Table 1 Overview of the methods and results of a previously published trial (Van Dulmen et al. [18])

Design

A cluster-randomized controlled trial was conducted among 10 communities of practice (CoPs) of Dutch physical therapists (n = 90) to compare the effectiveness of two implementation strategies: peer assessment (PA) and case discussion (CD). Both strategies aimed to improve adherence to the clinical practice guidelines for the management of patients with low back pain. The programs consisted of four meetings over a six-month period. Outcomes were measured at baseline and at 6 months follow up.

Randomization and intervention allocation

CoPs showing interest in the program were invited to a plenary meeting in November 2009. They were informed that the study compared two educational strategies, and that both programs required an equal amount of time and effort. All physical therapists regularly treating patients with low back pain were eligible for inclusion. Included CoPs were randomly allocated to the PA group and the CD group resulting in six CoPs for the PA program (n = 49) and four CoPs for the CD program (n = 41).

Interventions

PA is the process whereby professionals evaluate or are being evaluated by their peers and provide each other with performance feedback. The main difference between PA and CD is that in the PA approach the tasks were structured, with a focus on performance rather than discussion, and participant roles were pre-defined. In the CD approach the tasks were less structured with ample opportunity for in-depth elaboration and discussion, and participant roles were not defined. In PA and CD, participants worked on identical cases concerning problem content, but for PA these cases were adjusted to allow for performance of participants in different roles. In PA, written cases were not known in advance but were presented by a coach on the spot, simulating daily clinical practice. For CD groups, written cases were included in the program guide to allow for proper preparation, along with instructions and written questions to guide the discussion process.

Outcome measures

Outcomes were assessed at baseline and at six months. Primary outcome was knowledge and guideline-consistent reasoning, measured with 12 performance indicators using four vignettes that fully covered the patient profiles described in the guidelines. Changes in reflective practice were measured with the Self-Reflection and Insight Scale (Grant et al., [49]).

Results

Vignettes were completed by 78 participants (PA group n = 44; CD group n = 34). Multilevel analysis showed an increase in guideline-consistent clinical reasoning of 8.4 % in the peer-assessment groups whereas the control groups showed a decline of 0.1 % (estimated group difference 8.7 %; 95 % CI: 3.9 to 13.4; P < 0.001). No group differences were found for self-reflection.