Early discharge from the newborn nursery-effect on scheduling of follow-up visits by pediatricians

The Framework of NICU-discharge Plan System for Preterm Infants in Iran: Duties, Components and Capabilities

Introduction:

The development of comprehensive discharge plan system Not only, will facilitate the discharge process, increase staff and parent satisfaction, improve the care of preterm infants, also reduce the human error.

Aim:

to determine duties, components and capabilities of NICU discharge plan system as a multidimensional tool for facilitating the complex process of transition preterm infants to the home and support parents for post-discharge care.

Method:

The descriptive and qualitative study conducted in 2017. Firstly by literature review, components of framework were determined in 38 statements under 3 major themes: duties, components, and capabilities and then related questionnaire was provided. Cronbach’s alpha test was used to assess the reliability of the questionnaire. The result was more than 0.82 for all statements of questionnaire. The validity of the instrument was determined based on concepts in the valid scientific texts and comments of experts. The analysis was performed using SPSS software.

Result:

In overall, 29 experts participated in the consensus process. In the duties section, all of the statements reach more than 50% consensus. Among statements of the components and capabilities consensus was achieved in 12 out of 17, 12 out of 16 statements respectively.

Conclusion:

according to survey, checkout infant readiness determined as the main duty of the system. Alarm message for special examination before discharge and parent readiness checklist considered as the most important components. The ability to send alarm message, register and log in system were the key capabilities of the discharge system.

Timing of initial well-child visit and readmissions of newborns

BACKGROUND AND OBJECTIVES

Recommendations for the timing of the first well-child visit (WCV) after discharge from a well-baby nursery (WBN) suggest that the visit occur within 48 hours of discharge for those with a WBN length of stay of ≤48 hours and within 3 to 5 days for those with a WBN length of stay of >48 hours. The purpose of these early visits is to detect conditions that may cause readmission in the first weeks after birth, but the effectiveness of early visits to accomplish this has not been shown. The objectives of this study were to determine (1) the frequency of early visits and (2) to compare readmission rates for those who had an early visit compared with those who did not.

METHODS

Using data from a large health care system in Utah, we determined the readmission rates newborns with an estimated gestational age ≥34 weeks and compared the rates for those who had an early WCV with those who did not.

RESULTS

Of 79 720 newborns, 50 606 (63%) were discharged within 48 hours of birth. Of these, 7638 (15%) had a visit within 72 hours of discharge. The readmission rate for newborns who had a visit within the recommended time frame was 15.7 per 1000 compared with 18.4 for those with a later visit (odds ratio 0.85; 95% confidence interval 0.73-0.99) CONCLUSIONS: The frequency of first WCVs that occurred within the recommended time frames was low. Early visits were associated with a 15% reduction in the rate of readmissions.

Important considerations for the newborn: access to postdischarge newborn care, pulse oximetry screening for congenital heart disease, and circumcision

PURPOSE OF REVIEW

This article addresses three areas in which new policies and research demonstrate the opportunity to impact the health of neonates: access to postdischarge newborn care, pulse oximetry screening for congenital heart disease, and circumcision.

RECENT FINDINGS

Recent research has identified that child healthcare providers are not typically adhering to the recommended first newborn visit within 48 h of hospital discharge. Despite its benefits, cost-effectiveness, and the recommendation that routine screening for cyanotic congenital heart disease be added to the panel of universal newborn screening, adoption of this practice is variable. Evidence suggests a significant reduction in the transmission of HIV linked to circumcision, leading professional organizations to generate new policy statements on neonatal male circumcision.

SUMMARY

Pediatric healthcare providers should pay careful attention to the timing of the first newborn outpatient follow-up visit. Pulse oximetry screening for cyanotic congenital heart disease is specific, sensitive and meets criteria for universal screening, and providers should utilize well designed screening protocols. In addition, healthcare providers for newborns, especially those who perform circumcisions, should provide nonbiased, up-to-date information on the medical, financial, and ethical aspects of the procedure.

Neonatal visits to the pediatric emergency center and its implications on postnatal discharge practices in qatar

BACKGROUND

An early discharge from postnatal policy has been practiced at Women's Hospital, Hamad Medical Corporation.

AIM

This observational cohort study was conducted to evaluate the effect of early postnatal discharge practice on neonatal morbidity in the State of Qatar.

SETTING AND DESIGN

This is a data-based cohort study. All neonates ≤28 days visiting the Pediatric Emergency Centers (PEC) were evaluated for the need for re-hospitalization, referral for clinic appointments, or observation at the PEC setting.

MATERIALS AND METHODS

Differences in outcome rates were compared in neonates who visited in the first 24 hours postnatal discharge (2-3 days of life) and those who visited after the third day of life.

STATISTICAL ANALYSIS

Crude differences in incidence rate assessed by χ(2) or Fisher exact test were applicable.

RESULTS

Of 3528 PEC visits for 1915 neonates, 1.7% required admission (3.1% of neonates), 8.4% were observed, 1.1% were referred to a clinic, and the remaining were discharged home. There was no significant difference in re-hospitalization rates of neonates visiting PEC in the first 3 days and those visiting at a later age (OR 0.78, 95% CL 0.19-3.23, P=1). However, early presentations to PEC was more likely to result in periods of observation (OR 1.88, 95% CL 1.17-3.04, P=0.01), or clinic referral (OR 4.96, 95% CL 2.16-11.38, P=0.001) when compared to older neonates. Moreover, those who presented early were significantly more likely to revisit any of the PECs with in the 28 days period (OR 3.20, 95% CL 2.17-4.97, P<0.0001).

CONCLUSION

These results clearly demonstrate the need for a structured early post-discharge follow-up service that addresses the needs of all neonates and their families. The results, however, do not provide sufficient evidence that delaying postnatal discharges for apparently healthy neonates will provide significant health benefits to these neonates and their families.

Making time for well-baby care: the role of maternal employment

The American Academy of Pediatrics recommends children receive six well-baby visits between ages 1 month and 1 year, yet by age 14 months less than 10% of infants have received all six visits. Cost sharing under public and private insurance is very low. Low compliance rates despite the low cost of care suggest other factors, such as time costs, may be important. This paper examines the relationship between maternal employment and receipt of well-baby care. The Medical Expenditure Panel Survey contains rich information on use of preventive care, maternal employment, and other economic and non-economic factors that may influence care decisions. Several approaches, including a proxy variable strategy and instrumental variables analysis, are used to attempt to address the potential endogeneity of maternal employment and examine the sensitivity of findings. Findings indicate mothers who work full-time take their children to 0.18 fewer visits (or 9% fewer at the mean) than those who have quit their jobs. Mothers with employer provided paid vacation leave take their children to 0.20 more visits (or 9% more at the mean) than other working mothers. Time appears to be an important factor in determining well-baby care receipt. Policies that extend paid leave to more employed women may improve compliance with preventive care recommendations.

Adherence to discharge guidelines for late-preterm newborns

OBJECTIVE

To evaluate trends in adherence to American Academy of Pediatrics recommendations for early discharge of late-preterm newborns and to test the association between hospital characteristics and early discharge.

PATIENTS AND METHODS

This study was a population-based cohort study using statewide birth-certificate and hospital-discharge data for newborns in California, Missouri, and Pennsylvania from 1993 to 2005. A total of 282 601 late-preterm newborns at 611 hospitals were included. Using logistic regression, we studied the association of early discharge with regional and hospital factors, including teaching affiliation, volume, and urban versus rural location, adjusting for patient factors.

RESULTS

From 1995 to 2000, early discharge decreased from 71% of the sample to 40%. However, by 2005, 39% were still discharged early. Compared with Pennsylvania, California (adjusted odds ratio [aOR]: 5.95 [95% confidence interval (CI): 5.03-7.04]), and Missouri (aOR: 1.56 [95% CI: 1.26-1.93]) were associated with increased early discharge. Nonteaching hospitals were more likely than teaching hospitals to discharge patients early if they were uninsured (aOR: 1.91 [95% CI: 1.35-2.69]) or in a health maintenance organization plan (aOR: 1.40 [95% CI: 1.06-1.84]) but not patients with fee-for-service insurance (aOR: 1.04 [95% CI: 0.80-1.34]). A similar trend for newborns on Medicaid was not statistically significant (aOR: 1.77 [95% CI: 0.95-3.30]).

CONCLUSIONS

Despite a decline in the late 1990s, early discharge of late-preterm newborns remains common. We observe differences according to state, hospital teaching affiliation, and patient insurance. Additional research on the safety and appropriateness of early discharge for this population is necessary.

Assignment to a hospital-based breastfeeding clinic and exclusive breastfeeding among immigrant Hispanic mothers: a randomized, controlled trial

A randomized controlled trial is used to determine whether assigning mixed feeders to a breastfeeding clinic within 1 week postpartum will increase exclusive breastfeeding at 1 month among Hispanic immigrants. Subjects are eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and 85% are monolingual Hispanic. Mothers (n = 522) of infants at low risk for hyperbilirubinemia are approached at bedside 20 to 48 hours after delivery and randomly assigned to treatment or control groups. Intent-to-treat analysis of feeding behavior at 4 weeks postpartum indicates that the intervention group is more likely to be exclusively breastfeeding (16.4% vs 10% in the control group, P = .03; adjusted odds ratio 1.87; 95% confidence interval, 1.07-3.26); that the incidence of formula supplementation does not differ between groups; and that the intervention group is less likely to supplement with water and tea (P < .002).

Delayed pediatric office follow-up of newborns after birth hospitalization

BACKGROUND

Key recommendations of the American Academy of Pediatrics guideline on management of severe hyperbilirubinemia in healthy infants of >or=35 weeks' gestation include predischarge screening for risk of subsequent hyperbilirubinemia, follow-up at 3 to 5 days of age, and lactation support. Little information is available on contemporary compliance with follow-up recommendations.

OBJECTIVE

To assess timing and content of the first newborn office visit after birth hospitalization in urban and suburban pediatric practices in Houston, Texas.

METHODS

We reviewed office records for the first visit within 4 weeks of birth during January through July 2006 for apparently healthy newborns with a gestational age of >or=35 weeks or birth weight of >or=2500 g seen within a pediatric provider network. For each pediatrician, we selected every fifth patient up to a total of 6.

RESULTS

Of 845 records abstracted, 698 (83%) were eligible for analysis. Infants were seen by 136 pediatricians in 39 practices. They had vaginal (64%) or cesarean (36%) deliveries at 20 local hospitals, of which 17 had routine predischarge bilirubin screening policies. Only 37% of all infants, 44% of vaginally delivered infants, and 41% of exclusively breastfed infants were seen before 6 days of age. Thirty-five percent of the infants were seen after 10 days of age. Among 636 infants seen at <or=15 days, jaundice was noted on examination in 33%; of these, 44% had bilirubin measured. Nine infants had phototherapy documented after birth hospitalization.

CONCLUSIONS

Among a large group of urban and suburban pediatricians, implementation of the American Academy of Pediatrics recommendation for follow-up was inconsistent, and delayed follow-up was common. Understanding reasons for delayed follow-up and providing guidance for jaundice management may promote a safer first week of life.

Increase in incidence of medically treated thyroid disease in children with Down Syndrome after rerelease of American Academy of Pediatrics Health Supervision guidelines

OBJECTIVE

The purpose of this work was to estimate the incidence of medically treated thyroid disease in children with Down syndrome enrolled in Tennessee Medicaid (TennCare) during 1995-2005 and to determine whether rates increased after rerelease of American Academy of Pediatrics guidelines in 2001.

PATIENTS AND METHODS

We conducted a population-based retrospective cohort study in which we identified children with Down syndrome by using TennCare files and birth certificates. We included 1- to 18-year-olds who were continuously enrolled in TennCare and did not fill a prescription for thyroid medication during a 90-day prestudy period. The rate of medically treated thyroid disease (prescription filled for thyroid medication) was the main outcome. We used Poisson regression to estimate rates of medically treated thyroid disease according to study year, age, gender, race, region of residence, and payer type.

RESULTS

During the 11-year study period, 1257 children with Down syndrome (28% black, 72% white) met inclusion criteria. Overall, 10.8% filled a new prescription for thyroid medication. Rates of medically treated thyroid disease per 1000 child-years were 13.25 (1995-1997), 13.34 (1998-1999), 13.62 (2000-2001), 22.37 (2002-2003), and 22.51 (2004-2005). After adjusting for child age and race, there was an increased rate of medically treated thyroid disease in 2002-2003 and 2004-2005 compared with 1995-1997. In a comparison cohort of children without Down syndrome, there was a smaller increase in the rate of medically treated thyroid disease when comparing 2002-2003 and 2004-2005 with 1995-1997.

CONCLUSIONS

Over the 11-year period, 10.8% of children with Down syndrome filled a new prescription for a thyroid medication. A 73% increase in the incidence of medically treated thyroid disease occurred after rerelease of American Academy of Pediatrics guidelines, which may have influenced screening.

Limited access to care and home healthcare

Access to perinatal healthcare services for women living in poverty is complicated by many barriers and directly affects rates of premature births, low birthweight infants, and maternal and infant deaths. Health and social services delivered in the home can help improve pregnancy outcomes. Home visiting programs need sustainable funding and support from physicians and other healthcare providers. Ongoing research is needed to develop, refine, and evaluate systems of care that integrate home visiting components and different service delivery models that address pregnancies complicated by various psychosocial and medical complications.

Readmission for neonatal jaundice in California, 1991-2000: trends and implications

OBJECTIVE

We sought to describe population-based trends, potential risk factors, and hospital costs of readmission for jaundice for term and late preterm infants.

METHODS

Birth-cohort data were obtained from the California Office of Statewide Health Planning and Development and contained infant vital statistics data linked to infant and maternal hospital discharge summaries. The study population was limited to healthy, routinely discharged infants through the use of multiple exclusion criteria. All linked readmissions occurred within 14 days of birth. International Classification of Diseases, Ninth Revision, codes were used to further limit the sample to readmission for jaundice. Hospital discharge records were the source of diagnoses, hospital charges, and length-of-stay information. Hospital costs were estimated using hospital-specific ratios of costs to charges and adjusted to 1991.

RESULTS

Readmission rates for jaundice generally rose after 1994 and peaked in 1998 at 11.34 per 1000. The readmission rate for late preterm infants (as a share of all infants) over the study period remained at <2 per 1000. Factors associated with increased likelihood of hospital readmission for jaundice included gestational age 34 to 39 weeks, birth weight of <2500 g, male gender, Medicaid or private insurance, and Asian race. Factors associated with a decreased likelihood of readmission for jaundice were cesarean section delivery and black race. The mean cost of readmission for all infants was $2764, with a median cost of $1594.

CONCLUSIONS

Risk-adjusted readmission rates for jaundice rose following the 1994 hyperbilirubinemia guidelines and declined after postpartum length-of-stay legislation in 1998. In 2000, the readmission rate remained 6% higher than in 1991. These findings highlight the complex relationship among newborn physiology, socioeconomics, race or ethnicity, public policy, clinical guidelines, and physician practice. These trend data provide the necessary baseline to study whether revised guidelines will change practice patterns or improve outcomes. Cost data also provide a break-even point for prevention strategies.

Asistencia a neonatos en el servicio de urgencias de un hospital pediátrico terciario

OBJECTIVE

To determinate the chief complaints in neonates presenting to a pediatric emergency service and their management.

MATERIAL AND METHODS

We performed a retrospective study of patients younger than 28 days old who presented to the pediatric emergency department in 2003. Patients directly admitted to the neonatal unit and those attended by the surgery and orthopedic surgery departments were excluded. Information on sex, age, time and date, waiting time, visit duration, source of referral, presenting complaint, complementary examinations, final diagnosis, and hospital admission were analyzed.

RESULTS

There were 1,481 neonatal visits. The mean chronological age was 15.8 days and 57.3 % were boys. Visits were most frequent on Fridays, evening shifts, and in July and December. The most frequent chief complaints were crying/irritability (16.3 %), fever (13.6 %), vomiting (11 %), and influenza (10.8 %). The most frequent final diagnoses were feeding problems (12.6 %), infantile colic (12.4 %), and upper respiratory tract infections (12 %). No abnormalities were detected in 11.7 % of the patients and complementary examinations were not required in 45.9 %. The admission rate was 26 %, most commonly due to fever and bronchiolitis.

CONCLUSIONS

Many visits were due to minor problems that did not require complementary examinations and could have been resolved in primary care. Because of the greater vulnerability of this age group, thorough investigation is required to rule out severe disease. This phenomenon was reflected by the large number of complementary examinations and admissions.

The impact of nurses and mothers signing the discharge letter on maternal knowledge and satisfaction after discharge from a neonatal unit: a before and after study

OBJECTIVE

To assess the maternal recall of the neonatal discharge letter instructions with and without nurse and mother signing the document in addition to the physician signature.

METHODS

Maternal recall of the discharge letter instructions was assessed by telephone interviews conducted 2-3 weeks following discharge. One hundred and nine mothers who signed the discharge letter following a change of information delivery policy at discharge were compared with 110 mothers who gave birth when their signature was not yet required. The impact of the discharge form on maternal recall was evaluated by stepwise regression analysis adjusted for obstetric, perinatal and demographic variables.

RESULTS

Recall of specific instructions verified by the discharge notes and satisfactory understanding of the discharge letter as graded by the mother were higher among 109 mothers who signed the discharge letter (82% and 88%, respectively) than among 110 mothers who did not add their signature (58% and 73%, respectively), the differences being statistically significant (p=0.002 and 0.022, respectively). The statistical difference was maintained also following adjustment with independent variables.

CONCLUSION

Signing the neonatal discharge letter by both nurse and mother may improve maternal comprehension and recall of the delivered information. A prospective controlled study is necessary to validate this hypothesis.

Disponibilité des pédiatres libéraux et communautaires en Île-de-France après une sortie précoce de maternité

OBJECTIVES

To assess the possibility and time period within which a mother and her newborn can consult a pediatrician after their early discharge from the maternity ward.

METHODS

In May 2004, 2 investigators presenting themselves as mothers just discharged from the maternity ward, called pediatricians' offices and public infant cliniques (PMI centers) in the Paris metropolitan region, to request appointments.

RESULTS

Of 99 pediatricians' offices contacted, 89 (89%) offered appointments, for an average of 4.4 days later. Of the 93 PMI centers contacted, 55 (59%) offered appointments by telephone, with a mean waiting time of 18 days.

CONCLUSION

This study, conducted in the spring of 2004 in the Paris metropolitan region, showed that private-practice pediatricians are capable of taking over management of newborns rapidly after early discharge from the maternity ward. It is more difficult to make appointments by telephone with PMI centers, which operate differently, and the delay is substantially longer. We underline that these results observed in a region with a high density of pediatricians and during a favourable period for managing appointments. Further studies are needed in other regions and at different periods. The management of newborns after early discharge from the maternity ward should be actually throught the arising development of health networks.

Preserving Breastfeeding for the Rehospitalized Infant

The benefits of feeding newborns with human milk are well established. Unfortunately some hospital practices do not support successful breastfeeding; practices such as early hospital discharge after birth, lack of appropriate follow-up primary care providers, and lack of access to breastfeeding support services can contribute to breastfeeding failure, as well as morbidity and mortality in the infant. Infants experiencing breastfeeding difficulties are sometimes admitted to the hospital with diagnoses such as hyperbilirubinemia/jaundice, dehydration/hypernatremia, rule out sepsis, and weight loss/failure to thrive. This article describes a clinical pathway developed with the express purpose of maintaining and enhancing lactation in mother-infant dyads experiencing breastfeeding difficulties. The goal of the pathway is to maintain lactation and breastfeeding while returning the infant to a state of health. A key focus of the pathway is milk transfer, a concept that is missing from much of the research on lactation difficulties. The pathway considers breastfeeding from both a maternal and an infant perspective, with a goal of preserving breastfeeding. It uses technology to support the breastfeeding process and could be useful for all practitioners working with mother-infant dyads experiencing breastfeeding difficulties.

A comparison of morbidity rates attributable to conditions originating in the perinatal period among newborns discharged from United States hospitals, 1989-90 and 1999-2000

Perinatal conditions account for 60% of US neonatal deaths, yet little is known about rates of morbidity attributable to these conditions. To estimate these rates, we analysed newborn hospital discharges from the National Hospital Discharge Survey. We used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to classify discharge diagnoses among a weighted, nationally representative sample of newborns discharged from short-stay, non-federal US hospitals. We compared overall and cause-specific morbidity rates attributable to perinatal conditions (ICD-9-CM 760.0-779.9), as well as the average length of hospital stay among newborn discharges during 1989-90 and 1999-2000. The overall newborn morbidity rate declined from 36.3% in 1989-90 to 33.7% in 1999-2000 (P < 0.01), despite significant increases in high-risk births. The decline can be attributed to significant decreases in the reported rates of jaundice, fetal distress, birth trauma and birth asphyxia. Rates of jaundice decreased from 15.7% to 13.4% (P < 0.01). The average length of stay decreased among newborns with no morbid condition (2.37-2.04 days, P < 0.001) and among those with one perinatal condition (3.11-2.51, P < 0.001), but increased among those with multiple perinatal conditions (8.43-9.98, P < 0.05). Morbidity rates among newborns discharged from US hospitals declined. Shorter newborn hospital stays may have resulted in fewer cases of jaundice being diagnosed before discharge. Stricter diagnostic criteria and changes in obstetric practices may have led to a decline in the rates of fetal distress, birth trauma and birth asphyxia.

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.

Medicaid acceptance and availability of timely follow-up for newborns with Medicaid

OBJECTIVE

Decreased physician participation in Medicaid has been shown to affect adversely timeliness of adult acute care and pediatric specialty care, but it is not clear whether this is the case for newborn follow-up. The objectives of this study were to determine whether there is a difference within clinics in the timeliness of follow-up appointments that are given to newborns with Medicaid compared with newborns with private insurance and to determine whether there is a difference between clinics that do and do not accept Medicaid in the timeliness of appointments that are given for newborn follow-up.

METHODS

A randomized crossover study was conducted among general pediatric clinics and practices that were identified from the yellow pages and Internet searches of hospitals and health departments in 8 metropolitan areas from September 2003 to March 2004. A simulated parent telephoned clinics to find the earliest available appointment for a 1-day-old infant who needed routine follow-up after discharge that day. Clinics were randomly assigned to receive a first call from a patient with either Medicaid or private insurance; each clinic received the same call at least 3 weeks later with the patient's insurance status reversed. The main outcome measure was whether the appointment was timely (< or =2 days from the day of the call).

RESULTS

Of 401 participating clinics, 22% did not accept Medicaid. Among clinics that accepted Medicaid, availability of a timely appointment for a newborn with Medicaid was similar to that for a newborn with private insurance (87% vs 90%, respectively). Appointments that were provided to privately insured newborns were as likely to be timely in clinics that accept Medicaid as in clinics that do not accept Medicaid (89.5% vs 93.4%, respectively). However, providing timely appointments was significantly less likely in clinics that were in high-poverty locations compared with clinics that were not (86.1% vs 92.7%, respectively).

CONCLUSIONS

Although newborns with Medicaid did not have access to >20% of clinics because of their insurance, among clinics that did accept Medicaid, timeliness of available follow-up was similar for newborns with Medicaid compared with newborns with private insurance and similar between clinics that did and did not accept Medicaid. However, to the extent that care for newborns with Medicaid is concentrated in clinics in high-poverty areas, some newborns with Medicaid may not be able to receive timely appointments.

Barriers to first-week follow-up of newborns: findings from parent and clinician focus groups

BACKGROUND

Monitoring newborns within the first week is critical to assess the adequacy of feeding and weight gain and to identify instances of hyperbilirubinemia. As systems of maternal and newborn care have become increasingly fragmented, infants are at increased risk of poor outcomes because of poor follow-up. Structured focus groups were conducted in June--July 2001 to provide information about the barriers to timely newborn follow-up and strategies to address them.

METHODS

One focus group for physicians and one for nurses were held at the Henry Ford Health System, Detroit, and two focus groups of parents were recruited by Blue Cross Blue Shield of Texas, Dallas.

RESULTS

Barriers were identified in communication and information, systems and processes of care, and parental knowledge and education. Concerns raised by clinicians and parents were consistent and complementary. Some organizations have begun implementing some of the suggested strategies to achieve timely follow-up.

DISCUSSION

Implementing the AAP guideline and improving safe care in the first week of newborn life will require attention to linkages and transitions between these various microsystems.

National Institute of Child Health and Human Development (NICHD) conference on kernicterus: a population perspective on prevention of kernicterus

This paper reviews barriers to the prevention of kernicterus. Reports of kernicterus cases persist. We do not know why kernicterus continues to occur or how best to prevent it. We need evidence for key recommendations that make clinical guidelines usable by practitioners caring for newborns, especially for practitioners providing ambulatory care in the first week of life. Data on prevalence and incidence, mortality and morbidity are essential for launching a kernicterus public health campaign. Modeling cost-effectiveness requires data on costs and benefits of alternative strategies for managing hyperbilirubinemia and preventing kernicterus and on parental preferences concerning follow-up in the first days of life. Understanding how existing patterns of care obstruct preventive care involves exploration of the roles of clinicians, health-care organizations, parents, and payers and purchasers of health care. Lastly, discovering how to motivate change in existing practices can provide the guidance needed to prevent kernicterus in the US.

Does making newborn follow-up appointments from the hospital improve compliance?

OBJECTIVE

To test a system of arranging the first newborn follow-up appointments made from the hospital prior to discharge.

METHODS

Prospective randomized study of 328 term healthy newborns divided into control and intervention groups. As there were multiple practices, we checked for clustering in the two groups and then compared them for patient compliance with the first newborn appointment. We also compared the control and intervention groups for compliance with regard to insurance status.

RESULTS

There was difference between the control and intervention group in timeliness for the first appointment (control, 84.9%, intervention group, 94.2%, p=0.0062). There was also improvement in privately insured patients (control 89.1%, intervention 96.5%, p=0.0263), as well as in Medicaid+noninsured patients (control 64.7%, intervention 90.2%, p=0.0245).

DISCUSSION

We conclude that arranging for follow-up appointments from the hospital is a worthwhile inexpensive intervention that could significantly improve patient compliance with the first newborn visit.

Cost-effectiveness of strategies that are intended to prevent kernicterus in newborn infants

OBJECTIVE

There is concern about an increasing incidence of kernicterus in healthy term neonates in the United States. Although the incidence of kernicterus is unknown, several potential strategies that are intended to prevent kernicterus have been proposed by experts. It is necessary to assess the costs, benefits, and risks of such strategies before widespread policy changes are made. The objective of this study was to determine the direct costs to prevent a case of kernicterus with the following 3 strategies: (1) universal follow-up in the office or at home within 1 to 2 days of early newborn discharge, (2) routine predischarge serum bilirubin with selective follow-up and laboratory testing, and (3) routine predischarge transcutaneous bilirubin with selective follow-up and laboratory testing.

METHODS

We performed an incremental cost-effectiveness analysis of the 3 strategies compared with current practice. We used a decision analytic model and a spreadsheet to estimate the direct costs and outcomes, including the savings resulting from prevented kernicterus, for an annual cohort of 2,800000 healthy term newborns who are eligible for early discharge. We used a modified societal perspective and 2002 US dollars. With each strategy, the test and treatment thresholds for hyperbilirubinemia are lowered compared with current practice.

RESULTS

With the base-case assumptions (current incidence of kernicterus 1:100 000 and a relative risk reduction [RRR] of 0.7 with each strategy), the cost to prevent 1 case of kernicterus was 10,321463 dollars, 5,743905 dollars, and 9,191352 dollars respectively for strategies 1, 2, and 3 listed above. The total annual incremental costs for the cohort were, respectively, 202,300671 dollars, 112,580535 dollars, and 180,150494 dollars. Sensitivity analyses showed that the cost per case is highly dependent on the population incidence of kernicterus and the RRR with each strategy, both of which are currently unknown. In our model, annual cost savings of 46,179465 dollars for the cohort would result with strategy 2, if the incidence of kernicterus is high (1:10,000 births or higher) and the RRR is high (> or =0.7). If the incidence is lower or the RRR is lower, then the cost per case prevented ranged from 4,145676 dollars to as high as 77,650240 dollars.

CONCLUSIONS

Widespread implementation of these strategies is likely to increase health care costs significantly with uncertain benefits. It is premature to implement routine predischarge serum or transcutaneous bilirubin screening on a large scale. However, universal follow-up may have benefits beyond kernicterus prevention, which we did not include in our model. Research is required to determine the epidemiology, risk factors, and causes of kernicterus; to evaluate the effectiveness of strategies intended to prevent kernicterus; and to determine the cost per quality-adjusted life year with any proposed preventive strategy.

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.

Impact of early newborn discharge legislation and early follow-up visits on infant outcomes in a state Medicaid population

OBJECTIVE

Scant information exists on the effects of legislation mandating coverage of minimum postnatal hospital stays on infant health outcomes. There are also gaps in knowledge regarding the effectiveness of early follow-up visits for newborns. The objective of this study was to determine the impact of 1) legislation mandating coverage of minimum postnatal hospital stays and 2) early follow-up visits by the age of 4 days on infant outcomes during the first month of life.

METHODS

A retrospective analysis was conducted of Ohio Medicaid claims data linked with birth certificate data for the period 1991-1998. The impact of the legislation was evaluated using interrupted time-series analysis of health-related utilization. The effects of early follow-up visits for vaginally delivered newborns with short stays were analyzed using the day of the week on which the birth occurred (eg, Monday, Tuesday) as an instrumental variable to account for potential confounding. A total of 155,352 full-term newborns who were born to mothers who receive Medicaid were studied. The main outcomes measured were rehospitalizations, emergency department (ED) visits, and diagnoses of dehydration and infection within 10 and 21 days of birth.

RESULTS

Few outcomes exhibited significant changes after legislation mandating coverage of minimum postnatal hospital stays. Rates of rehospitalization for jaundice within 10 days of birth fell from 0.78% to 0.47% in the year after legislation was introduced but leveled off after the legislation took effect. Rates of ED visits within 21 days increased from 6.0% to 10.4% during periods of increasing short stay but fell to 8.0% during the year after introduction of the legislation and leveled off when the legislation took effect. Rates of all-cause rehospitalization, dehydration, and infection diagnoses showed no consistent relationship to Ohio's legislation. Using instrumental variable analysis, newborns who received early follow-up visits were significantly less likely to have rehospitalizations within the first 10 days of life than those who did not.

CONCLUSIONS

In this state Medicaid population, legislation mandating coverage of minimum postnatal hospital stays was associated with reductions in the rates of rehospitalization for jaundice and ED visits. For newborns with short stays, early follow-up visits may reduce rehospitalizations in the early postpartum period.

Newborn early discharge revisited: are California newborns receiving recommended postnatal services?

CONTEXT

Responding to safety concerns, federal and state legislation mandated coverage of minimum postnatal stays and state legislation in California mandated coverage of follow-up after early discharge. Little is known about the postnatal services newborns are receiving.

OBJECTIVE

To describe rates of early discharge and of timely follow-up for early-discharged newborns.

DESIGN AND SETTING

Retrospective, population-based cohort study using a 1999 postpartum survey in California.

PARTICIPANTS

A total of 2828 infants of mothers with medically low-risk singleton births.

MAIN OUTCOME MEASURES

Rates of early discharge (<or=1-night stay after vaginal delivery and <or=3-night stay after cesarean section) and untimely follow-up (no home or office visit within 2 days of early discharge).

RESULTS

Overall, 49.4% of newborns were discharged early. Of these, 67.5% had untimely follow-up. The odds of early discharge were greater with lower incomes: the adjusted odds ratios (AORs) (with 95% confidence intervals) were 2.06 (1.50-2.83) for incomes <or=100% of poverty, 2.20 (1.65-2.93) for incomes from 101%-200% of poverty, and 2.24 (1.63-3.08) for incomes from 201%-300% of poverty. Untimely follow-up was more likely for infants of women with incomes <or=100% of poverty (AOR = 1.89 [1.13-3.17]) and 201%-300% of poverty (AOR = 1.78 [1.09-2.91]), Medicaid coverage (AOR = 1.73 [1.20-2.47]), Latina ethnicity (AOR = 1.47 [1.02-2.14]), and non-English language (AOR = 1.72 [1.16-2.55]).

CONCLUSIONS

Despite an apparent decline in short stays after legislation, many newborns--particularly from lower-income families--continue to be discharged early. Most newborns discharged early--particularly those with Medicaid and those from low-income, Latina, and non-English-speaking homes--do not receive recommended follow-up. The most socioeconomically vulnerable newborns are receiving fewer postnatal services.

Patient compliance with the first newborn visit appointment

OBJECTIVE

To analyze patient compliance regarding the first newborn visit after hospital discharge.

STUDY DESIGN

We selected at random 640 charts over a 1-year period from two community hospitals of healthy term newborns who were cared for by four practices in Kalamazoo, MI. We collected demographic data from the hospital chart and recorded the discharge order for time of posthospital follow-up. We then accessed the individual clinics' appointment logs to determine when the patient came for the first visit. Lateness was defined as appearance for appointment >24 hours after the time stated on the hospital discharge order. We studied patient lateness with respect to the clinic, maternal age, insurance status, and distance from the patient's home to the medical facility, using both univariate and multivariate analyses.

RESULTS

We demonstrated a significant difference in lateness of the first appointment between Medicaid and non-Medicaid patients in both the univariate (p<0.001) and multivariate (p=0.0003) analyses. We also demonstrated significant differences in the univariate analysis in patient lateness among the different practices (p<0.001) as well as lateness with regard to maternal age (p=0.0009). We did not attain significance in either analysis for patient lateness with regard to distance of home from the medical facility, or the hospital in which the baby was born.

CONCLUSION

We demonstrated a need to improve upon newborn follow-up from the hospital and suggest strategies for other communities to analyze the process and improve upon patient and practice compliance with that first appointment.

A breast-feeding assessment score to evaluate the risk for cessation of breast-feeding by 7 to 10 days of age

OBJECTIVES

To develop a succinct and comprehensive breast-feeding assessment score (BAS) to accurately identify infants at risk for early cessation of breast-feeding before initial hospital discharge.

STUDY DESIGN

Mothers who intended to breast-feed their infants were solicited from 9 suburban hospitals. Two detailed data forms covering 107 items were completed before hospital discharge. A third form was completed at 7 to 10 days of age after telephone contact with the mother.

RESULTS

Cessation of breast-feeding occurred in 113 of 1075 infants (10.5%). A multiple logistic regression analysis revealed 8 variables that were significant (P <.05) in predicting breast feeding cessation. A BAS was developed based on the odds ratios and relative risks of breast-feeding cessation for these 8 variables.

CONCLUSIONS

The BAS was easily and quickly performed before hospital discharge for near term and term infants, which accurately predicted the risk of breast-feeding cessation within 7 to 10 days of age in the population studied.

Early newborn discharge: a tale of two hospitals

This study reviews physician documentation of compliance with The American Academy of Pediatrics (AAP) policy RE9539 regarding early newborn hospital discharge and follow-up. All pediatricians in Kalamazoo, MI, were educated at a grand rounds regarding the AAP early newborn discharge policy. Newborns are seen at 2 community hospitals. One of them simultaneously instituted a Quality Improvement/Feedback (QI/F) program regarding early newborn discharge, (intervention) and the other 1 did not (control). This is a retrospective chart analysis that compares performance of 4 pediatric practices seeing newborns at each hospital. Each practice was compared at each hospital for appropriateness of discharge orders before and after the educational grand rounds and the QI/F initiative. Statistical analysis was done using the chi square test and the Breslow-Day test for homogeneity, and the Fisher's Exact Test. Odds ratios with a 95% confidence interval based on Taylor's approximation were used. There were no significant differences between the pediatric practices' performance before and after the educational initiative at the control hospital. There were significant differences before and after the educational initiative in the intervention hospital with the QI/F initiative. There was a significant reduction in variation among the practices after the QI/F initiative at the intervention hospital. When both hospitals were compared after the educational initiative, there was a significant difference between compliance among the same practices at each hospital, with better compliance at the intervention hospital with the QI/F initiative. There were significant differences in physicians' performance at the intervention hospital before and after the educational and QI/F initiatives. However, it was noted that the very same physicians did not comply as well in the control hospital without the QI/F initiative, thus still raising questions as to whether QI measures alter physician "culture." It is possible that the driving force for change in physician behavior was more intragroup peer pressure than an external QI/F initiative.

A randomized comparison of home visits and hospital-based group follow-up visits after early postpartum discharge

OBJECTIVE

Short postpartum stays are common. Current guidelines provide scant guidance on how routine follow-up of newly discharged mother-infant pairs should be performed. We aimed to compare 2 short-term (within 72 hours of discharge) follow-up strategies for low-risk mother-infant pairs with postpartum length of stay (LOS) of <48 hours: home visits by a nurse and hospital-based follow-up anchored in group visits.

METHODS

We used a randomized clinical trial design with intention-to-treat analysis in an integrated managed care setting that serves a largely middle class population. Mother-infant pairs that met LOS and risk criteria were randomized to the control arm (hospital-based follow-up) or to the intervention arm (home nurse visit). Clinical utilization and costs were studied using computerized databases and chart review. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks postpartum.

RESULTS

During a 17-month period in 1998 to 1999, we enrolled and randomized 1014 mother-infant pairs (506 to the control group and 508 to the intervention group). There were no significant differences between the study groups with respect to maternal age, race, education, household income, parity, previous breastfeeding experience, early initiation of prenatal care, or postpartum LOS. There were no differences with respect to neonatal LOS or Apgar scores. In the control group, 264 mother-infant pairs had an individual visit only, 157 had a group visit only, 64 had both a group and an individual visit, 4 had a home health and a hospital-based follow-up, 13 had no follow-up within 72 hours, and 4 were lost to follow-up. With respect to outcomes within 2 weeks after discharge, there were no significant differences in newborn or maternal hospitalizations or urgent care visits, breastfeeding discontinuation, maternal depressive symptoms, or a combined clinical outcome measure indicating whether a mother-infant pair had any of the above outcomes. However, mothers in the home visit group were more likely than those in the control group to rate multiple aspects of their care as excellent or very good. These included the preventive advice delivered (76% vs 59%) and the skills and abilities of the provider (84% vs 73%). Mothers in the home visit group also gave higher ratings on overall satisfaction with the newborn's posthospital care (71% vs 59%), as well as with their own posthospital care (63% vs 55%). The estimated cost of a postpartum home visit to the mother and the newborn was $265. In contrast, the cost of the hospital-based group visit was $22 per mother-infant pair; the cost of an individual 15-minute visit with a registered nurse was $52; the cost of a 15-minute individual pediatrician visit was $92; and the cost of a 10-minute visit with an obstetrician was $92.

CONCLUSIONS

For low-risk mothers and newborns in an integrated managed care organization, home visits compared with hospital-based follow-up and group visits were more costly but achieved comparable clinical outcomes and were associated with higher maternal satisfaction. Neither strategy is associated with significantly greater success at increasing continuation of breastfeeding. This study had limited power to identify group differences in rehospitalization and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.

Problem identification in apparently well neonates: implications for early discharge

The frequency, time of identification, and type of problems of newborns in an urban indigent population were prospectively studied during their hospital stay to evaluate feasibility of early hospital discharge. Eight percent (563) of 7,021 term and near-term low-risk infants developed one or more predefined problems. Of those with problems, 42.1% received therapy and/or a higher level of care. Tachypnea, temperature instability, and cyanotic episodes were the most frequently treated problems. Nearly 69% of all problems were detected after the initial examination, and 31% developed problems after 24 hours of age; 5% were transferred to the NICU. Problems occurring after 24 hours of age emphasize the need for follow-up within days after hospital discharge in this population.

A competency based approach to comprehensive pregnancy care

This paper assesses the quality and cost of a pregnancy care program based on explicit and achieved patient competencies. By using the USPHS Content of Prenatal Care (1989), key psychosocial/education elements of perinatal care were identified. The goal was a process of patient education that is competency based, integrated, and outcome oriented. Psychosocial assessment, patient education tools, criterion-based length of postpartum stay, and home nursing follow-up were implemented as part of a Comprehensive Pregnancy Program (CPP). Case-control and cohort survey methodology were used to evaluate outcome. There was a significant decrease in hospital length of stay for mothers and newborns after implementation of the CPP. Post-discharge maternal emergency room visits and/or readmits did not increase. Differences in newborn emergency room visits and/or readmits were non-significant. There was a marked reduction in hospital costs for mothers and newborns. Patient satisfaction remained high. Core competencies forming the basis of educational and assessment programs allow the focus of care to be optimal outcome, and provide a useful template against which to measure prenatal, intrapartum, and postpartum care.

Noninvasive measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia

BACKGROUND

Jaundice in near-term and term newborns is a frequent diagnosis that may prompt hospital readmission in the first postnatal week. Hyperbilirubinemia, when excessive, can lead to potentially irreversible bilirubin-induced neurotoxicity. Predischarge risk assessment (at 24-72 hours of age) for subsequent excessive hyperbilirubinemia is feasible by a laboratory-based assay of total serum bilirubin (TSB). Hypothesis. Noninvasive, transcutaneous, point-of-care measurement of transcutaneous bilirubin (TcB) predischarge by multiwavelength spectral analysis, using a portable BiliCheck device (SpectRx Inc, Norcross, GA), is clinically equivalent to measurement of TSB in a diverse, multiracial term and near-term newborn population and predictive of subsequent hyperbilirubinemia.

METHODOLOGY

We evaluated a hand-held device that uses multiwavelength spectral reflectance analysis to measure TcB (BiliCheck). The study population (490 term and near-term newborns) was racially diverse (59.1% white, 29.5% black, 3.46% Hispanic, 4.48% Asian, and 3.46% other) and was evaluated at 2 separate institutions using multiple (11) devices. The postnatal age ranged from 12 to 98 hours and the ranges of birth weights and gestational ages were 2000 to 5665 g and 35 to 42 weeks, respectively. All transcutaneous evaluations were performed contemporaneously and paired with a heelstick TSB measurement. All TSB assays were performed by high performance liquid chromatography, as well as by diazo dichlorophenyldiazonium tetrafluoroborate techniques.

RESULTS

TSB values ranged from .2 to 18.2 mg/dL (mean +/- standard deviation: 7.65 +/- 3.35 mg/dL). The overall correlation of TSB (by high performance liquid chromatography technique) to TcB (by BiliCheck devices) was linear and statistically significant (r =.91; r(2) =.83; TcB =.84; TSB = +.75; standard error of regression line = 1.38; P <.001; n = 490 infants; 1788 samples). Similar regression statistics were evident in subset populations categorized by race (white: r =.91 [n = 289 infants]; black: r =.91 [n = 145 infants]) as well as by gestation (term: r =. 91 [n = 1625 samples]; near-term: r =.89 [n = 163 samples]). Intradevice precision was determined to be.59 mg/dL (2-3 measurements per infant with 1 device; n = 210 infants; 510 samples in a separate subset). Interdevice evaluation of 11 devices determined the precision to be.68 mg/dL (2-4 devices used for measurements per patient). In 23 of 419 of the study population infants who were in the 24- to 72-hour age range, the predischarge TSB values designated them to be at high risk for subsequent excessive hyperbilirubinemia (above the 95th percentile track on the hour-specific bilirubin nomogram). For these infants, the paired BiliCheck TcB values were all above the 75th percentile track (negative predictive value = 100%; positive predictive value = 32. 86%; sensitivity = 100%; specificity = 88.1%; likelihood ratio = 8. 43).

CONCLUSIONS

Our data demonstrate the accuracy and reproducibility of the predischarge BiliCheck measurements in term and near-term newborn infants of diverse races and ethnicities. Infants with predischarge BiliCheck values above the 75th percentile of hour-specific TSB values on the bilirubin nomogram may be considered to be at high risk for subsequent excessive hyperbilirubinemia. Further studies are needed to assess the efficacy of this technique in preterm infants, those undergoing phototherapy, and those with TSB values of >/=15 mg/dL (>/=256 micromol/L).

A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge

BACKGROUND

Recently enacted federal legislation mandates insurance coverage of at least 48 hours of postpartum hospitalization, but most mothers and newborns in the United States will continue to go home before the third postpartum day. National guidelines recommend a follow-up visit on the third or fourth postpartum day, but scant evidence exists about whether home or clinic visits are more effective.

METHODS

We enrolled 1163 medically and socially low-risk mother-newborn pairs with uncomplicated delivery and randomly assigned them to receive home visits by nurses or pediatric clinic visits by nurse practitioners or physicians on the third or fourth postpartum day. In contrast with the 20-minute pediatric clinic visits, the home visits were longer (median: 70 minutes), included preventive counseling about the home environment, and included a physical examination of the mother. Clinical utilization and costs were studied using computerized databases. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks' postpartum.

RESULTS

Comparing the 580 pairs in the home visit group and the 583 pairs in the pediatric clinic visit group, no significant differences occurred in clinical outcomes as measured by maternal or newborn rehospitalization within 10 days postpartum, maternal or newborn urgent clinic visits within 10 days postpartum, or breastfeeding discontinuation or maternal depressive symptoms at the 2-week interview. The same was true for a combined clinical outcome measure indicating whether a mother-newborn pair had any of the above outcomes. In contrast, higher proportions of mothers in the home visit group rated as excellent or very good the preventive advice delivered (80% vs 44%), the provider's skills and abilities (87% vs 63%), the newborn's posthospital care (87% vs 59%), and their own posthospital care (75% vs 47%). On average, a home visit cost $255 and a pediatric clinic visit cost $120.

CONCLUSIONS

For low-risk mothers and newborns in this integrated health maintenance organization, home visits compared with pediatric clinic visits on the third or fourth postpartum hospital day were more costly, but were associated with equivalent clinical outcomes and markedly higher maternal satisfaction. This study had limited power to identify group differences in rehospitalization, and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.

Control of severe hyperbilirubinemia in full-term newborns with the inhibitor of bilirubin production Sn-mesoporphyrin

OBJECTIVE

To assess the efficacy of Sn-mesoporphyrin (SnMP), a potent inhibitor of bilirubin production, in: a) moderating the need for phototherapy (PT) in full-term breastfed infants with plasma bilirubin concentrations (PBC) of >/=256.5 micromol/L and </=307.8 micromol/L (>/=15 mg/dL and </=18 mg/dL, respectively) that were reached between >/=48 and </=96 hours of age; b) diminishing the time required for the PBC to decline to </=222.3 micromol/L (</=13 mg/dL) (closure of the case); c) decreasing the number of bilirubin determinations required for monitoring hyperbilirubinemia.

STUDY PARTICIPANTS

Healthy full-term breastfed infants with a PBC between >/=256.5 micromol/L and </=307.8 micromol/L (>/=15 mg/dL and </=18 mg/dL, respectively) reached between 48 to 96 hours of age.

DESIGN/METHODS

After obtaining informed consent from the parents, infants were randomized to either the SnMP (6.0 micromol/kg birth weight, single dose, intramuscular) group or the control group. The infants' PBCs were followed by daily measurements either in the hospital or at discharge as outpatients until the hyperbilirubinemia had subsided (PBC </=222.3 micromol/L [13mg/dL]). The total number of newborns enrolled in the study was 84; the SnMP group comprised 40 infants; the control group comprised 44 infants. The groups were similar in sex ratio, birth weight, gestational age, PBC, and age at enrollment. All infants were breastfed. Phototherapy was initiated at a PBC of 333.5 micromol/dL (19.5 mg/dL).

RESULTS

SnMP entirely eliminated the need for supplemental PT to control hyperbilirubinemia; in contrast, of the 44 control infants, 12 required treatment with PT (27%) when their PBC reached or exceeded the level (333.5 micromol/dL; 19.5 mg/dL) at which time the use of PT was dictated by hospital guidelines. None of the 40 SnMP-treated infants reached a PBC of 19.5 mg/dL. SnMP also markedly diminished the median hours to case closure (SnMP: median, 86.5 hours; minimum/maximum, 24/216 hours; controls: median, 120 hours; minimum/maximum, 72/336 hours); and significantly reduced the number of bilirubin determinations required for clinical monitoring of the infants (SnMP: median, 3; minimum/maximum, 1/9; controls: median, 5; minimum/maximum, 3/11). No adverse effects of SnMP use were observed.

CONCLUSION

A single dose of SnMP proved effective in controlling severe hyperbilirubinemia in full-term breastfed newborns with high bilirubin levels between 48 and 96 hours. In addition, SnMP eliminated the need for PT and reduced the use of medical resources in the clinical treatment of this problem as well as the related, important and painful, emotional costs for both mothers and infants.

Clinical outcomes and maternal perceptions of an updated model of perinatal care

BACKGROUND

Postpartum hospital stays seem likely to remain limited even under new laws which mandate that insurers cover 48-hour hospitalization after uncomplicated delivery. Clinicians, who are increasingly practicing in capitated arrangements, need better information to maximize clinical benefit to mothers and newborns using finite resources. OBJECTIVE AND INTERVENTIONS: This study's aim was to evaluate the clinical outcomes, patient perceptions, and costs of a revised model of perinatal care services. In this model, a new postpartum care center was established for routine follow-up of newborns within 48 hours after hospital discharge, educational efforts were shifted from the postpartum hospitalization to the prenatal period, and lactation consultant hours were increased.

DESIGN AND PARTICIPANTS

Controlled, nonrandomized (double cohort) study that compared mothers and newborns with hospital stays of 48 hours or less during the Baseline Care (preintervention) study period (N = 344) with those under the Revised Care (postintervention) study period (N = 456).

SETTING

The Hayward, California, medical center of Kaiser Permanente, a nonprofit health maintenance organization.

DATA COLLECTION

Telephone interviews were attempted with all mothers 3 weeks after delivery. Data on rehospitalizations, emergency department (ED) and clinic visits, and costs during the first 14 postpartum days were collected from computerized databases and chart review.

OUTCOME MEASURES

The combined clinical outcome was defined as any undesirable health event, including rehospitalization, an ED visit, or an urgent clinic visit by either the mother or newborn within the first 14 days postpartum, or breastfeeding discontinuation within the first 21 days postpartum. Maternal satisfaction and costs were also studied.

RESULTS

Of 876 attempted interviews, 800 were completed (91%). Analyses were adjusted for age, race, education, parity, breastfeeding experience, and other relevant variables. Among the interviewed mother-newborn pairs, 45% in the Revised Care group experienced the combined clinical outcome, compared with 52% in the Baseline Care group. Newborns in the Revised Care group (29%) were significantly less likely to make urgent clinic visits during the first 14 days of life than those in the Baseline Care group (36%). There were no differences between groups in newborn ED visits or rehospitalizations, maternal clinical outcomes, or breastfeeding continuation. Mothers in the Revised Care group expressed higher satisfaction with the newborn's care, the amount of information they received about newborn care and breastfeeding, and the amount of help they received with breastfeeding. Planned hospital care, planned follow-up visits, and unplanned care costs decreased by $149 per delivery, while the new prenatal class and increased lactation consultant services cost $58 per delivery, for an estimated overall reduction in cost.

CONCLUSIONS

We conclude that the revised model of perinatal care in this health maintenance organization medical center improved clinical outcomes and maternal satisfaction for low-risk mothers and newborns without increasing costs.