Expect delays: poor connections between rural and urban health systems challenge multidisciplinary care for rural Americans with diabetic foot ulcers

Background Rural Americans with diabetic foot ulcers (DFUs) face a 50% increased risk of major amputation compared to their urban counterparts. We sought to identify health system barriers contributing to this disparity. Methods We interviewed 44 participants involved in the care of rural patients with DFUs: 6 rural primary care providers (PCPs), 12 rural specialists, 12 urban specialists, 9 support staff, and 5 patients/caregivers. Directed content analysis was performed guided by a conceptual model describing how PCPs and specialists collaborate to care for shared patients. Results Rural PCPs reported lack of training in wound care and quickly referred patients with DFUs to local podiatrists or wound care providers. Timely referrals to, and subsequent collaborations with, rural specialists were facilitated by professional connections. However, these connections often were lacking between rural providers and urban specialists, whose skills were needed to optimally treat patients with high acuity ulcers. Urban referrals, particularly to vascular surgery or infectious disease, were stymied by 1) time-consuming processes, 2) negative provider interactions, and 3) multiple, disconnected electronic health record systems. Such barriers ultimately detracted from rural PCPs' ability to focus on medical management, as well as urban specialists' ability to appropriately triage referrals due to lacking information. Subsequent collaboration between providers also suffered as a result. Conclusions Poor connections across rural and urban healthcare systems was described as the primary health system barrier driving the rural disparity in major amputations. Future interventions focusing on mitigating this barrier could reduce the rural disparity in major amputations.