Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(3):e2024192 1 Preventing Delays in Care For Racial Minorities: Examining Referral Patterns in a Nail Specialty Clinic Rachel C. Hill1,2, Rhiannon C. Miller2, Shari R. Lipner2 1 Weill Cornell Medical College, New York, USA 2 Weill Cornell Medicine, Department of Dermatology, New York, USA Key words: referrals, specialty dermatology, nails, nail malignancies, skin of color, racial disparities Citation: Hill RC, Miller RC, Lipner SR. Preventing Delays in Care For Racial Minorities: Examining Referral Patterns in a Nail Specialty Clinic. Dermatol Pract Concept. 2024;14(3):e2024192. DOI: https://doi.org/10.5826/dpc.1403a192 Accepted: March 5, 2024; Published: July 2024 Copyright: © Hill et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Shari R. Lipner MD, PhD, 1305 York Avenue, NY, NY 10021. Phone: 646-962-3376. Fax: 646-962-0033. Email: shl9032@med.cornell.edu Introduction In the US, it is commonplace for dermatology specialty clin- ics to require referrals for appointment scheduling. Similarly, health maintenance organization (HMO) insurance plans frequently require primary care physician (PCP) referrals prior to seeing dermatologists; however, effects of these poli- cies on outcomes are underexplored [1]. Our objectives were to examine demographics, visit characteristics, and patient outcomes based on specialized nail clinic referral patterns. Methods Patient charts in the Weill Cornell nail clinic 09/29/ 21– 04/29/22 were analyzed for referral, demographics, wait times, procedures performed, and diagnosis. Patients without refer- rals were excluded. Patients were grouped based on referral by: 1) dermatologist, 2) other physician, or 3) self-referral. T-tests, z-tests, and chi-square tests were performed, with α=0.05. Results and Discussion Two hundred and twenty-nine nail patients seen for initial visit were analyzed, with average age 51.6 years (range: 1–89), 66.4% female, and 45.9% White. Overall, 59% of patients were dermatologist-referred, 15.3% by other physi- cian, and 25.8% self-referred (Supplemental Figure 1). There was no difference in average age, sex, or ethnic- ity and nail biopsy rate between referral groups. There was a larger proportion of White patients in the dermatologist- referred vs. self-referred groups (51.9% vs. 37.3%, P = 0.02) (Table 1). Nail condition incidence was similar between self-referred vs. dermatologist referrals (P = 0.09–0.98) Overall, 30% of nail malignancies were diagnosed in self-referred patients. Nail malignancy incidence was 2 Research Letter | Dermatol Pract Concept. 2024;14(3):e2024192 Figure 1. Visit wait times for these initial appointments. “All” category includes both video and in-person initial appointments combined. Significant differences denoted with asterisks (P value < 0.05 = *; < 0.01 = **, < 0.001 = ***). similar in dermatologist-referred vs. other physician- referred and self-referred (P = 0.17 and 0.98, respec- tively). Dermatologist-referred vs. non-dermatology physician- referred patients had shorter wait time for in-per- son appointments (54.3 vs. 91.5 days, P = 0.01). Wait times were consistently shorter for video (14.2 days) vs. in-person visits (62.3 days) (P < 0.001, Figure 1). For a model requiring any physician referral, analysis of all patients referred by a physician (dermatologist, PCP, or other specialist) showed no difference on any parame- ter (demographics, outcomes, etc.) vs. self-referred patients (Supplemental Table 1). Limitations of this study include single-center, retrospec- tive design, and limited numbers of physician assistants and nurse practitioners to group. Our study shows no differences in prevalence of testing, malignancies, or diagnoses between dermatologist- referred vs. self-referred, but dermatologist-referred patients were more often White and experienced shorter wait times. In 2 SEER studies, skin of color patients more often had ad- vanced stage melanomas vs. Whites (1988-2011) [2] and worse outcomes and disease progression (1992–2009) [3]. Therefore, triaging patients based only on physician referrals is not an adequate or effective system. In a ret- rospective study of 1,526 outpatient dermatology visits, 57% of referrals were deferrable conditions, and 36% of referrals were inappropriately triaged as urgent cases [4]. Telemedicine might be effective for triage but not for all nail patients nor for procedures, with up to 6-10 weeks shorter wait time in other specialties and a 38–88% re- duction in need for a subsequent in-person appointment in dermatology [5]. We corroborate these studies, with an almost 7-week shorter wait time for a new patient telemed- icine vs in-person visit. Conclusion In conclusion, patients referred by dermatologists were more often White and experienced shorter wait times, high- lighting potential health care disparities in specialty clinics. Therefore, requiring referrals might represent significant barriers and delays in care that disparately affects minority populations. Research Letter | Dermatol Pract Concept. 2024;14(3):e2024192 3 Table 1. Demographic, Visit, and Outcomes Analysis Patient/Visit Characteristics All (n = 229) Dermatology Referral (n = 135) Other Physiciana (n = 35) Self-Referredb (n = 59) P P Demographics Average Age (Years) 51.59 52.0 55.7 0.32 48.3 0.24 % Female 66.4% 65.2% 68.6% 0.70 67.8% 0.73 Race White 45.9% 51.9% 37.1% 0.07 37.3% 0.02 Black 4.8% 6.7% 2.9% 1.7% Asian 6.6% 8.1% 2.9% 5.1% Other/Declined 42.8% 33.3% 57.1% 55.9% Ethnicity Hispanic 5.2% 5.2% 8.6% 0.74 3.4% 0.36 Not Hispanic 52.0% 54.8% 51.4% 45.8% Other/Declined 42.8% 40.0% 40.0% 50.8% Visit Details Wait Time for Visit (Days) 56.0 50.01 71.3 0.09 58.5 0.41 For In-Person 62.3 54.3 91.5 0.01 63.0 0.43 For Video Visit 14.2 16.1 10.6 0.24 15.8 0.96 Time Since Condition Start 44.9 42.6 47.2 0.76 48.7 0.61 % Having Nail Clipping 44.5% 37.0% 57.1% 0.03 54.2% 0.03 % Having Nail Biopsy 17.0% 18.5% 11.4% 0.32 16.9% 0.79 Avg # Doctors Seen Prior 1.4 1.4 1.3 0.34 1.5 0.68 Avg # Dermatologist Seen Prior 1.0 1.3 0.2 <0.0001 1.1 0.25 Outcomes % Malignant 4.4% 5.2% 0% 0.17 5.1% 0.98 Final Diagnosisc Benign melanonychia 15.7% 18.5% 14.3% 0.56 10.2% 0.14 Malignancy 4.4% 5.2% 0.0% 0.17 5.1% 0.98 Benign neoplasm of nail 7.0% 8.9% 0.0% 0.07 6.8% 0.62 Brittle nail 7.4% 8.1% 8.6% 0.94 5.1% 0.45 Chronic inflammatory condition 17.9% 20.0% 5.7% 0.046 20.3% 0.96 Fungal infection 17.9% 12.6% 31.4% 0.007 22.0% 0.09 Paronychia 3.5% 5.2% 0.0% 0.17 1.7% 0.26 Onychodystrophy-Related 24.9% 20.0% 37.1% 0.03 28.8% 0.18 Other/Unknown 1.3% 1.5% 2.9% 0.58 0.0% 0.35 a Non-dermatology physicians includes: PCP, orthopedic surgeon, podiatrist, rheumatologist, etc. b Self-Referred includes: found on internet, word-of-mouth, family, or friends. c Malignancy: subungual SCC, melanoma. Benign neoplasm: glomus tumor, myxoid cyst, onychopapilloma, verrruca, etc. Chronic inflam- matory: nail lichen planus, psoriasis, eczema. Onychodystrophy-related: beau’s lines, traumatic onychodystrophy/onycholysis/hematoma, onychomadesis, retronychia, onychotillomania. *P-values represent comparison of non-dermatology physician referral group or self-referred group to the dermatology referral group. Bolded values indicate significance at a level of α = 0.05. 4 Research Letter | Dermatol Pract Concept. 2024;14(3):e2024192 2016 Nov;75(5):983-991. doi: 10.1016/j.jaad.2016.06.006. Epub 2016 Jul 28. PMID: 27476974. 4. Deluca J, Goldschmidt A, Eisendle K. Analysis of effectiveness and safety of a three-part triage system for the access to der- matology specialist health care. J Eur Acad Dermatol Venereol. 2016 Jul;30(7):1190-4. doi: 10.1111/jdv.13295. Epub 2015 Oct 7. PMID: 26448132. 5. Caffery LJ, Farjian M, Smith AC. Telehealth interventions for reducing waiting lists and waiting times for specialist out- patient services: A scoping review. J Telemed Telecare. 2016 Dec;22(8):504-512. doi: 10.1177/1357633X16670495. Epub 2016 Sep 28. PMID: 27686648. References 1. Barnett ML, Song Z, Bitton A, Rose S, Landon BE. Gatekeep- ing and patterns of outpatient care post healthcare reform. Am J Manag Care. 2018 Oct 1;24(10):e312-e318. PMID: 30325192. 2. Mahendraraj K, Sidhu K, Lau CSM, McRoy GJ, Chamberlain RS, Smith FO. Malignant Melanoma in African-Americans: A Population-Based Clinical Outcomes Study Involving 1106 African-American Patients from the Surveillance, Epidemiology, and End Result (SEER) Database (1988-2011). Medicine (Baltimore). 2017 Apr;96(15):e6258. doi: 10.1097/MD.0000000000006258. PMID: 28403068; PMCID: PMC5403065. 3. Dawes SM, Tsai S, Gittleman H, Barnholtz-Sloan JS, Bordeaux JS. Racial disparities in melanoma survival. J Am Acad Dermatol.