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. 2025 May:280:114506.
doi: 10.1016/j.jpeds.2025.114506. Epub 2025 Feb 6.

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

Erika L Moen  1 , Seneca D Freyleue  2 , Mary Arakelyan  3 , Andrew P Schaefer  2 , A James O'Malley  1 , David C Goodman  2 , JoAnna K Leyenaar  4
Affiliations

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

Erika L Moen et al. J Pediatr. 2025 May.

Abstract

Objective: 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.

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 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).

Results: 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]).

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, 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.

Keywords: children with medical complexity; health services research; pediatric workforce.

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Conflict of interest statement

Declaration of Competing Interest Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award R01MD014735. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have no conflicts of interest to declare.

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