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Takeaway: Data from across 2 randomized trials and implementation at >20 VA facilities show that the Advanced Comprehensive Diabetes Care (ACDC) program improves hemoglobin A1c compared to clinic-based usual care and standard Home Telehealth diabetes services. In real-world use, ACDC lowers hemoglobin A1c by 1.6% (n=576 Veterans), and Veterans maintain most of this benefit for as long as three years after finishing the program. Further, because ACDC was specifically designed to use only existing VA staffing and infrastructure, it can be easily implemented at any VA site.
According to the Centers for Disease Control and Prevention (CDC), more than 37 million Americans (11% of the U.S. population) have diabetes and another 96 million (38%) have prediabetes. Diabetes is even more prevalent among Veterans, affecting nearly 25% of VA’s patient population. Further, diabetes is the leading cause of blindness, end-stage renal disease, and amputation among Veterans in the VA healthcare system (VA Research on Diabetes).
VA works continuously on improving the health and care of Veterans with chronic diseases, including diabetes. For example, VA's Center for Care and Payment Innovation has developed a new pilot study based on the Advanced Comprehensive Diabetes Care (ACDC) program. ACDC is a six-month telehealth program for Veterans with persistently poor control of diabetes type 2 (varies by site, typically ≥8.5%), despite the use of existing VA services. The ACDC program uses existing VA telehealth staffing (nurse administered) and equipment to deliver diabetes self-management support and clinician-guided medication management.
ACDC began as a QUERI-sponsored Rapid Response Project and was initially implemented and evaluated at a single VAMC in 2014 and 2015. VA’s Office of Rural Health (ORH) began supporting ACDC in 2017, and the program was implemented at five additional sites between 2017 and 2019. ACDC was named a Diffusion of Excellence Promising Practice in 2018 and was designated a Rural Promising Practice in 2020, since which it has been implemented at >20 VA sites. |
The Dynamic Diffusion Network (DDN) QUERI Program (DDN QUERI) works to expand evidence-based practices in diabetes and moral injury care (network of mental health/chaplain-led sessions for Veterans experiencing moral injury). As part of these efforts, QUERI investigators worked with the VHA Innovation Ecosystem to implement ACDC across 10 new VA facilities. Thus far, data from two randomized trials show that ACDC improved hemoglobin A1c compared to clinic-based usual care and standard Home Telehealth diabetes services; in real world use at >20 VA sites, ACDC lowered hemoglobin A1c by 1.6% among 576 Veterans, who maintained most of this benefit for as long as three years after finishing the program. Further, because ACDC was specifically designed to use only existing VA staffing and infrastructure, it can be easily implemented at any VA site.
Matthew Crowley, MD, MHS
By providing special support to Veterans whose diabetes remains poorly controlled despite receiving standard VA diabetes care, ACDC empowers Veterans to achieve improved control, better self-management, and a positive experience. The DDN QUERI Program builds on ACDC’s prior success and expands our understanding of how to implement this intervention most effectively. —Matthew Crowley, MD, MHS, Multiple Principal Investigator, DDN QUERI, and investigator with HSR&D’s Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC
ACDC is proven to lower HbA1c among Veterans with refractory poor control in research and clinical settings – it is, thus, effective enough to reduce VHA type 2 diabetes costs and complications. Because ACDC uses only existing VA staffing and infrastructure, requires minimal training, and calls for no new hiring, any VA healthcare facility can deliver the program. Therefore, ACDC is ideally suited for implementation in clinical practice (including in rural areas) and broad dissemination across the VA healthcare system.
Some of our sites have now been delivering ACDC in clinical practice for up to four years, which indicates that this approach can be sustained in clinical practice. Also, despite the drastic changes COVID-19 forced healthcare systems like VA to make, ACDC delivery continued unabated during the pandemic. ACDC is making a strong impact within VA, but one important question is whether the ACDC approach can be translated beyond [it]. We are engaged in work to help answer this question. —Elizabeth Kobe, MHS, Duke University School of Medicine
Kobe E, Lewinski A, Jeffreys A, et al. Implementation of an intensive telehealth intervention for rural patients with clinic-refractory diabetes. Journal of General Internal Medicine. September 2022;37(12):3080-3088.
