Effectiveness of peer assessment for implementing a Dutch physical therapy low back pain guideline: cluster randomized controlled trial.

Abstract

Clinical practice guidelines are considered important instruments to improve quality of care. However, success is dependent on adherence, which may be improved using peer assessment, a strategy in which professionals assess performance of their peers in a simulated setting. The aim of this study was to determine whether peer assessment is more effective than case-based discussions to improve knowledge and guideline-consistent clinical reasoning in the Dutch physical therapy guideline for low back pain (LBP). A cluster randomized controlled trial was conducted. Ten communities of practice (CoPs) of physical therapists were cluster randomized (N=90): 6 CoPs in the peer-assessment group (n=49) and 4 CoPs in the case-based discussion group (control group) (n=41). Both groups participated in 4 educational sessions and used clinical patient cases. The peer-assessment group reflected on performed LBP management in different roles. The control group used structured discussions. Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guideline-consistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0-100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20-100). Vignettes were completed by 78 participants (87%). Multilevel analysis showed an increase in guideline-consistent clinical reasoning of 8.4% in the peer-assessment group, whereas the control group showed a decline of 0.1% (estimated group difference=8.7%, 95% confidence interval=3.9 to 13.4). No group differences were found on self-reflection. The small sample size, a short-term follow-up, and the use of vignettes as a proxy for behavior were limitations of the study. Peer assessment leads to an increase in knowledge and guideline-consistent clinical reasoning.