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.