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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reducing the postpartum length of stay: Implications for emergency department presentations at a tertiary women's hospital

AIMS

Postpartum length of stay (LOS) in Australian hospitals has reduced over the past three decades. Although a reduction in LOS likely reduces hospital costs in the immediate postpartum period, there is concern that this is increasing the burden on emergency services, domiciliary staff and primary care providers. The aims were to determine whether the recent reduction in LOS at an Australian tertiary obstetric hospital resulted in a change in emergency department (ED) presentations by women in the first six weeks postpartum, and newborns within the first 28 days of life.

METHODS

We conducted a cross-sectional cohort study of all newborns ≤28 days of age and women ≤6 weeks postpartum who presented to the ED during four comparable time periods (2019-2022) at an Australian tertiary obstetric hospital. Logistic regression was used to determine the relationship between neonatal and maternal postpartum ED presentations and year of birth.

RESULTS

Reduced postpartum LOS was associated with a significant increase in maternal and neonatal presentations to the ED (odds ratio (OR): 1.15 (95% confidence interval (CI): 1.08-1.23), and OR: 1.11 (95% CI: 1.03-1.19), respectively). For every 100 births, an extra six women and three neonates presented to the ED for postpartum care in 2022 compared with 2019. There was no difference in maternal or neonatal admissions throughout the study periods.

CONCLUSION

The increase in maternal and neonatal ED presentations associated with reduced LOS should prompt reassessment of postnatal practice and encourage further research into allocation of in-hospital resources and postpartum education.

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.

Association of early discharge with increased likelihood of hospital readmission in first four weeks for vaginally delivered neonates

Aim

The main aim was to determine whether hospital readmission rates by 28 days of age are elevated with early discharge (ED) in Finland. We sought to identify the causes and predictors of ED, readmission rates, admissions to the intensive care unit (ICU) and death.

Methods

The data of 333,321 infants were retrieved from nationwide registers. Vaginally delivered single infants at gestational ages (GAs) of ≥37⁺⁰, born in 2008–2015 and treated in any maternity ward in Finland, were included. ED was defined as discharge on the day of birth or after one night stay on the maternity ward.

Results

During the study period, the ED and hospital readmission rates increased. Low‐risk infants and those born in high population‐density areas were more likely to be discharged early. ED predicted hospital readmission but not ICU admission or death. The most common reason for readmission was jaundice, followed by infection. ED seemed not to predict severe cardiologic problems. Rather than ED, being born at 38⁺⁰–38⁺⁶ weeks’ GA significantly predicted ICU admission or death.

Conclusion

Early discharge seems to be associated with increased hospital readmission. Birth at 38⁺⁰–38⁺⁶ weeks’ GA was a significant predictor of ICU admission or death, as opposed to early discharged infants.

Evaluation of compliance with early postbirth follow-up and unnecessary visits to the paediatric emergency department: a prospective observational study at the Lenval Children's Hospital in Nice

OBJECTIVE

To evaluate compliance with the French National Authority for Health's (Haute Autorité de Santé, HAS) postbirth follow-up recommendations for newborns attending our paediatric emergency department (PED) and identify risk factors associated with non-compliance and unnecessary emergency department utilisation.

DESIGN

Prospective, single centre.

SETTING

Fourth biggest PED in France in terms of attendance (CHU-Lenval).

PATIENTS

280 patients of whom 249 were included in the statistical analysis.

MAIN OUTCOME MEASURES

The primary outcome of this study was the evaluation of compliance of the care pathway for newborns consulting at the PED with respect to the French postbirth follow-up recommendations. Secondary outcome was the assessment of whether the visit to the PED was justified by means of PED reception software and two postconsultation interviews RESULTS: 77.5% (193) of the newborns had non-compliant care pathways and 43% (107) of PED visits were unnecessary. Risk factors associated with a non-compliance regarding the HAS's postbirth follow-up recommendations were: unnecessary visit to the PED (OR 2.0, 95% CI 1.1 to 3.9), precariousness (OR 2.8, 95% CI 1.4 to 6.2), birth in a public maternity hospital (OR 2.5, 95% CI 1.3 to 4.8) and no information about HAS's postbirth follow-up recommendations on discharge from maternity ward (OR 11.4, 95% CI 5.8 to 23.3). Risk factors for unnecessary PED visits were: non-compliant care pathway (OR 2.0, 95% CI 1.1 to 3.9) and a first medical visit at a PED (OR 1.8, 95% CI 1.1 to 3.1).

CONCLUSION

Postbirth follow-up may lead to decrease unnecessary emergency department visits unnecessary emergency department visits.

TRIAL REGISTRATION NUMBER

The study bears the clinical trial number NCT02863627.

Birth Hospital Length of Stay and Rehospitalization During COVID-19

OBJECTIVES

To determine if birth hospitalization length of stay (LOS) and infant rehospitalization changed during the coronavirus disease 2019 (COVID-19) era among healthy, term infants.

METHODS

Retrospective cohort study using Epic's Cosmos data from 35 health systems of term infants discharged ≤5 days of birth. Short birth hospitalization LOS (vaginal birth <2 midnights; cesarean birth <3 midnights) and, secondarily, infant rehospitalization ≤7 days after birth hospitalization discharge were compared between the COVID-19 (March 1 to August 31, 2020) and prepandemic eras (March 1 to August 31, 2017, 2018, 2019). Mixed-effects models were used to estimate adjusted odds ratios (aORs) comparing the eras.

RESULTS

Among 202 385 infants (57 110 from the COVID-19 era), short birth hospitalization LOS increased from 28.5% to 43.0% for all births (vaginal: 25.6% to 39.3%, cesarean: 40.1% to 61.0%) during the pandemic and persisted after multivariable adjustment (all: aOR 2.30, 95% confidence interval [CI] 2.25-2.36; vaginal: aOR 2.12, 95% CI 2.06-2.18; cesarean: aOR 3.01, 95% CI 2.87-3.15). Despite shorter LOS, infant rehospitalizations decreased slightly during the pandemic (1.2% to 1.1%); results were similar in adjusted analysis (all: aOR 0.83, 95% CI 0.76-0.92; vaginal: aOR 0.82, 95% CI 0.74-0.91; cesarean: aOR 0.87, 95% CI 0.69-1.10). There was no change in the proportion of rehospitalization diagnoses between eras.

CONCLUSIONS

Short infant LOS was 51% more common in the COVID-19 era, yet infant rehospitalization within a week did not increase. This natural experiment suggests shorter birth hospitalization LOS among family- and clinician-selected, healthy term infants may be safe with respect to infant rehospitalization, although examination of additional outcomes is needed.

Readmission of late preterm and term neonates in the neonatal period

OBJECTIVE

To determine the incidence of hospital readmissions in late preterm and term neonates, the most common reasons for readmission, and analyze the risk factors for readmission in the neonatal period.

METHODS

Newborn infants admitted to a well-baby nursery ≥ 36 weeks gestation were included in this retrospective cohort study. Data for all infants born in a 3-year period and readmitted in the first 28 days of life were analyzed. Indication for readmission was one diagnosed during initial workup in the pediatric emergency room visit before readmission.

RESULTS

The final cohort consisted of 5408 infants. The readmission rate was 4.0% (219/5408). Leading readmission causes were respiratory tract infection (29.58%), jaundice (13.70%), and urinary tract infection (9.59%). The mean ± SD age of readmitted infants was 13.3 ± 7.1 days. The mean ± SD treatment duration of treatment was 5.5 ± 3.0 days. In the multivariate regression analysis, infants that were during the initial hospitalization transferred to special care/NICU had a lower chance of readmission during the neonatal period (p = 0.04, OR = 0.23, 95% CI 0.06-0.93). Infants with mothers aged from 19-24 years had a higher risk of readmission (p = 0.005, OR = 1.62, 95% CI 1.16-2.26).

CONCLUSIONS

Finding that infants that were during the initial hospitalization transferred to special care or a NICU setting were less likely to require hospitalization in the neonatal period is an interesting one. Further research into how different approach in these settings reduce the risk of readmission is necessary.

Neonatal Intensive Care Utilization and Postdischarge Newborn Outcomes: A Population-based Study of Texas Medicaid Insured Infants

OBJECTIVE

To test the hypothesis that newborn infants cared for in hospitals with greater utilization of neonatal intensive care experienced fewer postdischarge adverse events.

STUDY DESIGN

We developed 3 retrospective population-based cohorts of Texas Medicaid insured singletons born in 2010-2014 (very low birth weight [VLBW n = 11 139], late preterm [n = 57 509], and non-preterm [n = 664 447]) who received care in higher volume hospitals with level III/IV neonatal intensive care units (NICUs). Measures of NICU care were hospital-level risk adjusted NICU admission rates, special care days (days of nonroutine care) per infant, and the percent of intensive (highest billable care code) special care days. The units of analysis were hospitals (n = 80) and the primary outcome was an adverse event, (defined as admission, emergency department visit, or death) within 30 days postdischarge.

RESULTS

Higher use of NICU care at a hospital level was not associated with lower postdischarge 30-day adverse event. Infants cared for in hospitals with above vs below median special care day rates experienced slightly higher postdischarge adverse event per 100 infants (VLBW: 14.01 [95% CI 12.74-15.27] vs 11.84 [10.52-13.16], P < .05; late preterm: 7.33 [6.68-7.97] vs 6.28 [5.87-6.69], P < .01; non-preterm: 4.47 [4.17-4.76] vs 3.97 [3.75-4.18], P < .01). Weak positive associations (Pearson correlations of 0.31-0.37, P < .01) were observed for adverse event with special care days; in no instance was a negative association observed between NICU utilization and adverse event.

CONCLUSION

Higher utilization of NICU care was not associated with lower rates of short-term events suggesting that there may be opportunities to safely decrease admission rates and length of NICU stays.

Admissions and Emergency Visits by Late Preterm Singletons and Twins in the First 5 Years: A Population-Based Cohort Study

OBJECTIVE

To compare admission and emergency visits of late preterm (34^0/7-36^6/7 weeks) versus term infants (37^0/7-41^6/7 weeks) in the first 5 years.

STUDY DESIGN

This population-based cohort study included all singletons and twins born alive at 34^0/7 to 41^6/7 weeks' gestation registered in a health administrative database in Ontario, Canada, between April 1, 2002 and December 31, 2012. Admissions and emergency visits from initial postnatal discharge to 5 years were compared between late preterm and term infants adjusting for maternal and infant characteristics.

RESULTS

A total of 1,316,931 infants (75,364 late preterm infants) were included. Late preterm infants had more frequent admissions than term infants in the first 5 years in both singletons (adjusted incidence rate ratio [95% confidence interval] = 1.46 [1.42-1.49]) and twins (1.21 [1.11-1.31]). The difference in admissions between late preterm and term infants were smaller in twins than singletons and decreased with children's ages. Twins had less frequent admissions than singletons for late preterm infants, but not for term infants. The emergency visits were more frequent in late preterm than term infants in all the periods.

CONCLUSION

Admissions and emergency visits were more frequent in late preterm than term infants through the first 5 years. Admissions were less frequent in late preterm twins than singletons.

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.

Hospital Care Cost and Resource Use of Early Discharge of Healthy Late Preterm and Term Singletons: A Population-based Cohort Study and Cost Analysis

OBJECTIVE

To assess the hospital care cost and resource use associated with discharge timings after late preterm and term births.

STUDY DESIGN

This population-based cohort study and cost analysis included all healthy singleton late preterm (35-36 weeks gestational age) and term infants (37-41 weeks gestational age) born vaginally in hospitals in Ontario, Canada, from 2003 to 2012. Early, late, and very late discharge (<48, 48-71, and 72-95 hours after birth, respectively) were compared using generalized linear models. The primary outcome was the total hospital care cost (hospitalizations and emergency department visits) per infant within 28 days of birth.

RESULTS

Among 860 693 singletons (3.7% late preterm), early discharge increased significantly over 10 years for term infants (from 69% to 82%; P < .001), but not late preterm infants (from 32% to 35%; P = .75). The mean total cost within 28 days after birth was not significantly different for late preterm infants between early discharge and late discharge after adjustment. However, for term infants, the adjusted cost was higher with early discharge than late discharge (aMCD $311 [95% CI, $211-$412] per infant; $366 [95% CI, $355-$377] per mother-infant dyad). The neonatal readmission rates were higher after early than late discharge for late preterm and term infants.

CONCLUSIONS

Early discharge was not associated with cost savings for vaginally born healthy singleton late preterm infants, and instead was associated with a cost increase for term infants. Early discharge was associated with higher neonatal readmission rates. Individualized approach balancing the risk and benefit is appropriate to determine the discharge timings.

Quality Improvement Learning Collaborative Improves Timely Newborn Follow-Up Appointments

BACKGROUND

American Academy of Pediatrics guidelines indicate that newborns should follow up with their primary care providers within three days of discharge from the newborn nursery. Many barriers exist to achieving timely follow-up, with potential implications on a newborn's health. The goal of this project was to improve rates of timely newborn follow-up through a nine-month quality improvement learning collaborative (QILC). Timely newborn follow-up was defined as an appointment scheduled within three days of newborn discharge.

METHODS

Both inpatient hospitalist and outpatient pediatric practices were eligible to participate. Inpatient and outpatient practices aimed to have 75% of newborns scheduled appropriately by six months into the project. In addition, outpatient practices aimed to have 60% of newborns seen appropriately by their provider. All practices aimed to have their progress sustained at conclusion of the QILC. Practices submitted data at baseline and nine subsequent phases. Monthly webinars featured a quality improvement didactic, data review, and discussion of practices' changes, successes, and challenges.

RESULTS

Eleven practices and 24 physicians participated in the QILC. Aggregate data from the practices showed continual improvement in all measured newborn scheduling metrics throughout the nine-month learning collaborative, with sustainment of progress over the last three months of the QILC.

CONCLUSION

A QILC is successful for increasing timely newborn follow-up for both the newborn hospitalist and outpatient pediatrician. Pediatric providers can learn from others' strategies and successes to incorporate meaningful changes in their practice.

Furosemide Exposure and Prevention of Bronchopulmonary Dysplasia in Premature Infants

OBJECTIVE

To evaluate the association between furosemide exposure and risk of bronchopulmonary dysplasia (BPD).

STUDY DESIGN

This retrospective cohort study included infants (2004-2015) born at 23-29 weeks gestational age and 501-1249 g birth weight. We compared the demographic and clinical characteristics of infants exposed and not exposed to furosemide between postnatal day 7 and 36 weeks postmenstrual age. We examined the association between furosemide exposure and 2 outcomes: BPD and BPD or death. We performed multivariable probit regression models that included demographic and clinical variables in addition to 2 instrumental variables: furosemide exposure by discharge year, and furosemide exposure by site.

RESULTS

Of 37 693 included infants, 19 235 (51%) were exposed to furosemide; these infants were more premature and had higher respiratory support. Of 33 760 infants who survived to BPD evaluation, 15 954 (47%) had BPD. An increase in the proportion of furosemide exposure days by 10 percentage points was associated with a decrease in both the incidence of BPD (4.6 percentage points; P = .001), and BPD or death (3.7 percentage points; P = .01).

CONCLUSIONS

More days of furosemide exposure between postnatal day 7 and 36 weeks was associated with decreased risk of BPD and a combined outcome of BPD or death.

Parental characteristics and perspectives pertaining to neonatal visits to the emergency department: a multicentre survey

BACKGROUND

Parents take neonates to the emergency department for many reasons, often nonurgent, pressuring an already burdened system. We aimed to characterize these visits and families to identify potential strategies to decrease neonatal emergency department visits.

METHODS

We developed and implemented a survey that explored characteristics of neonates and parents/guardians evaluated in the emergency department, perspectives of parents and use of health care services. Parents presenting with a neonate to the emergency department in 5 large academic hospitals in Ontario were surveyed between December 2013 and June 2015. We used descriptive statistics to report survey data and explored correlations between factors.

RESULTS

A total of 1533 surveys were completed. The most common reasons for presenting were jaundice (441 [28.8%]) and feeding issues (251 [16.4%]). The majority of respondents (73.9% [1104/1494]) had received advice before going to the emergency department. In most cases (86.4% [954/1104]), this was from a health care provider, who frequently advised going to the emergency department. Although most parents (86.8% [1280/1475]) reported high confidence in caring for a sick or injured child, 42.3% (643/1519) were unsure of the severity, and most (90.4% [578/639]) of these parents felt that the infant required assessment immediately or the same day. Of parents who felt the condition was not serious, 83.2% (198/238) thought that same-day evaluation was required. Nearly half of respondents (44.4% [621/1400]) said they would have gone to their health care provider with a same-day appointment, and 28.1% (344/1225) would have gone to their care provider with a next-day appointment.

INTERPRETATION

Parents' reported confidence in caring for sick or injured infants does not match the perceived urgency of neonatal conditions, which likely contributes to emergency department overuse. Any system to decrease nonurgent emergency department use by neonates would need to be immediately responsive, providing same-day help.

Newborn follow-up after discharge from a tertiary care hospital in the Western Cape region of South Africa: a prospective observational cohort study

Background

Current practice in the Western Cape region of South Africa is to discharge newborns born in-hospital within 24 h following uncomplicated vaginal delivery and two days after caesarean section. Mothers are instructed to bring their newborn to a clinic after discharge for a health assessment. We sought to determine the rate of newborn follow-up visits and the potential barriers to timely follow-up.

Methods

Mother-newborn dyads at Tygerberg Hospital in Cape Town, South Africa were enrolled from November 2014 to April 2015. Demographic data were obtained via questionnaire and medical records. Mothers were contacted one week after discharge to determine if they had brought their newborns for a follow-up visit, and if not, the barriers to follow-up. Factors associated with follow-up were analyzed using logistic regression.

Results

Of 972 newborns, 794 (82%) were seen at a clinic for a follow-up visit within one week of discharge. Mothers with a higher education level or whose newborns were less than 37 weeks were more likely to follow up. The follow-up rate did not differ based on hospital length of stay. Main reported barriers to follow-up included maternal illness, lack of money for transportation, and mother felt follow-up was unnecessary because newborn was healthy.

Conclusions

Nearly 4 in 5 newborns were seen at a clinic within one week after hospital discharge, in keeping with local practice guidelines. Further research on the outcomes of this population and those who fail to follow up is needed to determine the impact of postnatal healthcare policy.

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.

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.

Evaluating the Health Impact of Large-Scale Public Policy Changes: Classical and Novel Approaches

Large-scale public policy changes are often recommended to improve public health. Despite varying widely-from tobacco taxes to poverty-relief programs-such policies present a common dilemma to public health researchers: how to evaluate their health effects when randomized controlled trials are not possible. Here, we review the state of knowledge and experience of public health researchers who rigorously evaluate the health consequences of large-scale public policy changes. We organize our discussion by detailing approaches to address three common challenges of conducting policy evaluations: distinguishing a policy effect from time trends in health outcomes or preexisting differences between policy-affected and -unaffected communities (using difference-in-differences approaches); constructing a comparison population when a policy affects a population for whom a well-matched comparator is not immediately available (using propensity score or synthetic control approaches); and addressing unobserved confounders by utilizing quasi-random variations in policy exposure (using regression discontinuity, instrumental variables, or near-far matching approaches).

[Criteria for hospital discharge of the healthy term newborn after delivery]

Criteria for newborn hospital discharge have to include physiological stability and family competence to provide newborn care at home. In this document, the Committee of Standards of the Spanish Society of Neonatology reviews the minimum criteria to be met before hospital discharge of a term newborn infant. We include a review of hospital discharge criteria for the late preterm infants, as these infants are often not hospitalised and remain with their mother after birth. A shortened hospital stay (less than 48h after delivery) for healthy term newborns can be considered, but it is not appropriate for every mother and newborn. Newborn infants discharged before 48h of age, should be examined within 3-4 days of life.

Reducing hospital readmissions among medicaid patients: a review of the literature

Reducing hospital readmissions is a key approach to curbing health care costs and improving quality and patient experience in the United States. Despite the proliferation of strategies and tools to reduce readmissions in the general population and among Medicare beneficiaries, few resources exist to inform initiatives to reduce readmissions among Medicaid beneficiaries. Patients covered by Medicaid also experience readmissions and are likely to experience distinct challenges related to socioeconomic status. This review aims to identify factors related to readmissions that are unique to Medicaid populations to inform efforts to reduce Medicaid readmissions. Our search yielded 254 unique results, of which 37 satisfied all review criteria. Much of the Medicaid readmissions literature focuses on patients with mental health or substance abuse issues, who are often high utilizers of health care within the Medicaid population. Risk factors such as medication noncompliance, postdischarge care environments, and substance abuse comorbidities increase the risk of readmission among Medicaid patients.

Evaluating Educational Needs of Parents at Newborn Discharge: A Pilot Study

OBJECTIVE

The delivery of anticipatory guidance regarding newborn care is a standard practice for pediatricians. The purpose of this prospective study was to analyze the preexisting knowledge of routine newborn care in postpartum mothers.

METHODS

Inclusion criteria included all postpartum mothers of live-born infants at least two hours following delivery that had not yet received formal instruction in newborn care. Each eligible mother that agreed to the voluntary survey was asked four multiple-choice questions which evaluated her knowledge of newborn care. The four questions addressed knowledge of safe sleep, car seat position, feeding behavior, and neonatal fever. A standardized template was used to ensure validity. Results were recorded in Microsoft Excel.

RESULTS

Of the study population, 42% (55/131) of surveyed mothers were first-time mothers. Overall, results of the survey demonstrated that postpartum mothers answered the surveyed questions correctly 88% of the time previous to receiving anticipatory guidance.

CONCLUSIONS

Postpartum mothers appear to have a high preexisting knowledge of routine newborn care in this study. Further studies are needed to determine if postpartum mothers' knowledge base increases with inpatient education.

Newborn Readmissions to Slovenian Children's Hospitals in One Summer Month and One Autumn Month: A Retrospective Study

BACKGROUND

With the shortening length of stay of newborns in hospitals after birth, concerns have been raised about the possible rise in readmission rates. In Slovenia, where the normal length of stay is 3 days, no data on readmissions were available. We sought to determine the frequency and causes for readmissions.

METHODS

We conducted a retrospective study on all newborns readmitted to Slovenian children's hospitals and wards in June 2012 and November 2012. We obtained basic demographic data for newborns and mothers, analyzed the frequency of diagnoses, and compared the duration of treatment between summer months and autumn months.

RESULTS

The proportion of readmissions in June 2012 and November 2012 was 6% and 5.9%, respectively. Around 10% more boys were readmitted in June 2012 and November 2012. In June 2012, the mean age was 12.2 days, and the mean birth weight was 3444 g. In November, the mean age was 10.5 days, and the mean birth weight was 3271 g. Around 50% of mothers were primiparous, and their mean age was around 31 years. Most received > 10 prenatal check-ups and participated in a prenatal class. The most common diagnosis in June 2012 and November 2012 was jaundice. The duration of treatment did not statistically significantly differ between summer months and autumn months, but it was associated with the admission diagnosis and infants' characteristics.

CONCLUSION

Our study showed that the readmission rate in Slovenia was much higher than in some other developed countries. Prospective studies are needed to further confirm the findings and highlight the possible causes for this observation.

Association between day of delivery and obstetric outcomes: observational study

STUDY QUESTION

What is the association between day of delivery and measures of quality and safety of maternity services, particularly comparing weekend with weekday performance?

METHODS

This observational study examined outcomes for maternal and neonatal records (1,332,835 deliveries and 1,349,599 births between 1 April 2010 and 31 March 2012) within the nationwide administrative dataset for English National Health Service hospitals by day of the week. Groups were defined by day of admission (for maternal indicators) or delivery (for neonatal indicators) rather than by day of complication. Logistic regression was used to adjust for case mix factors including gestational age, birth weight, and maternal age. Staffing factors were also investigated using multilevel models to evaluate the association between outcomes and level of consultant presence. The primary outcomes were perinatal mortality and-for both neonate and mother-infections, emergency readmissions, and injuries.

STUDY ANSWER AND LIMITATIONS

Performance across four of the seven measures was significantly worse for women admitted, and babies born, at weekends. In particular, the perinatal mortality rate was 7.3 per 1000 babies delivered at weekends, 0.9 per 1000 higher than for weekdays (adjusted odds ratio 1.07, 95% confidence interval 1.02 to 1.13). No consistent association between outcomes and staffing was identified, although trusts that complied with recommended levels of consultant presence had a perineal tear rate of 3.0% compared with 3.3% for non-compliant services (adjusted odds ratio 1.21, 1.00 to 1.45). Limitations of the analysis include the method of categorising performance temporally, which was mitigated by using a midweek reference day (Tuesday). Further research is needed to investigate possible bias from unmeasured confounders and explore the nature of the causal relationship.

WHAT THIS STUDY ADDS

This study provides an evaluation of the "weekend effect" in obstetric care, covering a range of outcomes. The results would suggest approximately 770 perinatal deaths and 470 maternal infections per year above what might be expected if performance was consistent across women admitted, and babies born, on different days of the week.

FUNDING, COMPETING INTERESTS, DATA SHARING

The research was partially funded by Dr Foster Intelligence and the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre in partnership with the Health Protection Research Unit (HPRU) in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London. WLP was supported by the National Audit Office.

Hospital stay for healthy term newborn infants

The hospital stay of the mother and her healthy term newborn infant should be long enough to allow identification of problems and to ensure that the mother is sufficiently recovered and prepared to care for herself and her newborn at home. The length of stay should be based on the unique characteristics of each mother-infant dyad, including the health of the mother, the health and stability of the newborn, the ability and confidence of the mother to care for herself and her newborn, the adequacy of support systems at home, and access to appropriate follow-up care in a medical home. Input from the mother and her obstetrical care provider should be considered before a decision to discharge a newborn is made, and all efforts should be made to keep a mother and her newborn together to ensure simultaneous discharge.

Reducing hospital readmissions among medicaid patients: a review of the literature

Reducing hospital readmissions is a key approach to curbing health care costs and improving quality and patient experience in the United States. Despite the proliferation of strategies and tools to reduce readmissions in the general population and among Medicare beneficiaries, few resources exist to inform initiatives to reduce readmissions among Medicaid beneficiaries. Patients covered by Medicaid also experience readmissions and are likely to experience distinct challenges related to socioeconomic status. This review aims to identify factors related to readmissions that are unique to Medicaid populations to inform efforts to reduce Medicaid readmissions. Our search yielded 254 unique results, of which 37 satisfied all review criteria. Much of the Medicaid readmissions literature focuses on patients with mental health or substance abuse issues, who are often high utilizers of health care within the Medicaid population. Risk factors such as medication noncompliance, postdischarge care environments, and substance abuse comorbidities increase the risk of readmission among Medicaid patients.

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.

Early discharge of infants and risk of readmission for jaundice

OBJECTIVES

To examine the association between early discharge from hospital after birth and readmission to hospital for jaundice among term infants, and among infants discharged early, to investigate the perinatal risk factors for readmission for jaundice.

METHODS

Birth data for 781,074 term live-born infants born in New South Wales, Australia from 2001 to 2010 were linked to hospital admission data. Logistic regression models were used to investigate the association between postnatal length of stay (LOS), gestational age (GA), and readmission for jaundice in the first 14 days of life. Other significant perinatal risk factors associated with readmission for jaundice were examined for infants discharged in the first 2 days after birth.

RESULTS

Eight per 1000 term infants were readmitted for jaundice. Infants born at 37 weeks' GA with an LOS at birth of 0 to 2 days were over 9 times (adjusted odds ratio [aOR] 9.43; 95% CI, 8.34-10.67) and at 38 weeks' GA were 4 times (aOR 4.05; 95% CI, 3.62-4.54) more likely to be readmitted for jaundice compared with infants born at 39 weeks' GA with an LOS of 3 to 4 days. Other significant risk factors for readmission for jaundice for infants discharged 0 to 2 days after birth included vaginal birth, born to mothers from an Asian country, born to first-time mothers, or being breastfed at discharge.

CONCLUSIONS

This study can inform guidelines or policy about identifying infants at risk for readmission for jaundice and ensure that appropriate post-discharge follow-up is received.

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.

Individualized follow up programme and early discharge in term neonates

BACKGROUND

Early discharge of mother/neonate dyad has become a common practice, and its effects are measured by readmission rates. We evaluated the safety of early discharge followed by an individualized Follow-up programme and the efficacy in promoting breastfeeding initiation and duration.

METHODS

During a nine-month period early discharge followed by an early targeted Follow-up was carried out in term neonates in the absence of weight loss <10% or hyperbilirubinaemia at risk of treatment. Follow-up visits were performed at different timepoints with a specific flow-chart according to both bilirubin levels and weight loss at discharge.

RESULTS

During the study period early discharge was performed in 419 neonates and Follow-up was carried out in 408 neonates (97.4%). No neonates required readmission for hyperbilirubinaemia and dehydration during the first 28 days of life. Breastfeeding rate was 90.6%, 75.2%, 41.5% at 30, 90 and 180 days of life, respectively. A six-month phone interview was performed for 383 neonates (93.8%) and satisfaction of parents about early discharge was high in 345 cases (90.1%).

CONCLUSIONS

Early discharge in association with an individualized Follow-up programme resulted safe for the neonate and effective for breastfeeding initation and duration.

Impact of newborn follow-up visit timing on subsequent ED visits and hospital readmissions: an instrumental variable analysis

OBJECTIVE

To determine whether newborn first outpatient visit (FOV) within 3 days of discharge is associated with reduced rates of emergency department (ED) visits and hospital readmissions.

METHODS

Retrospective cohort analysis was performed of all newborns who were born and had outpatient follow-up within a large academic medical center to determine whether they had ED visits or hospital readmission within 2 weeks after hospital discharge. Multivariable regression using an instrumental variable for timing of FOV was conducted to estimate the relationship between FOV within 3 days of discharge and ED visits and hospital readmissions within 2 weeks of discharge, adjusting for potential confounders. Stratified analyses assessed this relationship in subpopulations with medical or social risk factors.

RESULTS

Of 3282 newborns, 178 (5%) had 1 or more ED visits or hospital readmissions within 2 weeks of hospital discharge. FOV within 3 days was not significantly associated with ED visits and readmissions in the instrumental variable analysis (IVA) (-0.035, P = .11) or the ordinary least squares analysis (OLS) (0.006, P = .52). The difference in coefficients between these analyses, however, suggests that IVA successfully adjusted for some unmeasured bias. In stratified analyses, only newborns born to African American mothers or discharged by family medicine providers demonstrated a significant relationship between FOV within 3 days and reduced odds of ED visits and readmissions.

CONCLUSIONS

No significant relationship between outpatient visit timing and ED visits and hospital readmissions was found. Further study is needed to assess the impact of early outpatient visits on other newborn outcomes.

Early readmission of newborns in a large health care system

BACKGROUND

Early readmissions of apparently healthy newborns after discharge from well baby nurseries (WBN) may reflect an inadequate assessment of the newborn's readiness for discharge.

OBJECTIVE

To determine the frequency, causes, costs, and variations in rates of early rehospitalization of newborns discharged from 21 WBNs in 1 health care system.

METHODS

We queried the Enterprise Data Warehouse of Intermountain Healthcare (IH), a large Utah health care system, to identify newborns with gestational ages of 34 to 42 weeks discharged from an IH WBN between 2000 and 2010. We identified all newborns admitted to an IH hospital within 28 days of discharge and recorded their birth hospital, age, reason(s) for admission, length of stay, and inpatient costs.

RESULTS

During the study period, 296 114 infants were discharged from IH hospital WBNs. Of these, 5308 (17.9/1000) were readmitted within 28 days of discharge. Of the 5308 infants who were readmitted, 41% had feeding problems, 35% had jaundice, and 33% had respiratory distress. The majority of newborns with feeding problems and jaundice were admitted in their first 2 weeks of life. Late preterm and early term newborns had higher rates of readmission than term infants. There were significant variations in readmission rates of newborns born at the 21 hospitals in the IH system.

CONCLUSIONS

Potentially preventable conditions, including feeding problems and jaundice, account for most early readmissions of newborns. Late preterm and early term newborns have higher rates of readmission and should be assessed for other factors associated with early readmission.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Length of postnatal hospital stay in healthy newborns and re-hospitalization following early discharge

Background:

The length of postnatal hospital stay for healthy newborns remains controversial. Proponents of early hospital discharge claim that it is safe, decreases the risk of iatrogenic infection, promotes family bonding and attachment, and reduces hospitalization care and patient costs. Disadvantages include delayed breastfeeding, manifestation of new conditions affecting newborns after early discharge, and improper discharge planning.

Aim:

The main aim of the study was to compare early discharge versus late discharge with the risk of readmission.

Patients and Methods:

The length of hospital stay was recorded for all healthy newborns and infants and followed by investigation of any medical problem arising after discharge. Factors associated with readmission to the hospital were analyzed by Chi square and Mantel-Haenszel Common Odds Ratio Estimate (OR) with Confidence Limits (CL).

Results:

A total of 478 babies were enrolled, of which 307 were discharged ≤ 48 hours. The overall length of stay was 39 hours (1.6 days). Thirty-eight (7.9%) newborns were re-hospitalized, with the most common cause being neonatal jaundice. Factors associated with readmission for jaundice were breastfeeding (OR: 10.3 CL3.10to32.20) and length of stay ≤ 48 hours (OR: 13.8, CL4.04 to 47.05).

Conclusion:

Hospital discharge at any time ≤ 48 hours significantly increases the risk for readmission as well as the risk for readmission due to hyperbilirubinemia. Planning and implementing a structured program for follow up of infants who are discharged ≤ 48 hours are vital in order to decrease the risk for readmission, morbidity and neonatal mortality.

The differential impact of delivery hospital on the outcomes of premature infants

BACKGROUND

Because greater percentages of women deliver at hospitals without high-level NICUs, there is little information on the effect of delivery hospital on the outcomes of premature infants in the past 2 decades, or how these effects differ across states with different perinatal regionalization systems.

METHODS

A retrospective population-based cohort study was constructed of all hospital-based deliveries in Pennsylvania and California between 1995 and 2005 and Missouri between 1995 and 2003 with a gestational age between 23 and 37 weeks (N = 1328132). The effect of delivery at a high-level NICU on in-hospital death and 5 complications of premature birth was calculated by using an instrumental variables approach to control for measured and unmeasured differences between hospitals.

RESULTS

Infants who were delivered at a high-level NICU had significantly fewer in-hospital deaths in Pennsylvania (7.8 fewer deaths/1000 deliveries, 95% confidence interval [CI] 4.1-11.5), California (2.7 fewer deaths/1000 deliveries, 95% CI 0.9-4.5), and Missouri (12.6 fewer deaths/1000 deliveries, 95% CI 2.6-22.6). Deliveries at high-level NICUs had similar rates of most complications, with the exception of lower bronchopulmonary dysplasia rates at Missouri high-level NICUs (9.5 fewer cases/1000 deliveries, 95% CI 0.7-18.4) and higher infection rates at high-level NICUs in Pennsylvania and California. The association between delivery hospital, in-hospital mortality, and complications differed across the 3 states.

CONCLUSIONS

There is benefit to neonatal outcomes when high-risk infants are delivered at high-level NICUs that is larger than previously reported, although the effects differ between states, which may be attributable to different methods of regionalization.

Osmolar therapy in pediatric traumatic brain injury

OBJECTIVES

To describe patterns of use for mannitol and hypertonic saline in children with traumatic brain injury, to evaluate any potential associations between hypertonic saline and mannitol use and patient demographic, injury, and treatment hospital characteristics, and to determine whether the 2003 guidelines for severe pediatric traumatic brain injury impacted clinical practice regarding osmolar therapy.

DESIGN

Retrospective cohort study.

SETTING

Pediatric Health Information System database, January, 2001 to December, 2008.

PATIENTS

Children (age <18 yrs) with traumatic brain injury and head/neck Abbreviated Injury Scale score ≥ 3 who received mechanical ventilation and intensive care.

INTERVENTIONS

: None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was hospital billing for parenteral hypertonic saline and mannitol use, by day of service. Overall, 33% (2,069 of 6,238) of the patients received hypertonic saline, and 40% (2,500 of 6,238) received mannitol. Of the 1,854 patients who received hypertonic saline or mannitol for ≥ 2 days in the first week of therapy, 29% did not have intracranial pressure monitoring. After adjustment for hospital-level variation, primary insurance payer, and overall injury severity, use of both drugs was independently associated with older patient age, intracranial hemorrhage (other than epidural), skull fracture, and higher head/neck injury severity. Hypertonic saline use increased and mannitol use decreased with publication of the 2003 guidelines, and these trends continued through 2008.

CONCLUSIONS

Hypertonic saline and mannitol are used less in infants than in older children. The patient-level and hospital-level variation in osmolar therapy use and the substantial amount of sustained osmolar therapy without intracranial pressure monitoring suggest opportunities to improve the quality of pediatric traumatic brain injury care. With limited high-quality evidence available, published expert guidelines appear to significantly impact clinical practice in this area.

Early hospital discharge of infants born to group B streptococci-positive mothers: a decision analysis

OBJECTIVE

To compare the cost-effectiveness of an additional 24-hour inpatient observation for asymptomatic term neonates born to group B streptococcus (GBS)-colonised mothers with adequate intrapartum antibiotic prophylaxis (IAP) after an initial 24-hour in-hospital observation.

DESIGN

Cost-effectiveness analysis from a societal perspective.

SETTING

United States.

POPULATION

Asymptomatic term neonates born to GBS-colonised mothers with IAP after an initial 24-hour in-hospital observation.

METHODS

Monte Carlo simulation for a decision tree model incorporating the following chance events: development of GBS sepsis during the second 24 hours of life, development of GBS sepsis between 48 hours and 7 days of life, prompt versus delayed treatment for sepsis, neonatal mortality and long-term health sequelae.

MAIN OUTCOME MEASURES

Expected cost and quality-adjusted life years (QALYs), Incremental cost-effectiveness ratio (ICER).

RESULTS

Delayed, versus early, hospital discharge results in similar mean expected QALYs, but substantially higher expected cost. The mean difference in QALY is 0.00016 (95% CI 0.00005-0.00040), whereas the mean difference in cost is $1170.96 (95% CI $750.13-1584.32). The ICER is estimated to be $9,771,520.87 per QALY (95% CI $2,573,139.89-24,407,017.82). The proportion of early-onset GBS that develops during the second 24 hours of life, the cost of 24 hours of inpatient observation, and the probability of long-term sequelae following prompt versus delayed treatment play important roles in determining the cost-effectiveness of delayed hospital discharge.

CONCLUSION

Cost-effectiveness analysis suggests that with adequate IAP, discharging asymptomatic term neonates to home after 24 hours is the preferred approach compared with 48 hours inpatient observation.

After Midnight: A Regression Discontinuity Design in Length of Postpartum Hospital Stays

Estimates of moral hazard in health insurance markets can be confounded by adverse selection. This paper considers a plausibly exogenous source of variation in insurance coverage for childbirth in California. We find that additional health insurance coverage induces substantial extensions in length of hospital stay for mother and newborn. However, remaining in the hospital longer has no effect on readmissions or mortality, and the estimates are precise. Our results suggest that for uncomplicated births, minimum insurance mandates incur substantial costs without detectable health benefits. (JEL D82, G22, I12, I18, J13)

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.

Hospital stay for healthy term newborns

The hospital stay of the mother and her healthy term newborn infant should be long enough to allow identification of early problems and to ensure that the family is able and prepared to care for the infant at home. The length of stay should also accommodate the unique characteristics of each mother-infant dyad, including the health of the mother, the health and stability of the infant, the ability and confidence of the mother to care for her infant, the adequacy of support systems at home, and access to appropriate follow-up care. Input from the mother and her obstetrician should be considered before a decision to discharge a newborn is made, and all efforts should be made to keep mothers and infants together to promote simultaneous discharge.

Neonatal hyperbilirubinemia and early discharge from the maternity ward

Early discharge from the maternity hospital is almost becoming the rule: it is not clear if this practice actually increases the rate of newborn rehospitalization, but it surely poses some problems for jaundice management, since hyperbilirubinemia is the most frequent reason for hospital readmission. Available guidelines for jaundice management and early discharge are reviewed. Evidence-based update is given about four new points: use of gestational age as predictor jointly with the nomogram evaluation, two-point bilirubin assay, and rate of rise evaluation; choice of the "right" curve and unforeseen jaundice risk factors. In conclusion, available predictive tools allow reliable jaundice prediction and safe early discharge if adequate follow-up is planned according to the prediction. Advice about things to avoid is provided together with a practical flowchart based on guidelines and recent evidence-based data.

Trends in pediatric and adult bicycling deaths before and after passage of a bicycle helmet law

OBJECTIVES

The goals were to examine bicycle-related mortality rates in Ontario, Canada, from 1991 to 2002 among bicyclists 1 to 15 years of age and 16 years of age through adulthood and to determine the effect of legislation (introduced in October 1995 for bicyclists <18 years of age) on mortality rates.

METHODS

The average numbers of deaths per year and mortality rates per 100000 person-years for the prelegislation and postlegislation periods, and the percentage changes, were calculated for each of the 2 age groups (1-15 years and >/=16 years). Differences before and after legislation in the 2 age groups were modeled in a time series analysis.

RESULTS

There were 362 bicycle-related deaths in the 12-year period (1-15 years: 107 deaths; >/=16 years: 255 deaths). For bicyclists 1 to 15 years of age, the average number of deaths per year decreased 52%, the mortality rate per 100000 person-years decreased 55%, and the time series analysis demonstrated a significant reduction in deaths after legislation. The estimated change in the number of deaths per month was -0.59 deaths per month. For bicyclists >/=16 years of age, there were only slight changes in the average number of deaths per year and the mortality rate per 100000 person-years, and the time series analysis demonstrated no significant change in deaths after legislation.

CONCLUSIONS

The bicycle-related mortality rate in children 1 to 15 years of age has decreased significantly, which may be attributable in part to helmet legislation. A similar reduction for bicyclists 16 years of age through adulthood was not identified. These findings support promotion of helmet use, enforcement of the existing law, and extension of the law to adult bicyclists.