Many patients with high blood pressure (BP) do not have anti-hypertensive medications appropriately intensified at clinician visits. We investigated whether an online spaced-education (SE) game among primary care clinicians can decrease time to BP target among their hypertensive patients.
We conducted a randomized controlled trial to test the hypothesis that an SE game delivered to primary care providers (PCPs) on treatment of hypertensive patients will significantly decrease time to BP target (<140/90 mm Hg) among their patients. Time to BP target (<140/90 mm Hg) was the primary outcome since this is a sensitive assessment of the effect of a provider-oriented intervention. Pre-specified secondary outcomes included last BP recorded during the study and differences in primary care providers' post-game test scores. We also performed a post-hoc analysis comparing patients based on their use of anti-hypertensive medications prior to the study.
A two-arm randomized trial was conducted over 52 weeks among primary care clinicians at 8 hospitals. Educational content consisted of 32 validated multiple-choice questions with explanations on hypertension management. Providers were randomized into two groups: SE clinicians were enrolled in the game while control clinicians received identical educational content in an online posting. SE game clinicians were e-mailed one question every 3 days. Adaptive game mechanics re-sent questions in 12 or 24 days if answered incorrectly or correctly, respectively. Clinicians retired questions by answering each correctly twice consecutively. Posting of relative performance among peers fostered competition. Primary outcome measure was time to BP target (<140/90 mm Hg).
One-hundred eleven clinicians enrolled. The SE game was completed by 87% (48/55) of clinicians, while 84% (47/56) of control clinicians read the online posting. In multivariable analysis of 17,866 hypertensive periods among 14,336 patients, the hazard ratio for time to BP target was 1.043 (p=0.018) in the SE game cohort. The number of hypertensive episodes needed to treat in order to normalize one additional patient's BP was 67.8. The number of clinicians needed to teach to achieve this was 0.43.
Our study demonstrates that an online SE game among PCPs can significantly reduce the time to BP target among their hypertensive patients. As a method to increase clinicians' long-term knowledge, the SE game was significantly more effective than providing the identical content as an online posting with email reminders. This study adds to the growing evidence that educational games may be effective tools to engage health professionals, boost learning, optimize practice patterns, and improve patient outcomes.
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