title: InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial With Primary Care Physicians.
abstract: Most patients with diabetes mellitus (DM) are followed by primary care physicians, who often lack knowledge or confidence to prescribe insulin properly. This contributes to clinical inertia and poor glycemic control. Effectiveness of traditional continuing medical education (CME) to solve that is limited, so new approaches are required. Electronic games are a good option, as they can be very effective and easily disseminated.
  
  
  
  The objective of our study was to assess applicability, user acceptance, and educational effectiveness of InsuOnline, an electronic serious game for medical education on insulin therapy for DM, compared with a traditional CME activity.
  
  
  
  Primary care physicians (PCPs) from South of Brazil were invited by phone or email to participate in an unblinded randomized controlled trial and randomly allocated to play the game InsuOnline, installed as an app in their own computers, at the time of their choice, with minimal or no external guidance, or to participate in a traditional CME session, composed by onsite lectures and cases discussion. Both interventions had the same content and duration (~4 h). Applicability was assessed by the number of subjects who completed the assigned intervention in each group. Insulin-prescribing competence (factual knowledge, problem-solving skills, and attitudes) was self-assessed through a questionnaire applied before, immediately after, and 3 months after the interventions. Acceptance of the intervention (satisfaction and perceived importance for clinical practice) was also assessed immediately after and 3 months after the interventions, respectively.
  
  
  
  Subjects' characteristics were similar between groups (mean age 38, 51.4% [69/134] male). In the game group, 69 of 88 (78%) completed the intervention, compared with 65 of 73 (89%) in the control group, with no difference in applicability. Percentage of right answers in the competence subscale, which was 52% at the baseline in both groups, significantly improved immediately after both interventions to 92% in the game group and to 85% in control (P<.001). After 3 months, it remained significantly higher than that at the baseline in both groups (80% in game, and 76% in control; P<.001). Absolute increase in competence score was better with the game (40%) than with traditional CME (34%; P=.01). Insulin-related attitudes were improved both after the game (significant improvement in 4 of 9 items) and after control activity (3 of 9). Both interventions were very well accepted, with most subjects rating them as "fun or pleasant," "useful," and "practice-changing."
  
  
  
  The game InsuOnline was applicable, very well accepted, and highly effective for medical education on insulin therapy. In view of its flexibility and easy dissemination, it is a valid option for large-scale CME, potentially helping to reduce clinical inertia and to improve quality of care for DM patients.
  
  
  
  Clinicaltrials.gov NCT001759953; https://clinicaltrials.gov/ct2/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6oeHoTrBf).
authors.affiliation: Internal Medicine Department, Health Sciences Center, Londrina State University (UEL), Londrina PR, Brazil.
authors.forename: Leandro Arthur
authors.identifier: 0000-0002-9958-7213
authors.initials: LA
authors.lastname: Diehl
authors.affiliation: Games Division, Oniria Software Industry, Londrina PR, Brazil.
authors.forename: Rodrigo Martins
authors.identifier: 0000-0002-0653-4711
authors.initials: RM
authors.lastname: Souza
authors.affiliation: Internal Medicine Department, Health Sciences Center, Londrina State University (UEL), Londrina PR, Brazil.
authors.forename: Pedro Alejandro
authors.identifier: 0000-0002-6602-6137
authors.initials: PA
authors.lastname: Gordan
authors.affiliation: Medicine Department, Maringá State University (UEM), Maringá PR, Brazil.|Pró-Ensino na Saúde, Pequeno Príncipe College, Pequeno Príncipe Complex, Curitiba PR, Brazil.
authors.forename: Roberto Zonato
authors.identifier: 0000-0001-6632-775X
authors.initials: RZ
authors.lastname: Esteves
authors.affiliation: Pró-Ensino na Saúde, Pequeno Príncipe College, Pequeno Príncipe Complex, Curitiba PR, Brazil.
authors.forename: Izabel Cristina Meister
authors.identifier: 0000-0002-4904-0746
authors.initials: IC
authors.lastname: Coelho
mesh_terms: D003920:Diabetes Mellitus / Q000628:therapy*; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D006801:Humans; D007328:Insulin / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D058007:Physicians, Primary Care; D011795:Surveys and Questionnaires; D018910:Video Games / Q000523:psychology*
chemical_list: D007328:Insulin
keywords: continuing medical education; diabetes mellitus; educational technology; insulin; medical education; video games