Children living in rural areas encounter unique, significant barriers to the receipt of health care, including pediatric specialty care. In this article, the authors review these barriers and evaluate the advantages and limitations of various access tools intended to better connect children to specialty care. They highlight the potential of some access tools to increase rural primary care physicians’ skill and involvement in their patient care, but also the risks of increasing rural primary care providers’ workload and responsibilities without increasing their resources. They contextualize these benefits and risks within the quintuple aims advanced by the Institute of Healthcare Improvement.
Key points
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Children in rural areas face increased barriers to accessing pediatric specialty care.
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Multiple access tools exist to improve rural access, including televisits, electronic consultations, and tele-mentoring, most of which involve increased effort and responsibility on the part of rural primary care providers.
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Health systems and policymakers must support primary care providers in the use of access tools to improve the care of their patients.
Introduction
Children living in rural areas encounter unique, significant barriers to the receipt of health care, including pediatric specialty care. In this article, the authors review these barriers and, taking the perspective of the primary care practitioners caring for children in rural areas, evaluate the advantages and limitations of various access tools intended to better connect children to specialty care. They highlight the potential of some access tools to increase rural primary care physicians’ skill and involvement in their patient care, but also the risks of increasing rural primary care providers’ workload and responsibilities without increasing their resources. They contextualize these benefits and risks within the quintuple aims advanced by the Institute of Healthcare Improvement.
Access to pediatric specialty care among children in rural areas
Over 13 million children in the United States live in rural areas, which are defined by smaller size settlements and low rates of commuting to nearby larger settlements. , The ability of these children to access pediatric specialty care may be impacted by their rural locations in multiple ways. Rural areas have decreased health care infrastructure, including a lack of local pediatric hospitals, , emergency care, and specialists. Due to limited local pediatric care, rural families may need to travel greater distances to care. Perversely, however, rurality is also associated with transportation challenges including limited public transportation. Other urban–rural differences affecting health include higher rates of tobacco use and less healthy diets and higher rates of obesity. , With these increased risk factors for chronic disease, rural children would be expected to need pediatric specialty care at higher rates than their urban counterparts, but in fact they utilize specialty care less.
Primary care in Rural America
Children are generally directed to pediatric specialty care from their primary care medical homes, which have unique features in rural America. Pediatric patients may receive primary care from a Pediatric or Family Medicine Physician, Nurse Practitioner, or Physician’s Assistant. The American Medical Association estimates that 95% of pediatricians work in areas designated as urban and only 12% of primary care physicians (Internal Medicine, Pediatrics, and Family Medicine) work in rural communities. Metropolitan counties have 5 times the number of pediatricians per 100,000 population as noncore rural counties and 5% of counties in the United States have no primary care physician. , This would suggest that rural children are more likely than their urban counterparts to have a primary care provider who is an advanced practice provider rather than a physician.
Rural practitioners have variable associations and affiliations with larger academic medical centers in or near which most specialty pediatric care resides and through which most research on access interventions is conducted. Some practitioners will have limited or no direct relationships with pediatric specialty providers. The presence or absence of direct affiliations or indirect associations may dictate how specialty care is delivered to rural pediatric patients. However, these rural primary care practitioners may have deep and significant knowledge of their patients and their community, local resources, and barriers to care.
Evaluating the available tools for improving rural access to subspecialty care
Although children in rural areas face disproportionate barriers in accessing specialty care, a growing kit of access tools exists to facilitate care receipt. Some of these tools were developed specifically to reduce transportation barriers among patients. Others have been developed to address local and national shortages of subspecialists by increasing a Primary Care Provider’s (PCP’s) capacity to deliver “specialty level” care, a shift that can represent both a challenge and opportunity to rural PCPs. Access tools also vary in their potential to improve access to specialty care among rural children and resources they require of patients, PCPs, and specialists. The best access tool for an individual patient will depend on the patient’s individual needs and barriers to care, as well as the resources of the patient, their medical home, and broader medical system. , There is relatively little research comparing different access tools to each other, and more research is needed to understand the experiences of clinicians and patients in using different access tools, as well as the health outcomes of different tools. Guided by the available literature, however, we summarize the features of several access strategies later in the following paragraphs and in Table 1 . Our general approach is to compare each access tool to a traditional subspecialist referral, focusing on the experiences of rural patients and their primary care providers.
| Tool | Overcomes Geographic Barriers | Reduces Demand for Subspecialists | Physical Examination | Patient Requirements (Beyond Visit with PCP) | Primary Care Provider Requirements | Specialist Requirements |
|---|---|---|---|---|---|---|
| Traditional Referral Patient is scheduled to see a specialist in-person | Specialist | Travel to specialist, Visit time | Visit time | |||
| Televisit Patient meets virtually with a specialist | ∗∗ | N | Specialist (limited) | AV device, Internet service | Visit time, AV device, software, Internet service | |
| Teleconference Patient, PCP, and specialist meet virtually | ∗ | N | PCP with specialist guidance | Travel (local), Visit time | Visit time, Coordination, AV device, software, Internet service, Coordination with specialist | Visit time, coordination, AV device, software, Internet service, Coordination with PCP |
| Outreach clinics Specialist holds clinics in locations with access barriers | ∗ | N | Specialist | Travel (local), Visit time | Visit time, travel time | |
| eConsult PCP sends questions asynchronously to specialist | ∗∗ | Y | PCP | EHR linked to specialist, time | eConsult system, time | |
| Tele-mentoring Specialist provides virtual, interactive guidance to PCP | ∗ | Y | PCP | Time for education, additional management | Time for education | |
| Referral Guidelines Specialist prepares asynchronous referral guidance for PCP | ∗ | Y | PCP | Referral pattern changes, additional management | Guideline development |
Televisits—Patient Meets Virtually with a Specialist
Because telemedicine visits allow patients to communicate directly with specialists without travel, this tool should be of disproportionate value to rural patients for whom travel to a subspecialist is particularly burdensome. However, telemedicine visits share some limitations with in-person visits: they do not improve subspecialist shortages, will incur copays, and do not directly involve primary care providers in care.
The virtual format of telemedicine visits also conveys specific limitations. Ideally, telemedicine visits include audiovisual (AV) technology for communication and examination, which may require of patients a smart device capable of such audio–visual connection and cellular or Internet access fast and reliable enough to sustain the visit. Given the cultural differences and socioeconomic depression experienced at higher rates in rural communities, smart device ownership trails that seen in suburban and urban areas. Furthermore, rural communities have less reliable cellular service, with 16% of US land and 1.4 million Americans having no LTE (long-term evolution- a standard for wireless speed and capacity for mobile devices) coverage and 20 to 30% of rural Americans reporting no access to broadband Internet service. , Even if patients have devices and service to facilitate telemedicine visits, data charges may result in an additional burden of care for them. Finally, specialists may feel that virtual physical examinations are insufficient and may require rural patients to travel for initial (or all) in-person visits.
Additional modifications could further reduce certain barriers to televisits. Facilities such as local medical offices, public libraries, or schools may provide private spaces, technology, and service to allow patients to connect to specialists without the burdens listed earlier (though with some degree of travel burden).
Teleconferencing—Patient, PCP, and Specialist Meet Virtually
Teleconferencing brings together a patient and providers at multiple sites. It has been studied in inpatient and emergency settings, where it can allow smaller and less specialized facilities to benefit from the knowledge of specialists at larger centers. , In outpatient pediatrics, teleconferencing can bring together patients, primary care providers, and specialists, as shown in Fig. 1 . This visit structure is unique in that primary care providers communicate directly with specialists in real time, which could allow for more collaboration and clarification than in traditional referrals. PCPs may also perform physical examination elements in real time, providing specialists with information that may not be available through telemedicine. From a patient perspective, teleconferencing entails no technology or connectivity requirements and requires travel only to a (generally local) PCP office.
