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IPP

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amalia reed

on 13 May 2013

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Transcript of IPP

Interprofessional
Practice Strengths of IPP “It is no longer enough for health workers to be professional. In the current global climate, health workers also need to be interprofessional”
(World Health Organization, 2010) Interprofessional practice is the process in which different professional groups work together to positively impact health care How did this short clip present inappropriate interprofessional practice?

How could this situation have been improved? Improved patient outcomes (Hearn & Higginson, 1998)

Job satisfaction (Manojlovich, 2005)

Increased resource-efficiency

Development of new skills (Firth-Cozens,1998; 2001)

Improved workplace practices and productivity

Raised staff morale

Improved patient safety

Better access to health-care (WHO 2010) Why does Dr. Smith always have to be in charge? Hmmm…not sure if this is a job for me or Dr. Nick I wouldn’t have treated her like that I don’t understand what he is saying! Role understanding
Effective communication
Level of commitment
Quality of leadership
Degree of involvement in the quality process
Tolerance of diversity
Availability of resources
Effective working relations
Willingness of team members
Adequate organisational resources
and support
Conflict resolution
IPP knowledge
IPP skills
IPP attitudes What makes good IPP? Literature Review Widespread use in healthcare including:

Home care
Family health centres
Palliative care
Nursing homes
Outpatient clinics
Mental health
Surgery/theatre Where is IPP used? Effects of high quality interprofessional collaboration against lower quality
Cultures of practitioners
Education What have the studies focused on? Majority of studies were qualitative
Interviews-mostly for practitioner culture and collaboration
Randomized control trials used patient focused studies Types of Study Gaps in the literature Lacking research of communication within interprofessional teams
Further research needed to determine how Interprofessional practice influences the outcome of the patient The article Markle-Reid, M., Orridge, C., Weir, R., Browne, G., Gafni, A., Lewis, M., Walsh, M., Levy, C., Daub, S., Brien, H., Roberts, J., & Thabane, L. (2011), Interprofessional Stroke Rehabilitation for Stroke Survivors Using Home Care, The Canadian Journal of Neurological Sciences, 38(2),317-334. Study Design: Randomized Control Trial
Conducted over 3 years
Ethics approval - from the Hamilton Health Sciences/Faculty of Health Sciences Research Ethics Board – Renewed yearly as required.
Initially participants provided written consent and completed baseline questionnaires before being allocated randomly to either a control or intervention. Methods Required to meet specific eligibility:
Confirmed diagnosis of stroke (1st or recurrent) or Transient Ischemic Attack (TIA) within the last 18 months.
Newly referred and eligible for home care services through CACC
Living in the community
Mentally competent to give informed consent (determined by a score of >5 on the Short Portable Mental Status Questionnaire (SPMSQ) Participants Calculated to detect clinically significant difference of 10pts mean change in the Short Form (SF)-36 health survey in physical functioning score from baseline to 12 months
Estimated 132 (66 per intervention group) would address this requirement (this included a 20% allowance for possible drop outs. Sample Size Randomisation Participants were randomly assigned to a group by the project coordinator at McMaster University using numbered, sealed opaque envelopes.
Envelopes contained randomly generated numbers constructed by a biostatician who was not involved in participant recruitment. CACC case managers, all members of the interprofessional team and the study participants were all aware following randomizations were aware of group assignments.
Participants were unable to be blinded
Outcome assessors and statistician/data analysts were able to be blinded. Blinding Intervention Methods Primary Measure: Change in health related quality of life (QOL) and functioning from baseline to 12 months (Measured using the Short Form (SF)-36 health survey.
Secondary Measure: Changes in the following variables from baseline to 12 months:
Physical functioning and related QOL - Stroke Impact Scale – 16 (SIS-16)
Perceived social support - Personal Resource Questionnaire (PRQ-85-Part 2)
Depressive symptoms – Centre for Epidemiological Studies in Depression Scale (CES-D)
Anxiety and depressive symptoms – Kessler-10
Cognitive function – (SPMSQ)
Community re-integration – Reintegration to Normal Living Index (RNLI) Measures of effect Number of strokes in the 12 months after randomisation were recorded
The cost of use of all types of health services from baseline to 12 months were determined using the Health and Social Services Utilization Inventory (HSSUI), which assesses costs from a societal perspective. Measures of effect continued.. Score: 6/10 - suggests insufficient statistical information which may impact the interpretability of the results. Pedro Scale Results Summary Critique of Article Stroke is the leading cause of adult disability and the third leading cause of death in Canada (Markle-Reid et al, 2010)
Globally, stroke results in an estimated 5.7 million deaths each year, and many more survivors living with residual disability
(Heeley et al, 2011)
Nursing home costs for stroke survivors in Canada are estimated at over $600 million per annum
(Markle-Reid et al, 2010) Importance of main findings Implementing Interprofessional Care for stroke survivors in the home could potentially reduce a number of post-stroke symptoms:

social isolation
restricted participation in leisure activities
delayed return to work
Anxiety
Depression
(Markle-Reid et al, 2010) Clinical Importance All measurements tools have established reliability and validity
Participants, members of the interprofessional team and case managers were not blinded after randomization
Participants in the Interprofessional care group received more home visits than participants in the usual care group
The final sample size was smaller than anticipated. Estimated sample size to detect clinical significance was 132, but the study only employed 101 participants and out of this 19 dropped out.
Self –report bias may have affected results
Participants in each group did not significantly differ at baseline
The 19 drop outs were lower in functioning Reliability of Results Measurement tools used have been assessed for validity and the study employs a randomised control trial design
RCT design minimises systematic bias, however this is impacted upon by the lack of blinding.

The methods were deemed appropriate to answer the research question due to:
The study used standardised measurement tools
The study used interview techniques to capture self rated outcomes via structured in home interviews
All participants shared a similar baseline due to eligibility requirements Validity of Results Family/ other community support
Willingness to be in the study and motivation
Compliance with stroke rehabilitation
Additional disorders/diseases/injuries
Life events Outside Variables Higher costs and resources related with IPP care
Time involved
Difficulties organising meetings between staff and with patients
Not clear how or why results were clinically important – future research needed
Generalisability Barriers to use of findings Generalisability Sample appeared to be representative of the wider population of Ontario. I.e. sufficient combination of participants:
Female or male
Married or unmarried
Living alone or with others
Although, information on ethnicity of participants is lacking
Potential for transferability to other Western cultures
Mainly feasible in 70-76 year olds living in the community in Canada
Suburban setting only
Drop outs of study primarily lower-functioning, limiting generalisability to this group Diversity in stroke survivors
Randomised control trial – Gold standard
94.2% engagement – dropout rate low Strengths final sample not truly representative of community-living stroke survivors 33.8%
Participants not blinded which effected willingness to participate
Only observed over 12 months
Carried out in suburban areas – not applicable to rural settings
Possibility of questionnaires acting as an extra intervention
70% turnover of staff involved
Unsure how or why the IPP approach works Weaknesses IPP- the process in which different professional groups work together to positively impact health care.

Clinically feasible results for the use of IPP in stroke rehabilitation within a community setting.

Further research- how/why IPP results in better health outcomes?

Recommendation-future studies need to develop methodologies to measure the different mechanisms of the intervention

Clinically feasible improvement in health outcomes= health care services should consider implementing IPP in their setting References POPULATION
Patients community-living stroke survivors (<18 months post stroke) using home care services.
Patients were required to be 75 yrs or older (Geriatric population focus).

INTERVENTION
Aspects of Interprofession team intervention different from the control (usual care)
COMPARISON
Interprofessional team approach to usual home care services over a 12 month period, specifically related to quality of life and functioning.
Secondary comparisons were that of cost to the health care system, perceived social support, community reintegration and anxiety and depressive symptoms.

OUTCOMES
Outcome measures monitored the Changes in health related Quality of life and functioning from baseline to 12 months.
All measurement tools were found to have established reliability and validity PICO Framework Several outcome measures were assessed and results obtained through various statistical tests.
All measurement tools were found to have established validity and reliability.
Data was assessed on the effects of intervention on the differences between pre and post intervention performance on each of the outcome measures and compared to the control (Home care)
Probability (P) values and Confidence Intervals (CI) were reported to ensure that significant results were due to the intervention and not to that of chance.  
The major results were outlined in the literature in tables and explained in an outcome measure point by point breakdown, comparing mean and standard deviations.
The results outlined no major clinical or statistical differences between the two groups for a majority of variables, with few comparable benefits outlined in the intervention to that of the control group. Results Primary Outcome: Health related quality of life (SF-36 Health survey)
8 subscale questionnaire with Physical and mental components.
Created in 1995 and has been reviewed and modified to increase its validity and reliability multiple times.
Accurate in giving a picture of ones health related quality of life and functioning. Minimal clinical important differences for SF-36 questionnaire was found to be (>5points).
MCID an important consideration for clinicians (Keurentjes, 2012)
Study was powered to detect a 10-point difference to be statistically significant.
Small sample size and limited power are possible explanations why the clinical important difference was not translated to a statistical significance
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