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

Purpose 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. Methods 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. Results 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. Conclusions 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.

Colorectal cancer screening among African Americans: the importance of physician recommendation.

INTRODUCTION: African Americans have higher colorectal cancer incidence and mortality rates than whites. They are also more likely to be diagnosed with late-stage disease and less likely to survive for at least five years after diagnosis. Lack of adherence to colorectal cancer screening recommendations has previously been found to be associated with lower income, lower educational level, and racial/ethnic minority status. METHODS: One hundred-fifty African-American patients (aged 50-79 years) of an inner city hospital, were surveyed by mail and telephone in early 2002. Seventy-six patients completed the survey, and data from 74 surveys were analyzed. RESULTS: Approximately one-half (55%) of the respondents reported having received a fecal occult blood test (FOBT) in the last 12 months, sigmoidoscopy in the last five years, or colonoscopy in the last 10 years. Thirty-nine percent of the survey participants reported never having received a physician recommendation for FOBT, 60% reported never having received a recommendation for sigmoidoscopy, and 57% reported never having received a recommendation for colonoscopy. Previous physician recommendation was strongly associated (p < 0.001) with levels of FOBT, sigmoidoscopy, and colonoscopy use. DISCUSSION: Future studies should examine factors that influence primary care physicians' decision-making about ordering colorectal cancer screening tests, as well as patients' decision-making regarding adherence to physician recommendations.