The findings defy popular assumptions that led the U.S. Congress and 41 states to pass laws requiring insurers to pay for 48-hour hospital stays after normal delivery.
Proponents of the law say that complications in the baby are more likely to be detected this way. Critics argue that any needed health-care services can just as easily and effectively be provided at home.
The American Academy of Pediatrics (AAP) outlines certain "minimum criteria" that need to be met before a newborn is sent home, adding that "it is unlikely that fulfillment of these criteria and conditions can be accomplished in less than 48 hours." Evidence-based recommendations advise examining newborns on the third or fourth day after birth.
In this study, appearing in tomorrow's issue of The New England Journal of Medicine, researchers at the Harvard Medical School/Harvard Pilgrim Health Care Department of Ambulatory Care and Prevention compared health outcomes when an HMO's early-discharge policy was in place, when the state law guaranteeing a 48-hour stay was in place, and when neither was in effect.
The researchers looked at seven-and-a-half years of data involving 20,366 mother-infant pairs with normal vaginal deliveries who had used the Harvard Pilgrim HMO.
Not surprisingly, there were more short-duration stays and more home visits by nurses when the HMO had its reduced-stay program.
After the legislation went into effect, hospital stays got longer and nurse visits declined appreciably. However, the decline, says lead author Jeanne Madden, "was nowhere near as dramatic as the change in the rate of early discharges."
When the reduced-stay program was in place, newborn examinations on the third or fourth day after birth skyrocketed from 24.5 percent to 65.6 percent, then dropped to 53 percent when the legislation was enacted.
Also during the early-discharge program, the number of stays that were less than two nights increased from 29 percent at baseline to 65.6 percent. After the law was passed, the rate plummeted to 13.7 percent.
There were no significant changes in the rate of emergency department visits or readmittance to the hospital.
Interestingly, the HMO didn't save that much money with their reduced-stay policy -- only $90 in per-delivery expenses.
The authors contend that a full accounting of costs might show the program actually lost money.
Health outcomes were the same in all three scenarios when outcomes are measured in terms of emergency visits and readmissions, the authors say. One apparent drawback to the legislation, however, was that examinations of newborns on day three or four of life decreased.
Both the study authors and other researchers caution against extrapolating these findings to other contexts.
"The study is in a very controlled place, the Harvard community health plan, which, as far as HMOs go, is very good. It shows what's possible when things are done right," says Dr. Gwen Wurm, director of community pediatrics at the University of Miami School of Medicine. "We know we can reduce a lot of hospital visits if we do more home visits and have enhanced services. If you have assurances that you're going to get that kind of care, you can follow this model. But often, HMOs take the cheapest component and inflict it on everyone else."
The early discharges were done "cautiously" and on a case-by-case basis, Madden says.
Also, "those who were sent home early had access to a range of outpatient services. My sense is that outpatient services were key in having good outcomes," she says.
"An early-discharge program can be implemented safely, [but] we don't want to generalize to other contexts where they perhaps didn't use all the same prudent measures," she adds.
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