Plain English Summary
Background and study aims
Clinical practice guidelines are considered important instruments to improve quality of care, but their use in clinical practice is limited. Many different types of barriers may influence the use of clinical guidelines. A range of interventions has been developed to increase the use of guidelines, including audit and feedback, continuing professional education and reminders. In physical therapy, the discrepancy between current practice and the recommendations of the guidelines is related to the knowledge or skills of the physical therapists. Those barriers ask for an educational and behavioral strategy. A specific educational strategy is peer assessment, where peers observe the performance of colleagues and give them feedback. The aim of this study is to find out whether peer assessment is more effective at improving guideline adherence and reflective practice than regular case-based discussions, which is the regular implementation strategy.
Who can participate?
Communities of practice that include physical therapists and manual therapists treating patients with low back pain on a regular basis
What does the study involve?
The communities of practice are randomly allocated to either peer assessment or case-based discussions. Both peer-assessment groups and case-based discussions groups consist of a series of four meetings during a six-month period in 2010. Both programs include strategies to improve knowledge about the Dutch physical therapy guideline on low back pain and on clinical reasoning skills according to the decision aid in the guideline. This guideline describes the diagnostic and therapeutic actions physical therapists should perform when faced with patients suffering from low back pain. Peer assessment consists of the performance and assessment of tasks of individual clinical cases derived from the Dutch physical therapy guideline on low back pain. During the peer-assessment meetings, participants perform the physical therapist role, patient role, and assessor role. In the physical therapist role they have to demonstrate diagnostic and therapeutic reasoning and skills based on written patient cases. Cases cover the content domain of the guideline on low back pain. In the assessor role they have to observe the performance of their peers and provide them with feedback. In the patient role, participants simulate a clinical problem according to brief simulation guidelines. The peer-assessment process is coached by an external assessor. Case-based discussion groups receive a program manual that contain a structured program schedule and written clinical cases accompanied by questions to guide group discussion. After every meeting, the learning results are evaluated by the group. There is no external coach to guide the discussion process. Outcomes are assessed at the start of the study and after 8 months when both groups have finished their meetings. Adherence to the low back pain guideline is assessed by means of a written assignment using four patient cases.
What are the possible benefits and risks of participating?
Both groups receive an intensive strategy for implementing the guideline on low back pain. One intervention might be more effective than another.
Where is the study run from?
Scientific Institute for Quality of Healthcare in collaboration with the Royal Dutch Society for Physical Therapy and the HAN University of Applied Sciences (Netherlands)
When is the study starting and how long is it expected to run for?
September 2009 to October 2010
Who is funding the study?
Royal Dutch Society for Physical Therapy, the Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, and the HAN University of Applied Sciences (Netherlands)
Who is the main contact?
Simone A van Dulmen
s.vandulmen@iq.umcn.nl
Trial website
Additional identifiers
EudraCT number
ClinicalTrials.gov number
Protocol/serial number
N/A
Study information
Scientific title
The effectiveness of peer-assessment to improve guideline adherence and reflective practice compared with regular case-based discussions about the Dutch physical therapy guideline on low back pain. A cluster randomized controlled trial in Communities of Practice (CoP) of primary care physical therapists.
Acronym
Study hypothesis
A significant improvement of guideline adherence, clinical reasoning, and self-reflection after the intervention peer-assessment compared with the regular intervention case-based discussions.
Ethics approval
The Regional Committee on Medical Research Ethics, Nijmegen, July 2012, ref: 2012/211
Study design
Cluster randomized trial
Primary study design
Interventional
Secondary study design
Cluster randomised trial
Trial setting
Other
Trial type
Treatment
Patient information sheet
Condition
Implementation of the Dutch guideline on low back pain for physical therapists
Intervention
All participants will be invited for a joint meeting where the updated low back pain guideline will be discussed in an interactive educational session. Both peer-assessment groups and case-based discussion groups (regular implementation) consist of a series of four meetings during a six month period. Both programs are aimed at improving clinical reasoning and clinical decision making according to de guideline low back pain.
Intervention group
Peer-assessment consist of the performance and assessment of tasks of individual clinical cases that are derived from the Dutch physical therapy guideline on low back pain. Peer groups will be provided with a manual that contained a highly structured program, guidelines for giving and receiving feedback and a scoring form.
During the peer-assessment meetings, participants will be performing the physical therapist role, a patient role, and an assessor role. In the physical therapist role they have to demonstrate diagnostic and therapeutic reasoning and skills based on written cases. Cases cover the content domain of the guideline. In the assessor role they have to observe the performance of their peers and provide them of improvement feedback. The peer-assessment meetings are tightly scheduled and discussion time is limited. Based on the feedback of their performance of the first two meetings the participants will develop a personal plan for improvement, including an action plan, which will be evaluated and discussed during the third meeting. In the final meeting another session of peer-assessment will be scheduled based on explicit learning objectives of the individual physical therapists. This session is identical to the first two meetings, with patient cases focused on learning objectives of the physical therapists. The peer-assessment process will be coached by an external assessor who provide additional feedback.
Control group
The case-based discussion groups will also receive a structured program schedule that allows time for group discussion. The manual include a preparation phase for each meeting, joint discussion and evaluation. Clinical cases are provided in advance to allow for preparation.
During the fourth meeting 25 statements about low back pain will be discussed. After this meeting participants will answer individually the statements as being true or false via an electronic system and received feedback on the results. There is no external coach to guide the discussion process.
Outcomes will be assessed at baseline and after 8 months when both groups have finalized their meetings.
Intervention type
Other
Phase
Not Applicable
Drug names
Primary outcome measure
Adherence to the low back pain guideline with 12 validated performance indicators. These indicators reflect all steps in the care process and are directly related to the clinical vignettes based on the Dutch physical therapy guideline on low back pain. The degree to which physical therapists adhere to these indicators will be assessed by means of an online assignment using vignettes of four cases of low back pain that adequately cover the patient profiles described in the guideline. For each vignette, a score of guideline adherence will be calculated by dividing the actual score by the maximum possible score, and multiplying the result by 100. In addition, a mean score of overall guideline adherence will be calculated by adding up the four scores per vignette and dividing the total by four.
Secondary outcome measures
Self-reflection, which is measured by the Self-Reflection and Insight Scale (SRIS) at baseline and after 8 months follow up.
Overall trial start date
01/09/2009
Overall trial end date
31/10/2010
Reason abandoned (if study stopped)
Eligibility
Participant inclusion criteria
Communities of Practice with physical therapists working in a primary care setting and treating patients with low back pain on a regular basis
Participant type
Health professional
Age group
Adult
Gender
Both
Target number of participants
12 Communities of Practice with 6-12 physical therapists per COP (2 x 6 groups)
Total final enrolment
10
Participant exclusion criteria
Communities of Practices with physical therapist who are not working in primary care and not treating patients with low back pain on a regular basis
Recruitment start date
01/09/2009
Recruitment end date
31/10/2010
Locations
Countries of recruitment
Netherlands
Trial participating centre
Harvard Medical School
Boston
MA 02115-5821
United States of America
Sponsor information
Organisation
Royal Dutch Society for Physical Therapy (Netherlands)
Sponsor details
PO Box 248
Amersfoort
3800 AE
Netherlands
+31 334 672 900
wees@kngf.nl
Sponsor type
Research organisation
Website
Funders
Funder type
Research organisation
Funder name
Koninklijk Nederlands Genootschap voor Fysiotherapie
Alternative name(s)
Royal Dutch Society for Physical Therapy, KNGF
Funding Body Type
private sector organisation
Funding Body Subtype
Associations and societies (private and public)
Location
Netherlands
Funder name
Radboud Universitair Medisch Centrum (ref: RG000365)
Alternative name(s)
Radboudumc, Radboud University Medical Center, Radboud University Nijmegen Medical Center, RUNMC
Funding Body Type
private sector organisation
Funding Body Subtype
Universities (academic only)
Location
Netherlands
Funder name
School for Physical Therapy, University of Applied Sciences (Netherlands) ref: 443142
Alternative name(s)
Funding Body Type
Funding Body Subtype
Location
Results and Publications
Publication and dissemination plan
Not provided at time of registration
Intention to publish date
Participant level data
Not provided at time of registration
Basic results (scientific)
Publication list
2014 results in https://pubmed.ncbi.nlm.nih.gov/24830716/ (added 17/12/2020)