Social Determinants of Health in Rural Versus Urban Patients with Hidradenitis Suppurativa

Introduction: Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease requiring ongoing multidisciplinary care. Healthcare resource utilization (HCRU) and access to dermatology care may depend upon social determinants of health including geographic location in the United States (US). This study aimed to evaluate differences in HCRU and access to care for patients with HS in rural vs. urban areas within the US. Procedure/Study: This retrospective longitudinal analysis was conducted using STATinMED RWD Insights all-payer medical and pharmacy claims data from 01/01/2014–‍11/30/2024 (study identification period: 01/01/2015–11/30/2023). Eligible patients were aged ≥12 years with codes (ICD-9 or ICD-10-CM) for either HS diagnosis, or HS symptoms without a diagnosis, plus continuous medical and pharmacy benefit enrollment for 12 months pre-/post-index (date of earliest HS diagnosis or symptom claim). Patients without an HS diagnosis required ≥2 visits 30 days to 12 months apart with related symptom claims (abscess, cyst, boil, furuncle, folliculitis). We report demographic variables, HCRU, and access to care, in rural vs. urban patients. Access to specialist dermatology care and treatment was compared between urban and rural groups using chi-squared tests. Results: In total, 1,763,183 eligible patients were included: 51,030 (2.9%) rural and 1,712,153 (97.1%) urban. Of all patients, 17% (n=297,982) had an HS diagnosis and 83% (n=1,465,201) had HS symptoms without a diagnosis. Mean age (standard deviation [SD]) was similar for rural vs. urban (52 [18.6] vs. 51 [18.4] years); both were 59% female. The largest proportions of each group were in the US South (47% rural vs. 38% urban, p<0.001) and White (90% vs. 85%, p<0.001). At index, a smaller proportion of rural vs. urban patients had received an HS diagnosis from a dermatologist (12% vs. 24%), whereas a greater proportion had been diagnosed by family medicine specialists (27% vs. 17%). During follow-up: utilization of biologics (any indication) was low (2.8% rural vs. 3.1% urban, p=0.139) and most commonly prescribed by rheumatologists, followed by dermatologists. A significantly greater proportion of rural vs. urban patients accessed primary care (HS-diagnosed/undiagnosed: 87% vs. 76%/87% vs. 72%; both p<0.001). A significantly smaller proportion of rural vs. urban patients accessed specialty care from dermatologists (HS-diagnosed/undiagnosed: 15% vs. 26%/23% vs. 41%; both p<0.001); similar was observed for rheumatologists (HS-diagnosed/undiagnosed: 2.6% vs. 3.7%/2.2% vs. 3.1%; both p<0.001). Rural patients had significantly more all-cause outpatient hospital visits than urban patients (baseline/follow-up means [SD]: 5.9 [7.7] vs. 5.1 [7.3]/7.3 [9.4] vs. 5.9 [8.3]; both p<0.001), and substantially higher pain medication use (opioid and non-opioid). HS-related HCRU was low overall; significantly more rural patients had HS-related outpatient hospital visits vs. urban (baseline/follow-up: 2.6% vs. 1.9%/39% vs. 25%; both p<0.001). Conclusion: Significant differences were observed between rural and urban HS patients’ access to specialized care by a dermatologist and HCRU. Rural HS patients had greater reliance on primary care for their HS management than urban patients.