A mixed methods analysis of access barriers to dermatology care in a rural state.

AIMS: To identify significant patient and system access barriers and facilitators to dermatology care in one rural health system with limited dermatology appointment availability. DESIGN: Mixed methods study using data from electronic medical records, patient surveys, stakeholder semi-structured interviews, and service area dermatologist demographics. Retrospective data were collected between 1 January 2017-1 March 2018, and interviews and surveys were conducted between June 1-August 31, 2018. Participants were recruited from two primary care practices in one rural Maine regional health system. METHODS: Findings from thematic analyses, descriptive statistics, and statistical modelling were integrated using Chi-square tests for homogeneity to develop a unified understanding. Statistical modelling using odd-ratio logistic and linear regression were performed for each outcome variable of interest. RESULTS: Urgent referrals by primary care increased the likelihood of dermatology care overall (OR: 6.771; p = .007) and at nearby sites with limited availability (OR: 4.024; p = .024), but not at geographically further sites with higher capacities (p = .844). Referral under-diagnosis occurred in 20.8% of those biopsied. Older (p = .041) or non-working (p = .021) patients were more likely to remain unevaluated than seek more available but geographically further care. CONCLUSIONS: In rural areas with scarce appointment availability, primary care provider diagnostic accuracy may be an important barrier of dermatology care receipt and health outcomes, especially among at-risk populations. IMPACT: Although melanoma mortality rates are decreasing throughout the US, little is known about why rates in Maine continue to rise. This study applied a comprehensive approach to identify several patient and system access barriers to dermatology care in one underserved rural regional health system. While specific to this population and large service area, these findings will inform improvement efforts here and support broader future research efforts aimed at understanding and improving health outcomes in this rural state.

Access to specialty healthcare in urban versus rural US populations: a systematic literature review.

BACKGROUND: Access to healthcare is a poorly defined construct, with insufficient understanding of differences in facilitators and barriers between US urban versus rural specialty care. We summarize recent literature and expand upon a prior conceptual access framework, adapted here specifically to urban and rural specialty care. METHODS: A systematic review was conducted of literature within the CINAHL, Medline, PubMed, PsycInfo, and ProQuest Social Sciences databases published between January 2013 and August 2018. Search terms targeted peer-reviewed academic publications pertinent to access to US urban or rural specialty healthcare. Exclusion criteria produced 67 articles. Findings were organized into an existing ten-dimension care access conceptual framework where possible, with additional topics grouped thematically into supplemental dimensions. RESULTS: Despite geographic and demographic differences, many access facilitators and barriers were common to both populations; only three dimensions did not contain literature addressing both urban and rural populations. The most commonly represented dimensions were availability and accommodation, appropriateness, and ability to perceive. Four new identified dimensions were: government and insurance policy, health organization and operations influence, stigma, and primary care and specialist influence. CONCLUSIONS: While findings generally align with a preexisting framework, they also suggest several additional themes important to urban versus rural specialty care access.