264 - Rural-Urban Differences in Continuity of Ambulatory Care for Children with Medical Complexity

Poster Number: 264
Publication Number: 264.198

Background: Children with medical complexity (CMC) are at high risk of care fragmentation given their multifaceted healthcare needs. Continuity of care (CoC) has been endorsed as a CMC national quality measure, but little is known about rural-urban differences in ambulatory care quality for this population.

Objective: To evaluate rural-urban disparities in CoC among CMC and propose a novel measure of geographic CoC to assess continuity within health services regions.

Design/Methods: CMC < 18 years of age were identified using all-payer claims data from Colorado, New Hampshire, and Massachusetts, 2012-2015. Propensity score weighting was used to create a balanced cohort of rural- and urban-residing CMC and assess differences in the continuity of ambulatory care using the Bice-Boxerman CoC Index (0-1 scale) during 2016-2017. For rural- and urban-residing CMC, we compared mean overall CoC as well as CoC with primary care and specialist clinicians. As measures of geographic continuity, we adapted the traditional CoC index to evaluate CoC within Hospital Service Areas (HSAs) and Health Referral Region (HRRs). Figure 1 presents the Bice-Boxerman CoC Index equation and example calculations.

Results: Among 110,287 CMC, 103,086 resided in urban areas and 7201 in rural areas. After weighting, the urban and rural cohorts were balanced across all sociodemographic and clinical characteristics (Table 1). In the weighted cohort, rural-residing CMC had a small but significantly higher overall CoC than urban-residing CMC (Table 2; 0.36 vs. 0.34, standardized difference [sd]: -0.100) driven by higher CoC with primary care providers (0.52 vs. 0.47, sd: -0.165). Compared to urban-residing CMC, rural-residing CMC had a significantly smaller proportion of ambulatory care visits within the HSA of their home ZIP Code (40.1% vs. 47.1%, sd: 0.141) and within their home HRR (70.3% vs. 87.4%, sd:0.427). Rural-residing CMC were also more likely to receive ambulatory care in >1 HSA and HRR. Measured at the HSA level, rural-residing CMC had lower CoC than urban-residing CMC (0.61 vs. 0.67, sd: 0.232) and lower HRR CoC (0.797 vs. 0.900, sd: 0.156).

Conclusion(s): Accounting for baseline characteristics, rural-residing CMC have comparable or higher CoC compared to urban-residing CMC but experience lower geographic continuity. Geographic fragmentation may increase direct and indirect costs and reduce linkage with local social and community services.