)

(#98

) 10.

Grip

test

(#98

) 11.

Wal

k te

stNo

t spe

cifie

d in

met

hods

sec

tions

:(#

113)

12.

pat

ient

sat

isfac

tion

(VAS

) #9

8. 1

3. U

se o

f ser

vices

of o

ther

he

alth

pro

fess

iona

ls; in

trodu

ctio

n of

ada

ptive

equ

ipm

ent;

num

ber o

f ho

spita

lisat

ions

; med

ical

trea

tmen

t

1.

All t

hree

gro

ups

impr

oved

on

HAQ

. Cha

nge

scor

es in

CNS

C gr

oup

at w

eeks

12

, 52,

and

104

: 0.2

(0.0

7 ±

0.33

); 0.

17 (0

.03

± 0.

30);

0.2

(0.0

6 ±

0.33

); ch

ange

sc

ore

in IM

TC g

roup

: 0.15

(0.0

2 ±

0.27

); 0.

19 (0

.06

± 0.

32);

0.13

–0.

03 ±

0.2

6).

In D

MTC

pat

ient

s: 0

.34

(0.2

1 ±

0.47

); 0.

366

(0.2

3 ±

0.50

); 0.

35 (0

.22

± 0.

48).

Sign

ifica

nt d

iffer

ence

bet

ween

CNS

C an

d DM

TC a

nd b

etwe

en C

NSC

and

IMTC

at

bas

elin

e. #

113

also

pro

vide

s da

ta a

t wee

ks 6

and

26;

pro

vide

sam

e pi

ctur

e.

Com

paris

on o

f clin

ical

out

com

e am

ong

thre

e gr

oups

and

com

paris

on b

etwe

en

CNSC

gro

up a

nd tw

o ot

hers

did

not

sho

w sig

nific

ant d

iffer

ence

s.2.

Si

gnifi

cant

impr

ovem

ent i

n M

ACTA

R; a

dditi

onal

impr

ovem

ent b

etwe

en w

eeks

12

and

52 a

nd d

eter

iora

tion

betw

een

week

s 52

and

104

in d

ay D

MTS

and

CNS

C.

DMTC

larg

est i

mpr

ovem

ent a

t wee

k 52

com

pare

d to

oth

er g

roup

s. C

hang

e sc

ores

in C

NSC

grou

p at

wee

ks 1

2, 5

2 an

d 10

4: –

2.1

(–4.

7 ±

0.5)

; –4.

3 (–

6.8

± –1

.8);

–0.6

(–3.

3 ±

2.1)

. In

IMTC

gro

up: –

0.3

(–2.

9 ±

2.4)

; 0.6

(–2.

0 ±

3.1)

; 0.8

(–

2.0

± 3.

6). I

n DM

TC g

roup

: –1.

5 (–

4.2

± 1.

2); –

5.3

(–7.

9 ±

2.6)

; –.2

(-3.

0 ±

2.5)

. #1

13 a

lso p

rovi

des

data

at w

eeks

6 a

nd 2

6; p

rovi

de s

ame

pict

ure.

3.

4. 5

. Pat

ient

s in

all g

roup

s sh

owed

sig

nific

ant i

mpr

ovem

ents

ove

r 2 y

ears

. Ag

greg

ated

ove

r all t

hree

gro

ups

of c

are,

ave

rage

impr

ovem

ents

wer

e 1.

5 ES

0.

21 (R

AQoL

), 0.

045

ES 0

.49

(SF-

36),

0.06

1 ES

0.18

(TSR

), an

d 0.

046

ES 0

.18

(TTO

). Q

ALY

diffe

renc

es le

ss th

an 0

.1 y

ear.

No d

iffer

ence

bet

ween

gro

ups.

#11

3 al

so p

rovi

des

data

at w

eeks

6 a

nd 2

6; p

rovi

de s

ame

pict

ure.

7.

Sign

ifica

ntly

high

er c

osts

for i

nitia

l car

e fo

r bot

h te

am c

are

grou

ps: 5

,000

eur

os

for i

npat

ient

and

4,10

0 eu

ros

for o

utpa

tient

vs

200

euro

s fo

r CNS

C. H

ealth

care

an

d no

n-he

alth

care

cos

ts w

ere

not s

igni

fican

tly d

iffer

ent

8.

Cost

s fo

r soc

iety

sig

nific

antly

lowe

r in

CNSC

vs

othe

r two

gro

ups,

at l

east

5,4

00

euro

s9.

Si

gnifi

cant

impr

ovem

ents

of D

AS a

t wee

ks 1

2, 5

2 an

d 10

4 co

mpa

red

to b

asel

ine

in e

ach

of th

e th

ree

grou

ps. #

113

also

pro

vide

s da

ta a

t wee

ks 6

and

26;

pro

vide

sa

me

pict

ure.

10. S

igni

fican

t im

prov

emen

t ove

r tim

e in

the

thre

e gr

oups

. Det

erio

ratio

n on

test

for

day

patie

nts

betw

een

week

s 52

and

104

.11

. Si

gnifi

cant

impr

ovem

ent o

ver t

ime

in th

e th

ree

grou

ps. D

eter

iora

tion

on te

st fo

r in

patie

nts

betw

een

week

s 52

and

104

.12

. At e

nd o

f tre

atm

ent p

erio

d, in

patie

nts

and

day

patie

nts

were

sig

nific

antly

mor

e sa

tisfie

d wi

th c

are

than

nur

se s

peci

alist

pat

ient

s (7

3mm

± 2

3mm

for n

urse

sp

ecia

lists

vs

85m

m ±

19m

m in

inpa

tient

s, a

nd 9

2mm

± 1

0mm

in d

ay p

atie

nts)

. 13

. In

gene

ral,

all n

ot s

igni

fican

t, ex

cept

for w

eeks

52–

104:

mor

e in

patie

nts

than

CN

S pa

tient

s re

ceive

d ho

me

help

(23

vs 1

0), a

nd d

urin

g th

e pe

riods

12–

52 a

nd

52–1

04 w

eeks

, visi

ts to

a C

NS w

ere

mor

e fre

quen

t in

the

CNS

grou

p th

an in

the

two

team

gro

ups.



66




67


Firs

t aut

hor,

year

Stud

y de

sign

, sa

mpl

e si

ze,

coun

try,

set

ting,

co

nditi

onIn

terv

entio

nO

utco

me

mea

sure

s Re

sults

Vl

iet V

liela

nd,

Bree

dvel

d an

d Ha

zes,

199

7

RCT

n =

80Ne

ther

land

sIn

patie

nts

and

outp

atie

nts

vs

outp

atie

nts

alon

eRh

eum

atoi

d ar

thrit

is

Inpa

tient

MD

team

ca

re

vs Rout

ine

outp

atie

nt

care

Fo

r act

ive R

A

1. M

odifi

ed R

itchi

e ar

ticul

ar in

dex

(MR

AI);

2. N

umbe

r of s

wolle

n jo

ints

; 3. V

AS p

ain;

4. V

AS d

iseas

e ac

tivity

; 5. P

hysic

ian

leve

l of

dise

ase

activ

ity (0

–3);

6.

Ery

thro

cyte

sed

imen

tatio

n ra

te (E

SR);

7. He

alth

ass

essm

ent

ques

tionn

aire

(HAQ

)

1. –

5. I

npat

ient

gro

ups

show

s sig

nific

ant i

mpr

ovem

ent a

t 2 w

eeks

; diff

eren

ce

betw

een

two

grou

ps fr

om 2

–104

wee

ks w

as s

igni

fican

t, bu

t MR

AI d

eter

iora

ted

signi

fican

tly ra

ther

than

impr

oved

. All o

utco

me

valu

es a

re p

rese

nted

in ta

ble

2,

for i

nter

vent

ion

and

cont

rol g

roup

sep

arat

ely

at e

ach

follo

w-up

per

iod!

!!1.

–7.

Inpa

tient

gro

ups

show

ed n

o sig

nific

ant i

mpr

ovem

ent a

t 104

wee

ksSi

gnifi

cant

ly gr

eate

r pro

porti

on o

f pat

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n =

n af

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a =

not a

pplic

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t sig

nific

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CI =

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terv

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R =

rela

tive

risk;

GP

= ge

nera

l pra

ctiti

oner



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