"The study tends to refute the premise that reduced maternity length of stay is harmful to infants and that state laws against early discharge would improve health outcomes," said lead author Jeanne M. Madden, PhD, a research fellow in the Department of Ambulatory Care and Prevention.
The study, which appears in the Dec. 19, 2002 New England Journal of Medicine, could add a new dimension to current policy debates about appropriate ways to regulate health care and about the trade-offs among recommended clinical services at key points in a newborn's development.
Madden and colleagues at the Department of Ambulatory Care and Prevention and Children's Hospital Boston used seven and half years of data on 20,366 mother-infant pairs with normal vaginal deliveries within a large Massachusetts health maintenance organization to determine the effects of reductions by the HMO in the postpartum length of stay and a subsequent state law establishing a minimum stay. The investigators measured the effects on lengths of hospital stay, follow-up care for newborns, use of outpatient care and hospital-based services during the first 10 days of life, and expenditures for hospital and home-based maternity services.
"To our knowledge, this is the best-controlled investigation to date comparing different maternity discharge policies, and the first comprehensive study of the impact of legislation guaranteeing minimum stays," said Stephen Soumerai, ScD, professor and principal investigator of the study at the Department of Ambulatory Care and Prevention.
Regardless of hospital length of stay, evidence-based recommendations in the clinical literature advise examining newborns on the third or fourth day after birth, when common problems such as jaundice and breastfeeding difficulties tend to peak. The Harvard Medical School study found the rate of newborn examinations on the third or fourth day after birth increased from 24.5 percent to 65.6 percent after the HMO initiated a reduced-stay program, but dropped to 53.0 percent following the state's minimum length of stay mandate, which established no follow-up care schedule. "These changes primarily reflect changes in the rate of home visits," said lead author Madden.
Although the rate of nonurgent visits to a health care center increased from 33.4 percent to 44.7 percent after the reduced-stay program was implemented, the study found no significant changes in the rate of emergency department visits or rehospitalizations.
"Several studies have suggested that short stays are associated with an increased risk of death or readmission of the infant, whereas others have found no effect," Madden said. "In the setting we studied, we found neither policy appeared to affect the health outcomes of newborns. But after coverage for longer stays was guaranteed by law, newborns were less likely to be examined as recommended on day 3 or 4."
Also flying in the face of popular assumptions, the study found the health plan's average per-delivery expenses decreased only $90 when it began its reduced postpartum length of stay policy.
"Added home services and shifts in prices for hospitalization were the factors which combined to thwart expected savings," Madden said.
Funding for this study was provided by the Agency for Healthcare Research and Quality, the Harvard Pilgrim Health Care Foundation, and the Maternal and Child Health Bureau. The patients in the study were members of Harvard Community Health Plan (now Harvard Pilgrim Health Care, a not-for-profit health plan), and were cared for at Harvard Community Health Plan's health centers, which have since reorganized as Harvard Vanguard Medical Associates, a self-governed, multi-specialty group practice.
Harvard Medical School has more than 5,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 17 affiliated teaching hospitals and research institutes. Those HMS affiliated institutions include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Hospital, Center for Blood Research, Children's Hospital, Dana-Farber Cancer Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Massachusetts Mental Health Center, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, VA Boston Healthcare System.
Journal
New England Journal of Medicine