1. 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. 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. 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
ffectivenessE
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. 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
ffectivenessE
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. 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.
aintenanceM
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

6. 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)