Rural–urban disparities in health care delivery for children with medical complexity and moderating effects of payer, disability, and community poverty

Purpose

Children with medical complexity (CMC) may be at increased risk of rural–urban disparities in health care delivery given their multifaceted health care needs, but these disparities are poorly understood. This study evaluated rural–urban disparities in health care delivery to CMC and determined whether Medicaid coverage, co-occurring disability, and community poverty modified the effects of rurality on care delivery.

Methods

This retrospective cohort study of 2012–2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire included CMC <18 years. Health care delivery measures (ambulatory clinic visits, emergency department visits, acute care hospitalizations, total hospital days, and receipt of post-acute care) were compared for rural- versus urban-residing CMC in multivariable regression models, following established methods to evaluate effect modification.

Findings

Of 112,475 CMC, 7307 (6.5%) were rural residing and 105,168 (93.5%) were urban residing. A total of 68.9% had Medicaid coverage, 33.9% had a disability, and 39.7% lived in communities with >20% child poverty. In adjusted analyses, rural-residing CMC received significantly fewer ambulatory visits (risk ratio [RR] = 0.95, 95% confidence interval [CI]: 0.94–0.96), more emergency visits (RR = 1.12, 95% CI: 1.08–1.16), and fewer hospitalization days (RR = 0.90, 95% CI = 0.85–0.96). The estimated modification effects of rural residence by Medicaid coverage, disability, and community poverty were each statistically significant. Differences in the odds of having a hospitalization and receiving post-acute care did not persist after incorporating sociodemographic and clinical characteristics and interaction effects.

Conclusions

Rural- and urban-residing CMC differed in their receipt of health care, and Medicaid coverage, co-occurring disabilities, and community poverty modified several of these effects. These modifying effects should be considered in clinical and policy initiatives to ensure that such initiatives do not widen rural–urban disparities.