title: Use of Adult-Trained Medical Subspecialists by Children Seeking Medical Subspecialty Care.
abstract: To quantify the use of adult-trained medical subspecialists by children and to determine the association between geographic access to pediatric subspecialty care and the use of adult-trained subspecialists. Children with limited access to pediatric subspecialty care may seek care from adult-trained subspecialists, but data on this practice are limited.
  
  
  
  We identified children aged <16 years in 2007-2012 Pennsylvania Medicaid claims. We categorized outpatient visits to 9 selected medical subspecialties as either pediatric or adult-trained subspecialty visits. We used multinomial logistic regression to examine the adjusted association between travel times to pediatric referral centers and use of pediatric vs adult-trained medical subspecialists for children with and without complex chronic conditions (CCCs).
  
  
  
  Among 1.1 million children, 8% visited the examined medical subspecialists, with 10% of these children using adult-trained medical subspecialists. Compared with children with a ≤30-minute travel time to a pediatric referral center, children with a >90-minute travel time were more likely to use adult-trained subspecialists (without CCCs: relative risk ratio [RRR], 1.94, 95% CI, 1.79-2.11; with CCCs: RRR, 2.33; 95% CI, 2.10-2.59) and less likely to use pediatric subspecialists (without CCCs: RRR, 0.66; 95% CI, 0.63-0.68; with CCCs: RRR, 0.76, 95% CI, 0.73-0.79).
  
  
  
  Among medical subspecialty fields with pediatric and adult-trained subspecialists, adult-trained subspecialists provided 10% of care to children overall and 18% of care to children living >90 minutes from pediatric referral centers. Future studies should examine consequences of adult-trained medical subspecialist use on pediatric health outcomes and identify strategies to increase access to pediatric subspecialists.
authors.affiliation: Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. Electronic address: Kristin.Ray@chp.edu.
authors.forename: Kristin N
authors.initials: KN
authors.lastname: Ray
authors.affiliation: Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Kahn
authors.affiliation: Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Miller
authors.affiliation: Department of Health Care Policy and Medicine, Harvard Medical School, Boston, MA; RAND Corporation, Boston, MA.
authors.forename: Ateev
authors.initials: A
authors.lastname: Mehrotra
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008297:Male; D008511:Medicine; D010372:Pediatrics; D010414:Pennsylvania
keywords: barriers to care; consultation; geographic access; pediatric; referral; specialty; subspecialty; travel time