Reviewed by Aleisha Nabower
What were the study questions?
Is the flipped classroom learning approach associated with students’ enhanced knowledge and behavior
more than the lecture-based learning approach in higher education? Does this differ by context?
How was the study done?
A search of the literature was conducted, using PRISMA guidelines which identified 1278 citations, of
which 46 met inclusion criteria for full review. Study methodological quality was assessed using the
Effective Public Health Practice Project Quality assessment tool. Data were extracted by two reviewers,
including characteristics of the study and types of outcomes. Outcome measures were classified as
examination scores, course grades, and objective structured clinical examinations and were categorized
according to the Kirkpatrick model and Bloom’s taxonomy. Data pooling was undertaken for analysis.
Heterogeneity of effect sizes were evaluated, and subgroup analyses were performed.
What were the results?
A total of 46 studies involving 9026 participants were included. Thirty-six studies had a high risk of bias,
mostly due to not blinding or poor-quality reporting. The flipped classroom was associated with higher
examination scores and course grades; however, this effect did not translate to OSCE scores. When
limited to only medical education studies the change in examination scores remained. When further
limited to include only medial education RCTs this difference did not persist. Outcomes rarely evaluated
What are the implications?
This study was the largest meta-analysis comparing the flipped classroom method to the standard
classroom. It was also the first to include multiple different learners, settings, and time frames allowing
for further analysis of factors contributing to results. While the data are promising with regards to the
use of flipped classroom techniques, more regimented studies and those including measures of higher
order learning are necessary to further evaluate the true efficacy of these techniques.
Editor’s note: This meta-analysis demonstrates that the heterogeneity in the included educational
research studies is largely due to missing information, influencing bias and resulting in inconclusive
findings. As stated by the authors, considering this in the larger context, without increased rigor in the
reporting of educational research, evidence-based decisions in medical education will not be possible