Since 1995, the U.S. Congress and more than 40 States have passed legislation aimed at discouraging early discharge of newborns, which was thought to negatively affect their health. However, a new study supported in part by the Agency for Healthcare Research and Quality (HS10060) suggests that newborn jaundice (hyperbilirubinemia) and infant feeding problems are not associated with short hospital stay, as long as infants are evaluated when they are 3 or 4 days old when these problems typically surface.
Stephen B. Soumerai, Sc.D., of Harvard Medical School, and his colleagues retrospectively analyzed the medical records of a large Massachusetts health maintenance organization (HMO) for infants born between October 1990 and March 1998 among 20,366 mother-infant pairs with uncomplicated vaginal deliveries. They compared several infant outcomes after the 1994 implementation of an HMO protocol—calling for a 1-night stay following uncomplicated vaginal delivery plus a nurse home visit within 48 hours of discharge—with the same outcomes after passage in 1996 of Massachusetts' 48-hour minimum stay mandate.
Jaundice diagnoses were flat at 8 percent of newborns at baseline and rose to a constant 11 percent throughout the HMO protocol and post-mandate periods. Diagnoses of feeding problems more than doubled at the time of HMO protocol implementation, yet they remained elevated after the mandate. These increases in jaundice and feeding problems seemed to be the result of more frequent evaluation of newborns during the critical day-3 to day-4 period.
Rates of outpatient bilirubin testing, severity of test results, phototherapy use for jaundice, diagnosis of feeding problems, and emergency department visits all experienced increases that began with the HMO program implementation and lasted well past the legislative mandate that followed. These changes closely aligned with rates of followup evaluation on day 3 or 4. Therefore, heightened vigilance rather than decreased length of stay is the most likely explanation for the change in outcomes.
See "Length-of-stay policies and ascertainment of postdischarge problems in newborns," by Jeanne M. Madden, Ph.D., Dr. Soumerai, Tracy A. Lieu, M.D., M.P.H., and others, in the January 2004 Pediatrics 113(1), pp. 42-49.
Editor's Note: Another AHRQ-supported study on a related topic shows how a single change around early discharge can disrupt existing patterns of care for newborn jaundice in unforeseen ways. For more details, see Palmer, R.H., Clanton, M. Ezhuthachan, S., and others (2003, December). "Applying the '10 simple rules' of the Institute of Medicine to management of hyperbilirubinemia in newborns" (AHRQ grant HS09782). Pediatrics 112(6), pp. 1388-1393.
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