Rehospitalization during the first year of life by insurance status

Newborn Weight Loss Tool and Readmission for Hyperbilirubinemia

OBJECTIVE

The aim of this study was to determine if the Newborn Weight Loss Tool (NEWT) can predict hospital readmission due to hyperbilirubinemia.

STUDY DESIGN

This is a case-control study of 93 newborns and 186 controls ≥35 weeks' gestation. All were discharged from the Mother-Baby unit of an urban academic center and subsequently readmitted for hyperbilirubinemia. Controls were matched for date of birth, gestational age, and Bhutani risk zone. All infants were screened for hyperbilirubinemia prior to discharge and managed according to American Academy of Pediatrics guidelines in place at the time. Chi-square, Fisher's exact test, and multivariate analysis were utilized as appropriate.

RESULTS

There was no significant difference between the groups for a NEWT < 50% at discharge. More cases than controls breastfed. A significantly greater percentage of cases had NEWT > 50% at readmission than discharge. NEWT > 90% was moderately associated with readmission for hyperbilirubinemia (p = 0.081).

CONCLUSION

NEWT provides a more nuanced assessment of weight loss following birth and can aid in highlighting newborns at risk for readmission due to hyperbilirubinemia.

KEY POINTS

· Weight loss is a risk factor for readmission after birth.. · NEWT is a more nuanced assessment of weight loss.. · NEWT > 90% is associated with readmission for jaundice..

Neonatologist at the Well-Child Clinic: A High-Risk Infant Follow-up Pilot Study

OBJECTIVE

 High-risk infant follow-up (HRIF) is a complex process lacking standardization. We present a simple, single-provider model that proved effective and is well-received by caregivers.

STUDY DESIGN

 In this study, we measured caregiver use and satisfaction with an HRIF visit attended by an experienced neonatologist in a well-care setting, soon after discharge.

RESULTS

 One hundred parents participated in the survey. Among the infants of these parents, 78% of infants were seen in the first 3 months of life and 39% within 1 month of discharge. Nutrition (98%) and development (97%) were the most commonly discussed topics, followed by general health (95%), iron supplementation (93%), and head size (90%). Using a 5-point Likert's scale, with 5 being the highest rating, parents responded that the meeting answered their questions (4.7, n = 93), organized their infants' needs (4.6, n = 90), and increased their confidence in caring for their infants (4.65, n = 92).

CONCLUSION

 HRIF with an experienced neonatologist is an effective means of increasing parents' understanding of their infants' medical needs and confidence in caring for their infants.

KEY POINTS

· Meeting with a neonatologist after discharge addressed many crucial aspects of patient care.. · Meeting with a neonatologist after discharge was met with a high level of caregiver satisfaction.. · Neonatal consultation in the community may promote caregiver confidence in caring for their infant.. · Neonatal consultation reduced parental anxiety, especially regarding growth and development..

Validating the early phototherapy prediction tool across cohorts

Background

Hyperbilirubinemia of the newborn infant is a common disease worldwide. However, recognized early and treated appropriately, it typically remains innocuous. We recently developed an early phototherapy prediction tool (EPPT) by means of machine learning (ML) utilizing just one bilirubin measurement and few clinical variables. The aim of this study is to test applicability and performance of the EPPT on a new patient cohort from a different population.

Materials and methods

This work is a retrospective study of prospectively recorded neonatal data from infants born in 2018 in an academic hospital, Regensburg, Germany, meeting the following inclusion criteria: born with 34 completed weeks of gestation or more, at least two total serum bilirubin (TSB) measurement prior to phototherapy. First, the original EPPT-an ensemble of a logistic regression and a random forest-was used in its freely accessible version and evaluated in terms of the area under the receiver operating characteristic curve (AUROC). Second, a new version of the EPPT model was re-trained on the data from the new cohort. Third, the predictive performance, variable importance, sensitivity and specificity were analyzed and compared across the original and re-trained models.

Results

In total, 1,109 neonates were included with a median (IQR) gestational age of 38.4 (36.6-39.9) and a total of 3,940 bilirubin measurements prior to any phototherapy treatment, which was required in 154 neonates (13.9%). For the phototherapy treatment prediction, the original EPPT achieved a predictive performance of 84.6% AUROC on the new cohort. After re-training the model on a subset of the new dataset, 88.8% AUROC was achieved as evaluated by cross validation. The same five variables as for the original model were found to be most important for the prediction on the new cohort, namely gestational age at birth, birth weight, bilirubin to weight ratio, hours since birth, bilirubin value.

Discussion

The individual risk for treatment requirement in neonatal hyperbilirubinemia is robustly predictable in different patient cohorts with a previously developed ML tool (EPPT) demanding just one TSB value and only four clinical parameters. Further prospective validation studies are needed to develop an effective and safe clinical decision support system.

Racial and ethnic disparities in outcomes after NICU discharge: An equity-focused model

Significant racial and ethnic disparities exist in birth outcomes and complications related to prematurity. However, little is known about racial and ethnic variations in health outcomes after premature infants are discharged from the neonatal intensive care unit (NICU). We propose a novel, equity-focused conceptual model to guide future evaluations of post-discharge outcomes that centers on a multi-dimensional, comprehensive view of health, which we call thriving. We then apply this model to existing literature on post-discharge inequities, revealing a need for rigorous analysis of drivers and strength-based, longitudinal outcomes.

Six-Month Outcomes of Infants Born to People With SARS-CoV-2 in Pregnancy

OBJECTIVES

To assess the 6-month incidence of laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, postnatal care, hospitalization, and mortality among infants born to people with laboratory-confirmed SARS-CoV-2 infection during pregnancy by timing of maternal infection.

METHODS

Using a cohort of liveborn infants from pregnancies with SARS-CoV-2 infections in the year 2020 from 10 United States jurisdictions in the Surveillance for Emerging Threats to Mother and Babies Network, we describe weighted estimates of infant outcomes from birth through 6 months of age from electronic health and laboratory records.

RESULTS

Of 6601 exposed infants with laboratory information through 6 months of age, 1.0% (95% confidence interval: 0.8-1.1) tested positive, 19.1% (17.5-20.6) tested negative, and 80.0% (78.4-81.6) were not known to be tested for SARS-CoV-2. Among those ≤14 days of age, SARS-CoV-2 infection occurred only with maternal infection ≤14 days before delivery. Of 3967 infants with medical record abstraction, breastmilk feeding initiation was lower when maternal infection occurred ≤14 days before delivery compared with >14 days (77.6% [72.5-82.6] versus 88.3% [84.7-92.0]). Six-month all-cause hospitalization was 4.1% (2.0-6.2). All-cause mortality was higher among infants born to people with infection ≤14 days (1.0% [0.4-1.6]) than >14 days (0.3% [0.1-0.5]) before delivery.

CONCLUSIONS

Results are reassuring, with low incidences of most health outcomes examined. Incidence of infant SARS-CoV-2, breastmilk feeding initiation, and all-cause mortality differed by timing of maternal infection. Strategies to prevent infections and support pregnant people with coronavirus disease 2019 may improve infant outcomes.

A Comparison of Methods Examining Time-to-Readmission in the First Year of Life

BACKGROUND AND OBJECTIVES

Readmissions analyses typically calculate time-to-readmission relative to hospital discharge. For newborns, this definition can be challenging when comparing groups with disparate birth stays. We compare 2 approaches to calculate readmissions and examine 1 year readmissions for newborns with versus without neonatal opioid withdrawal syndrome (NOWS; mean length of stay = 17 vs 2 days).

METHODS

Using birth discharge data from the Pediatric Health Information System (PHIS), we compared crude and adjusted 1 year readmissions by NOWS diagnosis using Cox regression models predicting time-to-readmission from: (1) birth discharge; and (2) birth (day-of-life), with left truncation allowing for delayed entry into the at-risk period at birth discharge.

RESULTS

We included N = 155 885 birth discharges (n = 1467 with NOWS). At 1 year, 10% of infants with NOWS versus 6% without had been readmitted. Readmission risk was highest within 1 week since discharge or birth for newborns without NOWS, whereas those with NOWS were at higher risk later into infancy. NOWS was associated with a higher adjusted hazard of 1 year readmissions since discharge (adjusted hazard ratio [aHR]=1.58; 95% CI: 1.20-2.08) and a higher adjusted hazard of 1 year readmissions since birth (aHR = 1.56; 95% CI: 1.21-2.03). Estimates vary by choice of index date, particularly at early time-points, converging later into infancy.

CONCLUSIONS

Our findings underscore the importance of methodological decisions for newborn readmissions. Although results were similar at 1 year with nearly identical adjusted hazards, approaches differed substantially through the neonatal period.

Leveraging Predictive Pharmacometrics-Based Algorithms to Enhance Perinatal Care-Application to Neonatal Jaundice

The field of medicine is undergoing a fundamental change, transforming towards a modern data-driven patient-oriented approach. This paradigm shift also affects perinatal medicine as predictive algorithms and artificial intelligence are applied to enhance and individualize maternal, neonatal and perinatal care. Here, we introduce a pharmacometrics-based mathematical-statistical computer program (PMX-based algorithm) focusing on hyperbilirubinemia, a medical condition affecting half of all newborns. Independent datasets from two different centers consisting of total serum bilirubin measurements were utilized for model development (342 neonates, 1,478 bilirubin measurements) and validation (1,101 neonates, 3,081 bilirubin measurements), respectively. The mathematical-statistical structure of the PMX-based algorithm is a differential equation in the context of non-linear mixed effects modeling, together with Empirical Bayesian Estimation to predict bilirubin kinetics for a new patient. Several clinically relevant prediction scenarios were validated, i.e., prediction up to 24 h based on one bilirubin measurement, and prediction up to 48 h based on two bilirubin measurements. The PMX-based algorithm can be applied in two different clinical scenarios. First, bilirubin kinetics can be predicted up to 24 h based on one single bilirubin measurement with a median relative (absolute) prediction difference of 8.5% (median absolute prediction difference 17.4 μmol/l), and sensitivity and specificity of 95.7 and 96.3%, respectively. Second, bilirubin kinetics can be predicted up to 48 h based on two bilirubin measurements with a median relative (absolute) prediction difference of 9.2% (median absolute prediction difference 21.5 μmol/l), and sensitivity and specificity of 93.0 and 92.1%, respectively. In contrast to currently available nomogram-based static bilirubin stratification, the PMX-based algorithm presented here is a dynamic approach predicting individual bilirubin kinetics up to 48 h, an intelligent, predictive algorithm that can be incorporated in a clinical decision support tool. Such clinical decision support tools have the potential to benefit perinatal medicine facilitating personalized care of mothers and their born and unborn infants.

Comparison of short-term outcomes of 35-weeks' gestation infants cared for in a level II NICU vs mother-baby, a retrospective study

BACKGROUND

Late preterm infants are at high risk for medical complications and represent a growing NICU population. While 34-weeks' gestation infants are generally admitted to the NICU and 36-weeks'gestation infants stay in mother-baby, there is wide practice variation for 35-weeks'gestation infants. The objective of this study was to compare short-term outcomes of 35-weeks' gestation infants born at two hospitals within the same health system (DUHS), where one (DRH) admits all 35-weeks' gestation infants to their level II NICU and the other (DUH) admits all 35-weeks' gestation infants to mother-baby, unless clinical concern.

METHODS

We conducted a retrospective cohort analysis of 35-weeks' gestation infants born at DUHS from 2014-2019. Infant specific data were collected for birth, demographics, medications, medical therapies, LOS, ED visits and readmissions. 35-weeks' gestation infants at each hospital (DRH vs DUH) that met inclusion criteria were compared, regardless of unit(s) of care.

RESULTS

726 infants of 35-weeks' gestation were identified, 591 met our inclusion criteria (DUH -462, DRH -129). Infants discharged from DRH were more likely to receive medical therapies (caffeine, antibiotics, blood culture, phototherapy, NGT), had a 4 day longer LOS, but were more likely to feed exclusively MBM at discharge. There were no differences in ED visits; however, more infants from DUH were readmitted within 30 days of discharge.

CONCLUSIONS

Our findings suggest admitting 35-weeks' gestation infants directly to the NICU increases medical interventions and LOS, but might reduce hospital readmissions.

Risk factors for hospital readmission among infants with prolonged neonatal intensive care stays

OBJECTIVE

To assess risk factors associated with 30-day hospital readmission after a prolonged neonatal intensive care stay.

STUDY DESIGN

Retrospective analysis of 57,035 infants discharged >14 days from the NICU between 2013 and 2016. Primary outcome was 30-day, all-cause hospital readmission. Adjusted likelihood of readmission accounting for demographic and clinical characteristics, including chronic conditions was also estimated.

RESULTS

The 30-day readmission rate was 10.7%. Respiratory problems accounted for most (31.0%) readmissions. In multivariable analysis, shunted hydrocephalus [OR 2.2 (95%CI 1.8-2.7)], gastrostomy tube [OR 2.0 (95%CI 1.8-2.3)], tracheostomy [OR 1.5 (95%CI 1.2-1.8)], and use of public insurance [OR 1.3 (95%CI 1.2-1.4)] had the highest likelihood of readmission. Adjusted hospital readmission rates varied significantly (p < 0.001) across hospitals.

CONCLUSIONS

The likelihood of hospital readmission was highest for infants with indwelling medical devices and public insurance. These findings will inform future initiatives to reduce readmission for high risk infants with medical and social complexity.

Outcomes from birth to 6 months of publicly insured infants born to mothers with severe acute respiratory syndrome coronavirus 2 infection in the United States

OBJECTIVES

We evaluated inpatient management, transition to home, breastfeeding, growth, and clinical outcomes of infants born to mothers diagnosed with SARS-CoV-2 infection in pregnancy and followed in a Federally Qualified Health Center (FQHC), that serves a diverse and low-income patient population, from birth through 6 months of life.

METHODS

Infants born between 4/3/20 and 7/26/20 at Prentice Women's Hospital with mothers who received prenatal care at Erie Family Health Center (Erie), the second largest FQHC in Illinois, and had confirmed SARS-CoV-2 during pregnancy were included. Data were abstracted from delivery hospital admission and outpatient follow-up appointments between 4/8/20 and 2/4/21.

RESULTS

Thirty-three infants met inclusion criteria. Average gestational age was 38.9 weeks (IQR 37.6-40.4), 3 (10%) were premature and 5 (15%) required NICU admission. Nearly all (97%) mothers expressed intent to breastfeed. Outpatient follow-up rates were similar to historical cohorts and 82% (23/28) of infants were vaccination compliant. Growth parameters showed normal distributions at all time points. At 6 months, any and exclusive breast milk feeding rates were lower compared to historic cohorts (18 vs. 36%, p<0.05, 0 vs. 21%, p<0.01). Three infants (10%) received development-related referrals, one carried an underlying genetic diagnosis. Outpatient visits were predominantly face-to-face with telemedicine use comprising only 6% of visits (11/182).

CONCLUSIONS

Longitudinal follow-up of 33 publicly insured infants born to mothers with SARS-CoV-2 infection in pregnancy followed in an FQHC showed high rates of follow-up and vaccination compliance, normal growth patterns and reassuring clinical status, and lower than expected rates of breastfeeding.

Comparison of Back-Propagation Neural Network, LACE Index and HOSPITAL Score in Predicting All-Cause Risk of 30-Day Readmission

Background

The main purpose of this study is to predict the all-cause risk of 30-day readmission by employing the back-propagation neural network (BPNN) in comparison with traditional risk assessment tools of LACE index and HOSPITAL scores.

Methods

This was a retrospective cohort study from January 1st, 2018 to December 31st, 2019. A total of 55,688 hospitalizations from a medical center in Taiwan were examined. The LACE index (length of stay, acute admission, Charlson comorbidity index score, emergency department visits in previous 6 months) and HOSPITAL score (hemoglobin level at discharge, discharge from an Oncology service, sodium level at discharge, procedure during hospital stay, Index admission type, number of hospital admissions during the previous year, length of stay) are calculated. We employed variables from LACE index and HOSPITAL score as the input vector of BPNN for comparison purposes.

Results

The BPNN constructed in the current study has a considerably better ability with a C statistics achieved 0.74 (95% CI 0.73 to 0.75), which is statistically significant larger than that of the other two models using DeLong’s test. Also, it was possible to achieve higher sensitivity (70.32%) without penalizing the specificity (71.76%) and accuracy (71.68%) at its optimal threshold, which is at the 20% of patients with the highest predicted risk. Moreover, it is much more informative than the other two methods because of a considerably higher LR+ and a lower LR-.

Conclusion

Our findings suggest that more attention should be paid to methods based on non-linear classification systems, as they lead to substantial differences in risk-scores.

Pediatric Hospital Readmissions for Infants With Neonatal Opioid Withdrawal Syndrome, 2016-2019

BACKGROUND AND OBJECTIVES

Neonatal opioid withdrawal syndrome (NOWS) is associated with long and costly birth hospitalization and increased readmission risk. Our objective was to examine readmissions in the first year of life for infants diagnosed with NOWS compared with infants without NOWS, adjusting for sociodemographic and clinical factors, and to describe use during readmissions in this population.

METHODS

Using data from the Pediatric Health Information System, we identified singleton term infants with NOWS and without NOWS or other major condition (by diagnosis codes and All Patient Refined Diagnosis Related Groups coding, respectively) discharged from 2016 to 2019. We predicted time to first readmission within the first year of life using Cox regression analysis. Predictors included NOWS diagnosis, sociodemographic factors, birth NICU use, and birth weight.

RESULTS

We included 155 885 birth discharges from 17 hospitals (n = 1467 NOWS) with 10 087 readmissions. Unadjusted 1-year readmission rates were 9.9% among NOWS infants versus 6.2% among those without NOWS. The adjusted hazard ratio for readmission within the first year was 1.76 (95% confidence interval: 1.40-2.22) for infants with NOWS versus those without. Readmissions for infants with NOWS were longer and costlier and more likely to require intensive care and mechanical ventilation. Readmissions among infants without NOWS were most commonly for jaundice and respiratory and other infections, whereas respiratory infections were the leading cause of readmissions among NOWS infants.

CONCLUSIONS

Infants with a NOWS diagnosis were more likely to be readmitted within the first year of life. In future work, researchers should explore potential interventions to prevent readmissions and provide resources to families affected by opioid dependence.

Cord blood bilirubin and prediction of neonatal hyperbilirubinemia and perinatal infection in newborns at risk of hemolysis

OBJECTIVE

To assess the accuracy of umbilical cord bilirubin values to predict jaundice in the first 48h of life and neonatal infection.

METHOD

Newborn infants treated at a regional well-baby nursery born at ≥36 weeks of gestation were included in this retrospective cohort study. All infants born in a 3-year period from mothers with O blood type and/or Rh-negative were included and had the umbilical cord bilirubin levels measured. Hyperbilirubinemia in the first 48h was defined as bilirubin levels above the phototherapy threshold. Neonatal infection was defined as any antibiotic treatment before discharge.

RESULTS

A total of 1360 newborn infants were included. Two hundred and three (14.9%) newborn infants developed hyperbilirubinemia in the first 48h of life. Hyperbilirubinemic infants had smaller birth weight, higher levels of umbilical cord bilirubin, a higher rate of infection and were more often direct antiglobulin test positive. Umbilical cord bilirubin had a sensitivity of 76.85% and a specificity of 69.58% in detecting hyperbilirubinemia in the first 48h, with the cut-off value at 34μmol/L. The area under the receiver operating characteristic curve was 0.80 (95% CI: 0.78-0.82). Umbilical cord bilirubin had a sensitivity of 27.03% and specificity of 91.31% in detecting perinatal infection. The area under the receiver operating characteristic (ROC) curve was 0.59 (95% CI: 0.57-0.63).

CONCLUSIONS

A positive correlation was found between umbilical cord bilirubin and hyperbilirubinemia in the first 48h of life. Umbilical cord bilirubin is a poor marker for predicting neonatal infection.

Difference in Hospital Utilization Within the First 12 Months Among Low-Birth-Weight Infants in Medicaid Managed Care Versus Fee-for-Service: A Regression Discontinuity Study

OBJECTIVE

To examine the effect of Medicaid managed care (MMC) versus Medicaid fee-for-service (FFS) on emergency department (ED) use and hospitalization during the first 6 and 12 months of life among low-birth-weight (LBW) infants.

METHODS

We used the New York City Office of Vital Statistics-Statewide Planning and Research Cooperative System (OVS-SPARCS) dataset to identify 9135 LBW infants born to female Medicaid beneficiaries in New York City from January 2008-March 2012. We applied a robust regression discontinuity framework using a New York State Medicaid policy in effect at that time. This policy automatically enrolled infants born to female Medicaid beneficiaries to Medicaid managed care (MMC) or Medicaid fee-for-service (FFS) based on their birth weight (less than 1200 g vs. 1200-2500 g) during the first 6 months of their lives.

RESULTS

LBW infants in MMC had an average 0.16% points higher probability of being hospitalized within the first year of their lives than those in Medicaid FFS (p-value = 0.04).

CONCLUSIONS FOR PRACTICE

More research is necessary to understand possible differences in healthcare utilization between MMC and FFS participants with high health risks.

Post-discharge healthcare utilization in infants with neonatal opioid withdrawal syndrome

The opioid epidemic in the United States has led to a significant increase in the incidence of neonatal opioid withdrawal syndrome (NOWS); however, the understanding of long-term consequences of NOWS is limited. The objective of this study was to evaluate post-discharge healthcare utilization in infants with NOWS and examine the association between NOWS severity and healthcare utilization. A retrospective cohort design was used to ascertain healthcare utilization in the first year after birth-related discharge using the CERNER Health Facts® database. ICD-9/ICD-10 diagnostic codes were used to identify live births and to classify infants into two study groups: NOWS and uncomplicated births (a 25% random sample). Evaluated outcomes included rehospitalization, emergency department (ED) visits within 30-days and one-year after discharge, and a composite one-year utilization event (either hospitalization or emergency department visit during that year). NOWS severity was operationalized as pharmacologic treatment, length of hospitalization, and medical conditions often associated with NOWS. In 3,526 infants with NOWS (restricted to gestational age ≥ 33 weeks), NOWS severity was associated with an increase in composite one-year utilization (OR: 1.1; 95% CI: 1.04-1.2) after adjusting for prematurity, sepsis, jaundice, use of antibiotics, infant sex, insurance status, race, hospital bed size, year of birth, and census division. In a subset of full-term infants (3008 with NOWS and 88,452 uncomplicated births), having a NOWS diagnosis was associated with higher odds of a 30-day (OR: 1.6; 95% CI: 1.03-2.4) and one-year rehospitalization (OR: 1.6; 95% CI: 1.1-2.4) after adjusting for infant sex, race, type of medical insurance, hospital location, census division, year of primary encounter, hospital bed size, and medical conditions. This study found higher healthcare utilization during the first year of life in infants diagnosed with NOWS, especially those with severe NOWS. Findings suggest a need for closer post-discharge follow-up and management of infants with NOWS.

Towards community-based nursing: Mothers' experiences caring for their preterm infants in an informal settlement, Gauteng

Background

Pregnant women who experience preterm labour rush to public hospitals closest to the informal settlement in which they reside. Preterm infants are discharged when they reach a certain weight. Mothers take their preterm infants to their homes inside the informal settlements. Yet, preterm infants have special needs and require specific management. Research confirmed that nurses working in community clinics near informal settlements are unaware of the challenges faced by such mothers. Community nurses are at the heart of nursing, they work closest to the community and have a distinct opportunity to provide contextual, community-based care and support to these mothers, to promote good health and prevent diseases.

Aim

This article aims to enhance community nurses’ insight about the mothers’ experiences in caring for their preterm infants post-hospitalisation.

Setting

The study was conducted in an informal settlement in Midvaal, Gauteng.

Methods

A qualitative, exploratory, descriptive and contextual research design was used. In-depth, phenomenological interviews were conducted with 10 purposefully sampled mothers to explore their experiences in caring for their preterm infants in an informal settlement. Data were analysed using Giorgi’s coding method. Ethical approval was received from the University of Johannesburg. Measures were applied to ensure trustworthiness.

Results

Three themes emerged: mothers experienced intrapersonal responses, interpersonal responses and numerous physical challenges in taking care of their preterm infants.

Conclusion

Study findings revealed that mothers experienced several responses in caring for their preterm infants. Sharing their experiences can enhance community clinic nurses’ insight to provide contextual health education.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status

OBJECTIVE

To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90 days after discharge.

STUDY DESIGN

This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37 weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5 days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors.

RESULTS

Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5 years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits.

CONCLUSIONS

Among immigrant mothers, non-English primary language, >5 years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Hospital admissions in the first year of life: inequalities over three decades in a southern Brazilian city

BACKGROUND

Hospital admissions in infancy are declining in several countries. We describe admissions to neonatal intensive care units (NICU) and other hospitalizations over a 33-year period in the Brazilian city of Pelotas.

METHODS

We analysed data from four population-based birth cohorts launched in 1982, 1993, 2004 and 2015, each including all hospital births in the calendar year. NICU and other hospital admissions during infancy were reported by the mothers in the perinatal interview and at the 12-month visit, respectively. We describe these outcomes by sex of the child, family income and maternal skin colour.

RESULTS

In 1982, NICUs did not exist in the city; admissions into NICUs increased from 2.7% of all newborns in 1993 to 6.7% in 2015, and admission rates were similar in all income groups. Hospitalizations during the first year of life fell by 29%, from 23.7% in 1982 to 16.8% in 2015, and diarrhoea admissions fell by 95.2%. Pneumonia admissions fell by 46.3% from 1993 to 2015 (no data available for 1982). Admissions due to perinatal causes increased during the period. In the poorest income quintile, total admissions fell by 33% (from 35.7% to 23.9%), but in the richest quintile these remained stable at around 10%, leading to a reduction in inequalities. Over the whole period, children born to women with black or brown skin were 30% more likely to be admitted than those of white-skinned mothers.

CONCLUSIONS

Whereas NICU admissions increased, total admissions in the first year of life declined by nearly one-third. Socioeconomic disparities were reduced, but important gaps remain.

Predictive risk score for unplanned 30-day rehospitalizations in the French universal health care system based on a medico-administrative database

Background

Reducing unplanned rehospitalizations is one of the priorities of health care policies in France and other Western countries. An easy-to-use algorithm for identifying patients at higher risk of rehospitalizations would help clinicians prioritize actions and care concerning discharge transitions. Our objective was to develop a predictive unplanned 30-day all-cause rehospitalization risk score based on the French hospital medico-administrative database.

Methods

This was a retrospective cohort study of all 2015 discharges from acute-care inpatient hospitalizations in a tertiary-care university center comprising four hospitals. The study endpoint was unplanned 30-day all-cause rehospitalization via emergency departments, and we collected sociodemographic, clinical, and hospital characteristics based on hospitalization database computed for reimbursement of fees. We derived a predictive rehospitalization risk score using a split-sample design and multivariate logistic regression, and we compared the discriminative properties with the LACE index risk-score.

Result

Our analysis included 118,650 hospitalizations, of which 4,127 (3.5%) led to rehospitalizations via emergency departments. Variables independently associated with rehospitalization were age, gender, state-funded medical assistance, as well as disease category and severity, Charlson comorbidity index, hospitalization via emergency departments, length of stay (LOS), and previous hospitalizations 6 months before. The predictive rehospitalization risk score yielded satisfactory discriminant properties (C statistic: 0.74) exceeding the LACE index (0.66).

Conclusion

Our findings indicate that the possibility of unplanned rehospitalization remains high for some patient characteristics, indicating that targeted interventions could be beneficial for patients at the greatest risk. We developed an easy-to-use predictive rehospitalization risk-score of unplanned 30-day all-cause rehospitalizations with satisfactory discriminant properties. Future works should, however, explore if other data from electronic medical records and other databases could improve the accuracy of our predictive rehospitalization risk score based on medico-administrative data.

Transition Home Plus Program Reduces Medicaid Spending and Health Care Use for High-Risk Infants Admitted to the Neonatal Intensive Care Unit for 5 or More Days

OBJECTIVE

To evaluate the effects of a transition home intervention on total Medicaid spending, emergency department visits, and unplanned readmissions for preterm infants born at ≤36^6/7 weeks gestation and high-risk full-term infants.

STUDY DESIGN

The Transition Home Plus (THP) program incorporated enhanced support services before and after discharge from the neonatal intensive care unit (NICU) provided by social workers and family resource specialists (trained peers) working with the medical team from October 2012 to October 2014. Rhode Island Medicaid claims data were used to study the 321 infants cared for in the NICU for ≥5 days, who were enrolled in the THP program. THP infants were compared with a historical comparison group of 365 high-risk infants born and admitted to the same NICU in 2011 before the full launch of the THP program. Intervention and comparison group outcomes were compared in the eight 3-month quarters after the infant's birth. Propensity score weights were applied in regression models to balance demographic characteristics between groups.

RESULTS

Infants in the intervention group had significantly lower total Medicaid spending, fewer emergency department visits, and fewer readmissions than the comparison group. Medicaid spending savings for the intervention group were $4591 per infant per quarter in our study period.

CONCLUSIONS

Transition home support services for high-risk infants provided both in the NICU and for 90 days after discharge by social workers and family resource specialists working with the medical team can reduce Medicaid spending and health care use.

The Effect of Comprehensive Medical Care on the Long-Term Outcomes of Children Discharged from the NICU with Tracheostomy

Background:

Survival of infants with complex care has led to a growing population of technology-dependent children. Medical technology introduces additional complexity to patient care. Outcomes after NICU discharge comparing Usual Care (UC) with Comprehensive Care (CC) remain elusive.

Objective:

To compare the outcomes of technology-dependent infants discharged from NICU with tracheostomy following UC versus CC.

Methods:

A single site retrospective study evaluated forty-three (N=43) technology-dependent infants discharged from NICU with tracheostomy over 5½ years (2011-2017). CC provided 24-hour accessible healthcare-providers using an enhanced medical home. Mortality, total hospital admissions, 30-days readmission rate, time-to-mechanical ventilation liberation, and time-to-decannulation were compared between groups.

Results:

CC group showed significantly lower mortality (3.4%) versus UC (35.7%), RR, 0.09 [95%CI, 0.12-0.75], P=0.025. CC reduced total hospital admissions to 78 per 100 child-years versus 162 for UC; RR, 0.48 [95% CI, 0.25-0.93], P=0.03. The 30-day readmission rate was 21% compared to 36% in UC; RR, 0.58 [95% CI, 0.21-1.58], P=0.29). In competing-risk regression analysis (treating death as a competing-risk), hazard of having mechanical ventilation removal in CC was two times higher than UC; SHR, 2.19 [95% CI, 0.70-6.84]. There was no difference in time-to-decannulation between groups; SHR, 1.09 [95% CI, 0.37-3.15].

Conclusion:

CC significantly decreased mortality, total number of hospital admissions and length of time-to-mechanical ventilation liberation.

Apnea, bradycardia and desaturation spells in premature infants: impact of a protocol for the duration of 'spell-free' observation on interprovider variability and readmission rates

OBJECTIVE

To study the impact of implementing a protocol to standardize the duration of observation in preterm infants with apnea/bradycardia/desaturation spells before hospital discharge on length of stay (LOS) and readmission rates.

STUDY DESIGN

A protocol to standardize the duration of in-hospital observation for preterm infants with apnea, bradycardia and desaturation spells who were otherwise ready for discharge was implemented in December 2013. We evaluated the impact of this protocol on the LOS and readmission rates of very low birth weight infants (VLBW). Data on readmission for apnea and an apparent life-threatening event (ALTE) within 30 days of discharge were collected. The pre-implementation epoch (2011 to 2013) was compared to the post-implementation period (2014 to 2016).

RESULTS

There were 426 and 368 VLBW discharges before and after initiation of the protocol during 2011 to 2013 and 2014 to 2016, respectively. The LOS did not change with protocol implementation (66±42 vs 64±42 days before and after implementation of the protocol, respectively). Interprovider variability on the duration of observation for apneic spells (F-8.8, P=0.04) and bradycardia spells (F-17.4, P<0.001) decreased after implementation of the protocol. The readmission rate for apnea/ALTE after the protocol decreased from 12.1 to 3.4% (P=0.01).

CONCLUSION

Implementing an institutional protocol for VLBW infants to determine the duration of apnea/bradycardia/ desaturation spell-free observation period as recommended by the American Academy of Pediatrics clinical report did not prolong the LOS but effectively reduced interprovider variability and readmission rates.

Severe neonatal hyperbilirubinaemia is frequently associated with long hospitalisation for emergency care in Nigeria

AIM

This study investigated the frequency and predictors of a long hospital stay (LHS) for severe neonatal hyperbilirubinaemia in Nigeria.

METHODS

Length of stay (LOS) for severe hyperbilirubinaemia was examined among neonates consecutively admitted to the emergency department of a children's hospital in Lagos from January 2013 to December 2014. The median LOS was used as the cut-off for LHS. Multivariate logistic regression determined the independent predictors of LHS based on demographic and clinical factors significantly associated with the log-transformed LOS in the bivariate analyses.

RESULTS

We enrolled 622 hyperbilirubinaemic infants with a median age of four days (interquartile range 2-6 days) and 276 (44.4%) had LHS based on the median LOS of five days. Regardless of their birth place, infants were significantly more likely to have LHS if they were admitted in the first two days of life (p = 0.008) - especially with birth asphyxia - or had acute bilirubin encephalopathy (p = 0.001) and required one (p = 0.020) or repeat (p = 0.022) exchange transfusions. Infants who required repeat exchange transfusions had the highest odds for LHS (odds ratio 4.98, 95% confidence interval 1.26-19.76).

CONCLUSION

Severe hyperbilirubinaemia was frequently associated with long hospitalisation in Nigeria, especially if neonates had birth asphyxia or required exchange transfusions.

Newborn Length of Stay and Risk of Readmission

BACKGROUND

Evidence on the association between newborn length of hospital stay (LOS) and risk of readmission is conflicting. We compared methods for modelling this relationship, by gestational age, using population-level hospital data on births in England between 2005-14.

METHODS

The association between LOS and unplanned readmission within 30 days of postnatal discharge was explored using four approaches: (i) modelling hospital-level LOS and readmission rates; (ii) comparing trends over time in LOS and readmission; (iii) modelling individual LOS and adjusted risk of readmission; and (iv) instrumental variable analyses (hospital-level mean LOS and number of births on the same day).

RESULTS

Of 4 667 827 babies, 5.2% were readmitted within 30 days. Aggregated data showed hospitals with longer mean LOS were not associated with lower readmission rates for vaginal (adjusted risk ratio (aRR) 0.87, 95% confidence interval (CI) 0.66, 1.13), or caesarean (aRR 0.89, 95% CI 0.72, 1.12) births. LOS fell by an average 2.0% per year for vaginal births and 3.4% for caesarean births, while readmission rates increased by 4.4 and 5.1% per year respectively. Approaches (iii) and (iv) indicated that longer LOS was associated with a reduced risk of readmission, but only for late preterm, vaginal births (34-36 completed weeks' gestation).

CONCLUSIONS

Longer newborn LOS may benefit late preterm babies, possibly due to increased medical or psychosocial support for those at greater risk of potentially preventable readmissions after birth. Research based on observational data to evaluate relationships between LOS and readmission should use methods to reduce the impact of unmeasured confounding.

Impact of a Transition Home Program on Rehospitalization Rates of Preterm Infants

OBJECTIVES

To evaluate the effects of a transition home program on 90-day rehospitalization rates of preterm (PT) infants born at <37 weeks gestational age implemented over 3 years for infants with Medicaid and private insurance, and to identify the impact of social/environmental and medical risk factors on rehospitalization.

STUDY DESIGN

In this prospective cohort study of 954 early, moderate, and late PT infants, all families received comprehensive transition home services provided by social workers and family resource specialists (trained peers) working with the medical team. Rehospitalization data were obtained from a statewide database and parent reports. Group comparisons were made by insurance type. Regression models were run to identify factors associated with rehospitalization and duration of rehospitalization.

RESULTS

In bivariable analyses, Medicaid was associated with more infants hospitalized, more than 1 hospitalization, and more days of hospitalization. Early PT infants had more rehospitalizations by 90 days than moderate (P = .05) or late PT infants (P = .01). In regression modeling, year 3 of the transition home program vs year 1 was associated with a lower risk for rehospitalization by 90 days (OR, 0.57; 95% CI, 0.36-0.93; P = .03). Medicaid (P = .04), non-English-speaking (P = .02), multiple pregnancies (P = .05), and bronchopulmonary dysplasia (P = .001) were associated with increased risk. Both bronchopulmonary dysplasia and Medicaid were associated with increased days of rehospitalization in adjusted analyses. The major cause of rehospitalization was respiratory illness (61%).

CONCLUSIONS

Transition home prevention strategies must be directed at both social/environmental and medical risk factors to decrease the risk of rehospitalization.

Proportion of neonatal readmission attributed to length of stay for childbirth: a population-based cohort study

OBJECTIVE

Most literature on length of stay (LOS) for childbirth focuses on 'early' discharge as opposed to 'optimal' time of discharge and has conflicting results due to heterogeneous definitions of 'early' discharge and differing eligibility criteria for these programmes. We aimed to determine the LOS associated with the lowest neonatal readmission rate following childbirth by examining the incidence pattern of neonatal readmission for different LOS using the Kitagawa decomposition.

DESIGN

Retrospective cohort study using administrative hospitalisation data.

SETTING

Canada (excluding Quebec) from 2003 to 2010.

PATIENTS

Term, singleton live births without congenital anomalies.

INTERVENTIONS

LOS for childbirth.

MAIN OUTCOME MEASURE

Neonatal readmissions within 30 days of birth.

RESULTS

1 875 322 live births were included. Neonatal LOS peaked at day 1 (47.3%) after vaginal birth and day 3 (49.3%) following caesarean section; 4.2% of infants were readmitted following vaginal birth and 2.2% after caesarean section. In 2008-2010, most readmissions occurred among infants discharged in the first 2 days (83.8%) following a vaginal birth and among infants discharged in the first 3 days (81.7%) following a caesarean birth. Readmissions increased from 4.1% in 2003-2005 to 4.6% in 2008-2010 among vaginal births and from 2.0% to 2.4% among caesarean births and occurred mostly due to changes in the day-specific readmission rates and not due to reductions in LOS.

CONCLUSIONS

Patterns of readmission suggest that readmission rates are lowest following a 1-2-day stay following a vaginal birth and a 2-4-day stay following a caesarean birth given the outpatient support in the community.

Hospital Admission and Emergency Department Utilization in an Infant Medicaid Population

BACKGROUND AND OBJECTIVE

In the first year of life, the rate of rehospitalization for infants has been shown to be between 4.4% and 9.5%. Reducing avoidable health care utilization is a population health priority. The goal of this study was to identify maternal and infant factors associated with rehospitalization and emergency department (ED) utilization in a cohort of newborn Medicaid recipients.

METHODS

A longitudinal database was created by linking mother-infant dyads giving birth at a regional perinatal referral center with Delaware state Medicaid data. Multivariable logistic regression and negative binomial regression were used to examine inpatient hospitalization and ED utilization within 6 months after birth.

RESULTS

The study cohort included 4112 infants; 452 (11.0%) were rehospitalized, and 1680 (41%) used the ED within 6 months of birth. Variables independently associated with inpatient rehospitalization included NICU admission (odds ratio [OR]: 1.7 [95% confidence interval (CI): 1.3-2.3]), maternal bipolar diagnosis (OR: 1.5 [95% CI: 1.1-2.2]), count of maternal prenatal hospital admissions (OR: 1.3 [95% CI: 1.1-1.5]), and count of maternal ED visits (OR: 1.08 [95% CI: 1.04-1.1]). Black race (incident rate ratio [IRR]: 1.2 [95% CI: 1.1-1.3]), fall birth (IRR: 1.2 [95% CI: 1.01-1.3]), count of maternal ED visits (IRR: 1.1 [95% CI: 1.09-1.12]), number of maternal medications (IRR: 1.02 [95% CI: 1.01-1.03]), and maternal age (IRR: 0.97 [95% CI: 0.96-0.98]) were associated with ED utilization.

CONCLUSIONS

In this newborn Medicaid population, multiple maternal factors (including age, race, and mental health diagnoses) were associated with health care utilization in the 6 months after initial hospital discharge. Our data provide potential risk factors for targeted intervention and suggest that maternal factors should be considered in identifying a population at risk for rehospitalization and ED utilization.

Health Care Use Outcomes of an Integrated Hospital-to-Home Mother-Preterm Infant Intervention

OBJECTIVE

To compare health care use from initial hospital discharge through 6 weeks corrected age in two groups of mother-preterm infant dyads: those who received an intervention, Hospital to Home: Optimizing Premature Infant's Environment (H-HOPE), and an attention control group.

DESIGN

Prospective randomized controlled trial.

SETTING

Two community hospital NICUs.

PARTICIPANTS

Mothers (n = 147) with social-environmental risk factors and their stable preterm infants.

METHODS

Mother-infant dyads were randomly assigned to the H-HOPE or control group. When infants reached 6 weeks corrected age, information about health care visits since their hospital discharges was collected through an interview.

RESULTS

Only half of all infants received all recommended well-child visits. Infants in H-HOPE were half as likely to have acute care episodes (illness visit to the clinic or emergency department or hospital readmission) as control infants (odds ratio [OR] = 0.46, 95% confidence interval [CI] [0.22, 0.95]). Infants of mothers with high trait anxiety were nearly 3 times more likely to have an acute care episode (OR = 2.78, 95% CI [1.05, 7.26]), and mothers who had low education levels (OR = .22, 95% CI [0.08, 0.60]) were less likely to have acute care episodes. There was a trend toward fewer acute care visits for infants whose mothers preferred an English interview (OR = .47, 95% CI [0.21, 1.06]).

CONCLUSION

Findings emphasize the importance of reinforcing well-child visits for vulnerable preterm infants. H-HOPE, an integrated mother-infant intervention, reduces acute care episodes (visits to the clinic or emergency department or hospital readmissions) for preterm infants.

Prevalence and temporal pattern of hospital readmissions for patients with type I and type II diabetes

OBJECTIVE

Repeated hospitalisation for patients is common and costly, yet partly preventable. However, we know little about readmissions for patients with diabetes in China. The current study aims to assess the frequency and temporal pattern of and risk factors for all-cause readmission among hospitalised patients with diabetes in Tianjin, China.

METHOD

This retrospective, cohort analysis used the Tianjin Basic Medical Insurance Register System data of 2011. The patterns of and the reasons for all-cause readmissions for patients with diabetes were described. The differences of readmission-free survival (RFS) between newly and previously diagnosed patients were compared. Time-dependent Cox models were established to identify the risk factors for readmission at different time intervals after discharge.

RESULTS

Readmission rates were approximately 30%, with the most common diagnoses of cerebral infarction (for type I) or diabetes (for type II) for patients with diabetes. The majority of patients were readmitted to the hospital after more than 90 days, followed by 8-30 days (all p=0.002). Approximately 37.2% and 42.8% of readmitted patients with type I and type II diabetes were diagnosed previously, and the RFS rates for previously diagnosed patients were significantly lower than for newly diagnosed patients at any time interval after discharge. Prior history of diabetes (all p<0.05), length of stay (all p<0.01) and reimbursement ratio (90% vs >92%, all p<0.0002) were consistently associated with the RFS for patients readmitted to the hospital at <7, 8-30, 31-60 and 61-90 days.

CONCLUSIONS

Hospital readmissions among patients with diabetes were affected by the diagnosis status. Patient characteristics and the quality of healthcare might regulate short-interval and long-interval hospital readmission, respectively, after discharge.

Risk of Hospital Readmission Among Infants With Neonatal Abstinence Syndrome

OBJECTIVE

Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that may last for months. Our objective was to determine if infants with NAS are at increased risk for hospital readmission compared with uncomplicated term and late preterm newborns.

METHODS

In this longitudinal retrospective cohort study, administrative data were used for all births from 2006 to 2009 in the New York State Inpatient Database. We identified infants with NAS, born late preterm or uncomplicated term, as independent groups using diagnostic codes and determined readmission rates. We fit a multivariable logistic regression model with 30-day readmission after discharge as the outcome and infant characteristics, clinical morbidities, insurance type, and length of birth hospitalization as predictors.

RESULTS

From 2006 to 2009 in New York State, 700 613 infants were classified as uncomplicated term, 51 748 were born late preterm, and 1643 infants were diagnosed with NAS. After adjusting for confounders, infants with NAS (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.75-3.55) were more likely than uncomplicated term infants to be readmitted within 30 days of birth hospitalizations. The risk of readmission was similar to late preterm infants (OR 2.26, 95% CI 2.09-2.45). Length of birth hospitalization in days was inversely related to odds of being readmitted within 30 days of birth hospitalization (OR 0.94 95% CI 0.92-0.96).

CONCLUSIONS

When compared with uncomplicated term infants, infants diagnosed with NAS were more than twice as likely to be readmitted to the hospital. Future research and state-level policies should investigate means to mitigate risk of hospital readmission for infants with NAS.