Introduction
Background
RA affects an estimated 1.5 million adults in the United States with a substantial negative impact on quality of life and mortality.1 Despite advances in treatment over the past two decades, a significant percentage of RA patients either do not respond to therapy or lose their response to therapy over time.2 JAK inhibition represents a novel and effective way to treat patients with RA.3 

Gaps in Clinician Knowledge and Competence
Our survey of clinicians caring for patients with RA, including rheumatologists and primary care clinicians, demonstrated a lack of knowledge regarding the role JAK plays in RA pathogenesis and how JAK inhibitors work to treat the disease. Without this foundational knowledge, clinicians cannot appropriately use JAK inhibitors in practice. Published data and clinician interviews confirmed these gaps. It became clear that clinicians working as part of a multidisciplinary team to care for patients with RA would need education to enhance their understanding of oral JAK inhibitors’ multilayered MOA and how these innovative agents can be used optimally in appropriate patients with RA.

Methods
Innovative Educational Design
How could we address the identified needs to develop an engaging CME activity that wouldn’t be the “same old CME?” Its design had to create opportunities to increase knowledge and competence, with the hope of improving clinical performance. The idea for a game originated with a staff member’s childhood memories of playing Oregon Trail. That game’s most memorable components were how the element of fun enhanced learning, and the way the game repeatedly visualized learner progress by showing a covered wagon moving across a map of the United States. Similar elements could be used to communicate and visually illustrate fundamental information about JAK inhibitors.

Using an active learning design facilitates retention and application of information. 4 Moreover, fun has a positive effect on motivation levels, determining what we learn and how much we retain. Making learning fun increases its effectiveness and the likelihood of changing behavior.5,6 Blending childhood inspiration with adult learning principles and recent educational research, Paradigm envisioned a unique CME activity featuring a quiz-style game called Do You Know JAK?

The Do You Know JAK? activity began with a short video primer laying the groundwork about RA and JAK inhibition, information with which clinicians were unfamiliar according to our survey. Next, the game presented learners with knowledge- and case-based quiz questions, building on the information from the primer and putting it in real-world context. 

We designed an animated visual scorecard for the game, but instead of using a map of the Oregon Trail, we used the MOA of JAK inhibitors. Correctly answering a question resulted in successful JAK inhibition of the RA inflammatory cascade while answering incorrectly resulted in continued inflammation. This unique feature not only tracked learners’ success in the game, it repeatedly reinforced one of the scientific concepts the activity endeavored to teach. Learners visually tracked their score through the additional JAK inhibitors present and through the numerical score. Additional feedback was also provided in the form of short video rationales of the correct answers from the faculty members. 

The activity ended with a brief video of the faculty summing up important take-home messages for clinical practice. This component featured expert application of the educational content and provided memorable “hooks” on which participants could hang information from the primer and the game. Participants could also reflect on their answers to the game questions in light of the expert faculty’s comments.

Analyses
Matched pre/posttest results were analyzed to show increases in knowledge and competence. Cochran’s Q test was used to analyze the percentage of correct responses to each learning objective and to determine the statistical significance. The effectiveness of education was measured by calculating the Odds Ratio (OR) for providing a correct response on the posttest compared to the pretest. 

Results
A total of 849 learners participated in the Do You Know JAK? web activity. Analysis was conducted of pretest and posttest responses for 490 matched participants. For all statistics described, the significance level was set at p<.001. The percent correct responses and Q values are summarized in Table 1. To demonstrate the effectiveness of the training, the ORs of providing a correct answer on the posttest compared with the pretest were determined. (Table 1) An OR greater than 1 indicates a positive effect.

Table 1: Pretest/Posttest results following Do You Know JAK activity

*p<.001. All Q values were statistically significant.

Figure 2. Correct Pretest/Posttest Responses by Question

The results illustrated in Figure 2 represent a 242% increase in knowledge related to the role of JAK in the RA inflammatory cycle, a 222% increase in knowledge related to immune and anti-inflammatory effects of JAK inhibitors in RA and a 379% increase in competence related to using JAK inhibitors in appropriate patients. 

As another measure of competence, participants were asked to indicate on the postactivity evaluation, what they would do differently in the care of patients with RA based on participation in this activity. 79% of respondents (n=159) indicated they would make a practice change. The top 3 changes indicated by learners were: using or considering use of a JAK inhibitor to treat patients with RA; improving patient assessment to diagnose RA earlier; and consulting colleagues/prompt rheumatology referral.  

• Learners had the opportunity to provide comments in a free-text item on the postactivity evaluation. Following are some representative comments:
• Excellent activity!!!!!!
• Excellent graphics. They will help me remember the content.
• Good review and explanation of a challenging topic. 
• Great CME. Really enjoyed the game.
• The interactive game was good. Overall, excellent CME.
• Thank you for such a great activity.

Discussion
Educational Impact
The Do You Know JAK? activity was associated with significant increases in knowledge and competence. These were accompanied by a large percentage of participants intending to make practice changes. Additionally, participants acknowledged that the activity was enjoyable and effective. The results of the Do You Know JAK? interactive game activity demonstrate such formats can be highly effective in improving clinician knowledge and competence (Moore’s Levels 3 and 4).7 

To determine success in implementing their intended changes to practice, learners received a follow-up survey 2 months following their completion of the activity (Moore’s Level 5)7. The survey response rate (n=5) was too low to draw definitive conclusions, but the 20% of respondents who did implement changes suggests that the activity had some impact on clinical behavior.

Lessons Learned
We learned there are particular considerations that may impact the design and execution of gaming activities. First, although faculty members may be on-board with the format in theory, in practice it can be difficult for more seasoned CME presenters to step outside of a more traditional lecture format. Having examples or diagrams of how the game will work can be helpful for faculty members to envision the anticipated final product. Second, communicating ideas for visualizations to web development vendors who may not have scientific or clinical knowledge can be challenging. We found our production timeline was extended because of the number of iterations necessary to get the animated scoring mechanism right. However, these lessons learned have better prepared us to meet these challenges when implementing our next game activity.

CME is limited only by the creativity of the team developing the education. The outcomes from this activity demonstrate the effectiveness of game formats for CME. Do You Know JAK? provides one example, but games can be created in a variety of styles and functions to suit the content to be communicated and the outcomes desired. Given the success of this intervention, we plan to develop different gaming approaches for education about RA and other disease states.

Conclusions
There is a substantial need for clinician education about the role of JAK inhibition in the treatment of RA as uncovered during our research and evidenced by the low scores on pretest. Without such education, an important treatment option for improving the health and quality of life will be either overlooked or possibly used inappropriately. A gaming format engages learners in purposeful action, linking their recall and application of information to immediate results in the form of a score. It also adds elements of competition and fun, increasing the education’s effectiveness and impact. Results from this activity indicate gaming formats can result in significant improvements in knowledge and competence, as well as commitment to change among participants. Additionally, our learner feedback indicates clinicians enjoyed and valued the game format. 

Acknowledgements
Paradigm gratefully acknowledges Luciane Pereira-Pasarin, PhD for statistical analysis of outcomes data.

References

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4. Dale E. Audio-Visual Methods in Teaching. 3rd ed. New York, NY: Holt, Rinehart and Winston; 1969:108
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