A team-based online game aimed at improving self-management of type 2 diabetes lowers HbA1c at 1 year, according to results of a randomized controlled trial. The magnitude of the reduction is similar to that seen when patients start a new diabetes drug, researchers report in an article published online August 8 in Diabetes Care.
With an intervention delivered via mobile app or email, the trial aimed to test whether online games improved longer-term diabetes management. For the first 6 months of the study, patients in the active intervention arm participated in a diabetes self-management education (DSME) game online, whereas those in the control group participated in a civics game online. Patients were then followed for an additional 6 months.
At 12 months, 227 participants in the DSME group had a -8 mmol/mol drop in HbA1c, compared with -5 mmol/mol (95% CI, -7 to -3) among the 227 participants in the control group (P = .048). The authors note that the difference between groups continued to increase throughout follow-up, such that the difference was greatest at 12 months.
The data demonstrate that an online DSME game leads to “significant improvements in HbA1c over 12 months,” write B Price Kerfoot, MD, a urological surgeon from the Veterans Affairs Boston Healthcare System, Boston, Massachusetts, and colleagues. “This may be an effective and scalable method by which to improve health outcomes in patients with diabetes and other chronic diseases.”
“Among the subgroup of patients with uncontrolled diabetes, we saw a reduction in HbA1c levels that you would expect to see when a patient starts a new diabetes medication,” Dr Kerfoot said in a press release from Brigham and Women’s Hospital, where is he an associate professor of surgery. “Although their blood glucose levels were still above the target range, this was a strong step in the right direction and resulted in a sustained and meaningful improvement in blood glucose control.”
“Veterans with diabetes not only learned health information that benefited them but also enjoyed the experience,” said senior author Paul R Conlin, MD, endocrinologist and vice chair, department of medicine, at Brigham and Women’s Hospital and chief of medical service at VA Boston Healthcare System, in the news release. “About 89% of participants requested to participate in future programs using this game.”
Trial Designed to Improve Disease Control
In total, 456 Veteran Affairs patients from the eastern United States who had type 2 diabetes with inadequate glucose control while taking oral diabetes medications enrolled in the study. The researchers randomly assigned half the patients to the diabetes education game (and to receive a printed pamphlet about civics) and the other half to a civics education game (and to receive a printed pamphlet about diabetes management).
Players received two multiple-choice questions twice a week via email or mobile app over a 6-month period. The questions featured clinical case scenarios related to glucose management, exercise, long-term diabetes complications, medication adherence, and nutrition. After an attempted answer, the participant was presented with the correct answer and an explanation, and the same question was re-sent after 4 weeks to reinforce the message. The game also included a take-home message and references.
Response rates were very good, with 94% and 90% of participants in the DSME and civics groups, respectively, submitting answers. Participants earned points for correct answers and were assigned to teams based on their geographic region. Individual and team scores were posted on leader boards to foster a sense of competition and community.
Of interest is the educational method used that involves “spaced education,” whereby discrete packages of information are presented and repeated over intervals of time. Spaced education is thought to improve long-term retention of learning and to generate meaningful behavioral change.
The authors point out that the greatest effect of the game on HbA1c was in the 6 months following end of the game. “This may be due to the time lag in appropriate adoption of health-improvement behaviors induced by the DSME game.”
They also note that, contrary to their initial hypothesis that diabetes control would be achieved via better adherence to medications, this was not seen. Instead, the authors speculate that the game “may have affected longer-term glucose control via lifestyle changes such as exercise and nutrition,” but such data were not collected, so their effect remains unclear. Substantial reductions in HbA1c were also observed in the control group. The authors add that the DSME booklets (given to controls) are known to improve HbA1c levels over 12 months.
The authors note that further research is needed to determine whether and how such games can maintain or increase improvements over time.
Dr Kerfoot disclosed that he is an equity owner of Qstream Inc, an online platform launched by Harvard University to host spaced education. Funding for this study was provided by the Agency for Healthcare Research and Quality. The coauthors report no relevant financial relationships.
Diabetes Care. Published online August 8, 2017. Abstract
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