Access to Inpatient Dermatology Care in Pennsylvania Hospitals

Access to care is a known issue in dermatology, and many patients may experience long waiting periods to see a physician.¹ Previous research has evaluated access to outpatient dermatology services, but access to dermatology in inpatient medicine is also a growing problem.² Reports depict a decrease in dermatologist involvement in inpatient care and an increase in nondermatologist physicians caring for inpatients with dermatologic needs.^2,3 This lack of access could potentially lead to missed and/or incorrect diagnoses. One study showed that most cases in which dermatology was consulted required a change in treatment once correctly diagnosed by a dermatologist.⁴

Despite the known trend of decreasing involvement of dermatologists in inpatient care, there remains a paucity of data quantifying the current gap in access to care for inpatients with dermatologic needs. The purpose of this study was to evaluate differential access to inpatient dermatology services across licensed hospitals within the state of Pennsylvania.

Methods

In July 2014, an invitation to participate in an anonymous online survey was mailed to all 274 hospitals throughout Pennsylvania that were currently licensed by the US Department of Health. This study was declared exempt from review by the University of Pennsylvania (Philadelphia, Pennsylvania) institutional review board. Study data were collected and managed using electronic data capture tools hosted by the University of Pennsylvania. Hospital administrators were encouraged to report dermatology access and details regardless of current status of inpatient dermatology services in order to inform efforts to improve access to care. Invitation letters to participate in the online survey were addressed to “Administrator” according to the contact method used by the US Department of Health for accreditation of state hospitals. Addresses for accredited state hospitals were obtained from the US Department of Health Web site and were supplemented with additional addresses of Veterans Administration hospitals obtained from public listings. Three weeks after initial survey invitations were sent, reminder letters were sent to nonresponsive hospitals. Only data from hospitals currently offering inpatient services were included in the analysis; exclusion criteria included psychiatric hospitals, substance abuse treatment centers, physical rehabilitation facilities, and outpatient centers.

Results

Of the 204 (74%) hospitals that met the inclusion criteria, 32 responded (16% response rate). Of the 32 hospitals that responded, 31 (97%) were privately owned facilities, 3 of which were specialty surgical centers. One (3%) hospital was a Veterans Administration hospital. Of the responders, 16 (50%) reported having any form of access to inpatient dermatology consultations. Of the 16 with reported access, 9 (56%) received their consultations through a local or private dermatology group, while 4 (25%) had a dermatologist on staff. The remaining 3 hospitals (19%) provided dermatology consultations through nondermatologist physicians on staff (a surgeon, an emergency care physician, and an internist, respectively).

The survey also sought to gain information about the various degrees of access to inpatient dermatology care that hospitals provide. Of the 16 hospitals that reported access to inpatient dermatology services, 11 (69%) provided specific details related to access (eg, coverage, anticipated response times) of dermatology consultations (Figure). The type of access to inpatient dermatology in relation to the type of hospital ownership is shown in the Table.

Relative availability of access to inpatient dermatology care provided in 11 Pennsylvania hospitals.

Comment

The survey results indicated suboptimal access to inpatient dermatology services in Pennsylvania hospitals. Only 50% (16/32) of respondents reported providing access to dermatology consultation, the majority of which appeared to have extremely limited same-day, evening, and weekend coverage. Although our study was limited by a low response rate (16%) and represents a narrow geographic distribution, these results suggested that lack of access to inpatient dermatology consultation may be a widespread problem and may be independent of the type of hospital ownership. Furthermore, the results of this study may offer insight into the different types and availability of inpatient dermatology services offered in hospitals across the United States.

The decrease in inpatient dermatology access has been driven by many factors. First, advances in medical research and pharmacotherapy may have decreased the need for dermatologic inpatient care, as patients who formerly would have required inpatient treatments are now able to receive therapies in an outpatient setting (eg, treatment of psoriasis).⁵ This may create less demand for hospitals to have a dermatologist on staff. Additionally, hospitals may be less able to incentivize dermatologists to provide inpatient dermatology consultations due to low reimbursement rates, time and distance required to visit inpatient facilities (taking away from outpatient clinic time), and the perception that inpatient cases carry greater liability given their greater complexity.^6-8 Together, these factors may have contributed to the current lack of inpatient dermatology services in Pennsylvania hospitals and likely in hospitals throughout the United States.

Conclusion

Although a relatively small number of academic hospitals are experiencing an emergence of dermatology hospitalists, poor access to inpatient dermatology care continues to be a problem.⁸ Innovation (eg, the use of teledermatology to improve access to care⁹) and further studies are needed to address this gap in access to inpatient dermatology care.