Associations of rurality, child opportunity, and distance with use of pediatric asthma specialists

BACKGROUND: Receipt of asthma specialty care reduces children's asthma morbidity, but children living in rural, socioeconomically disadvantaged, and remote areas face potential barriers to accessing specialists. OBJECTIVE: To evaluate the associations of rurality, Child Opportunity Index (COI), and distance with pediatric asthma specialist utilization among children with an indication for specialist referral. METHODS: In this retrospective cohort study using 2015-2021 Maine Health Data Organization All-Payer Claims Data, we identified children (<18 years) with asthma and one of the following indications for specialist referral: a complicating comorbidity, higher-level controller medications, 3 or more courses of systemic corticosteroids within a year, or a respiratory hospitalization. We performed multivariate logistic regressions to calculate the adjusted associations between use of pediatric asthma specialists (physicians or advanced practice providers specializing in allergy-immunology or pediatric pulmonology) in the year after indication and children's rurality, COI, and driving time to specialists. RESULTS: Among 12,014 children with indications for pediatric asthma specialist referral, 47% lived in micropolitan or rural areas and 15% lived over 1 hour from any specialist. 2,296 children (19%) utilized specialists within a year of their indication. In adjusted analyses, children were significantly less likely to utilize specialists if they lived in small town (aOR 0.54, 95% CI 1.09-1.39) or isolated small rural areas (aOR 0.82, 95% CI 0.71-0.94), areas with a COI less than "very high" (for "very low", aOR 0.65, 95% CI 0.56-0.75), or farther from specialists (aOR 0.62 per hour, 95% CI 0.57-0.68). CONCLUSION: Children in rural areas, in areas of low socioeconomic opportunity, and far from specialists are at an increased risk of not receiving indicated asthma specialist care. CLINICAL IMPLICATIONS: Fewer children living in rural, remote, and socioeconomically disadvantaged areas received indicated pediatric asthma specialty care, highlighting the need for efforts to improve access among these populations. CAPSULE SUMMARY: In this review of statewide medical claims data only 19% of children with an indication for asthma specialty care utilized specialists within one year, with lower rates among rural, remote, and socioeconomically disadvantaged children.