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Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United States. JAMA Dermatol. 2018;154(11):1286–1291. doi:10.1001/jamadermatol.2018.3114
What differences in use of dermatologic care exist in the United States between demographic and socioeconomic groups?
Among 183 054 Medical Expenditure Panel Survey respondents, Hispanic and black patients were less likely to receive outpatient dermatologic care than non-Hispanic white patients. Patients who were male, uninsured, Midwestern, from a lower income group, had a lower educational level, or had Medicaid or Medicare coverage were less likely to receive outpatient dermatologic care.
Differences in sex, race/ethnicity, insurance status, region, and socioeconomic characteristics exist in use of dermatologic care in the United States; there is a need to further characterize potential differences in use of outpatient dermatologic care among disadvantaged populations.
Knowledge regarding differences in dermatologic care for patients with a broad range of dermatologic conditions is limited.
To elucidate nationwide differences in use of outpatient dermatologic care.
Design, Setting, and Participants
Retrospective analysis of nationally representative data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS) provided by the Agency for Healthcare Research and Quality. Health care use outcomes for dermatologic conditions (skin cancers, infections, dermatologic inflammatory conditions/ulcers, and other skin disorders) were examined via multivariable logistic regression analyses of outpatient and office-based dermatologist visit rates accounting for sex, age, race/ethnicity, educational level, income, insurance status, region, self-reported condition, and self-reported health status. Participants were 183 054 MEPS respondents who visited a dermatologist from 2007 to 2015.
Main Outcomes and Measures
The primary outcome measure was whether the patient received outpatient care for any dermatologic condition (by payment). The secondary outcomes were annual health care use by individuals with dermatologic conditions (including per capita expenditure for the visit).
Of 183 054 MEPS respondents (mean [SD] age, 34  years; 52.1% female), 19 561 (10.7%) self-reported a dermatologic condition; 9645 patients had a total of 11 761 outpatient visits to dermatologists. Hispanic (adjusted odds ratio [aOR], 0.55; 95% CI, 0.49-0.61) and black (aOR, 0.42; 95% CI, 0.38-0.46) patients were both less likely to receive outpatient care for their dermatologic condition relative to non-Hispanic white patients. Male patients were less likely to receive outpatient dermatologic care than female patients (aOR, 0.66; 95% CI, 0.62-0.70), and Midwestern patients were less likely to receive outpatient dermatologic care than Northeastern patients (aOR, 0.80; 95% CI, 0.70-0.91). Patients with Medicaid or Medicare coverage (aOR, 0.75; 95% CI, 0.68-0.83) and uninsured patients (aOR, 0.39; 95% CI, 0.33-0.47) were both less likely to receive outpatient dermatologic care than privately insured patients. Increasing educational level and income were associated with increased odds of receiving outpatient care for the dermatologic condition.
Conclusions and Relevance
These findings highlight wide-ranging differences in use of dermatologic care in the United States across various demographic and socioeconomic lines. Results of this study suggest an urgent need to further characterize potential dermatologic health care differences and improve use of outpatient dermatologic care among disadvantaged populations.
Dermatologic diseases are common, causing upwards of 85 million Americans to visit a physician for at least 1 skin disease in 2013 and generating an estimated direct health care cost of $75 billion.1 Considering the projected increase in the elderly American population and increasing costs of dermatologic treatments, it is likely that the social and economic burden of skin disease will continue to grow.
Visits to dermatologists reduce adverse events, mortality, and hospitalizations for patients living with dermatologic conditions.2,3 Improved melanoma outcomes are associated with visiting a dermatologist before diagnosis, and dermatologist visits have been reported to improve diagnostic accuracy of melanoma.2,3 However, differences in access to and use of dermatologic care have been reported for a wide array of clinical and sociodemographic factors, including sex, age, poverty rate, rurality, distance to dermatologic care, and clinician supply.4,5 Race/ethnicity and insurance status, in particular, have been associated with differences in all-cause and disease-specific mortality for a few dermatologic conditions, including melanoma and mycosis fungoides.6-8
However, minimal information exists regarding differences in outpatient dermatologic use for a variety of dermatologic conditions. As demographics in the United States continue to become more diverse, there is a growing need to better characterize demographic and socioeconomic differences in use of dermatologic care. As such, the objective of this study was to elucidate nationwide differences in use of outpatient dermatologic care.
In this retrospective study, we analyzed 9 years of data from the Medical Expenditure Panel Survey (MEPS) (2007-2015), a nationally representative survey, to assess patterns of use of outpatient dermatologic care in the United States. The Agency for Healthcare Research and Quality (AHRQ) administers the MEPS annually to collect detailed information regarding health status, demographics, health conditions, health care use, cost of health care, and sources of payments.9 The MEPS is a nationally representative survey of the civilian noninstitutionalized US population that is administered annually and oversamples Hispanics and blacks. The methods of administration for the MEPS are detailed elsewhere.9 Institutional review board approval was not required for use of this publicly available, deidentified database.
To examine use and expenditure of visits to outpatient dermatologists by demographic information and diagnosis, we linked the MEPS household component, event files, and medical conditions. We first tabulated the number of outpatient visits per year to dermatologists for each individual. Patients in this study who were considered to have a dermatologic condition were diagnosed as having a dermatologic condition as per the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The MEPS clinical classification codes for skin conditions classify ICD-9-CM codes as melanomas of the skin, other nonepithelial cancers of the skin, skin and subcutaneous tissue infections, other inflammatory conditions of the skin, and chronic ulcers of the skin. Corresponding ICD-9-CM codes for each of the MEPS clinical classification codes are available on the MEPS website.9
We calculated total expenditures associated with visits to outpatient dermatologists by including all payments by third-party payers and out-of-pocket costs. To report this, all costs were adjusted to 2015 US dollars using the urban Consumer Price Index of the US Bureau of Labor Statisics.10
We investigated per capita expenditures and visit rates for outpatient dermatologic conditions according to various demographic characteristics. Age was categorized as younger than 18, 18 to 34, 35 to 64, or 65 years and older. Self-identified race/ethnicity was categorized as non-Hispanic white, Hispanic, or black. We excluded Asians and other or mixed race/ethnicity because of the wide 95% CIs produced by the MEPS for those groups. Educational level was categorized as having no degree, a high school diploma or general equivalency diploma, some college, or a bachelor’s degree or higher. Income was calculated in relation to the 2015 federal poverty level (FPL); individuals were categorized as poor (<100% of the FPL), near poor (100%-124% of the FPL), low income (125%-199% of the FPL), middle income (200%-399% of the FPL), or high income (>399% of the FPL). We categorized insurance status as private (including those with concurrent Medicare coverage), public (Medicaid or Medicare, excluding concurrent private insurance), or uninsured. For regional analysis, each patient was categorized as living in the Northeast, Midwest, South, or West. Self-reported health status was coded on a 5-point scale (poor, fair, good, very good, or excellent).
We first determined the percentage of patients with at least 1 visit to an outpatient dermatologist from 2007 to 2015. After this, we reported the percentage of individuals with each of the dermatologic conditions who had 1 or more visits to outpatient dermatologists from 2007 to 2015.
To determine the association of each of the demographic and socioeconomic characteristics with use of outpatient dermatologic care, we constructed a multivariable logistic regression model with receipt of outpatient dermatologic care during the year as the outcome variable. Predictor variables included sex, age, race/ethnicity, educational level, income, insurance status, region, self-reported condition, and self-reported health status. We adjusted and controlled for all predictor variables in the multivariable logistic regression model by calculating adjusted odds ratios (aORs) and 95% CIs for each predictive variable. Finally, we tabulated the percentage of each race/ethnicity (non-Hispanic white, Hispanic, and black) with at least 1 visit to an outpatient dermatologist and the cost per person with a dermatologic condition for the outpatient visit to elucidate differences in health care expenditures. The reference categories were female (sex), 65 years and older (age), non-Hispanic white (race/ethnicity), a bachelor’s degree or higher (educational level), high income (income), privately insured (insurance status), Northeast (region), no self-reported condition, and excellent self-reported health status. All of the tables herein summarize annual averages from 2007 to 2015, which were derived using person-level weights provided by the AHRQ to extrapolate these data to the civilian noninstitutionalized US population. All analyses were performed at the person level using statistical software (R; R Foundation for Statistical Computing) accounting for the complex sample design of the MEPS.11
In total, our sample included 183 054 MEPS respondents from 2007 to 2015 (Table 1). The mean (SD) age of the population was 34 (23) years, and 52.1% of the participants were female. Of these participants, 19 561 (10.7%) self-reported a dermatologic condition. The 9645 patients who had at least 1 outpatient visit with a dermatologist had a total of 11 761 outpatient visits to dermatologists during this period. In total, 405 of these patients were diagnosed as having melanomas of the skin, 2045 were diagnosed as having other nonepithelial cancers of the skin, 3152 were diagnosed as having skin and subcutaneous tissue infections, 3152 were diagnosed as having other inflammatory conditions of the skin, and 870 were diagnosed as having chronic ulcers of the skin (Table 2). Of patients with a dermatologic condition, 36.5% had at least 1 visit to an outpatient dermatologist from 2007 to 2015. The percentage of patients with at least 1 visit to an outpatient dermatologist differed for patients with melanomas of the skin (70.9%), other nonepithelial cancers of the skin (74.0%), skin and subcutaneous tissue infections (13.2%), other inflammatory conditions of the skin (44.1%), and chronic ulcers of the skin (10.6%) (Table 3). Of the respondents, 74 547 were non-Hispanic white, 54 943 were Hispanic, 36 146 were black, and 17 418 were of other races/ethnicities (not included in analyses because of limited sample size).
The multivariable logistic regression model revealed marked differences in use of outpatient dermatology services (Table 4). Male patients were less likely to visit an outpatient dermatologist compared with female patients (aOR, 0.66; 95% CI, 0.62-0.70). Hispanic patients (aOR, 0.55; 95% CI, 0.49-0.61) and black patients (aOR, 0.42; 95% CI, 0.38-0.46) were both less likely to visit an outpatient dermatologist for their dermatologic condition compared with non-Hispanic white patients. Increasing educational level was associated with an increased odds of visiting an outpatient dermatologist for the dermatologic condition. Specifically, those with some college (aOR, 0.69; 95% CI, 0.64-0.75), a high school degree or general equivalency diploma (aOR, 0.49; 95% CI, 0.45-0.54), or no degree (aOR, 0.52; 95% CI, 0.46-0.59) all had lower odds of outpatient dermatologist health care use compared with those with a bachelor’s degree or higher. Increasing income was associated with increased odds of visiting an outpatient dermatologist. Individuals with an income classified as poor (aOR, 0.48; 95% CI, 0.43-0.54), near poor (aOR, 0.56; 95% CI, 0.48-0.66), low income (aOR, 0.54; 95% CI, 0.48-0.60), or middle income (aOR, 0.68; 95% CI, 0.63-0.73) had lower odds of visiting an outpatient dermatologist compared with those with high income. Patients with Medicaid or Medicare coverage (aOR, 0.75; 95% CI, 0.68-0.83) and uninsured patients (aOR, 0.39; 95% CI, 0.33-0.47) were both less likely to visit an outpatient dermatologist compared with privately insured patients. Midwestern patients were less likely to visit an outpatient dermatologist compared with Northeastern patients (aOR, 0.80; 95% CI, 0.70-0.91). Patients with chronic ulcers of the skin did not have greater odds of visiting an outpatient dermatologist compared with patients without a dermatologic condition (aOR, 1.11; 95% CI, 0.76-1.64).
The racial/ethnic differences persisted in analyses regarding annual health care use among patients self-reporting dermatologic conditions (Table 5). Among individuals with dermatologic conditions, more than twice as many non-Hispanic white patients had at least 1 outpatient dermatologist visit compared with Hispanic and black patients. Similarly, the per capita expenditure of outpatient dermatologist visits for non-Hispanic white patients ($209.50) was approximately 3 times that of Hispanic ($73.09) and black ($62.70) patients. The cost per visit was also greater for non-Hispanic white patients ($244.88) than for Hispanic ($191.14) and black ($170.94) patients.
Our findings reveal substantial differences in national dermatologic health care use across various demographic and socioeconomic lines. There are substantial differences in outpatient dermatologic care for minority, less-educated, lower-income, publicly insured, uninsured, and Midwestern Americans. Further research is necessary to characterize the etiology of these differences and investigate potential differences in outpatient dermatologic care.
Differences between racial/ethnic groups are particularly concerning because the US population is projected by 2044 to be majority minority (ie, the non-Hispanic white population will no longer be the majority population).12 Although differences in outcomes for patients of different racial/ethnic groups with dermatologic conditions (including melanoma and mycosis fungoides) have been reported, little is known regarding why they exist.6,7 Differences in use of outpatient dermatologic care may be due to barriers in socioeconomic access to care and lack of awareness regarding dermatologic conditions among minority populations, which has been demonstrated with regard to skin cancer.13,14 It is possible that minority populations are less aware of the role of dermatologists in management of skin disease of importance to their populations. Another possible explanation is that the marketing campaigns of specialty societies may emphasize skin cancer more than inflammatory and infectious diseases, thus targeting patients at higher risk for skin cancer and inadvertently excluding minority groups, younger individuals, and lower-income patients who are at decreased risk for skin cancer. More research is necessary to further elucidate the differences in use of outpatient dermatologists among racial/ethnic minorities.
Beyond issues of access to care, it has been reported that the most likely causes of differences in use of health care among minorities include differences in medical knowledge and information sources, mistrust and skepticism of the medical profession, clinician bias, and variations in the quality of care at facilities attended by different racial/ethnic groups.15-17 These may be contributory factors in the decreased per capita expenditure on outpatient dermatologist visits for racial/ethnic minorities found in the present research. In addition, the difference in cost per visit may be a result of different rates of use of high-cost dermatologic services. This is possibly due to differences in the types of dermatologic conditions between races/ethnicities (resulting in more expensive services for dermatologic conditions that necessitate procedural intervention). These findings may also be partially explained by different clinical approaches and services available for patients of different races/ethnicities. More research is necessary to elucidate the reasons underlying this difference in per capita expenditure and cost per visit between races/ethnicities.
Many issues inherent to the organization and financing of the US health care system may also exacerbate differences in use of outpatient dermatologic care. It is possible that institutions providing primary care for uninsured or minority patients do not offer dermatologic outpatient service, which may greatly complicate the referral process and worsen patient outcomes.18 Beyond this, language barriers may impede both clinicians’ understanding of the condition and patients’ ability to navigate the health care system. Although language barriers are primarily a concern for Hispanic patients, at least 18.7% of Americans speak a language other than English at home, and more than 8% of Americans have self-reported limited English-language proficiency.19
The geographic differences in this study draw attention to the importance of equity in distribution of the dermatologist workforce. Geographic variation in melanoma mortality has been associated with dermatologist density, and many regions in the Midwest have 0 dermatologists per 100 000 people.20 Recruitment of dermatologists to regions of the United States that lack dermatologists may increase access to and use of outpatient dermatologic care and increase equity in dermatologic outcomes nationwide. In addition, increased availability of dermatologists with training and interest in teledermatology may enable underserved populations to have better access to dermatologic care.21
Future research should investigate the differential effects of the Patient Protection and Affordable Care Act (PPACA) on health care access and use between demographic and socioeconomic groups to develop tailored policy interventions for specific racial/ethnic groups. It has previously been reported that, although the PPACA increased access to health care among low-income and low-education individuals, the difference between non-Hispanic white Americans and either black or Hispanic Americans did not decrease substantially (in terms of health insurance coverage, affordability, and access to care) after passage of the PPACA.22 Understanding the changes in access to and use of dermatologic health care after passage of the PPACA is critical to understanding the effect of health care policy changes on dermatologic care, particularly in light of current health care reform.
Differences in access to dermatologic care for patients with Medicaid or Medicare coverage and uninsured patients are concordant with research revealing delays in melanoma treatment associated with insurance type.8 This is of particular concern considering the association of decreased survival from melanoma and many other conditions in patients without private insurance.23,24 Although the PPACA attempted to quell this issue by increasing access to health care substantially among low-income and low-education individuals, access to specialist care did not increase for all demographic and insurance subgroups.22 Previous research has also shown differences in treatment of dermatologic conditions by insurance type, including delay of surgical treatment for melanoma in Medicare-insured patients and decreased access to dermatologists for Medicaid-insured children with eczema.25,26 In addition, although new Medicare patients are widely accepted by dermatology practices, few dermatologists accept new Medicaid and uninsured lower-income patients.27 Further research is necessary to elucidate the reasons for the association of particular insurance types with decreased outpatient dermatologic care.
There are many limitations to this study. The MEPS is representative of the civilian noninstitutionalized US population but does not represent persons living in prisons, nursing homes, or other institutionalized settings.9 In addition, although most patients’ reports of visits are verified by the AHRQ with the clinicians (including the diagnoses and outcome of each visit), recall bias may affect the reports of some patients. There are also limitations in the MEPS coding of different diagnoses, as well as the fact that many diseases may be contained in a single ICD-9-CM code, which may have limited our ability to analyze differences in care for more complex diagnoses. The limited sample size of the MEPS also made analysis of less populous racial/ethnic groups (eg, Asians or Pacific Islanders) not possible. In addition, patients with Medicaid and Medicare coverage were analyzed together, which did not allow for separate characterization of potential differences in use of outpatient dermatologic care between the 2 groups. Finally, we would have liked to evaluate patient and clinician attitudes and the characteristics of the site (eg, tertiary care center, private practice, etc) of outpatient dermatologist visits to better understand the etiology of the health care differences explored in this study.
Ultimately, our findings reveal substantial differences in outpatient dermatologic care in the United States and underscore the need to further characterize the existence of potential differences for individuals with dermatologic conditions. More specifically, it is important to further examine potential barriers in access to dermatologic care among disadvantaged populations. Our study adds to the growing body of literature documenting differences in care for other specialties.28
It is critical for dermatologists to engage policy makers regarding targeted interventions based on public and population health to improve access to and use of outpatient dermatologic care. Dermatologists should also encourage initiatives to increase access to multicultural care and minority-specific care, including improving patient education and health literacy. Equitable access to dermatologists is a critical component of comprehensive care, and better understanding the differences in use of outpatient dermatologic care by various socioeconomic and demographic groups is a key step in improving the overall health of Americans.
Accepted for Publication: July 19, 2018.
Corresponding Author: Raghav Tripathi, MPH, Department of Dermatology, University Hospitals Cleveland Medical Center, Lakeside 3500, 11100 Euclid Ave, Cleveland, OH 44106 (email@example.com).
Published Online: September 26, 2018. doi:10.1001/jamadermatol.2018.3114
Author Contributions: Messrs Tripathi and Knusel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Tripathi, Knusel, Ezaldein, Bordeaux.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Tripathi, Knusel, Ezaldein.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Tripathi, Knusel.
Administrative, technical, or material support: Tripathi.
Supervision: Tripathi, Ezaldein, Scott, Bordeaux.
Conflict of Interest Disclosures: None reported.