Online Program Achieves Long-Term Improvement in Glucose Control

Diabetes self-management education delivered via an online game reduced hemoglobin A1c levels in patients with type 2 diabetes.

Interview with B. Price Kerfoot, MD, EdM, and commentary by Caroline Apovian, MD

Developing teaching approaches that improve the overall health of patients with type 2 diabetes (T2D) remains a clinical challenge. A research team from Harvard examined the effectiveness of an online game used for diabetes self-management education (DSME) on hemoglobin A1c (HbA1c) levels;their findings were published in Diabetes Care

Patients who played an online game had a significant reduction in HbA1c levels that were sustained over 12 months in comparison to a control group, suggesting this method may be an effective self-management tool to guide patients in their diabetes care.A Cochrane Review found ample support for DSME as a useful tool used in the management of T2D.2 However, current DSME tools seem to lose their effectiveness 1-3 months after completion of the educational trial.3

Patients achieve better glucose control after playing educational online game.

“Over the last 8 years, we have conducted several large, randomized trials showing that this game methodology delivered to clinicians could boost long-term learning, improve their practice patterns, and improve the health measures of their patients,” B. Price Kerfoot, MD, EdM, associate professor of surgery at Harvard Medical School in Boston, Massachusetts, and lead author of the study.

“Given that the game is effective with clinicians, we wondered whether it could be even more effective when implemented directly with patients,” Dr. Kerfoot said.

Implementing the Self-Management Study

Of the prospective individuals who were contacted, 456 patients met the study criteria and fully completed the enrollment process, and were randomized into two groups: DSME (227) and civics (229) games. Patients represented a wide geographic distribution. However, 95% of participants were male.

The researchers delivered two questions biweekly via email or mobile text for six months to patients attending the Veterans Affairs centers in the eastern U.S.1 They selected participants with T2D who had good glucose control with oral medications with or without concomitant use of insulin.1 The patients HbA1c levels were measured before the game was introduced, after 6 months of game participation, and after 6 months post-game use.1

The researchers employed “spaced education,” which is based on two well-known psychological phenomena known as the spacing and testing effects.1 These experiences have been demonstrated to improve long-term retention of information and cause behavioral changes.4,5

The questions were presented to the participants who were given the correct answer immediately after responding with a detailed explanation for the preferred response.1 Each question was repeated 4 weeks later to reinforce the learning points.1

Patients were given the opportunity to answer missed questions after 2 weeks. In addition, patients were assigned to teams, scores were posted on leaderboards to facilitate competition, and there were cash prizes for the top teams as well as top 30% of individuals on losing teams. The control group was given an online civics game to play with a paper DSME booklet.

Sustained Improvement in Glucose Control Achieved

At 12 months, patients with baseline levels of HbA1c ≥ 75 mmol/mol were assessed.1 Patients in the DSME game group showed a significant reduction in HbA1c levels as compared to civics game players (16 mmol/mol vs. 9mmol/mol reduction, P = 0.031, respectively). This reduction was similar to findings in patients after a new diabetes medication has been initiated.1

“I think the most important finding was that the game was able to generate significant longer-term improvements in HbA1c, especially among patients with an HbA1c >9%,” Dr. Kerfoot said.  A short-term increase in empowerment was also noted.1

The initial hypothesis was that patients would have increased adherence to their oral medications, and that would be reflected in lower HbA1c levels.1 However, this was not supported by the findings. The authors speculate that the glucose control observed may have been due to lifestyle changes such as nutrition and exercise, but they did not collect data on these factors for this study.1

What is the Potential for Online, Self-Management Tools?

“We do not know the exact mechanism or mechanisms yet by which the game improved HbA1c,” said Dr. Kerfoot, “We only had limited power to detect these associations. The DSME game content focused on glucose management, exercise, long-term diabetes complications, medication adherence, and nutrition. In future research, mobile applications to track lifestyle changes used in combination with the DSME game may help define the role of exercise and nutrition in the longer-term HbA1c changes we observed,”

“This research shows that making education fun for patients can help them take better care of themselves,” Caroline Apovian, MD, professor of medicine and pediatrics at Boston Medical Center in Boston, Massachusetts, who was not associated with the study, told EndocrineWeb.

This study was conducted in a patient population of veterans, but both Dr. Kerfoot and Dr. Apovian can see a wider use for a game of this type. Dr. Apovian observed, “I think it’s amenable to different populations, and would probably be a good study to do in adolescents with type 1 diabetes.”

Dr. Kerfoot sees a wider applicability, “Since participants merely require a computer or mobile device with an Internet connection to participate, the DSME game has the potential to scale easily to larger patient populations, to healthcare systems, and to remote healthcare settings across the globe.  In addition, the game methodology is content-neutral and thus can be utilized to deploy games to improve health outcomes in patients with other chronic diseases, not just diabetes.”

In the near-term, Dr. Kerfoot hopes “the endocrinologist will learn that they now have a new effective and easily scalable tool with which they can generate sustained and meaningful improvements in their patients' HbA1c. To play, patients only need a desire to improve their health, a competitive spirit, and an email account or mobile device.”

B. Price Kerfoot, MD, is an equity owner of QstreamInc., an online platform launched by Harvard University to host SE outside of its firewalls. No other conflicts of interest relevant to study were reported.

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Managing Diabetes with Blood Glucose Control
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