Rural-Urban Differences in Patient-Sharing by Clinicians Caring for Children with Medical Complexity: Network Analysis of the Pediatric Workforce in 3 States.

Abstract

Objective: To examine rural-urban differences in the clinician workforce caring for children with medical complexity (CMC) in ambulatory settings, and determine how measures of clinician patient-sharing differ for rural- and urban-residing CMC.

Study design: We analyzed Massachusetts, New Hampshire, and Colorado all-payer claims data from 2012 through 2017 to identify CMC and their clinicians. We assembled patient-sharing networks where clinicians were connected based on having encounters with common pediatric patients. We evaluated rural-urban differences in CMC care team size, composition (ie, which specialists were included), and care density (ie, extent to which a CMC's care team shared patients) and network measures of primary care clinician (PCC) centrality (eg, number of patient-sharing relationships).

Results: Analysis included 107,692 CMC, of whom 7,065 (7.0%) were rural-residing and 100,627 (93.0%) were urban-residing. Rural-residing CMC had lower relative risk (RR) of having a PCC specialized in pediatrics (RR [95% CI])=0.81 [0.73-0.89]) compared with urban-residing CMC. Despite having similarly sized care teams, rural-residing CMC had substantially lower care density (median [IQR]=21.6 [7.9-72.8]) compared with urban-residing CMC (median [IQR]=48.3 [13.0-158.7]). Rural PCC were less central in the networks and had a greater percentage of connections with advanced practice providers compared with their urban counterparts (median [IQR]=19.2 [14.3-24.5] vs. 14.3 [7.5-23.4]).

Conclusions: Our study provides new insight into the clinicians and teams caring for CMC. Rural-residing CMC were more likely to receive care from clinicians with fewer connections and lower care density, leading to fewer shared patients within the team. Programs that promote care delivery to CMC may benefit from recognizing rural-urban differences in team composition and relationships between clinicians.