Barriers to Engagement in Collaborative Care Treatment of Uncontrolled Diabetes in a Safety-Net Clinic

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The purpose of the study was to evaluate patient factors associated with nonengagement in a Diabetes Collaborative Care Team (DCCT) program in a safety-net clinic.


The first 18 months of a multidisciplinary care, team-based diabetes care management program in a safety-net primary care clinic were studied. Nonengagement was defined as fewer than 2 visits with a team member during the 18 months of the program. Patients who did not engage in the program were compared with those who did engage on demographics, comorbid medical and psychiatric diagnoses, and cardiovascular risk factors, using univariate and multivariable analyses.


Of the 151 patients referred to the DCCT, 68 (45%) were nonengaged. In unadjusted analyses, patients who did not engage were more likely to be female and have higher baseline A1C values; they were less likely to have major depressive disorder, anxiety disorder, any depression diagnosis, and hyperlipidemia. Female gender and chronic pain were independently associated with nonengagement after multivariable adjustment.


The findings suggest that among patients with uncontrolled diabetes in an urban safety-net primary care clinic, there is a need to address barriers to engagement for female patients and to integrate chronic pain management strategies within multicondition collaborative care models.

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