title: Supply and utilization of pediatric subspecialists in the United States.
abstract: OBJECTIVE
  The wide geographic variation in pediatric subspecialty supply in the United States has been a source of concern. Whether children in areas with decreased supply receive less subspecialty care or have worse outcomes has not been adequately evaluated. Among children with special health care needs, we examined the association between pediatric subspecialty supply and subspecialty utilization, need, child disease burden, and family disease burden.
  
  
  METHODS
  We measured pediatric subspecialist supply as pediatric subspecialists per capita in each residential county. By using the 2009-2010 National Survey of Children With Special Health Care Needs and controlling for many potential confounders, we examined the association between quintile of pediatric subspecialty supply and parent-reported subspecialty utilization, perceived subspecialty need, and child and family disease burden.
  
  
  RESULTS
  County-level pediatric subspecialty supply ranged from a median of 0 (lowest quintile) to 59 (highest quintile) per 100 000 children. In adjusted results, compared with children in the highest quintile, children in the lowest quintile of supply were 4.8% less likely to report ambulatory subspecialty visits (P < .001), 5.3% less likely to perceive subspecialty care needs (P < .001), and 2.3% more likely to report emergency department visits (P = .018). There were no meaningful differences between pediatric subspecialty supply quintiles for other measures of child or family disease burden.
  
  
  CONCLUSIONS
  Children living in counties with the lowest supply of pediatric subspecialists had both decreased perceived need for subspecialty care and decreased utilization of subspecialists. However, the differences in supply were not associated with meaningful differences in child or family disease burden.
authors.affiliation: Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; kristin.ray@chp.edu.
authors.forename: Kristin N
authors.initials: KN
authors.lastname: Ray
authors.affiliation: Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
authors.forename: Debra L
authors.initials: DL
authors.lastname: Bogen
authors.affiliation: University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania;
authors.forename: Marnie
authors.initials: M
authors.lastname: Bertolet
authors.affiliation: Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania;
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Forrest
authors.affiliation: Harvard Medical School, Boston, Massachusetts; andRAND Corporation, Boston, Massachusetts.
authors.forename: Ateev
authors.initials: A
authors.lastname: Mehrotra
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease / Q000453:epidemiology* / Q000628:therapy; D017281:Cost of Illness; D019988:Children with Disabilities / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008297:Male; D008507:Medically Underserved Area; D010372:Pediatrics / Q000706:statistics & numerical data*; D013038:Specialization / Q000706:statistics & numerical data*; D014481:United States; D014600:Utilization Review / Q000706:statistics & numerical data; D000078329:Workforce
keywords: access to care; children with special health care needs; subspecialty need; subspecialty supply; utilization