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

OBJECTIVE: Short postpartum stays are common. Current guidelines provide scant guidance on how routine follow-up of newly discharged mother-infant pairs should be performed. We aimed to compare 2 short-term (within 72 hours of discharge) follow-up strategies for low-risk mother-infant pairs with postpartum length of stay (LOS) of <48 hours: home visits by a nurse and hospital-based follow-up anchored in group visits. METHODS: We used a randomized clinical trial design with intention-to-treat analysis in an integrated managed care setting that serves a largely middle class population. Mother-infant pairs that met LOS and risk criteria were randomized to the control arm (hospital-based follow-up) or to the intervention arm (home nurse visit). Clinical utilization and costs were studied using computerized databases and chart review. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks postpartum. RESULTS: During a 17-month period in 1998 to 1999, we enrolled and randomized 1014 mother-infant pairs (506 to the control group and 508 to the intervention group). There were no significant differences between the study groups with respect to maternal age, race, education, household income, parity, previous breastfeeding experience, early initiation of prenatal care, or postpartum LOS. There were no differences with respect to neonatal LOS or Apgar scores. In the control group, 264 mother-infant pairs had an individual visit only, 157 had a group visit only, 64 had both a group and an individual visit, 4 had a home health and a hospital-based follow-up, 13 had no follow-up within 72 hours, and 4 were lost to follow-up. With respect to outcomes within 2 weeks after discharge, there were no significant differences in newborn or maternal hospitalizations or urgent care visits, breastfeeding discontinuation, maternal depressive symptoms, or a combined clinical outcome measure indicating whether a mother-infant pair had any of the above outcomes. However, mothers in the home visit group were more likely than those in the control group to rate multiple aspects of their care as excellent or very good. These included the preventive advice delivered (76% vs 59%) and the skills and abilities of the provider (84% vs 73%). Mothers in the home visit group also gave higher ratings on overall satisfaction with the newborn's posthospital care (71% vs 59%), as well as with their own posthospital care (63% vs 55%). The estimated cost of a postpartum home visit to the mother and the newborn was $265. In contrast, the cost of the hospital-based group visit was $22 per mother-infant pair; the cost of an individual 15-minute visit with a registered nurse was $52; the cost of a 15-minute individual pediatrician visit was $92; and the cost of a 10-minute visit with an obstetrician was $92. CONCLUSIONS: For low-risk mothers and newborns in an integrated managed care organization, home visits compared with hospital-based follow-up and group visits were more costly but achieved comparable clinical outcomes and were associated with higher maternal satisfaction. Neither strategy is associated with significantly greater success at increasing continuation of breastfeeding. 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.

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 outcomes and maternal perceptions of an updated model of perinatal care.

BACKGROUND: Postpartum hospital stays seem likely to remain limited even under new laws which mandate that insurers cover 48-hour hospitalization after uncomplicated delivery. Clinicians, who are increasingly practicing in capitated arrangements, need better information to maximize clinical benefit to mothers and newborns using finite resources. OBJECTIVE AND INTERVENTIONS: This study's aim was to evaluate the clinical outcomes, patient perceptions, and costs of a revised model of perinatal care services. In this model, a new postpartum care center was established for routine follow-up of newborns within 48 hours after hospital discharge, educational efforts were shifted from the postpartum hospitalization to the prenatal period, and lactation consultant hours were increased. DESIGN AND PARTICIPANTS: Controlled, nonrandomized (double cohort) study that compared mothers and newborns with hospital stays of 48 hours or less during the Baseline Care (preintervention) study period (N = 344) with those under the Revised Care (postintervention) study period (N = 456). SETTING: The Hayward, California, medical center of Kaiser Permanente, a nonprofit health maintenance organization. DATA COLLECTION: Telephone interviews were attempted with all mothers 3 weeks after delivery. Data on rehospitalizations, emergency department (ED) and clinic visits, and costs during the first 14 postpartum days were collected from computerized databases and chart review. OUTCOME MEASURES: The combined clinical outcome was defined as any undesirable health event, including rehospitalization, an ED visit, or an urgent clinic visit by either the mother or newborn within the first 14 days postpartum, or breastfeeding discontinuation within the first 21 days postpartum. Maternal satisfaction and costs were also studied. RESULTS: Of 876 attempted interviews, 800 were completed (91%). Analyses were adjusted for age, race, education, parity, breastfeeding experience, and other relevant variables. Among the interviewed mother-newborn pairs, 45% in the Revised Care group experienced the combined clinical outcome, compared with 52% in the Baseline Care group. Newborns in the Revised Care group (29%) were significantly less likely to make urgent clinic visits during the first 14 days of life than those in the Baseline Care group (36%). There were no differences between groups in newborn ED visits or rehospitalizations, maternal clinical outcomes, or breastfeeding continuation. Mothers in the Revised Care group expressed higher satisfaction with the newborn's care, the amount of information they received about newborn care and breastfeeding, and the amount of help they received with breastfeeding. Planned hospital care, planned follow-up visits, and unplanned care costs decreased by $149 per delivery, while the new prenatal class and increased lactation consultant services cost $58 per delivery, for an estimated overall reduction in cost. CONCLUSIONS: We conclude that the revised model of perinatal care in this health maintenance organization medical center improved clinical outcomes and maternal satisfaction for low-risk mothers and newborns without increasing costs.

Follow-up of newborns and their mothers after early hospital discharge.

As postpartum hospital stays have become increasingly shorter, more attention has been focused on the importance of routine postdischarge follow-up for newborns and mothers. Recent guidelines and legislation, however, include few specifics on how follow-up services should be provided. Based on the authors' review of the recent literature, it was concluded that the research to date provides little useful information to guide follow-up practices under current conditions. Additional studies that focus on postdischarge follow-up, rather than on length of hospital stay, are needed to provide the basis for more specific practice guidelines.

Differences in hospital resource allocation among sick newborns according to insurance coverage.

OBJECTIVE: To assess whether newborns' insurance coverage was associated with differences in the allocation of hospital services. DESIGN: Retrospective analysis of computerized hospital discharge data, comparing resource allocation among newborns according to insurance status, controlling for race/ethnicity, diagnoses, hospital characteristics (ownership, teaching status, nursery level), and disposition. SETTING: All California civilian acute-care hospitals. PATIENTS: Population-based sample, excluding out-of-hospital and military hospital births. Resource allocation was studied among all newborns discharged in 1987 with evidence of serious problems (N = 29,751). MAIN OUTCOME MEASURES: Length of stay, total charges, and charges per day. RESULTS: Sick newborns without insurance received fewer inpatient services than comparable privately insured newborns with either indemnity or prepaid coverage. This pattern was observed across all hospital ownership types. Mean stay was 15.7 days for all privately insured newborns (15.6 days for those with indemnity and 15.7 days for those with prepaid coverage), 14.8 days for Medicaid-covered newborns, and 13.2 days for uninsured newborns (P less than .001). Length of stay, total charges, and charges per day were 16%, 28%, and 10% less, respectively, for the uninsured than for all privately insured newborns (P less than .001). Resources for newborns covered by Medicaid were generally greater than for the uninsured and less than for the privately insured. Both uninsured and Medicaid-covered newborns were found to have more severe medical problems than the privately insured. CONCLUSIONS: The findings cannot be explained by differences in medical need or by differences in non-medically indicated services; they constitute prima facie evidence of inequities that need to be addressed by policy changes.

Training physicians for community-oriented primary care in Latin America: model programs in Mexico, Nicaragua, and Costa Rica.

Under the rubrics of preventive and social medicine, public health, and family and community medicine, medical educators in Latin America have developed programs to train physicians for community-oriented health care (COPC). The historical background for such programs in Latin America is reviewed. Three relevant examples of programs in Mexico, Nicaragua, and Costa Rica are highlighted, drawing on the author's direct experience with and in these faculties. The paper addresses the relation between these programs and national and regional trends in education and services.

Health personnel training in the Nicaraguan health system.

The "Unified National Health System" of Nicaragua was established in 1979, in an attempt to transform some of Latin America's worst health indices. This system, based on the stated principles of planning, regionalization, public participation, and primary care, has prioritized the development of health professions training programs appropriate to its special needs and principles. Public Health and Epidemiology training was inaugurated in 1982. A new campus of the School of Medicine was opened in 1981, increasing the number of medical students by a factor of five. Formal residency training (never before available within the country) in primary care specialties has been established. Training for allied health personnel has been formalized in several fields, with the establishment of the Polytechnical Institute of Health. The rapid increase in number and size of training programs has created a tremendous need for educational resources both human and material. This article reviews the status of health personnel training in Nicaragua today, the integration of these programs into planning for the health system, and problems arising from their rapid appearance.

PIP: This article explores the policies and early experiences of the extensive changes in the preparation of health personnel in Nicaragua; massive changes in the health care system were launched after the victory of the Sandinista Revolution in 1979. It reviews the status of health personnel training in the country today, the integration of these programs into planning for the health system, and problems arising their rapid appearance. The Unified National Health System was established in 1979 in an attempt to transform some of Latin America's worst health indices. This system is based on the stated principles of planning, regionalization, public participation, and primary care. To implement these policies, high priority has been given to the development of health professions training programs appropriate to the system's special needs and principles. Public Health and Epidemiology training was inaugurated in 1982. A new campus of the School of Medicine was opened in 1981, increasing the number of meidcal students by a factor of 5. Formal residency training in primary care specialties has been established. Training for allied health professions has been formalized in several fields, with the establishment of the Polytechnical Institute of Health. The rapid increase in number and size of training programs has created a trmendous need for educational resources, both human and material. The greatest constraint in expanding medical education was the lack of qualified teachers. As a solution, the new health system has made public sector employment much more available and attractive; most Nicaraguan physicians today divide their time between public and private practice, and the pressures on voluntary teaching time are heavy. The Health Ministry has developed strategies for making clinical teaching more attractive and prestigious in compensation. Medical curriculum reform since 1979 is designed to turn out doctors capable along 4 lines: clinical service, teaching, administration and research. Special importance is placed on integrated teaching and service. These multiple objectives are built into the teaching program from the very beginning. To date there are 6 schools of nursing in the country (4 before 1979), with 5 times the pre-1979 enrollment. Nicaragua has made a deliberate decision not to train mid-level medical workers. However, volunteer health personnel, the Brigadistas, have played a definite role in Nicaraguan communities. They concentrate on public education and mobilize the people for immunization and sanitation campaigns. Additionally, traditional birth attendants in rural areas have been recognised by the Health Ministry and been given training to upgrade their performance. Much in the new System has emulated policies of Cuba, especially the emphasis on public education, models for personnel training and community-oriented primary care.