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Effects of a law against early postpartum discharge on newborn follow-up, adverse events, and HMO expenditures.
N. Engl. J. Med..Dec 19, 2002;347(25):2031-8.
Madden JM, Soumerai SB, Lieu TA, Mandl KD, Zhang F, Ross-Degnan D.
Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA 02215, USA.
Concern about harm to newborns from early postpartum discharges led to laws establishing minimum hospital stays in the mid-1990s. We evaluated the effects of an early-discharge protocol (a hospital stay of one postpartum night plus a home visit) in a health maintenance organization (HMO) and a subsequent state law guaranteeing a 48-hour hospital stay.
Using interrupted-time-series analysis and data on 20,366 mother-infant pairs with normal vaginal deliveries, we measured changes in length of stay, newborn examinations on the third or fourth day of life, and office visits, emergency department visits, and hospital readmissions for newborns. We also examined expenditures for hospitalizations and home-based care.
The early-discharge program increased the rate of stays of less than two nights from 29.0 percent to 65.6 percent (P<0.001). The rate declined to 13.7 percent after the state mandate (P<0.001). The rate of newborn examinations on the third or fourth day of life increased from 24.5 percent to 64.4 percent with the program (P<0.001), then dropped to 53.0 percent after the mandate (P<0.001)--changes that primarily reflected changes in the rate of home visits. The rate of nonurgent visits to a health center increased from 33.4 percent to 44.7 percent (P<0.001) after the reduced-stay program was implemented. There were no significant changes in the rate of emergency department visits (quarterly mean, 1.1 percent) or rehospitalizations (quarterly mean, 1.5 percent). Results were similar for a vulnerable subgroup with lower incomes, younger maternal age, a lower level of education, or some combination of these characteristics. Average HMO expenditures on hospital and home-based services decreased by $90 per delivery with the early-discharge program and increased by $100 after the mandate.
Neither policy appears to have affected the health outcomes of newborns. After the mandate, newborns were less likely to be examined as recommended on day 3 or 4. Because of changes in hospital prices, the two policies had minimal effects on HMO expenditures for hospital and home-based services.