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Reuters Health Information (2004-01-12): Ascertainment policy, not early discharge, tied to increase in neonatal jaundice

Public Health

Ascertainment policy, not early discharge, tied to increase in neonatal jaundice

Last Updated: 2004-01-12 10:41:58 -0400 (Reuters Health)

NEW YORK (Reuters Health) - The former managed care policy of sending most mothers and newborns home less than two days after delivery does not appear to have caused a spike in infant jaundice and feeding problems, Harvard researchers report.

Early discharges were common in the 1990s in the U.S., as managed care plans tried to curb costs. By the late 90s, however, public reaction had moved Congress and most states to pass minimum-stay laws guaranteeing that insurance plans would cover 48 hours of hospital care after delivery.

Still, whether early-discharge policies had ill effects on newborn health -- and whether minimum-stay laws have had health benefits -- remains unclear.

A new study, reported in the January issue of Pediatrics, looked at nearly 20,400 mother-infant pairs covered by one large Massachusetts HMO between 1990 and 1998. In 1994, the health plan started a policy under which most women with uncomplicated deliveries were sent home with their babies after only one overnight hospital stay. The policy was ended in 1996 when Massachusetts passed its minimum-stay law.

Researchers found that although jaundice and feeding difficulties rose during the HMO's early-discharge policy, they remained elevated after the state law was passed.

In the 4 years before the early-discharge policy, jaundice diagnoses remained steady at about 8% of newborns, then increased to 11% during the policy, and remained there after the law.

Similarly, feeding problems -- mainly difficulties with breastfeeding -- more than doubled after the policy was launched, then remained elevated after the law took hold.

According to the study authors, better detection of these complications -- due, in part, to the design of the early-discharge policy -- seem to explain the increase. Under the HMO's policy, mothers and infants who were discharged less than two days after delivery received a home visit from a nurse when the baby was 3 or 4 days old.

It's this visit that was probably key, since jaundice and feeding problems peak around the third or fourth day of life, lead author Dr. Jeanne M. Madden told Reuters Health.

"I suspect the most important thing...was the home visits," said Dr. Madden, of Harvard Medical School and Harvard Pilgrim Health Care, the HMO that covered the women in the study.

Other likely contributing factors include two national guidelines on newborn care issued around the time of the HMO policy -- one on hospital stays after delivery, and one on jaundice management -- according to Dr. Madden's team. The researchers say these factors created lasting changes in newborn care that kept diagnoses of jaundice and feeding problems elevated after the minimum-stay law went into effect.

Dr. Madden noted that even after the law, many women in the HMO still received a home visit on day three or four, since the law mandated coverage of a home visit if a woman chose to stay in the hospital for less than 48 hours.

Dr. Madden said the new findings add to earlier evidence that the early-discharge policy was instituted safely. Using the same study population, she and her colleagues had previously found that newborns who stayed in the hospital for one night were no more likely than those kept two nights to be rehospitalized or visit the emergency department in their first 10 days of life.

Pediatrics 2004;113:42-49.

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