Patient compliance with the first newborn visit appointment

Optimal site of care for administration of extended half-life respiratory syncytial virus (RSV) antibodies to infants in the United States (US)

INTRODUCTION

New extended half-life antibodies for the single-dose prevention of medically attended (MA) respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) have been developed for administration to all infants before or during their first RSV season. For infants born during the season, administration as soon as feasible after birth would provide optimal protection and minimize access disparities. The objective of this study was to assess the time from birth hospitalization discharge to the first outpatient visit (FOV) among US infants in order to determine optimal site of administration for the extended half-life antibody.

MATERIAL AND METHODS

This retrospective, observational, time-to-event analysis uses the Merative™ MarketScan® Commercial and Multi-State Medicaid Databases. Time to FOV is reported separately for the COVID-19 and recent pre-COVID-19 eras and for commercially insured and Medicaid infants.

RESULTS

Overall, 73.8 % of Medicaid infants had an FOV within 5 days as compared to 84.7 % of commercially insured infants. Estimates were higher during the COVID-19 era. Urban commercially insured infants had much higher FOV completion than their counterparts. Among Medicaid infants, urban Black and rural White infants were least likely to complete their FOV within 5 days of birth hospitalization discharge.

DISCUSSION AND CONCLUSION

FOV within 5 days after birth hospitalization discharge for Medicaid infants is substantially lower than that of commercially insured infants. Approximately 1 in 4 Medicaid infants and 1 in 8 infants with commercial insurance did not have an outpatient visit within 5 days of birth hospitalization discharge. For US infants born during the RSV season, administration of extended half-life RSV antibodies in the newborn nursery prior to discharge would ensure optimal uptake and minimize access disparities.

Newborn Clinic: A Novel Model to Provide Timely, Comprehensive Care to Newborns Following Nursery Discharge

Ensuring safe and timely follow-up after well baby nursery (WBN) discharge is an ongoing challenge. This study demonstrates the efficacy of a novel model for follow-up, the Newborn Clinic (NBC), in reducing time to outpatient follow-up after WBN discharge. Our retrospective chart review of 17 952 newborns found that time to follow-up visit decreased significantly following NBC establishment. Emergency department visits, a marker of infant morbidity, were slightly increased in the post-establishment cohort. There was no difference, however, in hospital readmissions. Analysis within the post-establishment cohort showed that newborns with jaundice, a high-risk group, were much more likely to have early follow-up if their visit was scheduled with NBC. Our study demonstrates that NBC is an effective model for decreasing time from WBN discharge to follow-up visit. It should be considered as an initiative to run concurrently with expedited newborn discharge initiatives so that safe follow-up need not be sacrificed.

Maternal and infant predictors of attendance at Neonatal Follow-Up programmes

BACKGROUND

Neonatal Follow-Up (NFU) programmes provide health services for families of infants at high risk of developmental problems following difficult or extremely premature birth: yet, up to 30% of families do not attend these programmes with their infants.

METHODS

The study objective was to determine maternal and infant factors that predicted attendance at NFU programmes. Utilizing Andersen's Behavioural Model of Health Services Use, a prospective two-phase multi-site descriptive cohort study was conducted in three Canadian Neonatal Intensive Care Units (NICU) that refer to two affiliated NFU programmes. In Phase 1, 357 mothers completed standardized questionnaires that addressed maternal and infant factors, prior to their infants' NICU discharge. In Phase 2, attendance at NFU was followed at three time points over a 12-month period. Factors of interest included predisposing factors (e.g. demographic characteristics and social context); enabling factors (e.g. social support, travel distance, and income); and infant illness severity (i.e. needs factors). Multivariate logistic regression was used to estimate the odds ratio for each independent factor.

RESULTS

Mothers parenting alone, experiencing higher levels of worry about maternal alcohol or drug use, or at greater distances from NFU were less likely to attend. Mothers experiencing higher maternal stress at the time of the infant's NICU hospitalization were more likely to attend NFU. No infant factors were predictive of NFU attendance.

CONCLUSIONS

Mothers at risk of not attending NFU programmes with their infants require better identification, triage, referral and additional support to promote engagement with NFU programmes and improved quality of life for their high-risk infants.

Factors associated with timing of first outpatient visit after newborn hospital discharge

OBJECTIVE

To determine factors associated with newborns having their first outpatient visit (FOV) beyond 3 days after postpartum hospital discharge.

METHODS

Retrospective cohort analysis of all newborns born at a large urban university hospital during a 1-year period, discharged home within 96 hours of birth, and with an outpatient visit with an affiliated provider within 60 days after discharge.

RESULTS

Of 3282 newborns, 1440 (44%) had their FOV beyond 3 days after discharge. Newborns born to first-time mothers, breast-feeding, at high risk for hyperbilirubinemia, or with a pathological diagnosis were significantly (P < .05) less likely to have FOV beyond 3 days in adjusted multivariable analysis, while newborns born via Caesarian section, of older gestational age, with Medicaid insurance, or discharged on a Thursday or Friday were more likely to have FOV beyond 3 days. Discharging provider characteristics independently associated with FOV beyond 3 days included family medicine providers, providers out of residency longer, and providers practicing at the institution longer. In addition, practice of outpatient follow-up had an independent impact on timing of FOV. Having an appointment date and time recorded on the nursery record or first appointment with a home nurse decreased the odds that time to FOV was beyond 3 days of discharge.

CONCLUSIONS

Physician decisions regarding timing of outpatient visit after newborn discharge may take into account newborn medical and social characteristics, but certain patient, provider, and practice features associated with this timing may represent unrecognized barriers to care.

Are 2 weeks of daily breastfeeding support insufficient to overcome the influences of formula?

OBJECTIVE

To evaluate the effectiveness of proactive telephone breastfeeding support in low-income, primiparous, primarily Latina women on 1) duration and exclusivity of breastfeeding, 2) satisfaction with feeding, 3) rationale for discontinuing breastfeeding and 4) health care utilization.

METHODS

Randomized controlled trial comparing usual care to 2 weeks of daily telephone calls by nurses by using culturally informed scripted protocols; and qualitative study of focused interviews on a sample of women in the intervention group (n = 40).

RESULTS

Breastfeeding duration and exclusivity rates, feeding method satisfaction, and reasons for stopping breastfeeding did not differ significantly between intervention (n = 161) and control (n = 180) groups, with 74% of both breastfeeding at 1 month and 28% and 37%, respectively, at 6 months. Insufficient milk supply was the main reason for stopping in both groups. Intervention infants were less likely to have a sick visit by 1 month (25%) than controls (35%, P = .05). Qualitative interviews revealed that the intervention was informative and helpful, with breastfeeding reported as healthier but harder; formula was a good alternative. Intervention mothers reporting < or =2 supplemental formula feedings on day 4 were more likely than mothers reporting > or =3 supplemental feedings to breastfeed at 1 month (odds ratio 7.7; 95% confidence interval 2.4-24.3).

CONCLUSIONS

Two weeks of daily telephone support did not increase breastfeeding duration but was associated with a decrease in sick visits in the first month. Early supplementation and the perception of formula as a good alternative to dealing with the breastfeeding difficulties appeared to be factors in failure of the intervention.

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.

A 1999 quality improvement initiative-reassessment in 2004

We obtained a longitudinal overview of physician compliance with the American Academy of Pediatrics Policy RE9539 regarding early newborn discharge between 1999 and 2004. In previous studies we reported the results of a Quality Improvement/Feedback (QI/F) initiative at one community hospital (intervention) in 1999, during which time physician education occurred at a grand rounds and the hospital QI department reviewed all newborn charts for a 1-year period, notifying physicians of any deviations from the policy. We also assessed the very same physicians at another community hospital (control), which did not have this initiative and found significant changes in physician behavior only at the intervention hospital. In this study we reassessed the same physicians in the year 2004 and compared their performance with that in 2000, after the intervention was well established, once again at both the intervention and control hospitals. Physicians caring for newborns at the intervention hospital continued to demonstrate improvement in compliance with the Early Newborn Discharge Policy (p = 0.0036), whereas there was no significant change in physician performance over time at the control hospital (p = 0.6874). We conclude, similarly to the first study, that improvement in physician practice continued, but there was still no overall change in physician culture.

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 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.