Access to Pediatric Subspecialty Care: A Population Study of Pediatric Rheumatology Inpatients in California NOELLE PINEDA, 1 LISA J. CHAMBERLAIN, 1 JIA CHAN, 1 MICHAL J. CIDON, 2 AND PAUL H. WISE 2 Objective. To examine trends in the specialty care hospitalization of pediatric rheumatology patients and determine how nonclinical factors influence access. Methods. This study used California’s Office of Statewide Health Planning and Development discharge database to perform a retrospective population analysis of pediatric rheumatology hospitalizations in California between 1999 and 2007. We used logistic regression to examine the relationship between hospitalization in specialty care centers with a pediatric rheumatologist and nonclinical patient characteristics. Results. A total of 18,641 pediatric discharges revealed that 57% were discharged from a specialty care center with a pediatric rheumatologist. Multivariate analysis showed that the factors associated with increased utilization of specialty care centers with a pediatric rheumatologist were public insurance (odds ratio [OR] 1.62, 95% confidence interval [95% CI] 1.51–1.74; P < 0.0001), being Hispanic (OR 1.29, 95% CI 1.19 –1.40; P < 0.0001) or Asian non-Hispanic (OR 1.39, 95% CI 1.26 –1.54; P < 0.0001), and high pediatric rheumatology specialty care bed supply (OR 2.79, 95% CI 2.49 –3.14; P < 0.0001). A decreased utilization of specialty care centers with a pediatric rheumatologist was seen for patients ages <1 year (OR 0.45, 95% CI 0.40 – 0.52; P < 0.0001), ages 1– 4 years (OR 0.50, 95% CI 0.46 – 0.55; P < 0.0001), ages 5–9 years (OR 0.68, 95% CI 0.62– 0.75; P < 0.0001), ages 15–18 years (OR 0.51, 95% CI 0.47– 0.56; P < 0.0001), males (OR 0.75, 95% CI 0.70 – 0.80; P < 0.0001), and patients residing farther away from a specialty care center with a pediatric rheumatologist (OR 0.57, 95% CI 0.51– 0.63; P < 0.0001). Conclusion. Nonclinical factors play an increasingly important role in the hospitalization patterns of pediatric rheuma- tology patients in California. Understanding these factors is crucial if we are to ensure that the variation in access to care reflects clinical need. INTRODUCTION Rheumatologic conditions comprise a significant category of common chronic illnesses in children and can be asso- ciated with considerable disability. The diagnosis and clinical management of many rheumatologic conditions in children can be complex, and many require sustained specialty care engagement over long periods. Accordingly, the American College of Rheumatology (ACR) (1) and the British Society for Pediatric and Adolescent Rheumatol- ogy (2) recommend that a pediatric rheumatologist be involved in the care of children diagnosed as having a rheumatologic condition. However, despite these recom- mendations, there are concerns that many children with rheumatologic conditions many not receive care from a pediatric rheumatologist because of the relatively low number of board-certified pediatric rheumatologists in the US (3–10). In California, children with rheumatologic conditions who are eligible for Medicaid or other public insurance programs are covered largely by the California Children’s Services (CCS) program, which is the state’s version of the federal Title V Program for Children with Special Health Care Needs. The CCS program provides care coordination services and insurance coverage for children with a variety of serious chronic conditions. Its reimbursement policies include the provision that children with covered condi- tions receive any required hospital-based care at desig- nated centers that meet the criteria of relevant clinical expertise and subspecialty capacity. CCS designation as a Supported by a grant from the Lucile Packard Foundation for Children’s Health awarded to Dr. Wise. 1 Noelle Pineda, BA, Lisa J. Chamberlain, MD, MPH, Jia Chan, MA: Stanford University School of Medicine, Stan- ford, California; 2 Michal J. Cidon, MD, Paul H. Wise, MD, MPH: Stanford University School of Medicine, Stanford, and Lucile Packard Children’s Hospital at Stanford, Palo Alto, California. Address correspondence to Noelle Pineda, BA, Stanford University, 117 Encina Commons, Room 179, Stanford, CA 94305-6019. E-mail: noellep@stanford.edu. Submitted for publication June 17, 2010; accepted in re- vised form February 10, 2011. Arthritis Care & Research Vol. 63, No. 7, July 2011, pp 998 –1005 DOI 10.1002/acr.20458 © 2011, American College of Rheumatology ORIGINAL ARTICLE 998