Access to Specialty Healthcare in Urban Versus Rural US Populations: A Systematic Literature Review

Background: Access to healthcare is a poorly defined construct, with insufficient understanding of differences in facilitators and barriers between US urban versus rural specialty care. We summarize recent literature and expand upon a prior conceptual access framework, adapted here specifically to urban and rural specialty care.

Methods: The Cumulative Index to Nursing and Allied Health Complete (CINAHL), Medline, PubMed, PsycInfo, and ProQuest Social Sciences databases were searched systematically using the following terms: (“health services accessibility” OR “access to care”) AND (“specialties, medical” OR “specialties, surgical” OR “specialty care”) AND (“urban area” OR “urban population” OR “urban” OR “rural population” OR “rural area” OR “rural”). Search terms targeted peer-reviewed academic publications (January 2013 to August 2018) pertinent to access to US urban or rural specialty healthcare. Exclusion criteria produced 67 articles. Findings were organized into an existing ten-dimension care access conceptual framework where possible, with additional topics grouped thematically into supplemental dimensions.

Results: Of the 67 reviewed articles, 65.7% reported results related to one or more system-focused dimensions and 28.4% reported on one or more patient-focused dimensions; 38.8% reported on urban issues, 32.8% on rural issues, and 28.4% on both. Despite geographic and demographic differences, many access facilitators and barriers were common to both populations; only three dimensions did not contain literature addressing both urban and rural populations. The most commonly represented dimensions were availability and accommodation, appropriateness, and ability to perceive. Acceptability (1.5%), ability to seek (1.5%), and approachability (4.5%) were discussed the least, with all dimensions discussed at least once. Four new identified dimensions were: government and insurance policy, health organization and operations influence, stigma, and primary care and specialist influence.

Conclusions: Access to specialty care is an important and ubiquitous problem, with insufficient capacity or time delays having direct implications on health outcomes, mortality, and morbidity.While findings generally align with a preexisting framework, they also suggest several additional themes important to urban versus rural specialty care access.