Identifying Disparities in Pediatric Specialty Referral Completion

Abstract

Background: Disparities exist in access to pediatric specialty care. The extent to which the referral and scheduling processes contribute is not well understood. Objective: To determine whether sociodemographic factors are associated with appointment scheduling and completion in a cohort of pediatric specialty referrals. Methods: This was a retrospective cohort study of children referred for specialty care to a large children's hospital between 03/01/19 – 03/31/21. Referrals for children who were receiving primary care at clinics within 5 miles of the hospital were included to create a local cohort of children. Generalized estimating equations tested for associations between demographic variables (race and ethnicity, language, and insurance type serving as proxies for structural racism and discrimination) and odds of scheduling and completing a referral, while adjusting for clustering of multiple referrals per child. Cox proportional hazard models assessed time to appointment scheduling and completion. Multivariable analyses controlled for child age, specialty volume, and type of visit. Results: Of the 38,334 new referrals, 62% resulted in appointment scheduling and 54% resulted in completion. For children with Black race, Native Hawaiian/Pacific Islander race, Spanish language preference, and public insurance, < 50% of referrals resulted in a completed appointment. In adjusted analyses, Asian, Black and publicly insured children had significantly lower odds of both scheduling and completing referrals, with adjusted odds ratios ranging from 0.70 to 0.94. The adjusted hazard analysis indicated that families with non-English language preference, publicly insured children, Black children, and Hispanic children experienced longer times to scheduling and completing appointments. Conclusion: Significant disparities exist in the odds and timing of referral scheduling and completion by race and ethnicity, language, and insurance type for a cohort of children local to the specialty care center. This variation indicates that institutional scheduling procedures structurally disadvantage some families more than others. Comprehensive metrics for specialty care access are necessary as current measures maybe overlooking disparities that could be addressed by restructuring scheduling and referral processes. Tracking access metrics and family experience of care can help guide interventions to simplify and enhance the inclusiveness of the referral process, which may help to reduce disparities in accessing pediatric specialty care.