ABCD Project Bulletin Overall Summary & Final Results

ABCD Alberta’s Caring for Diabetes Project Bulletin

Overall Summary & Final Results

We are happy to share the final results of the ABCD project. Thank you for your ongoing support and commitment to the project and its quality improvement interventions.

Project Review

2010 Training; registry development and patient recruitment

2011 Ongoing patient recruitment; initial data collection

2012 Patient recruitment completed; ongoing data collection

2013 Final data collection; data analysis and preliminary reporting

2014 Data analysis and reporting; economic evaluation; knowledge translation

Thank you

ABCD, TeamCare & HEALD in PCNs

We partnered with four Primary Care Networks (PCNs) in Alberta to deliver two quality improvement interventions, TeamCare and HEALD, for people with type-2 diabetes. Both interventions were part of a larger project called Alberta’s Caring for Diabetes (ABCD).

We showed TeamCare was effective in reducing depressive symptoms in patients with type-2 diabetes, through a nurse-led collaborative care model. In addition, HEALD was effective in increasing daily activity through an exercise specialist-led walking program.

Often, evaluations of health interventions are limited to assessing efficacy or effectiveness. To better understand the overall impact of the ABCD interventions, we adapted the RE-AIM framework and addressed five dimensions: Reach, Effectiveness, Adoption, Implementation and Maintenance.

Here, we report the overall results of TeamCare and HEALD by RE-AIM dimension. Reach, Adoption and Maintenance are reported collectively, while Effectiveness and Implementation are reported by intervention. We listed our current publications on the last page for your reference.

If you want more information, please do not hesitate to contact us. Our contact information is on the last page.

2

ABCD Project Bulletin Overall Summary & Final Results

each

Patient registries are fundamental in chronic disease management. Diabetes-specific patient registries are associated with better processes and outcomes of care. As part of the ABCD project and recruitment process for TeamCare and HEALD, we helped establish, update and implement type-2 diabetes patient registries with our partner PCNs. We found that the quality of the registries depended on:

• whether physicians granted PCN access to patient lists

• the strategies used in development

• the reliability of diagnostic information

• the data elements collected

However, there was limited ability to update the registries once developed. We concluded that proactive management of chronic diseases, like diabetes, requires the ability to reach targeted patients through high quality, functioning registries.

Key elements of a diabetes registry

We found the minimum necessary data elements to capture in a diabetes registry to be…

• patient information: name, address, phone number, birthdate, PHN, family physician

• clinical information: current HbA1c, LDL, blood pressure, height, weight, waist circumference

doption Our partnership with the PCNs was unique. There were many successes, challenges and outcomes to report in the adoption of TeamCare and HEALD.

Ready – The PCNs were all in a favourable position to adopt the interventions Set – The PCNs reported prioritization and willingness to initiate the interventions Go – Regardless, the continuous dynamic interplay of leadership support, existing physician culture and unique context of each PCN influenced adoption

Strong collaboration and novel strategies that involve policy-makers, PCNs and providers are needed to help find solutions to

improve registry quality and resolve maintenance issues.

Overall, we found the alignment of priorities, sustained leadership support and culture of innovation facilitate the adoption of interventions. The ability to tolerate

innovation or disruption was fluid and non-linear. This organizational stability should be re-assessed on an

ongoing basis when adopting interventions.

R

A

The quality of patient registries improves outcomes

Organizational stability affects intervention adoption

3

ABCD Project Bulletin Overall Summary & Final Results

TeamCare

2

Economic – More depression-free days is worth it

We compared all three groups in the economic analysis of TeamCare; our two study groups (TeamCare and active-control), and a non-screened usual care group. We used depression-free days (DFDs), based on changes in depressive symptoms; and QALYs, based on changes in quality of life measures, as outcomes. The TeamCare intervention cost $1,021 per patient over and above usual care; the active-control group cost $450 more.

Both study groups improved DFDs and QALYs gained compared to usual care. The TeamCare group had 118 more DFDs than usual care, and the active-control group had 66 more. Compared to usual care, the incremental cost-effectiveness ratio (ICER) is $9/DFD for TeamCare and $7/DFD for the active-control group. The corresponding ICER per QALYs gained is $24,368 for TeamCare and $76,271 for the active-control group.

Compared to literature-based thresholds, TeamCare is cost-effective.

“We saw that there were clear results with the patients. We saw the reduction in the [PHQ] scores occurring every couple of weeks…”

Psychiatrist

ffectiveness E

TeamCare improved depressive symptoms among patients, similar to those demonstrated in previous trials. It cost $571 more than active-control and $1,021 more than usual care. If additional resources are available, the greatest improvements in depressive symptoms for people with type-2 diabetes could be

achieved through collaborative TeamCare.

Usual Care

(n=71)

Intervention (n=95) Δ

Active-Control (n=61) Δ

Cost per participant (CAD)

5889

6910 571 (-3129,4241)

6339 450 (-3814,4727)

DFDs - 214 52 (15.9, 87.3)

162 66 (31.8,100.2)

ICER - 9 7

0  

5  

10  

15  

20  

Baseline   6  month   12  month  

   Control  (n=62)      Interven9on  (n=95)      Usual  Care  (n=71)  

PHQ-9 Results

1

Perceived – Anticipated patient improvement

Prior to learning about the demonstrated effectiveness of TeamCare, PCN staff reported varying opinions regarding its potential for improving patient outcomes. Interestingly, PCN staff anticipated improved outcomes as a result of the key intervention components: 1) active patient follow up, 2) specialist consultation and 3) treat-to-target principles.

Clinical – Patients improved their depressive symptoms Full results available (see Publications, page 6)

The majority of TeamCare patients had substantial improvements in depressive symptoms, as measured by the PHQ-9 (figure below). We found greater improvements were achieved through this collaborative care model (intervention group). However, there were also benefits to actively identifying patients with type-2 diabetes and depressive symptoms and notifying their physician (active-control) compared to usual care. Given that enrolled patients were already well managed, their diabetes measure remained controlled.

4

ABCD Project Bulletin Overall Summary & Final Results

PCN Staff Recommendations

Clinical – Patients walked more Full results available (see Publications, page 6)

This six month exercise specialist-led lifestyle management program was effective in increasing daily physical activity among adults with type-2 diabetes. However, given that enrolled patients were generally already at recommended clinical targets, the increase in daily steps was not associated with improved metabolic outcomes. Perceived – Varying opinions

Prior to learning about the demonstrated effectiveness of HEALD, PCN staff reported varying opinions regarding its potential for improving patient outcomes. Rationales for their views of limited effectiveness included:

• inadequate intensity or dose (i.e., frequency or duration) of the intervention

• quality of usual care for people with diabetes was already good

• patients were already managing their diabetes well

• potential co-intervention among active-control patients

Intervention (n=94)

Active-Control (n=92)

Difference

Cost per participant (CAD)

1176 1172 102

(-318, 464)

Average steps per participant

7038 6645 919

(116, 1666)

ICER 111

ffectiveness E HEALD

Economic – Increasing daily steps was cost-effective The HEALD intervention cost $340 per patient over the six month follow-up. The difference in total costs (intervention plus health care expenses) was $102 per patient, resulting in an incremental cost-effectiveness ratio (ICER) of $111 per 1000 steps/day. This is less than the estimated cost-effectiveness threshold, suggesting that HEALD may be a cost-effective approach to increase daily steps among adults with type-2 diabetes.

PCN staff made the following recommendations to improve to HEALD and expand its potential for success at the patient level.

• increase the dose of the intervention (i.e., more frequent or long-term follow up)

• expand it to other modes of exercise for people with limited mobility

• incorporate a medical clearance process for higher-risk patients

HEALD increased daily steps through an exercise specialist-led group program in primary care. For $340 per patient, it is a cost-effective strategy to improve daily physical activity among adults with

type-2 diabetes. Minor recommendations, like increasing the intervention dose, may be incorporated to further improve patient outcomes.

“I think overall it did improve [patient outcomes] with those patients that participated… [It] got them active”

PCN Management 3000

5000

7000

9000

Baseline 3 month 6 month

Average Daily Steps

Active-Control (n=96)

Intervention (n=102)

5

ABCD Project Bulletin Overall Summary & Final Results

TeamCare - mplementation

HEALD intervention components were implemented as intended, with adequate fidelity across all four PCNs. Implementation facilitators included:

• appropriate human resources

• training

• on-going implementation support

• provision of space

• simplicity of the intervention

Based on the high degree of fidelity, we are confident that the demonstrated effectiveness of HEALD was the result of sound implementation

of an efficacious intervention.

HEALD - mplementation

We were unable to fully evaluate this dimension of RE-AIM for both TeamCare and HEALD. However, we interviewed HEALD participants, and many identified facilitators and challenges to maintaining behavioural changes. Participants reported improved awareness and knowledge of lifestyle changes in managing diabetes, increased physical activity and improved self-efficacy. Increasing the intensity of physical activity and maintaining learned behaviours were identified as challenges.

Many of our TeamCare and HEALD participants have joined our ongoing ABCD Diabetes Complications study. Through this annual cohort survey, we will continue to measure some outcomes, like depressive symptoms and physical activity, over the next 5-10 years.

I

A stronger culture of collaborative care may have yielded greater implementation fidelity of

TeamCare, possibly resulting in even better outcomes.

TeamCare intervention components were implemented as intended, but without optimal fidelity across the PCNs due to:

• degree of collaboration practiced, related to varying physician participation due to the existing culture (e.g., autonomy, referral practices)

• limited comfort with collaborative care among team members

Despite the suboptimal fidelity, implementation facilitators included:

• training

• on-going implementation support

• pre-existing professional relationships

• professional and personal qualities of the care managers

Ongoing ABCD cohort study analyses will give us more insight regarding maintenance of TeamCare and HEALD patient outcomes. It is up to policy-makers and PCN management to sustain the

interventions over time.

aintenance M

Intended implementation, not full fidelity Intended implementation and full fidelity I

“It made me feel more positive about this whole situation. It helped me overcome a lot of negative things about being diabetic.”

HEALD participant

Ongoing Research and Analyses We invited all TeamCare and HEALD participants to join the ABCD Diabetes Complications Study. In total, 2,040 Albertans with type-2 diabetes are enrolled in the cohort study. We intend to follow this cohort over the next 5-10 years, collecting measurements on health behaviours, self-management, lifestyle, medications, treatments and satisfaction with healthcare. As well, we have a number of sub-studies planned, enhancing our survey-based analyses with data from accelerometers and in-depth food diaries. We will keep you posted as more results are available!

ABCD Project Bulletin Overall Summary & Final Results

Controlled trial of a collaborative primary care team model for patients with diabetes and depression: Rationale and design for a comprehensive evaluation. BMC HSR 2012; 12: 258.

Healthy Eating and Active Living for Diabetes in Primary Care Networks (HEALD-PCN): Rationale, design, and evaluation of a pragmatic controlled trial for adults with type-2 diabetes. BMC PH 2012; 12: 455.

Evaluation of the Alberta’s Caring for Diabetes (ABCD) project: Applying the RE-AIM framework. BMJ Open 2012; 2:e002099.

Collaborative care vs screening and follow-up for patients with depression and diabetes: Results of a primary-care based comparative effectiveness trial. Diabetes Care 2014; 37: 3220-3226.

Social support, self-efficacy and motivation: A qualitative study of the journey through the Healthy Eating and Active Living for Diabetes in primary care networks (HEALD) program. Practical Diabetes 2014; 31(89): 370-374.

Increase in daily steps after a 6-month lifestyle intervention for adults with type-2 diabetes in primary care: A controlled implementation trial. Journal of Physical Activity & Health [in press].

Association of inadequate health literacy with health outcomes in patients with type-2 diabetes and depression: Secondary analysis of a controlled trial. Canadian Journal of Diabetes [in press].

Thank you for your hard work, commitment and support. We could not have done it without you!

Planned Supplement Issue of Canadian Journal of Diabetes We have planned, prepared and submitted the following manuscripts for consideration in a special supplemental issue of the Canadian Journal of Diabetes, highlighting the ABCD project:

• The Alberta’s Caring for Diabetes (ABCD) study: Rationale, design and baseline characteristics of a prospective cohort of adults with type-2 diabetes

• Challenges in identifying type-2 diabetes patients for quality-improvement interventions in primary care settings and the importance of disease registries

• “This was a really easy intervention to do. I mean, it’s just to get people walking”: Contextualizing the proven effectiveness of a lifestyle intervention for type-2 diabetes in primary care (HEALD)

• Contextualizing the effectiveness of a collaborative care model for primary care patients with diabetes and depression (TeamCare): A qualitative assessment

• Impact of organizational stability on adoption of quality-improvement interventions for diabetes in primary care settings

For questions or project

materials, please call or email

ACHORD

1-855-819-ABCD (2223)

achord@ualberta.ca

Publications (to date)