No Difference Between Early and Later Discharge After Childbirth on Health of Newborns or HMO Expenditures
In the early 1990s, health maintenance organizations (HMOs) implemented early discharge policies that allowed for one night of hospitalization after childbirth. Forty-one states responded by enacting legislation in the mid 1990s that mandated insurance coverage for at least 48 hours of hospitalization after a normal vaginal delivery.
The American Academy of Pediatrics recommends at least 48 hours of postpartum hospitalization, but they add that releasing a newborn earlier than 48 hours may be appropriate if the newborns are examined again within 48 hours of being discharged.
Studies examining the effects of early versus later discharge have had conflicting results. Some studies have linked early discharge to increased risk of death or readmission of the infant to the hospital. Other studies have found no effect.
In a study published in the December 19, 2002 New England Journal of Medicine , researchers did not find any difference in newborn health between the early and later discharge policies. However, once the 48-hour minimum stay went into effect, newborns were less likely to be examined (as recommended) on the third or fourth day of life. Finally, there was little difference in HMO expenditure between the two policies.
About the Study
Researchers from Harvard Medical School, Harvard Pilgrim Health Care, and Children’s Hospital recruited 20,366 mother-newborn pairs between 1990 and 1998. During the first four years of this study, there was no discharge policy in place. This time period acted as the control for the study. The Reduced Obstetrical Length of Stay (ROLOS) program, which authorized a standard of one night in the hospital after normal vaginal delivery, was enacted in 1994. State legislation establishing a minimum hospital stay of 48 hours after normal vaginal delivery went into effect in 1996.
The ROLOS program featured increased prenatal preparation, detailed criteria for discharge, and a home visit by a nurse within 48 hours after discharge.
The researchers compared the length of hospital stay, use of follow-up services, urgent care visits, emergency-department visits, and readmissions during the ROLOS program to after the 48-hour minimum hospital stay went into effect and to the control group. They also estimated the effects on cost by comparing the HMO’s expenditures for hospital stays and home-based services for 12 months before and after each policy went into effect.
After the ROLOS program went into effect, the rate of stays of less than two nights increased from 29.0% to 65.6%. Once the state mandated 48-hour minimum took effect, that rate declined to 13.7%
Examinations on the third or fourth day of life declined by 11.4%, to 53.0%, after the transition from the ROLOS program to the state mandate. This was in comparison to a rate of 24.5% of babies being examined on the third or fourth day of life at the start of the study period.
Although the rate of non-urgent visits to health centers increased from 33.4% to 44.7% after the reduced-stay program was implemented, there was no significant change in the rate of emergency room visits or of readmittance to the hospital.
These results all held true for a subgroup that the researchers deemed “vulnerable,” characterized by lower incomes, younger maternal age, a lower level of education, or any combination of these traits.
The average cost to the HMO for hospital and home-based care decreased by $90 per delivery after the implementation of ROLOS. That cost increased by $100 after the 48-hour minimum took effect. This represented a $10 increase from baseline. These differences in cost were not substantial compared to the approximately $4,550 spent by HMOs for total maternity care.
One limitation of this study is that because teenage mothers and Medicaid recipients were underrepresented, the results cannot necessarily be generalized to those populations.
How Does This Affect You?
Reacting to what many doctors, patients, and healthcare policymakers felt was an unreasonable and unsafe ROLOS program, more than 40 states have since mandated a minimum hospital stay of 48 hours after normal vaginal delivery. In hindsight, the ROLOS program did not harm newborns, nor did it save HMO’s much money. And ironically, the legislation to overturn it has had the unintended negative consequence of decreasing the number of newborns who are examined three to four days after birth, when difficulties with breast feeding and the incidence of ]]>jaundice]]> tend to peak.
What the study did not address is the effect earlier versus later discharge had on the health of the mothers of these infants. Research into the risk of complications to mothers who are discharged after a short stay versus after a 48-hour hospitalization should be conducted to more fully address the consequences of early versus later postpartum discharge.
American Academy of Pediatrics
Madden JM, Soumerai SB, Lieu TA, et al. Effects of a law against early postpartum discharge on newborn follow-up, adverse events, and HMO expenditures. NEJM . 2002;347:2031-2038
Last reviewed Dec 19, 2002 by ]]>Richard Glickman-Simon, MD]]>
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