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An innovative Peer Assessment approach to enhance guideline adherence
ISRCTN ISRCTN69003553
DOI 10.1186/ISRCTN69003553
ClinicalTrials.gov identifier
EudraCT number
Public title An innovative Peer Assessment approach to enhance guideline adherence
Scientific title A cluster randomized controlled trial comparing two educational strategies that aim for enhanced guideline adherence in physical therapy with Peer Assessment as the intervention and Case Discussion as the control condition
Acronym N/A
Serial number at source Reference number 8203 Royal Dutch Society for Physical Therapy
Study hypothesis We assume that Peer Assessment will more positively affect guideline adherence compared with Case Discussion. Moreover we hypothesise that Peer Assessment will prompt ‘reflective practice’ and that increased reflective practice will raise ‘levels of awareness‘ will be associated with increased guideline adherence.
Lay summary Background and study aims
Clinical guidelines are designed to facilitate evidence based practise in health care.
Research has demonstrated that guidelines do not easily find their way to clinical practice. Systematic reviews studying the effectiveness of educational strategies however, showed little to moderate effects on the improvement of evidence-based practice.
We introduced Peer Assessment (PA) as a new educational strategy for the implementation of the Dutch guideline on upper extremity disorders in physical therapy. Peer Assessment is the process whereby professionals evaluate or are being evaluated by their peers and provide each other
face-to-face feedback and scores.
The aim of this study is to compare the effectiveness of ‘peer assessment’ (PA) with the regular implementation strategy ‘case discussion’ (CD).

Who can participate?
Physical therapists in the Netherlands, organised in Communities of Practice (CoPs) are invited to participate. The need to register for the post graduate training program on upper extremity complaints, offered by the Dutch Association of Physical therapy. CoP’s in the Netherlands are composed of 5 – 15 professionals that share the same interests or the same clinical setting. All CoP’s that show interest for the program are eligible for inclusion.

What does the study involve?
Both PA – and CD- programs consist of four meetings of three hours. The program content of the PA-program and the CD-program is identical; the educational format is different. Participants work on written cases that fully cover the patient profiles described in the guidelines.
The main difference between the two interventions is, that in the PA-approach, the tasks are ‘highly structured’ and supervised by a coach. Participants individually perform in the role of PT, ‘simulated patient’ and ‘assessor’. The PA-approach is focussed on ‘performance’ rather than discussion. In the CD-approach tasks are ‘loosely structured’ with ample space for in-depth elaboration and discussion and participant’s roles are not defined.
Guideline adherence will be measured by an online test at baseline and at 8 months follow up. We also will assess the extent to which participants are aware of their guideline adherence (awareness) and their reflective practice and commitment to behavioural change.

What are the possible benefits and risks of participating?
Participation is awarded with 20 credit points for the Dutch Quality Register of Physical Therapy. Participants may additionally benefit of feedback on their knowledge and skills at post-tests.
There are no risks related to participation in this trial.

Where is the study run from?
The study will be conducted by Radboud University Medical Centre, at the Scientific Institute for Quality of Health Care, Nijmegen, the Netherlands.

When is the study starting and how long is it expected to run for?
The trial began recruiting participants from November 2011 until January 2012. The study started in February 2012 and ended in October 2012.

Who is funding the study?
Royal Dutch Society for Physical Therapy (KNGF)

Who is the main contact?
Marjo Maas
m.maas@iq.umcn.nl
Ethics approval The Regional Committee on Medical Research Ethics, Involving Human Subjects (CMO), Arnhem – Nijmegen, The Netherlands, stated in writing that ethical approval was not necessary.
CMO Registration number: 2013/036, Date: 14/01/2013
Study design Clustered randomised controlled trial
Countries of recruitment Netherlands
Disease/condition/study domain Upper Extremity Complaints of the muscular-skeletal system related to stressful postures and movements in work, sports and daily life
Participants - inclusion criteria 1. All Communities of Practice that are registered by the Royal Dutch Society for Physical Therapy (KNGF) and that show interest for the implementation program, are eligible for inclusion in the trial (PA-group or the CD-group).
2. We include all Physical Therapists that are organised in Communities of Practice. Individual Physical Therapists are excluded from the trial.
Participants - exclusion criteria Physical Therapists that do not participate in a Community of Practice are excluded from the trial
Anticipated start date 01/01/2012
Anticipated end date 01/10/2012
Status of trial Completed
Patient information material Not available in web format, please use the contact details below to request a patient information sheet
Target number of participants 20 - 22 Communities of Practice because the group sizes of CoPs vary widely, we target on 80 Physical Therapists in the Intervention Group and 80 Control Group.
Interventions Peer Assessment as intervention and Case Discussion as control.

Interventions
Before the start of the program, both PA-group and CD-group receive a link to the KNGF guidelines. Subsequently all participants receive a program guide tailored to the intervention, with detailed information about learning objectives, learning content, training schedule, didactic format and procedure. The program for both groups consists of four sessions of 3 hours and will be launched in February 2012. Participants work on written cases that fully cover the patient profiles described in the guidelines. The main difference between the two interventions is, that in the PA-approach, the tasks are ‘highly structured and supervised by a coach. Participants individually perform in the role of Physical Therapist, ‘simulated patient’ and ‘assessor’. The PA-approach is focussed on ‘performance’ rather than discussion. In the CD-approach tasks are ‘loosely structured’ with ample space for in-depth elaboration and discussion. Participant roles are not defined. In PA and CD participants work on identical cases concerning problem content, but for PA these cases are adjusted to allow for performance of participants in different roles. In PA written cases are not known in advance, but are presented by an external coach on the
spot.

Participants are provided with rules for giving and receiving constructive feedback and for creating a safe learning environment. In the role of PT, participants analyse the case by reasoning aloud and demonstrate (hands-on) diagnostic and treatment skills. Peer performance is assessed by using a global scoring sheet containing global criteria that will be scored on a 5-point Likert scale (1 = much improvement needed to 5 = no improvement needed). Accordingly qualitative oral improvement feedback is given. The four external coaches are trained in the peer assessment procedure and only provide feedback when all peer feedback is collected and additional feedback is needed. Coaches will be provided with a coach manual.

For CD-groups, written cases will be included in the program guide together with questions to guide the discussion process to allow for proper preparation and in-depth discussion.
Primary outcome measure(s) Guideline Adherence will be assessed at baseline and after 6-7 months when both groups have finalized their meetings.

Pre-test and post-test is an online questionnaire based on four clinical vignettes. Each vignette is accompanied by 12 quality indicators for diagnosis and treatment of shoulder complaints. Each indicator contains a set of test-items in the format of statements that can be scored on a 3-point scale: D = disagree, U = disagree nor agree, A = agree. Post-intervention mean total scores on the four vignettes of both PA and CD group will be included as outcome variable, and baseline scores will be included as covariate. Multilevel analyses will be performed to account for baseline differences and for clustering within CoPs. The same procedure will be performed for the secondary outcome measures.
Secondary outcome measure(s) 1. Awareness
Awareness is measured by comparing the assessed improvement measured by clinical vignettes with self-reported improvement. The relationship between the ‘perceived improvement’ and ‘assessed improvement’ is conceived as a measure of ‘awareness’’.
2. Reflective Practice
At pre-test and post-test participants complete the validated questionnaire ‘Self Reflection and Insight Scale’. Pre- and post-test differences are conceived as a measure of ‘improved reflective practice’.
3. Goals attainment
At pre-test participants were asked to formulate three learning goals in order of personal importance according to the concept of ‘Commitments to Change’. At post-test they will be asked to indicate the extent to which their goals are achieved on a 3-point scale from 1 = not achieved, 2 = partially achieved, to 3 = achieved. Mean scores will be calculated and conceived as a measure for ‘goal attainment’.
4. Perceived learning value
At post-test participants will be asked to indicate the learning value of the key elements of the program on a 5-point Likert scale from 1 = little instructive to 5 = very instructive. Mean scores will be calculated and conceived as a measure for ‘perceived learning value’.
Sources of funding 1. Royal Dutch Society for Physical Therapy (Netherlands)
2. Radboud University Nijmegen Medical Centre (Netherlands) - Scientific Institute for Quality of Healthcare
Trial website
Publications
Contact name Prof  Maria  Nijhuis-van der Sanden
  Address Scientific Institute for Quality of Healthcare (IQ healthcare)
Radboud University Nijmegen
Medical Centre
Geert Grooteplein noord 21
  City/town Nijmegen
  Zip/Postcode 6500 HB
  Country Netherlands
Sponsor Royal Dutch Society for Physical Therapy (Netherlands)
  Address Stadsring 159b
3817 BA Amersfoort
  City/town Amersfoort
  Zip/Postcode 3800AE
  Country Netherlands
  Sponsor website: http://www.fysionet.nl
Date applied 24/02/2013
Last edited 26/04/2013
Date ISRCTN assigned 26/04/2013
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