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

Abstract

To examine rural-urban differences in the clinician workforce caring for children with medical complexity (CMC) in ambulatory settings and to determine how measures of clinician patient-sharing differ for rural- and urban-residing CMC. 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 in which clinicians were connected on the basis of 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). Analysis included 107 692 CMC, of whom 7065 (7.0%) were rural-residing and 100 627 (93.0%) were urban-residing. Rural-residing CMC had lower relative risk of having a PCC specialized in pediatrics (relative risk 0.81, 95% CI 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]). 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, reflecting fewer shared patients within the team. Programs supporting care of CMC may benefit from recognizing rural-urban differences in team composition and relationships between clinicians.