A pilot randomized controlled trial of a depression and disease management program delivered by phone

Which Remote Rehabilitation Interventions Work Best for Chronic Musculoskeletal Pain and Depression? A Bayesian Network Meta-Analysis

OBJECTIVE: To evaluate the effectiveness of remote rehabilitation interventions for people living with chronic musculoskeletal pain and depression. DESIGN: A systematic review with network meta-analysis (NMA) of randomized controlled trials. LITERATURE SEARCH: We searched the Cochrane Central Register of Controlled Trials, CINAHL, EMBASE, LILACS MEDLINE, PSYNDEX, and PsycINFO databases from inception to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials that evaluated the effectiveness of remote rehabilitation interventions in people with chronic musculoskeletal pain and depression. DATA SYNTHESIS: We used Bayesian random-effects models for the NMA. Effect estimates were comparisons between rehabilitation interventions and waitlist. We performed a sensitivity analysis based on bias in the randomization process, large trials (>100 patients per arm) and musculoskeletal condition. RESULTS: Fifty-eight randomized controlled trials involving 10 278 participants (median sample size: 137; interquartile range [IQR]: 77-236) were included. Interactive voice response cognitive behavioral therapy (CBT; standardized mean difference [SMD] -0.66, 95% credible interval [CrI] -1.17 to -0.16), CBT in person (SMD -0.50, 95% CrI -0.97 to -0.04), and mobile app CBT plus exercise (SMD -0.37, 95% CrI -0.69 to -0.02) were superior to waitlist at 12-week follow-up for reducing pain (> 98% probability of superiority). For depression outcomes, Internet-delivered CBT and telecare were superior to waitlist at 12-week follow-up (SMD -0.51, 95% CrI -0.87 to -0.13) (> 99% probability of superiority). For pain outcomes, the certainty of evidence ranged from low to moderate. For depression outcomes, the certainty of evidence ranged from very low to moderate. The proportion of dropouts attributed to adverse events was unclear. No intervention was associated with higher odds of dropout. CONCLUSION: Interactive voice response CBT and mobile app CBT plus exercise showed similar treatment effects with in-person CBT on pain reduction among people living with chronic musculoskeletal pain and depression had over 98% probability of superiority than waitlist control at 12-week follow-up. Internet-delivered CBT and telecare had over 99% probability of superiority than waitlist control for improving depression outcomes at 12-week follow-up. J Orthop Sports Phys Ther 2024;54(6):1-16. Epub 26 February 2024. doi:10.2519/jospt.2024.12216.

Effectiveness of Telecare Interventions on Depression Symptoms Among Older Adults: Systematic Review and Meta-Analysis

BACKGROUND

Depression is the most common psychiatric disorder among older adults. Despite the effectiveness of pharmacological and psychological therapies, many patients with late-life depression (LLD) are unable to access timely treatment. Telecare has been shown to be effective in addressing patients' psychosocial issues, while its effectiveness in serving patients with LLD remains unclear.

OBJECTIVE

This study aimed to evaluate the effectiveness of telecare in reducing depression and anxiety symptoms and improving quality of life (QoL) in patients with LLD.

METHODS

Databases including the Cochrane Library, Web of Science, PubMed, Embase, and EBSCO were searched for randomized controlled trials (RCTs) evaluating the effectiveness of telecare for LLD from database establishment to December 28, 2022.

RESULTS

A total of 12 RCTs involving 1663 participants were identified in this study. The meta-analysis showed that (1) telecare significantly reduced depressive symptoms in patients with LLD compared to those in usual care (UC; standardized mean difference [SMD]=-0.46, 95% CI -0.53 to -0.38; P<.001), with the best improvement observed within 3 months of intervention (SMD=-0.72, 95% CI -1.16 to -0.28; P<.001); (2) other scales appeared more effective than the Patient Health Questionnaire-9 for LLD in telecare interventions (SMD=-0.65, 95% CI -0.96 to -0.35; P<.001); (3) telecare was more effective than telephone-based interventions for remote monitoring of LLD (SMD=-1.13, 95% CI -1.51 to -0.76; P<.001); (4) the reduction of depressive symptoms was more pronounced in patients with LLD with chronic conditions (SMD=-0.67, 95% CI -0.89 to -0.44; P<.001); (5) telecare was more effective for LLD in Europe and the Americas than in other regions (SMD=-0.73, 95% CI -0.99 to -0.47; P<.001); (6) telecare significantly reduced anxiety symptoms in patients with LLD (SMD=-0.53, 95% CI -0.73 to -0.33; P=.02); and (7) there was no significant improvement in the psychological components of QoL in patients with LLD compared to those receiving UC (SMD=0.30, 95% CI 0.18-0.43; P=.80).

CONCLUSIONS

Telecare is a promising modality of care for treatment, which can alleviate depression and anxiety symptoms in patients with LLD. Continued in-depth research into the effectiveness of telecare in treating depression could better identify where older patients would benefit from this intervention.

Pharmacists' role in detection and evaluation of adverse drug reactions: Developing proactive systems for pharmacosurveillance

PURPOSE

To identify current challenges in detection of medication-related symptoms, and review technology-based opportunities to increase the patient-centeredness of postmarketing pharmacosurveillance to promote more accountable, safer, patient-friendly, and equitable medication prescribing.

SUMMARY

Pharmacists have an important role to play in detection and evaluation of adverse drug reactions (ADRs). The pharmacist's role in medication management should extend beyond simply dispensing drugs, and this article delineates the rationale and proactive approaches for pharmacist detection and assessment of ADRs. We describe a stepwise approach for assessment, best practices, and lessons learned from a pharmacist-led randomized trial, the CEDAR (Calling for Detection of Adverse Drug Reactions) project.

CONCLUSION

Health systems need to be redesigned to more fully utilize health information technologies and pharmacists in detecting and responding to ADRs.

Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes

BACKGROUND

Rural patients with type 2 diabetes (T2D) may experience poor glycemic control due to limited access to T2D specialty care and self-management support. Telehealth can facilitate delivery of comprehensive T2D care to rural patients, but implementation in clinical practice is challenging.

OBJECTIVE

To examine the implementation of Advanced Comprehensive Diabetes Care (ACDC), an evidence-based, comprehensive telehealth intervention for clinic-refractory, uncontrolled T2D. ACDC leverages existing Veterans Health Administration (VHA) Home Telehealth (HT) infrastructure, making delivery practical in rural areas.

DESIGN

Mixed-methods implementation study.

PARTICIPANTS

230 patients with clinic-refractory, uncontrolled T2D.

INTERVENTION

ACDC bundles telemonitoring, self-management support, and specialist-guided medication management, and is delivered over 6 months using existing VHA HT clinical staffing/equipment. Patients may continue in a maintenance protocol after the initial 6-month intervention period.

MAIN MEASURES

Implementation was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The primary effectiveness outcome was hemoglobin A1c (HbA1c).

KEY RESULTS

From 2017 to 2020, ACDC was delivered to 230 patients across seven geographically diverse VHA sites; on average, patients were 59 years of age, 95% male, 80% white, and 14% Hispanic/Latinx. Patients completed an average of 10.1 of 12 scheduled encounters during the 6-month intervention period. Model-estimated mean baseline HbA1c was 9.56% and improved to 8.14% at 6 months (- 1.43%, 95% CI: - 1.64, - 1.21; P < .001). Benefits persisted at 12 (- 1.26%, 95% CI: - 1.48, - 1.05; P < .001) and 18 months (- 1.08%, 95% CI - 1.35, - 0.81; P < .001). Patients reported increased engagement in self-management and awareness of glycemic control, while clinicians and HT nurses reported a moderate workload increase. As of this submission, some sites have maintained delivery of ACDC for up to 4 years.

CONCLUSIONS

When strategically designed to leverage existing infrastructure, comprehensive telehealth interventions can be implemented successfully, even in rural areas. ACDC produced sustained improvements in glycemic control in a previously refractory population.

Implementation of Telemental Health Services Before COVID-19: Rapid Umbrella Review of Systematic Reviews

BACKGROUND

Telemental health care has been rapidly adopted for maintaining services during the COVID-19 pandemic, and a substantial interest is now being devoted in its future role. Service planning and policy making for recovery from the pandemic and beyond should draw on both COVID-19 experiences and the substantial research evidence accumulated before this pandemic.

OBJECTIVE

We aim to conduct an umbrella review of systematic reviews available on the literature and evidence-based guidance on telemental health, including both qualitative and quantitative literature.

METHODS

Three databases were searched between January 2010 and August 2020 for systematic reviews meeting the predefined criteria. The retrieved reviews were independently screened, and those meeting the inclusion criteria were synthesized and assessed for risk of bias. Narrative synthesis was used to report these findings.

RESULTS

In total, 19 systematic reviews met the inclusion criteria. A total of 15 reviews examined clinical effectiveness, 8 reported on the aspects of telemental health implementation, 10 reported on acceptability to service users and clinicians, 2 reported on cost-effectiveness, and 1 reported on guidance. Most reviews were assessed to be of low quality. The findings suggested that video-based communication could be as effective and acceptable as face-to-face formats, at least in the short term. Evidence on the extent of digital exclusion and how it can be overcome and that on some significant contexts, such as children and young people's services and inpatient settings, was found to be lacking.

CONCLUSIONS

This umbrella review suggests that telemental health has the potential to be an effective and acceptable form of service delivery. However, we found limited evidence on the impact of its large-scale implementation across catchment areas. Combining previous evidence and COVID-19 experiences may allow realistic planning for the future implementation of telemental health.

Response to the COVID-19 Outbreak in Urban Settings in China

The COVID-19 outbreak in China was devastating and spread throughout the country before being contained. Stringent physical distancing recommendations and shelter-in-place were first introduced in the hardest-hit provinces, and by March, these recommendations were uniform throughout the country. In the presence of an evolving and deadly pandemic, we sought to investigate the impact of this pandemic on individual well-being and prevention practices among Chinese urban residents. From March 2-11, 2020, 4607 individuals were recruited from 11 provinces with varying numbers of COVID-19 cases using the social networking app WeChat to complete a brief, anonymous, online survey. The analytical sample was restricted to 2551 urban residents. Standardized scales measured generalized anxiety disorder (GAD), the primary outcome. Multiple logistic regression was conducted to identify correlates of GAD alongside assessment of community practices in response to the COVID-19 pandemic. We found that during the COVID-19 pandemic, the recommended public health practices significantly (p < 0.001) increased, including wearing facial mask, practicing physical distancing, handwashing, decreased public spitting, and going outside in urban communities. Overall, 40.3% of participants met screening criteria for GAD and 49.3%, 62.6%, and 55.4% reported that their work, social life, and family life were interrupted by anxious feelings, respectively. Independent correlates of having anxiety symptoms included being a healthcare provider (aOR = 1.58, p < 0.01), living in regions with a higher density of COVID-19 cases (aOR = 2.13, p < 0.01), having completed college (aOR = 1.38, p = 0.03), meeting screening criteria for depression (aOR = 6.03, p < 0.01), and poorer perceived health status (aOR = 1.54, p < 0.01). COVID-19 had a profound impact on the health of urban dwellers throughout China. Not only did they markedly increase their self- and community-protective behaviors, but they also experienced high levels of anxiety associated with a heightened vulnerability like depression, having poor perceived health, and the potential of increased exposure to COVID-19 such as living closer to the epicenter of the pandemic.

Response to the COVID-19 Outbreak in Urban Settings in China

The COVID-19 outbreak in China was devastating, and spread throughout the country before being contained. Stringent physical distancing recommendations and shelter-in-place were first introduced in the hardest-hit provinces, and by March, these recommendations were uniform throughout the country. In the presence of an evolving and deadly pandemic, we sought to investigate the impact of this pandemic on individual well-being and prevention practices among Chinese urban residents. From March 2-11, 2020, 4,607 individuals were recruited from 11 provinces with varying numbers of COVID-19 casers using the social networking app WeChat to complete a brief, anonymous, online survey. The analytical sample was restricted to 2,551 urban residents. Standardized scales measured generalized anxiety disorder (GAD), the primary outcome. Multiple logistic regression was conducted to identify correlates of GAD alongside assessment of community practices in response to the COVID-19 pandemic. We found that during the COVID-19 pandemic, recommended public health practices significantly (p <0.001) increased, including wearing facial mask, practicing physical distancing, handwashing, decreased public spitting, and going outside in urban communities. Overall, 40.3% of participants met screening criteria for GAD and 49.3%, 62.6%, and 55.4% reported that their work, social life, and family life were interrupted by anxious feelings, respectively. Independent correlates of having anxiety symptoms included being a healthcare provider (aOR=1.58, p <0.01), living in regions with a higher density of COVID-19 cases (aOR=2.13, p <0.01), having completed college (aOR=1.38, p =0.03), meeting screening criteria for depression (aOR=6.03, p <0.01) and poorer perceived health status (aOR=1.54, p <0.01). COVID-19 had a profound impact on the health of urban dwellers throughout China. Not only did they markedly increase their self- and community-protective behaviors, but they also experienced high levels of anxiety associated with a heightened vulnerability like depression, having poor perceived health, and the potential of increased exposure to COVID-19 such as living closer to the epicenter of the pandemic.

Identifying critical psychotherapy targets in serious cardiac conditions: The importance of addressing coping with symptoms, healthcare navigation, and social support

OBJECTIVE

In seriously ill cardiac patients, several psychotherapy efficacy studies demonstrate little to no reduction in depression or improvement in quality of life, and little is known about how to improve psychotherapies to best address the range of patient needs. An interpersonal and behavioral activation psychotherapy was a key component of the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) multisite randomized clinical trial. Although depressive symptoms did improve in the CASA trial, questions remain about how best to tailor psychotherapies to the needs of seriously ill patient populations. The study objective was to describe psychosocial needs emerging during a clinical trial of a palliative care and interpersonal and behavioral activation psychotherapy intervention that were not specifically addressed by the psychotherapy.

METHOD

During the CASA trial, patient needs were prospectively tracked by the psychotherapist in each visit note using an a priori code list. Preplanned analysis of study data using directed content analysis was conducted analyzing the a priori code list, which were collapsed by team consensus into larger themes. The frequency of each code and theme were calculated into a percentage of visits.

RESULT

A total of 150 patients received one or more visits from the therapist and were included in the analysis. Participants screened positive for depressive disorder (47%), had poor heart failure-specific health status (mean Kansas City Cardiomyopathy Questionnaire score = 48.6; SD = 17.4), and multiple comorbidities (median 4.3). Common needs that emerged during the therapy included difficulty coping with fatigue (48%), pain (28%), and satisfaction issues with medical care (43%). The following broader themes emerged: social support (77% of sessions), unmet symptom needs (67%), healthcare navigation (48%), housing, legal, safety, and transportation (32%), and end of life (12%).

SIGNIFICANCE OF RESULTS

Coping with chronic symptoms and case management needs commonly emerged during psychotherapy visits. Future psychotherapy interventions in seriously ill populations should consider the importance of coping with chronic symptoms and case management.

The use of technology for mental healthcare delivery among older adults with depressive symptoms: A systematic literature review

Depression has been identified as the single largest contributor to poor health and functioning worldwide. Global estimates indicate that 4.4% of the world's population lives with depression, equating to about 322 million individuals. Research demonstrates that telehealth interventions (i.e. delivering therapy by phone or videoconferencing) have potential for improving mental health care among community-based older adults. This review analyses scholarly literature on telehealth interventions among older adults with depressive symptoms. Following PRISMA guidelines, a systematic search of peer-reviewed papers was conducted using the following key terms: telemedicine, telepsychogeriatrics, telepsychiatry, eHealth, mental health, depression, and geriatric. The review included nine articles examining telehealth for mental health care, published in English between 1946 and 26 September 2017. Telehealth for mental health care among older adults demonstrates a significant impact on health outcomes, including reduced emergency visits, hospital admissions, and depressive symptoms, as well as improved cognitive functioning. Positive or negative influences on the use of telehealth among older adults are identified. This review highlights keys aspects to consider in using telehealth interventions, including levels of education, cognitive function, and prior technology experience. The review highlights vital factors for designing interventions which aim to capitalize on the benefits of the use of telehealth for mental healthcare service delivery, especially in older adults with depressive symptoms.

Improving Early Palliative Care with a Scalable, Stepped Peer Navigator and Social Work Intervention: A Single-Arm Clinical Trial

BACKGROUND

Patients with cancer could benefit from early primary (i.e., basic) palliative care. Scalable models of care delivery are needed.

OBJECTIVE

Examine the feasibility of a stepped peer navigator and social work intervention developed to improve palliative care outcomes.

DESIGN

Single-arm prospective clinical trial. The peer navigator educated patients to advocate for pain and symptom management with their healthcare providers, motivated patients to pursue advance care planning, and discussed the role of hospice. The social worker saw patients with persistent psychosocial distress.

SETTING/SUBJECTS

Patients with advanced cancer at a VA Medical Center not currently in palliative care or hospice whose oncologist would not be surprised if the patient died in the subsequent year.

MEASUREMENTS

Participation and retention rates, patient-reported symptoms and quality of life, advance directive documentation, patient satisfaction survey, and semistructured interviews.

RESULTS

The participation rate was 38% (17/45), and 35% (7/17) completed final survey measures. Patients had stage IV (81%) and primarily genitourinary (47%) and lung (24%) malignancies. Median Eastern Cooperative Oncology Group performance status was 0. Patient-reported surveys indicated low distress (mean scores: Functional Assessment of Cancer Therapy-General, 75.3 [standard deviation {SD} 17.6]; Edmonton Symptom Assessment Scale symptom scores ranged from 1.6 to 3.8; Patient Health Questionnaire-9, 5.7 [SD 5.2]; and Generalized Anxiety Disorder-7, 2.8 [SD 4.1]). Of those who had not completed advance directives at baseline (n = 11, 65%), five completed them by the end of study (5/11, 45%). Patients who completed satisfaction surveys (n = 7) and interviews (n = 4) provided mixed reviews of the intervention.

CONCLUSIONS

At a single site, a stepped peer navigator and social work palliative care study had several challenges to feasibility, including low patient-reported distress and loss to follow-up.

Design and development of a stepped-care behavioral intervention to support parents of young children newly diagnosed with type 1 diabetes

One of the most common chronic conditions of childhood, the prevalence of type 1 diabetes (T1D) in young children is increasing. Early childhood development complicates optimal T1D management and glycemic outcomes. Parents are at risk for elevated psychological distress, especially immediately following diagnosis. Few empirically supported interventions are available to support parents and promote optimal T1D management during this vulnerable period. This paper reports on the development and study design of First STEPS: Study of Type 1 in Early childhood and Parenting Support. The aim of this trial is to evaluate the efficacy of a stepped care behavioral intervention for parents of young children over the first year following a new T1D diagnosis. The stepped care design provides participants with up to three intensity levels, or steps, of clinical behavioral intervention support based on need, compared to usual care. Intervention steps include peer parent coaching, telephone-based behavioral support, personalized psychological assessment and recommendations, and intensive assessment of T1D glycemic management with recommendations. Primary outcomes include children's glycemic control and parents' psychosocial functioning. Secondary outcomes include children's behavioral and psychosocial functioning. Exploratory analyses will evaluate demographic, disease-specific, and psychosocial factors related to progression in and response to each step of the intervention.

A Nationally Scaled Telebehavioral Health Program for Chronic Pain: Characteristics, Goals, and Psychological Outcomes

BACKGROUND

Millions of U.S. adults suffer from chronic pain with a high prevalence of comorbid mental health issues. Telehealth-delivered behavioral therapy for chronic pain has been evaluated in the research setting. The purpose of this study was 1) to describe a nationally scaled, standardized, telebehavioral therapy program for patients with chronic pain and behavioral comorbidities, and 2) evaluate characteristics, goals, and psychosocial outcomes among program participants.

MATERIALS AND METHODS

This was mixed-methods retrospective cohort analysis among consecutive program graduates (mean age 53y; 24% male). The 8-week program was delivered by a licensed therapist and a behavior coach through telephone/secure video and tailored to each participant's behavioral health needs and goals. Participant chief complaints, behavioral goals, and mood triggers were abstracted by deidentified clinical record review using structured qualitative research methods. Depression, anxiety, and stress symptom data were collected at baseline and program graduation using the validated Depression Anxiety Stress Scales 21.

RESULTS

Back pain (42%) and hip/leg/knee pain (28%) comprised the most common chief complaints. Pain management (44%) and weight loss (43%) were the most frequently cited goals. At baseline, approximately half of participants had elevated depression (59%), anxiety (54%), and/or stress (48%) scores. Triggers for depressed, anxious, or stressed mood included severe pain (47%), health concerns (46%), and interpersonal relationship challenges (45%). At graduation, significant improvement in median depression (-54%), anxiety (-50%), and stress (-33%) symptom scores was observed among those with non-normal baseline values (p < 0.001); degree of improvement did not vary by participant age or sex.

CONCLUSIONS

Participants in a nationally scaled telebehavioral health program for chronic pain experienced significant improvement in depression, anxiety, and stress symptoms and shared several complaints, goals, and mood triggers.

Implementation and evaluation of a pharmacist-run mental health treatment clinic via clinical video telehealth

Introduction

The Veterans Health Administration is extending its mental health services to reach those in rural areas who find it difficult to travel to a Veterans Affairs Medical Center (VAMC). This project aimed to outline implementation of a Pharmacy Mental Health Clinical Video Telehealth (MHCVT) clinic for veterans. Secondary endpoints were to assess patient satisfaction with MHCVT, describe the potential benefits of this clinic regarding travel saved, and summarize no-show rates.

Methods

Veterans received mental health disease state medication management from a mental health clinical pharmacy specialist via clinical video telehealth (CVT) in place of an in-clinic appointment and were asked to complete a satisfaction survey after the initial CVT appointment. Data collected from all veterans enrolled in the CVT clinic from September 8, 2014, through March 23, 2015 included: patient demographics, service connection percentage, number of CVT visits, travel miles saved, travel reimbursement, no-show rate, and documentation of medication management therapy.

Results

As of March 23, 2015, there were 22 veterans enrolled in the MHCVT clinic, of whom, 19 completed their appointments. Of the 48 potential encounters, 7 were considered a no-show (17%). On average veterans saved 34 travel miles per visit with cumulative savings of 1432.6 miles. Of those who were eligible to receive travel reimbursement (n = 13), the medical center potentially saved $674.50 in a 7-month period. Overall clinic satisfaction per survey (n = 14) was 100% (strongly agreed or agreed). A majority (93%) would recommend the clinic to other veterans.

Conclusions

This project successfully implemented a MHCVT pilot clinic. The veterans were satisfied with the services. The 41 clinic visits resulted in a potential cost savings. Expansion of this clinic in the future will expand more mental health resources to veterans.

Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial

BACKGROUND

Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems. In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus (PPDM) despite clinic-based care, we evaluated a comprehensive telemedicine intervention that we specifically designed for delivery using existing Veterans Health Administration (VHA) clinical staffing and equipment.

MATERIALS AND METHODS

We conducted a 6-month randomized trial among 50 veterans with PPDM; all maintained hemoglobin A1c (HbA1c) levels continuously >9.0% for >1 year despite clinic-based management. Participants received usual care or a telemedicine intervention combining telemonitoring, medication management, self-management support, and depression management; existing VHA clinical staff delivered the intervention. Using linear mixed models, we examined HbA1c, diabetes self-care (measured by the Self-Care Inventory-Revised questionnaire), depression, and blood pressure.

RESULTS

At baseline, the model-estimated common HbA1c intercept was 10.5%. By 6 months, estimated HbA1c had improved by 1.3% for intervention participants and 0.3% for usual care (estimated difference, -1.0%, 95% confidence interval [CI], -2.0%, 0.0%; p = 0.050). Intervention participants' diabetes self-care (estimated difference, 7.0; 95% CI, 0.1, 14.0; p = 0.047), systolic blood pressure (-7.7 mm Hg; 95% CI, -14.8, -0.6; p = 0.035), and diastolic blood pressure (-5.6 mm Hg; 95% CI, -9.9, -1.2; p = 0.013) were improved versus usual care by 6 months. Depressive symptoms were similar between groups.

CONCLUSIONS

A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care. Because we specifically designed this intervention with scalability in mind, it may represent a practical, real-world strategy to reduce the burden of poor diabetes control among veterans.