Travel burden on patients at a subspecialty hidradenitis suppurativa clinic: a single-center retrospective study : International Journal of Women's Dermatology

Secondary Logo

Journal Logo

Research Letters

Travel burden on patients at a subspecialty hidradenitis suppurativa clinic: a single-center retrospective study

Kim, Diana S. BAa,b; Giannotti, Nicole BSb; Salian, Prerna MPHb; Kimball, Alexa B. MD, MPHb,c; Porter, Martina L. MDb,c,*

Author Information
International Journal of Women’s Dermatology 8(4):p e027, December 2022. | DOI: 10.1097/JW9.0000000000000027

What is known about this subject in regard to women and their families?

  • Hidradenitis suppurativa (HS) disproportionately affects females in the United States.
  • HS is a disease that can result in debilitating pain and reduced quality of life.
  • The majority of women with HS experience a worsening of symptoms during pregnancy. High rates of postpartum flares have also been reported. Therefore, HS care is essential during the perinatal and postpartum periods.

What is new from this article as messages for women and their families?

  • This study demonstrates a dearth of HS specialty clinics in the United States that results in greater travel burdens for patients of lower socioeconomic status.
  • As HS is a progressive disease that requires routine care, women who find the travel burden prohibitive may face worsened disease progression.

Dear Editors,

The prevalence of hidradenitis suppurativa (HS) is estimated to be 0.00033 to 4.1% with 33 HS specialty clinics in the United States1,2 (Supplementary Fig. 1, https://links.lww.com/IJWD/A14) The low number of HS specialty clinics presents a challenge for patients seeking subspecialty care, and long travel distances may also exacerbate healthcare disparities. Our study demonstrates a significant travel burden on HS patients compared to patients with psoriasis, which has a similar prevalence but over 1,000 specialists nationwide.3,4

Patients seen in the Department of Dermatology at Beth Israel Deaconess Medical Center from 2016 to 2019 with either a diagnosis of (1) HS or (2) psoriasis with previous documentation of phototherapy or systemic therapy were included. Socioeconomic status (SES) was measured by insurance, percent of individuals living under the poverty line at the patients’ zip codes of residence, and percent of households participating in the Supplemental Nutrition Assistance Program (SNAP) at the patients’ zip codes of residence. Information for the latter two measures were acquired from the 2019 American Community Surveys.5 Distance between patients’ addresses and BIDMC was calculated using Google Maps. Analysis was performed using SPSS v.27.0.1.0 (Kruskal-Wallis test, P < .001 for statistical significance).

Of 313 HS patients, 81.5% were female, 21.4% were on Medicaid, and 66.5% were White, with a median age of 37 (IQR: 29-49) years (Table 1). Of 187 psoriasis patients, 47.6% were female, 7% were on Medicaid, and 71.7% were White, with a median age of 55 (IQR: 43-65) years (Table 1). HS patients traveled a median distance of 21.0 versus 9.9 miles for psoriasis patients (P < .001). The range of distance traveled was greater in the HS group (1307.6 vs 210.7 miles), and 11.2% of HS patients traveled more than 100 miles to access care versus 0.05% of psoriasis patients (Table 1).

Table 1 - Demographic characteristics of HS and psoriasis patients seen at BIDMC5
HS count (%) Psoriasis count (%) P
Sex Male 58 (18.5%) 98 (52.4%) <.001**
Female 255 (81.5%) 89 (47.6%)
Age, years Median (IQR, range) 37 (29-49, 62) 55 (43-65, 65) <.001**
SES, insurance Medicaid 67 (21.4%) 13 (7.0%) <.001**
Non-Medicaid 246 (78.6%) 174 (93.0%)
SES, % individuals living under poverty line <5% 72 (23.2%) 44 (23.7%) 0.393
5-20% 198 (63.7%) 125 (67.2%)
>20% 41 (13.2%) 17 (9.1%)
SES, % households receiving SNAP <5% 70 (22.5%) 59 (31.7%) 0.030
5-20% 181 (58.2%) 86 (46.2%)
>20% 60 (19.3%) 41 (22.0%)
Race Asian 9 (2.9%) 23 (12.3%) <.001**
Black 66 (21.1%) 18 (9.6%)
Hispanic 21 (6.7%) 9 (4.8%)
Other 9 (2.9%) 3 (1.6%)
White 208 (66.5%) 134 (71.7%)
Language English 307 (98.1%) 163 (87.2%) <.001**
Non-English 6 (1.9%) 24 (12.8%)
Hurley 1 101 (32.3%)
2 138 (44.1%)
3 74 (23.6%)
Miles from BIDMC Median (IQR, range) 21.0 (5.7-52.7, 1307.6) 9.9 (4.8-24.2, 210.7) <.001**
Miles from BIDMC, binned by Distance ≤20.0 154 (49.2%) 132 (70.6%) <.001**
20.1-100.0 124 (39.6%) 54 (28.9%)
>100.0 35 (11.2%) 1 (0.05%)
BIDMC, Beth Israel Deaconess Medical Center; HS, hidradenitis suppurativa; IQR, interquartile range; SES, socioeconomic status; SNAP, Supplemental Nutrition Assistance Program.
**Statistical significance (P < .001).

Subgroup analysis of HS patients indicates that higher SES patients traveled further distances by all measures of SES: (1) Insurance: 8.9 (Medicaid) versus 28.9 (non-Medicaid) miles; (2) percent of individuals living under poverty line: 29.6 (<5%) versus 22.4 (5-20%) versus 3.7 (>20%) miles; and (3) percent of households receiving SNAP: 26.6 (<5%) versus 25.1 (5-20%) versus 5.8 (>20%) miles; all P < .001 (Table 2, Supplementary Fig. 2, https://links.lww.com/IJWD/A15).

Table 2 - Distances traveled by HS and psoriasis patients to BIDMC5
HS (n = 313) Psoriasis (n = 187)
Count (%) Median (IQR) P Count (%) Median (IQR) P
Sex Male 58 (18.5%) 21.4 (6.9-58.3) 0.626 98 (52.4%) 9.2 (4.3-22.0) 0.128
Female 255 (81.5) 20.9 (5.3-52.3) 89 (47.6%) 11.8 (5.7-26.5)
Age, years <30 97 (31.0%) 22.3 (6.2-57.5) 0.037 15 (8.0%) 15.2 (7.3-30.0) 0.564
31-50 145 (46.3%) 12.8 (5.0-45.2) 57 (30.5%) 8.8 (5.3-23.7)
>51 71 (22.7%) 34.8 (9.8-56.8) 115 (61.5%) 10.1 (4.2-25.7)
SES, Insurance Medicaid 67 (21.4%) 8.9 (4.0-22.5) <.001** 13 (7.0%) 8.7 (4.1-11.0) 0.5
Non-Medicaid 246 (78.6%) 28.9 (6.5-56.8) 174 (93.0%) 9.9 (4.8-24.8)
SES, % individuals living under poverty line <5% 72 (23.2%) 29.6 (14.2-51.2) <.001** 44 (23.7%) 18.8 (11.5-25.5) <.001**
5-20% 198 (63.7%) 22.4 (6.0-56.2) 125 (67.2%) 9.6 (5.3-25.7)
>20% 41 (13.2%) 3.7 (2.5-5.6) 17 (9.1%) 2.5 (1.9-3.2)
SES, % households receiving SNAP <5% 70 (22.5%) 26.6 (6.6-47.3) <.001** 59 (31.7%) 16.2 (7.3-25.2) 0.2
5-20% 181 (58.2%) 25.1 (7.4-56.8) 86 (46.2%) 9.7 (4.1-18.0)
>20% 60 (19.3%) 5.8 (3.6-31.4) 41 (22.0%) 7.7 (4.2-26.5)
Race White 208 (66.5%) 35.8 (10.0-57.9) <.001** 134 (71.7%) 10.25 (5.4-26.5) 0.2
Non-White 105 (33.5%) 6.2 (3.7-21.8) 53 (28.3%) 8.1 (3.7-17.1)
Language English 307 (98.1%) 21.7 (5.7-53.3) 0.222 163 (87.2%) 10.0 (5.3-24.8) 0.137
Non-English 6 (1.9%) 7.9 (4.8-22.5) 24 (12.8%) 6.6 (3.0-15.0)
Hurley 1 101 (32.3%) 8.9 (4.1-38.7) <.001**
2 138 (44.1%) 22.7 (7.1-50.8)
3 74 (23.6%) 37.4 (7.3-74.1)
BIDMC, Beth Israel Deaconess Medical Center; HS, hidradenitis suppurativa; IQR, interquartile range; SES, socioeconomic status; SNAP, Supplemental Nutrition Assistance Program.
**Statistical significance (P < .001).

Limitations for this study include being a single-center study and comparing HS patients of all disease stages to psoriasis patients with moderate-to-severe disease. ACS information is the representative of US zip codes.

HS patients were found to travel more than twice the distance of psoriasis patients to obtain access to specialized care. Higher SES patients travel further than lower SES patients, who may be unable to afford to travel long distances for care. As HS requires routine follow-ups to prevent disease progression, steps must be taken to expand the reach of HS care, especially to lower SES patients. Providing HS-specific training to providers, increasing the use of telemedicine, and providing transport options can reduce disparities in HS severity and protect at-risk populations from disease progression.

Conflicts of interest

M.P. is a consultant and an investigator for UCB, Pfizer, Eli Lilly, and Novartis and an investigator for Abbvie, Janssen, and Bristol Meyers Squibb. A.B.K. is a consultant and Investigator for Abbvie, Bristol Meyers Squibb, Janssen, Eli Lilly, Novartis, Pfizer, and UCB; a consultant for Kymera, Amirall, Investigator ChemoCentryx; receives fellowship funding from Janssen and Abbvie; and served as previous Board of Directors and Past President of the International Psoriasis Council and Board of Directors of the HS Foundation. D.K., N.G., and P.S. do not have any conflicts of interest to disclose.

Funding

None

Study approval

Informed, written consent was received from all patients and confirmed to the journal pre-publication, stating that the patients gave consent for their photos and case history to be published. Reviewed and approved by Beth Israel Deaconess Medical Center Committee on Clinical Investigations (CCI/IRB).

References

1. Goldburg SR, Strober BE, Payette MJ. Hidradenitis suppurativa: Epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol 2020;82:1045–1058.
2. Hidradenitis Suppurativa Foundation. Hidradenitis Suppurativa specialty clinics. Available from: https://www.hs-foundation.org/hs-specialty-clinics. Accessed July 28, 2021.
3. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CEM. Psoriasis prevalence in adults in the United States. JAMA Dermatol 2021;157:940–946.
4. National Psoriasis Foundation. Psoriasis statistics. Available from: https://www.psoriasis.org/cure_known_statistics. Accessed July 28, 2021.
5. [dataset] U.S. Census Bureau. (2019). 2019 American Community Survey 5-Year Estimates Data Profiles, Table ID: DP03 [Excel Data file]. Accessed from https://data.census.gov/cedsci/table?q=selected%20economic&tid=ACSDP1Y2019.DP03. Accessed July 28, 2021.
Keywords:

hidradenitis suppurativa; psoriasis; travel burden; zip code; socioeconomics

Supplemental Digital Content

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Women’s Dermatologic Society.