Newborn length of stay, health care utilization, and the effect of Minnesota legislation

Newborn readmissions and virtual primary care delivery: a population-based case-control study

BACKGROUND

Early post-discharge assessments for newborns are recommended. Virtual care has become more prevalent during the pandemic, providing an opportunity to better understand its impact on the quality of post-discharge newborn care. The objective of this study was to understand whether primary care visit modality (in-person vs. virtual) is associated with early newborn hospital readmissions and emergency department (ED) visits.

METHODS

We conducted a population-based, case-control study using linked health administrative databases between September 1, 2020 and March 31, 2022 in Ontario, Canada. We compared the modality of primary care visits among cases (hospital readmission within 14 days of life) and controls (newborns without a readmission), matched on infant sex, gestational age, and maternal parity. We included an alternative definition of cases as a composite of either a newborn hospital readmission or emergency department (ED) visit or in-hospital death within the first 14 days of life. Conditional logistic regression models were used to model odds ratios (ORs), comparing those exposed to a virtual visit versus in-person visit, adjusting for infant birth weight, birth hospitalization length of stay, neighbourhood level material deprivation, rurality and presence of active maternal comorbidities.

RESULTS

Among 73,324 eligible newborns, 2,220 experienced a hospital readmission within 14 days of life and were matched to 8,880 controls. Jaundice was the primary reason for readmission (75% of readmissions). Compared to newborns who were seen in-person post-discharge, newborns who were seen virtually had higher odds of hospital readmission (adjusted odds ratio [aOR] 1.41 (95% CI 1.09, 1.83); the magnitude of effect was not different using the composite outcome (aOR 1.35, 95% CI 1.05, 1.75).

CONCLUSIONS

Newborns who receive a virtual post-discharge visit are more likely than those who receive an in-person visit to require hospital readmission.

Developing and validating multivariable prediction models for predicting the risk of 7-day neonatal readmission following vaginal and cesarean birth using administrative databases

BACKGROUND

Approximately 3.5% of deliveries in Canada result in potentially preventable neonatal readmission, often times due to preventable morbidities. With complexities in hospital discharge planning, health care providers may benefit in identifying infants at risk of readmission for additional monitoring.

OBJECTIVES

To develop and validate models for predicting 7-day neonatal readmission following vaginal or cesarean births.

METHODS

All liveborn term singleton infants without congenital anomalies in the province of Alberta who were not admitted to the NICU were identified using perinatal and hospitalization databases. A temporal split-sample was used for model development (2012-2014, vaginal n = 63,378; cesarean n = 21,225) and external validation (2014-2015, vaginal n = 21,583, cesarean n = 7,477). Multivariable logistic regression models using backward stepwise selection were used to identify predictors of 7-day readmission. We evaluated predictors of maternal age, Apgar score, length-of-stay, birthweight, gestational age, parity, residence, and sex. Hosmer-Lemeshow test and c-statistics were used to estimate calibration and discrimination.

RESULTS

The rate of readmission was 3.3% (95% CI 3.1%, 3.4%) and 2.1% (95% CI 1.9%, 2.3%) following vaginal and cesarean births in the development dataset. Prediction model following vaginal birth, excluding predictors of length-of-stay and birthweight, had sub-optimal performance in development (c-statistics 0.69) and validation data (c-statistics 0.68). Prediction model following cesarean birth, excluding predictors of maternal age, birthweight, and residence, had sub-optimal performance in development (c-statistics 0.62) and validation data (c-statistics 0.64). Readmission was observed in 7.9% (95% CI 7.1%, 8.8%) and 4.9% (95% CI 3.9%, 6.1%) of infants of vaginal and cesarean births, respectively, in the top quintile for the risk of 7-day readmission.

CONCLUSION

Using routinely collected administrative data, we developed and validated prediction models for neonatal readmission following vaginal and cesarean births. Presently the model is sub-optimal for use in risk assessment and planning at discharge, however, additional information may improve the predictive performance.

Length of stay and readmission among late preterm infants: an instrumental variable approach

OBJECTIVE

Evidence to guide safe discharge for late preterm infants (34-36 weeks' gestation) is lacking. Previous studies have demonstrated the increased risk of neonatal readmission for these infants compared with those born at term (> or =37 weeks' gestation). The purpose of this study was to estimate the effect of length of stay (LOS) on 7-day readmissions in this population.

METHODS

This was a retrospective study using hospital discharge data linked with vital records for late preterm infants delivered vaginally in California from 1993 to 2005. Exclusion criteria included complications likely requiring neonatal intensive care. The effect of LOS was assessed by using birth hour as an instrumental variable to account for unmeasured confounding. By using a matching algorithm, we created pairs of infants with different LOS based on birth hour but otherwise matched on known confounders for readmission risk, including birth year, hospital, and clinical and demographic covariates such as gestational age, birth weight, race, and insurance.

RESULTS

We produced 80600 matched pairs of infants with different LOS based on birth hour. In 122 pairs, both infants were readmitted within 7 days, and in 75362 pairs, neither infant was readmitted. Of the remaining 5116 matched pairs in which only 1 infant was readmitted, 2456 infants with long LOS and 2660 infants with short LOS were readmitted. We found no evidence that longer LOS reduces the odds of readmission (1-sided P value = .99).

CONCLUSIONS

By using an instrumental variable approach and matching algorithm, longer LOS was not associated with decreased readmission within 7 days of discharge for these late preterm infants.

Neonatal presentations to a Mixed Emergency Department

AIMS

To investigate the characteristics of neonates presenting to a metropolitan Mixed Emergency Department (MED). To examine whether there are maternal and neonatal characteristics which increase the risk of presentation to the ED in the neonatal period.

METHODS

A retrospective chart review was performed of all neonatal presentations occurring between July 2002 and June 2003 to Liverpool Hospital Emergency Department, a Level 6 MED located in south-western Sydney, New South Wales, Australia, seeing approximately 45,000 presentations annually of which 20% are paediatric. Comparisons of maternal and neonatal characteristics were made with Liverpool Hospital, Area Health Service and New South Wales Mothers and Babies data, and with other paediatric presentations to the MED.

RESULTS

179 neonates made 194 neonatal presentations. Compared with all paediatric presentations, the neonatal triage category assignment, admission and transfer proportions were significantly higher, although just over half had 'primary care type illnesses'. Mothers of neonates presenting to this MED were more likely to be younger and first time mothers in comparison to the general population of mothers and newborns. This study did not find an over-representation of neonates who were discharged within 48 h after birth.

CONCLUSION

The implications of these results for practice include a consideration of the availability and appropriateness of after-hours service available to new mothers. Further studies investigating parental reasons for neonatal ED presentation are recommended.

Preventable newborn readmissions since passage of the Newborns' and Mothers' Health Protection Act

BACKGROUND

Congress passed the Newborns' and Mothers' Health Protection Act in 1996, reversing the trend of shorter newborn nursery lengths of stay. Hope existed that morbidities would lessen for this vulnerable population, but some reports indicate that the timeliness and quality of postdischarge care may have worsened in recent years.

OBJECTIVE

Our goal was to determine risk factors for the potentially preventable readmissions because of jaundice, dehydration, or feeding difficulties in the first 10 days of life in Pennsylvania since passage of the Newborns' and Mothers' Health Protection Act.

PATIENTS AND METHODS

Birth records from 407,826 newborns > or = 35 weeks' gestation from 1998 to 2002 were merged with clinical discharge records. A total of 2540 newborns rehospitalized for jaundice, dehydration, or feeding difficulties in the first 10 days of life were then compared with 5080 control infants. Predictors of readmission were identified by using multiple logistic regression analysis.

RESULTS

An unadjusted comparison of baseline characteristics revealed numerous predictors of readmission. Subsequent adjusted analysis revealed that Asian mothers, those 30 years of age or older, nonsmokers, and first-time mothers were more likely to have a readmitted newborn, as were those with diabetes and pregnancy-induced hypertension. For neonates, female gender and delivery via cesarean section were protective for readmission, whereas vacuum-assisted delivery, gestational age < 37 weeks, and nursery length of stay < 72 hours were predictors of readmission in the first 10 days of life.

CONCLUSIONS

Although readmissions for jaundice, dehydration, and feeding difficulties may be less common for some minority groups and Medicaid recipients in the era of the Newborns' and Mothers' Health Protection Act compared with nonminorities or privately insured patients, several predictors of newborn readmission have established associations with inexperienced parenting and/or breastfeeding difficulty. This is one indication that this well-intentioned legislation and current practice may not be sufficiently protecting the health of newborns and suggests that additional support for mothers and newborns during the vulnerable postdelivery period may be indicated.

A comparative analysis of mandated benefit laws, 1949-2002

OBJECTIVE

To understand and compare the trends in mandated benefits laws in the United States.

DATA SOURCES/STUDY SETTING

Mandated benefit laws enacted in 50 states and the District of Columbia for the period 1949-2002 were compiled from multiple published compendia.

STUDY DESIGN

Laws that require private insurers and health plans to cover particular services, types of diseases, or care by specific providers in 50 states and the District of Columbia are compared for the period 1949-2002. Legislation is compared by year, by average and total frequency, by state, by type (provider, health care service, or preventive), and according to whether it requires coverage or an offer of coverage.

DATA COLLECTION/EXTRACTION METHOD

Data from published tables were entered into a spreadsheet and analyzed using statistical software.

PRINCIPAL FINDINGS

A total of 1,471 laws mandated coverage for 76 types of providers and services. The most common type of mandated coverage is for specific health care services (670 laws for 34 different services), followed by laws for services offered by specific professionals and other providers (507 mandated benefits laws for 25 types of providers), and coverage for specific preventive services (295 laws for 17 benefits). On average, a mandated benefit law has been adopted or significantly revised by 19 states, and each state has approximately 29 mandates. Only two benefits (minimum maternity stay and breast reconstruction) are mandated in all 51 jurisdictions and these were also federally mandated benefits. The mean number of total mandated benefit laws adopted or significantly revised per year was 17 per year in the 1970s, 36 per year in the 1980s, 59 per year in the 1990s, and 76 per year between 2000 and 2002. Since 1990, mandate adoption increased substantially, with around 55 percent of all mandated benefit laws enacted between 1990 and 2002.

CONCLUSIONS

There was a large increase in the number of mandated benefits laws during the managed care "backlash" of the 1990s. Many states now use mandated benefits to prescribe not only what services and benefits would be provided but how, where, and when services will be provided.

Unstudied infants: outcomes of moderately premature infants in the neonatal intensive care unit

BACKGROUND

Newborns of 30-34 weeks gestation comprise 3.9% of all live births in the United States and 32% of all premature infants. They have been studied much less than very low birthweight infants.

OBJECTIVE

To measure in-hospital outcomes and readmission within three months of discharge of moderately premature infants.

DESIGN

Prospective cohort study including retrospective chart review and telephone interviews after discharge.

SETTING

Ten birth hospitals in California and Massachusetts.

PATIENTS

Surviving moderately premature infants born between October 2001 and February 2003.

MAIN OUTCOME MEASURES

(a) Occurrence of assisted ventilation during the hospital stay after birth; (b) adverse in-hospital outcomes-for example, necrotising enterocolitis; (c) readmission within three months of discharge.

RESULTS

With the use of prospective cluster sampling, 850 eligible infants and their families were identified, randomly selected, and enrolled. A total of 677 families completed a telephone interview three months after hospital discharge. During the birth stay, these babies experienced substantial morbidity: 45.7% experienced assisted ventilation, and 3.2% still required supplemental oxygen at 36 weeks. Readmission within three months occurred in 11.2% of the cohort and was higher among male infants and those with chronic lung disease.

CONCLUSIONS

Moderately premature infants experience significant morbidity, as evidenced by high rates of assisted ventilation, use of oxygen at 36 weeks, and readmission. Such morbidity deserves more research.

Early postnatal care among healthy newborns in 19 States: pregnancy risk assessment monitoring system, 2000

OBJECTIVE

To examine early postnatal care among healthy newborns during 2000 in 19 states.

METHODS

Using data from the Pregnancy Risk Assessment Monitoring System, a multistate population-based postpartum survey of women, we calculated prevalences of early discharge (ED; stays of < or =2 days after vaginal delivery and < or =4 days after Cesarean delivery) and early follow-up (within 1 week) after ED. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) describing how ED and lack of early follow-up were associated with state legislation and maternal characteristics.

RESULTS

While most healthy term newborns (83.5-93.4%) were discharged early, and most early-discharged newborns (51.5-88.5%) received recommended early follow-up, substantial proportions of early-discharged newborns did not. Compared with newborns in states where legislation covered both length of hospital stay (LOS) and follow-up, newborns in states without such legislation were more likely to have ED (aOR: 1.25; CI: 1.01-1.56). Lack of early follow-up was more likely among newborns in states with neither LOS nor follow-up legislation (aOR: 2.70, CI: 2.32-3.14), and only LOS legislation (aOR: 1.38, CI: 1.22-1.56) compared with those in states with legislation for both. ED was more likely among newborns born to multiparous women and those delivered by Cesarean section and less likely among those born to black and Hispanic mothers and mothers with less education.

CONCLUSIONS

Lack of early follow-up among ED newborns remains a problem, particularly in states without relevant legislation. These findings indicate the need for continued monitoring and for programmatic and policy strategies to improve receipt of recommended care.

Cost-effectiveness of postnatal home nursing visits for prevention of hospital care for jaundice and dehydration

OBJECTIVES

(1) To describe the relationship between postnatal home nursing visitation and readmissions and emergency department (ED) visits for neonatal jaundice and dehydration in the first 10 days of life. (2) To evaluate the cost-effectiveness of providing home nursing visits after newborn discharge with specific attention to prevention of jaundice and dehydration that require hospital-based services.

METHODS

A retrospective analysis of a financial database allowed for review of the discharge disposition and subsequent care for all neonates who were born at a single center from January 2000 through December 2002. Financial data reflect reimbursement values and costs of care from the payers' perspective at the single center. We performed a deterministic cost-effectiveness analysis using a decision tree that reflected the costs and probabilities of infants in each particular health state after nursery discharge.

RESULTS

A total of 73 (2.8%) of 2641 newborns who did not receive a home visit were readmitted to the hospital in the first 10 days of life with jaundice and/or dehydration compared with 2 (0.6%) of 326 who did receive a home visit. Similarly, 92 (3.5%) of 2641 newborns who were discharged without subsequent home nursing care had an ED visit for these reasons in the first 10 days of life compared with 0 (0%) of 326 who did have such a visit. Of infants who received a home visit, 324 (99.4%) of 326 did not require subsequent hospital services in this time period compared with 2497 (94.5%) of 2641 of those who did not receive a visit. After nursery discharge, the average cost per child who received a home health visit was 109.80 dollars compared with 118.70 dollars for each newborn who did not receive a visit. The incremental cost-effectiveness ratio of a routine home visit strategy compared with a no visit strategy was -181.82 dollars.

CONCLUSIONS

A home nursing visit after newborn nursery discharge is highly cost-effective for reducing the need for subsequent hospital-based services.