Access to dermatologic care in Indigenous American communities
Authors: Betty Nguyen, Fleta N. Bray
Journal: Journal of the American Academy of Dermatology (2022)

To the Editor: American Indian and Alaska Native (AIAN) tribes in the United States experience poorer health outcomes compared with other Americans, including increased melanoma mortality1Wu X.C. Eide M.J. King J. et al.Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999-2006.J Am Acad Dermatol. 2011; 65: S26-S37PubMed Google Scholar and acne scarring.2Zullo S.W. Maarouf M. Shi V.Y. Acne disparities in Native Americans.J Am Acad Dermatol. 2021; 85: 499-501Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Several factors explain this disparity, including inadequate health literacy, disproportionate poverty, cultural differences, and decreased accessibility to dermatologic care. Although the density of dermatologists (3.4 per 100,000 individuals) across the United States has risen, it is still less than the 4 per 100,000 individuals recommended for achieving sufficient care.3Glazer A.M. Farberg A.S. Winkelmann R.R. Rigel D.S. Analysis of trends in geographic distribution and density of US dermatologists.JAMA Dermatol. 2017; 153: 322-325Crossref PubMed Scopus (75) Google Scholar Given the undersupply of dermatologists and geographic variations in provider density, dermatologists have been supplemented with dermatology physician assistants (DPAs). However, it remains unclear whether this has sufficiently improved dermatologic health care accessibility. This study reports the density of dermatologists and DPAs in AIAN homelands and explores the potential contributing factors to these health disparities. Based on the 2020 decennial United States census, 5,117,371 individuals living in 705 AIAN homelands were identified, and the most populous 100 homelands of 4,742,579 (92.7%) individuals were analyzed. Locations of dermatologists and DPAs were obtained from the American Academy of Dermatology and Society of Dermatology Physician Assistants and were correlated with homeland borders defined by the census. Providers located within homeland borders were counted. There were 56 dermatologists and 3 DPAs in the most populous 100 homelands, yielding a mean dermatology provider density of 1.24 per 100,000 individuals. Only 23 homelands had at least 1 dermatology provider, and only 7 homelands exceeded the minimum recommended dermatologist density of 4 per 100,000 individuals. Table I and Figure 1 summarize data on the total numbers and densities of dermatologists and DPAs in each homeland.Table INumber of dermatology providers practicing within the 10 most populous and 10 most provider-dense American Indian and Alaska Native homelands in the United StatesRankHomelandTotal populationTotal dermatologistsTotal DPAsTotal providersProviders per 100,000Most populous homelands1Creek OTSA, OK813,184160161.972Cherokee OTSA, OK513,1781010.193Lumbee SDTSA, NC510,7113030.594Chickasaw OTSA, OK306,4604151.635Choctaw OTSA, OK226,9840000.006Kiowa-Comanche-Apache-Fort Sill Apache OTSA, OK187,6461010.537Cheyenne and Arapaho OTSA, OK186,6281010.548United Houma Nation SDTSA, LA186,0564042.159Navajo Nation Reservation and Off-Reservation Trust Land, AZ--NM--UT165,1581010.6110Citizen Potawatomi Nation-Absentee Shawnee OTSA, OK126,9870000.00Most provider-dense homelands1United Cherokee Ani-Yun-Wiya Nation SDTSA, AL618410116.172Salt River Reservation, AZ632110115.823Cher-O-Creek SDTSA, AL85,0091011112.944Kaw/Ponca joint-use OTSA, OK26,1461127.655Natchitoches SDTSA, LA26,5282027.546Bayou Lafourche SDTSA, LA14,1951017.047Kenaitze ANVSA, AK34,6372025.778Uintah and Ouray Reservation and Off-Reservation Trust Land, UT25,1921013.979Wind River Reservation and Off-Reservation Trust Land, WY25,7591013.8810Kickapoo OTSA, OK26,2591013.81ANVSA, Alaska Native Village Statistical Area; DPA, Dermatology physician assistant; OTSA, Oklahoma Tribal Statistical Area; SDTSA, State Designated Tribal Statistical Area. Open table in a new tab ANVSA, Alaska Native Village Statistical Area; DPA, Dermatology physician assistant; OTSA, Oklahoma Tribal Statistical Area; SDTSA, State Designated Tribal Statistical Area. Access to dermatologic care in AIAN communities mirrors that of the least dermatologist-dense areas in the United States and is likely influenced by their location in rural areas.3Glazer A.M. Farberg A.S. Winkelmann R.R. Rigel D.S. Analysis of trends in geographic distribution and density of US dermatologists.JAMA Dermatol. 2017; 153: 322-325Crossref PubMed Scopus (75) Google Scholar Only 5 homelands had more than 2 practitioners, and these 5 all contained an urban center. This disparity in provider density between rural and metropolitan areas has been steadily increasing over the years.4Feng H. Berk-Krauss J. Feng P.W. Stein J.A. Comparison of dermatologist density between urban and rural counties in the United States.JAMA Dermatol. 2018; 154: 1265-1271Crossref PubMed Scopus (86) Google Scholar Given the shortage of dermatologists practicing on AIAN homelands, transportation (to potentially distant dermatology providers) remains a barrier to accessing care. In one study evaluating dermatologic care in rural AIAN communities, the median driving distance between a dermatology clinic and a tribal hospital was 68 miles.5Morenz A.M. Wescott S. Mostaghimi A. Sequist T.D. Tobey M. Evaluation of barriers to telehealth programs and dermatological care for American Indian individuals in rural communities.JAMA Dermatol. 2019; 155: 899-905Crossref PubMed Scopus (25) Google Scholar This study has several limitations, including the lack of available data for nondermatology physicians, nonphysician providers (eg, nurse practitioners), and practitioners who are not members of American Academy of Dermatology or Society of Dermatology Physician Assistants. Our study is also unable to account for dermatology providers who practice directly outside of AIAN homeland borders. Our report emphasizes the undersupply of dermatology providers in AIAN homelands. Moreover, DPAs have not adequately supplemented dermatologic care in these regions. Improving practice incentives, creating AIAN-focused residency training tracks, promoting rural health programs on tribal lands, expanding telehealth, and increasing recruitment of medical students and dermatology residents from AIAN homelands may improve health care accessibility in these areas. None disclosed.