A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge.

BACKGROUND: Recently enacted federal legislation mandates insurance coverage of at least 48 hours of postpartum hospitalization, but most mothers and newborns in the United States will continue to go home before the third postpartum day. National guidelines recommend a follow-up visit on the third or fourth postpartum day, but scant evidence exists about whether home or clinic visits are more effective. METHODS: We enrolled 1163 medically and socially low-risk mother-newborn pairs with uncomplicated delivery and randomly assigned them to receive home visits by nurses or pediatric clinic visits by nurse practitioners or physicians on the third or fourth postpartum day. In contrast with the 20-minute pediatric clinic visits, the home visits were longer (median: 70 minutes), included preventive counseling about the home environment, and included a physical examination of the mother. Clinical utilization and costs were studied using computerized databases. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks' postpartum. RESULTS: Comparing the 580 pairs in the home visit group and the 583 pairs in the pediatric clinic visit group, no significant differences occurred in clinical outcomes as measured by maternal or newborn rehospitalization within 10 days postpartum, maternal or newborn urgent clinic visits within 10 days postpartum, or breastfeeding discontinuation or maternal depressive symptoms at the 2-week interview. The same was true for a combined clinical outcome measure indicating whether a mother-newborn pair had any of the above outcomes. In contrast, higher proportions of mothers in the home visit group rated as excellent or very good the preventive advice delivered (80% vs 44%), the provider's skills and abilities (87% vs 63%), the newborn's posthospital care (87% vs 59%), and their own posthospital care (75% vs 47%). On average, a home visit cost $255 and a pediatric clinic visit cost $120. CONCLUSIONS: For low-risk mothers and newborns in this integrated health maintenance organization, home visits compared with pediatric clinic visits on the third or fourth postpartum hospital day were more costly, but were associated with equivalent clinical outcomes and markedly higher maternal satisfaction. This study had limited power to identify group differences in rehospitalization, and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.

Clinical evaluation of a latex agglutination test for streptococcal pharyngitis: performance and impact on treatment rates.

The accuracy and clinical utility of a latex agglutination test were compared with anaerobic throat culture on selective media for detection of Group A streptococcal pharyngitis in an urban pediatric emergency department. Among 255 symptomatic cases prevalence of positive culture was 29% and antigen test sensitivity was 55%. Among 100 asymptomatic controls prevalence of positive culture was 20% and antigen test sensitivity was 20%. Controls with positive cultures and cases with false negative antigen tests had significantly fewer colonies on culture than cases with true positive antigen tests (P less than 0.01). Symptoms and clinical findings were not associated with antigen test result or number of colonies on culture. Eighty percent of patients with positive cultures received treatment when the antigen test was used as an adjunct to culture, compared with a 57% treatment rate among the subgroup in whom follow-up treatment was attempted based on positive culture results alone (P less than 0.05). We conclude that: (1) the antigen test had lower sensitivity in routine clinical use than previously reported; (2) the high rate of false negative tests may result, in part, from a high proportion of specimens with low colony counts; and (3) the availability of the antigen test as an adjunct to culture significantly increased treatment rates.