Evidence of Inter-Professional and Multi-Professional Interventions for Geriatric Patients: A Systematic Review

The current demographic shift raises the demand for provision of health care tailored to the complex care needs for older adults. Given the growing number of national care plans and best practice models there is an urgent need to build evidence for inter- and multiprofessional care provision for older people when offered an integrated care approach. The aim of this study was to determine whether an inter-professional or multi-professional care intervention, can improve geriatric patients’ health determinants. A systematic review was performed according to PRISMA Guidelines. Databases were searched for clinical trials which compare inter-professional or multi-professional complex care interventions with usual care among people aged ≥60 years, in hospital or emergency care settings. Based on nine studies, inter-professional or multi-professional intervention has no impact on mortality rate but either positive or neutral effects on physical health, psychosocial wellbeing and utilization of health care service. It shows that these inter-professional or multi-professional interventions were feasible. This systematic review highlights the scarcity of evidence showing either positive or neutral impact of intervention based on inter-professional or multi-professional teamwork across care settings on the health determinants among geriatric patients. International harmonization of assessment tools may allow direct comparisons for future interventions.


Data resources and search strategies
Relevant clinical trials published between 1 st Jan 2008 and 31 st December 2018 in English or German languages were identified using PubMed, Cochrane, CENTRAL, CINAHL, Medline and Embase database. Search strategy using the following Medical Subject Headings: "treatment outcome", AND "aged" AND "Patient Care Team". If required, the Medical Subject Headings were adapted to the specific database options with synonyms of the Medical Subject Headings. Further search via greylit.org and reference tracking were performed to identify additional studies.

Inclusion Criteria
To be included, trials must meet all of the following criteria: (1) Randomized controlled trials or non-randomized controlled trials; (2) compares inter-professional or multiprofessional complex care interventions with usual care; (3) included people aged 60 years or older; and (4) admission to a hospital or emergency care setting. The intervention must demonstrate an integrated care approach by various professionals from the hospital or emergency care setting, with outreach to difference care settings. Interprofessional interventions link between disciplines into a coordinated and coherent whole. Multi-professional interventions are based on knowledge of different disciplines but stays in the boundaries of these fields [12].

Outcomes of interest
The primary outcome were physical health, psychosocial wellbeing, mortality, and utilization of health care services including length of stay, and admission and readmission rates in the hospital setting. The secondary outcome was the exact composition of the inter-professional and multiprofessional teams. The results were sub-categorized into micro, meso and macro levels [13].

Quality assessment
The risk of bias of the included studies were assessed by two independent reviewers (E.P. and R. E. R-W.) using the Critical Appraisal for Therapy Articles Worksheet -Centre for Evidence-based Medicine, University of Oxford 2005 [14]. The independence of all reviewers was ensured by local separation. After evaluation, results were compared and discussed until a consensus was reached. Disagreement was resolved by a third independent reviewer (K.S or P.D.).

Data synthesis and analysis
Meta-analysis was not performed due to the expected heterogeneity of the interventions. Relevant outcome data from the included studies will be summarized and appraised.

Results
A total of 256 relevant citations were identified through search strategy. Two additional studies were detected by hands-on search. After cleaning from duplicates, one reviewer screened titles and abstracts to exclude papers that were clearly not relevant to the research question. After that, a total of 58 full-text studies were assessed for eligibility. Finally, nine studies, involving a total of 1,739 participants, met the inclusion criteria. The PRISMA diagram illustrates the selection process of the studies and shows reasons for exclusion (Figure 1). Table 1 demonstrates the results of the quality assessment run for the studies finally included into the systematic review. As may be seen there was homogeneity between the studies concerning the quality of randomization and group characteristics between the intervention groups. Substantial inconsistency was found for description of other treatments and interventions offered to participants during the inter-or multiprofessional complex care, also affecting the outcomes addressed.

Study characteristics
The baseline characteristics of the nine studies, included in this systematic review were summarized in Table 2. All studies are randomized controlled trials (apart from the study by Trombetti et al.) and were published between 2008 [15] and 2015 [16]. Sample size ranged from 71 [16] to 368 participants [17]. The mean age ranged from 74,9 [18] to 86,8 years [17].
Seven studies focused on multi-professional studies while only two assessed the effect of inter-professional interventions. The duration of the interventions ranged from the total hospital stay to six months after discharge. Eight studies compared their interventions with usual care group [15,[17][18][19][20][21][22][23].

Nature of intervention
As expected, there was a significant heterogeneity in the nature of intervention (Table 4). Overall, six studies included home based intervention in addition to those within the clinical settings [15,16,18,19,21,22].

Effectiveness of interventions on microlevel Physical health
The analysis of the physical functioning by activities of daily living (ADL) was based on five trials using either Barthel index, the 6-item Katz Index, Groningen Activity Restriction Scale or the Chinese Barthel Index as primary endpoints [16,18,[20][21][22]. Three studies showed significant improvement in functional status [20][21][22]. Shyu et al. (2010) and Shyu et al. (2013) showed significant improvement in Chinese Barthel Index [21,22]. Deschodt et al. (2011) showed a significant improvement in ADL status within the eight days post-operatively, which was not sustained at one year [20]. In contrast, two other studies showed no significant improvement in ADL [16,18]. Shyu et al (2010) showed that inter-professional intervention led to a significant reduction in falls [22]. However, three other studies showed no effect on the number of falls [18,21,23]. Three studies showed some benefit of multi-professional intervention on either mobility score, handgrip, gait speed maximum, timed up and go, and the walking ability [16,22,23].
Seven studies evaluated the impact of an intervention on individual mortality, but none of the studies could demonstrate significant reduction of mortality rates due to an inter-or multi-professional intervention [15][16][17][20][21][22][23].

Psychosocial well being
Four studies assessed outcomes related to psychological health including quality of life, mental health and depressive symptoms [16,18,21,22]. Shyu et al (2010) showed that inter-professional intervention improved quality of life based on the SF36 score [22]. In contrast, two other studies showed no significant improvement in quality of life [16,18]. Shyu et al. (2013) showed that both the inter-professional and comprehensive interventions significantly lower the risk of depression after one year [21]. Similarly, Shyu et al. (2010) showed that intervention significantly reduces depressive symptoms [22]. In contrast, Hendriks et al (2008) showed that multi-professional intervention has no significant impact on mental health and Depression score [18].

Effectiveness of interventions on Meso-level and Macro-level Utilization of health care service
Six studies assessed the re-admission rates to hospital as an outcome on the macrolevel [15-17, 19, 20, 22]. The multi-professional liaison team intervention with additional dietitian counselling and home care resulted in a significantly lower re-admission within six month [16]. Similarly, Courtney et al. (2009) showed that intervention significantly reduces readmission rates [19]. On the other hand, Azad et al. (2008) showed a significantly fewer readmissions, but only for those with chronic heart failure In total 258 studies were identified during the systematic data search (256 in scientific literature, two additional publications by hands-on search). Following qualitative evaluation and screening full text, only nine studies fulfilled predefined inclusion criteria of the study and were further processed in the review process. Studies included in qualitative synthesis (n = 9) [15]. Three other studies showed no significant effect of intervention on re-admission rates [17,20,22]. Two studies showed that multi-professional intervention has no significant impact on the length of stay in hospital [15,23]. Two studies showed a significant reduction in emergency department visit following multi-professional intervention [15,19].

Professionals involved in the interventions
Multi-professional and inter-professional team composition of the included studies were summarised in Table 3. All included studies described multi-professional team structures in their interventions. All interventions described physicians and nurses as part of the team [15][16][17][18][19][20][21][22][23]. Four provided service from trained professions      and individual at home rehab program (nurse, physio therapist) At discharge planning a geriatric nurse did predischagre assessment (resources, self-care ability needs, long term care service, and referrals) home environmental modifications.

Discussion
This systematic review highlighted the paucity of evidence on the impact of intervention based on inter-professional or multi-professional teamwork across care settings on the health determinants among geriatric patients. Therefore, the overall results of this systematic review need to be interpreted cautiously. Based on the data from nine studies, the overall evidence remains scarce and inconsistent, most likely, inherent to the nature of the intervention and difference in professionals involved. For instance, one study only included women [13] while the others excluded frail people [20] and those with low renal clearance [17]. One study had a significantly higher mortality rate (32,1%) [15]. The assessment for ADL, quality of life and depressive symptoms differ significantly, rendering direct comparison impossible. Furthermore, the healthcare settings are different worldwide, rendering generalization of the results impossible. But also in similar healthcare systems, the composition for one setting may not be desired or even feasible in another. Even in a practice setting, teams, resources or availability of time may change [27]. Overall, our systematic review showed that inter-professional or multi-professional intervention has no impact on mortality rate, consistent with previous systematic reviews [4,11,28,29]. There are conflicting results, demonstrating either positive or neutral outcome, on physical health, psychosocial wellbeing and utilization of health care service, in contrast with previous systematic reviews [2,29,30].
Our systematic review also demonstrated that inter-professional or multi-professional interventions were feasible. These interventions were performed by various professionals, which were predominantly doctors and nurses [15][16][17][18][19][20][21][22][23]. Apart from objective health outcomes, the questions about composition of teams are of interest in the context of the topic. Some interventions involved physiotherapists, dietitians, occupational therapists and social workers [15,[20][21][22][23]. In fact, collaborative interventions by several different professions have been shown to be effective in improving patient-related outcomes [31][32][33]. As could be shown in a recent publication by LaDonna et al. 2017 physicians, nurses as well as pharmacists should be part of the health care team [33]. Similar results were obtained in our review but individuals revealed a broader sense of care team than the traditional definition used by literature. Results of this study indicate that patients identify between paid and unpaid team members as well as housekeepers and spiritual advisors. Therefore, it may be beneficial to ask patients who they consider to be in their team and engage these individuals in collaboration [33]. However, it is not clear in the data from our review which team composition is the most favourable for patients in transition from hospital to other care settings. This important result of the current review highlights the need for a broadly accepted and consented framework of collaboration in inter-and multiprofessional teams.
Currently, the comprehensive Geriatric Assessment (CGA) remains the core element of evidence for integrated complex care management of older patients [6]. The Cochrane Review by Ellis et al. (2017) [4] and other studies [2,11,28], provided evidence for the effectiveness of multi-professional comprehensive geriatric care when extended to different care settings on health care utilization. Our systematic review highlights the importance of international harmonization of assessment tools, especially for physical health and psychosocial wellbeing, within the CGA, to allow direct comparisons for future interventions.

Limitations
Our systematic review has several limitations. Firstly, there are inconsistencies of several results, inherent to the heterogeneous nature of the intervention and multi-professional involvement. Secondly, despite low risk of overall selection bias, there were some risk for performance bias [19,21,22] and attrition bias [17,23]. There was also a considerable risk for observer bias due to the characteristics of the interventions [15-18, 20, 21]. Thirdly, the generalisability of these results may be limited due to the inherent differences in various healthcare systems and the availability of these interventions [27]. Fourthly, this is the most updated systematic review based on an extensive search of studies in both the German and English languages only. Despite this, we found no relevant studies in German language. Finally, published articles were expected to be more likely to report positive findings as compared with unpublished articles. However, we have specifically selected RCTs to mitigate this risk. The work was performed according to best evidence. However, it cannot be excluded that the quality of the studies included in that review may also impact the inconsistent findings of the current work.

Conclusion
This systematic review showed that inter-professional or multi-professional intervention has no impact on mortality rate but either positive or neutral effects on physical health, psychosocial wellbeing and utilization of health care service. It showed that inter-professional or multiprofessional interventions were feasible. It also highlighted the importance of harmonization of assessment tools, to allow direct comparisons for future systematic review.