 |
|
 |
|
 |
 |
|
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PEDIATRICS Vol. 108 No. 3 September 2001, pp. 719-727
,
, and
From * Kaiser Permanente Medical Care Program Perinatal Research
Unit Division of Research, Oakland, California; 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.
Kaiser Permanente
Medical Center Department of Pediatrics, Walnut Creek, California;
§ Department of Family and Community Medicine University of California,
San Francisco, San Francisco, California; Kaiser Permanente Medical
Center Department of Pediatrics, Santa Clara, California; and
¶ Department of Ambulatory Care and Prevention Harvard Pilgrim Health
Care and Harvard Medical School, Boston, Massachusetts.
ABSTRACT
Top
Abstract
Methods
Results
Discussion
Conclusion
References
Recently enacted federal legislation mandates insurance
coverage of at least 48 hours of hospitalization after uncomplicated delivery of a newborn.1 In California, new legislation also mandates insurance coverage for maternal and neonatal follow-up visits within 48 hours if the postpartum hospital stay was <48 hours.
Although the legislation's passage removed the political spotlight
from postpartum care, important gaps in clinical knowledge remain.
National guidelines focus primarily on the prevention of catastrophic
morbidity (eg, severe hyperbilirubinemia, dehydration).2 They provide far less guidance on how, where, and by whom routine follow-up of newly discharged mother-infant pairs should be performed to achieve optimal health outcomes.3-6
One potentially promising approach to providing postpartum follow-up of
low-risk mother-infant pairs is to offer visits to groups of mothers
and their infants. Although the concept of group (or "cluster")
visits in medicine may be gaining popularity because such visits are
considered less expensive,7 use of this strategy antedates
the current cost-conscious era.8 In pediatrics, the major
reason for advocating group visits has been a concern with the limited
amount of information transmitted in routine, one-on-one
interchanges.9,10 Because a group visit permits more time
for patients to absorb information, it is theoretically advantageous
for handling situations in which the educational needs of a group of
patients are similar. Consequently, group visits have been advocated
for various populations, including those who have
diabetes,7 those who are obese,11 older
people with chronic illnesses,12 and the parents of
pediatric patients who require anticipatory guidance.13
Past studies have evaluated the effectiveness of home visits for
postpartum follow-up, usually in comparison with extended hospitalization or outpatient clinic visits.14-19 However, we are unaware of any randomized studies that have compared group visits with home visits for postpartum follow-up. In 1996, the
Department of Pediatrics at the Kaiser Permanente Medical Center in
Santa Clara, California, implemented an innovative hospital-based program and changed its standard of care, offering group visits as
routine postpartum follow-up. Taking advantage of the experience that
we acquired in 2 recent studies,14,20 we compared this
model with the use of home visits using a randomized, controlled trial
study design. As was the case in our first trial, the population of
interest consisted of low-risk mothers and newborns with postpartum
hospital stays of 48 hours or less.
Study Population
The target population consisted of low-risk mothers and newborns
who delivered at the Kaiser Foundation Hospital in Santa Clara,
California, during July 1998 through November 1999. All of these
infants are cared for by the same Department of Pediatrics, which
provides care at the Santa Clara, Mountain View, Marina Playa, and
Milpitas clinics. Low-risk newborns whose families planned to seek
follow-up care at these clinics were eligible. Mothers and newborns
were excluded if they lived outside the Kaiser Permanente Medical Care
Program (KPMCP) Santa Clara Home Health service area. Eligibility was
restricted to those mother-infant pairs whose hospital length of stay
(LOS) was expected to be 48 hours or less based on the hospital's
clinical protocol for selecting mothers and newborns at low medical and
social risk. This protocol is based on the guidelines published by the
American Academy of Pediatrics and American College of Obstetricians
and Gynecologists.21
We excluded mother-infant pairs for medical reasons if the infant
weighed <2500 or >4600 g at birth, was <36 or >42 weeks' gestation, or was admitted to the intensive care nursery or if the
mother or the infant had a medical problem that warranted special
follow-up by a pediatrician or a nurse practitioner. By clinical
protocol, pediatricians ordered complete blood counts only for newborns
with medical problems (eg, "rule out sepsis"). Newborns with a
hematocrit of <40 or an absolute neutrophil count of <7000 at any
time were ineligible for this study. We excluded mothers and newborns
whose anticipated LOS was >48 hours, usually because of cesarean
delivery.
We excluded potential patients for social reasons: if the mother was 14 years old or younger; was 15 to 17 years old without a parent or a
guardian available for informed consent; had a positive toxicology
screen for drugs of abuse after admission to labor and delivery; or if
a social worker had requested, before eligibility assessment for the
study, that a home visit be done. We also excluded pairs of patients if
the mother did not speak English; the newborn did not have Kaiser
Foundation Health Plan, Inc, coverage or was being adopted; or if the
family lived outside the area served by the home health nurses, was not
reachable by telephone, or was in the process of moving. For those
mother-infant pairs with multiple reasons for exclusion, we recorded
only the first reason for exclusion on a hierarchically ordered list of
exclusions.
The study was approved by the Kaiser Permanente Institutional Review
Board for the Protection of Human Subjects. Written informed consent
was obtained from all study subjects.
Hospital-Based Follow-up at the KPMCP Santa Clara Medical Center
Unless an infant is considered to be at high risk, first-time
mothers at the KPMCP Santa Clara Medical Center are offered a package
of services within 72 hours after discharge. These services are
referred to as "the Newborn Club" and include group visits, one-on-one clinic visits, breastfeeding consultation, and prompt access
to a neonatologist if necessary. The Newborn Club originally was funded
as a demonstration project by the Kaiser Permanente Innovation Program
to foster breastfeeding and to decrease short-term (within 2 weeks of
birth) neonatal morbidity.22 Subsequently, the Santa Clara
Medical Center elected to continue funding this program, making it the
standard of care. This decision was based in part on the results of the
Innovation project and on the experience of two other KPMCP facilities
(Redwood City and Walnut Creek), which had used this approach for
infant well-child visits and lactation counseling.
The Newborn Club, located at the Santa Clara facility, operates 7 days
a week and focuses on the needs of first-time mothers. However, all
women who are served by the Department of Pediatrics are given the
option to participate in the group visit, which consists of a
11/2- to 2-hour session that focuses on the newborn. Limited
time is spent on maternal topics. Postpartum care or physical examination of the mother is not provided, although mothers may be
referred to the Obstetrics and Gynecology clinic if necessary. Up to 8 mother-infant pairs can attend each session, although typical sessions
involve 5 to 6 pairs. Sessions are led by a registered nurse who also
is a certified lactation educator.
Physical assessment of the newborn occurs during the first 10 to 15 minutes of the group visit. The nurse weighs the infant and performs a
partial physical examination that emphasizes checking the following:
color, turgor, tone, condition of cord, head, fontanel, presence of eye
drainage or clavicle fracture, any obvious deformities, and strength
and quality of suck. If serious abnormalities are found, then the
on-call neonatologist is paged immediately. For mild degrees of
jaundice, the Newborn Club nurse notifies the on-call neonatologist and
may order a serum bilirubin test. Home phototherapy is available at the
neonatologist's discretion. The remaining time is spent on
breastfeeding and basic infant care (eg, taking a temperature, when to
call the advice nurse), preventive education, and anticipatory
guidance. Women are instructed to nurse 8 to 12 times in 24 hours for
10 to 15 minutes per breast. The number of minutes per breast is an
average and depends on the infant's weight and other characteristics.
Whether the infant is receiving adequate nourishment also is reviewed
(by recounting an individual infant's recent breastfeeding frequency
and having parents count the number of wet diapers). Women with
breastfeeding problems usually stay an additional 10 to 15 minutes
after the group visit to discuss their specific concerns.
Women who have had a previous child may opt to have a 15-minute
individual provider visit at the Newborn Club rather than the group
visit. Women who have many children may elect to have telephone
follow-up only, although the latter option rarely is exercised. Some
multiparous women elect to attend the group visit if they did not
breastfeed their previous infant or to have their partners learn about
infant care and breastfeeding.
Enrollment and Interventions
Seven days a week, research nurses on the postpartum hospital
floor reviewed charts and approached eligible mothers whose discharge
was anticipated that day. To minimize any potential effects of study
participation on the mother's LOS, the research nurses attempted to
enroll mothers after the decision to discharge them had been made. For
each enrolled mother, the research nurse completed informed consent and
a baseline interview, then assigned the mother-infant pair to either
hospital-based follow-up (the Newborn Club) or to a home health visit
using a series of sealed, opaque, sequentially numbered envelopes
containing study group assignments determined in advance by a random
number generator. Once randomized, the mother-infant pair was included
in all analyses in the group to which they initially were assigned,
regardless of actual care received.
We assigned each newborn in the control group to usual hospital-based
follow-up care. We assigned each mother-infant pair in the
intervention group to a home health visit within 48 hours after
hospital discharge by a registered nurse from the KPMCP Home Health
department. The month before the study, the home health nurses were
given 20 hours of didactic instruction and 2-week-long preceptorships
in breastfeeding instruction, newborn and maternal history and physical
examination, and postpartum anticipatory guidance. The clinical
protocol and a standardized charting form specified the recommended
elements of history, physical examination, and anticipatory guidance
for the home visits, which were intended to last 60 to 90 minutes.
The home visit protocol was based on recommendations in Bright Futures,
a national guideline document for preventive maternal and child health
care,23 and included the following elements: 1) a general
assessment of the home environment and mother-infant interaction; 2)
obtaining a history and conducting a focused physical examination of
both the newborn (to assess for signs of dehydration or jaundice) and
the mother (which included examining the breasts, fundus, and
perineum); 3) weighing the infant; 4) assessing feeding of the infant,
using the LATCH score24 if appropriate; 5) providing
instruction on infant care, infant feeding, maternal physical care, and
maternal emotional changes; and 6) when necessary, drawing blood for
bilirubin testing and arranging for follow-up of test results,
including discussing results with the on-call neonatologist.
Data Collection
Research nurses used chart review and the enrollment interview
on the postpartum floor to collect baseline data on clinical and
demographic variables, as well as on maternal experiences and
perceptions about prenatal care and breastfeeding. At 2 weeks postpartum, a research interviewer contacted each mother by telephone to conduct a 15-minute interview about breastfeeding, other outcomes (eg, maternal depressive symptoms), and satisfaction with care received. Information on race/ethnicity was obtained from the KPMCP
hospitalization database, which categorizes self-reported race/ethnicity according to the standard scheme used in California birth certificates. For analysis, respondents were classed as white
(non-Hispanic), black, Hispanic, Asian/Pacific Islander, or other race.
The Center for Epidemiologic Studies Depression Scale, a widely used
20-item instrument that has been validated in English and in Spanish,
was used to evaluate maternal depressive symptoms. A cutoff score of 16 or more was considered to indicate the presence of a significant level
of depressive symptoms.25,26 Questions on satisfaction
with care were modified from a validated instrument developed for the
Group Health Association of America.14,27
Clinic visits, emergency department visits, and hospitalizations were
identified from KPMCP computerized databases using techniques that we
have described elsewhere.28-35 The average regional costs
of these services were derived using the KPMCP's computerized Cost
Management Information System, which estimates the costs of each unit
of service (eg, a 10-minute urgent clinic visit) using standard
"step-down" accounting methods. Personnel time, supply costs, and
administrative overhead are factored into the cost of each unit of
service. The cost of home health visits was estimated on the basis of
personnel time, mileage, space, administration, and overhead costs
using methods similar to those used in the Cost Management Information
System.
Outcome Measures
The primary study outcome was a combined clinical outcome
measure that was considered present if either the mother or the newborn
experienced any of the following: 1) rehospitalization, emergency
department use, or urgent clinic visit use within 10 days after
delivery; 2) occurrence of maternal depressive symptoms as documented
by a telephone interview 2 weeks after delivery; and/or 3)
discontinuation of breastfeeding as documented by a telephone interview
2 weeks after delivery. We searched KPMCP computerized databases, which
use a common medical record number across the continuum of care, to
identify rehospitalization, emergency department visits, and urgent
clinic visits by the mother or the newborn during the 10 days after
delivery. The 2-week interview contributed information on
breastfeeding discontinuation and maternal depressive symptoms.
Maternal satisfaction was assessed using questions from the
aforementioned instrument on consumer satisfaction.
Widely accepted severity scoring systems for rehospitalized newborns do
not exist. Consequently, one of us (G.J.E.), who practices general
pediatrics and neonatology and who was kept blinded to group
assignment, reviewed all rehospitalizations using objective criteria.
For example, with respect to newborns who were readmitted with feeding
difficulties and/or jaundice, the degree of weight loss, highest serum
sodium (if obtained), highest total serum bilirubin (if obtained),
presence of significant neurologic signs, and total LOS were compared.
Similarly, for newborns who were readmitted to "rule out sepsis,"
maternal risk factors (eg, length of rupture of membranes, intrapartum
antibiotic treatment) were assessed, and it was determined whether a
positive culture was present or other confirmation of the presence of
infection existed. Blinded review included both the birth
hospitalization records and the rehospitalization records to determine
whether the infant's illness might have been due to a problem that
could have been detected or prevented during the birth hospitalization
(eg, in the case of a newborn with reflux, was the infant feeding
normally at time of discharge?). Maternal rehospitalizations were
reviewed in a similar manner and in consultation with an adult
cardiologist and an obstetrician, who also were blinded to group
assignment.
Statistical Methods
With 500 people in each treatment group, we would have more than
85% power to detect a difference of 10% in the rate of the combined
outcome, assuming that the rate in 1 of the 2 groups was 50%, the type
I error rate was 5%, and a Study Population
Of the 4295 deliveries at the KPMCP Medical Center in Santa Clara
during the study period, 2547 met exclusion criteria. We excluded 1349 for the previously mentioned medical risk factors (eg, 795 women who
had a cesarean section). An additional 96 women were ineligible because
of social risk criteria; 493 because they lived outside the home health
service area; 463 because the mother did not speak English; 9 for
logistic reasons (eg, not having a telephone, planning to move out of
the area); and 137 for other reasons. Among the 1748 eligible mothers,
235 were not approached (usually because the mother was discharged
before a research nurse could contact her) and 499 declined to
participate, leaving 1014 women who were randomized. Of the 499 women
who declined to participate, 397 agreed to answer a limited set of
questions. Women who declined to enroll did not differ from enrollees
with respect to age, race/ethnicity, education, time of initiation of
prenatal care, parity, infant's birth weight, Apgar scores, or LOS.
Women who were not approached had infants with significantly lower LOS
(mean ± SD: 28.3 ± 10.2 hours) than the enrollees
(32.3 ± 10.4 hours; P < .001); however, they did
not differ from enrollees with respect to age, race, parity, infant's
birth weight, Apgar scores, or LOS (Fig
1).
METHODS
Top
Abstract
Methods
Results
Discussion
Conclusion
References
2 test was used.
All analyses were conducted using intention-to-treat (ie, women were
analyzed as being members of the group to which they were randomized
regardless of whether they actually received the treatment to which
they were assigned). Comparisons between the 2 groups were made using
2 tests for categorical variables, 2-sample
t tests for continuous variables, or Wilcoxon rank sum tests
for ordinal variables.
RESULTS
Top
Abstract
Methods
Results
Discussion
Conclusion
References
View larger version (43K):
[in a new window]
Fig. 1.
Patient flow in randomized trial of home visits (intervention) versus
hospital-based follow-up visits (control) after early postpartum
hospital discharge. Note that 397 women who refused randomization did
agree to participate in a telephone interview.
Among enrolled mother-infant pairs, 508 were randomized to home health visits and 506 to hospital-based follow-up. Among those randomized to a home health visit, 96% actually received a home visit and 4% received hospital-based follow-up care (Fig 1). An additional 75 of 508 (15%) mothers who were assigned to the home health group received hospital as well as home-based follow-up care. Only 1 infant in the home health group did not receive follow-up within 72 hours of discharge; none were lost to follow-up. Among those who were randomized to hospital-based care, 264 mother-infant pairs had an individual visit, 157 had a group visit, 64 had both a group and an individual visit, 4 had a home health visit and hospital-based follow-up, 13 did not have follow-up within 72 hours, and 4 were lost to follow-up. Table 1 shows that there were no significant differences between the study groups with respect to maternal age, race, education, household income, parity, previous breastfeeding experience, timing of initiation of prenatal care, and LOS. There were no differences with respect to neonatal LOS or Apgar scores.
|
Clinical Outcomes
Table 2 shows data regarding clinical outcomes for the mother-infant pairs. No significant differences occurred between the 2 study groups with respect to maternal urgent visits, neonatal urgent visits, maternal rehospitalization, or neonatal rehospitalization. The 2-week interview was completed with 96% of enrolled mothers. There were no significant differences with respect to breastfeeding discontinuation or the occurrence of maternal depressive symptoms. Similar proportions (49% vs 48%; P = .8; Table 2) experienced the combined clinical outcome measure, which was scored as positive if either the mother or the newborn had any of the above outcomes. The home health and hospital-based follow-up neonatal visit groups did not differ in the proportion of mothers who made any calls to the pediatric advice nurse during the first 2 weeks (55% vs 53%) or in the number of calls that the mothers made.
|
With 1 exception (maternal urgent care visits), clinical outcomes among mother-infant pairs in the hospital-based care group did not differ between those who had individual and those who had group visits (data available on request). In the hospital-based follow-up group, the rate of maternal urgent clinic visits was 18.8% among those who had a group visit and 10.2% among those who had an individual visit (P < .01).
In the hospital-based follow-up group, 81.3% of first-time mothers attended the group visit. In contrast, among the experienced mothers in the hospital-based follow-up group, only 12.7% attended the group visit; 83.7% made an individual visit.
Rehospitalizations Within 10 Days After Discharge
We compared the 2 study groups with respect to rehospitalization within 10 days after discharge. In the intervention group, a total of 9 of 508 infants were rehospitalized, whereas 5 of 506 of the hospital-based care infants where rehospitalized. This difference was not significant (P = .29). None of the 14 newborns who were rehospitalized had a severe illness (eg, requiring surgery or assisted ventilation), and none had evidence of neurologic problems at the time of discharge from the rehospitalization. None of the infections were judged to have been preventable by prolonging the birth hospitalization LOS or by postnatal follow-up care. In the intervention group, mean rehospitalization LOS was 79 hours (range: 23 to 317 hours). In the hospital-based follow-up group, mean rehospitalization LOS was 53 hours (range: 29 to 87 hours). There were 3 mothers who were hospitalized, 2 in the home health group and 1 in the hospital-based care group. In the home health group, 1 mother was hospitalized briefly because of spinal headache and 1 because of new onset of atrial flutter. In the hospital-based care group, 1 mother was hospitalized because she developed endometritis. None of these maternal hospitalizations were judged to have been preventable by prolonging the birth hospitalization LOS or by postnatal follow-up care.
Mothers in the home visit group were more likely than those in the hospital-based care group to rate multiple aspects of their care as excellent or very good (Table 3). We also compared maternal satisfaction according to type of care received (group visits vs individual provider visits) in the hospital-based care group. In general, women who attended the group visits were more satisfied with their care than those who had individual provider visits.
|
The estimated cost of a postpartum home visit to the mother and 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, and the cost of a 15-minute individual pediatrician visit was $92. Because the hospital-based visits did not formally address the medical needs of the mother, we also evaluated the cost of a 10-minute visit to the obstetric-gynecologic clinic; this also was estimated at $92.
Subgroup Analyses
We conducted analyses limited to subgroups with demographic risk factors, including first-time mothers, first-time breastfeeders, mothers with less than a high school degree, families with household income <$40 000, nonwhite mothers, teenage mothers, mother-infant pairs with postpartum hospitalization of 24 hours or less, and mothers with their first prenatal care visit after the first trimester. There were no significant differences found in these subgroup analyses. Breastfeeding discontinuation among first-time breastfeeders did not differ between the home visit and hospital-based follow-up groups (22% vs 19%; P = .39).
Patient Satisfaction Among Mothers Who Refused Enrollment
Table 4 shows patient satisfaction results among 397 mothers who refused enrollment and compares them with results among the home health group as well as the hospital-based follow-up group. In general, mothers who refused enrollment had satisfaction ratings that were very similar to those of the hospital-based follow-up group. The only exceptions to this were with respect to skills and abilities of the provider and with the availability of services/equipment, for which mothers in the hospital-based care group were more satisfied with their care than those who refused enrollment. Mothers who enrolled in the study were more satisfied with all aspects of their care than those who refused enrollment.
|
| |
DISCUSSION |
|---|
|
Top
Abstract
Methods
Results
Discussion
Conclusion
References
|
|---|
We found that group postnatal visits and home visits achieved equivalent clinical outcomes. However, group visits had far lower costs, whereas home visits had markedly higher maternal satisfaction.
Although cost may be a strong impetus for the adoption of group visits, patient satisfaction and choice also are appropriate drivers of decisions about postpartum services. Health care providers may choose to make home visits available despite their higher cost, especially when they view women of childbearing age as an important group to attract and retain. Within KPMCP's Northern California region, early postpartum follow-up visits have been offered by all medical centers since 1995, but there is wide variation in whether such visits are offered in the home, hospital, or pediatric clinic setting, as well as whether they are individual or group visits. This study, like our previous comparison of home visits with pediatric clinic visits in Sacramento, suggests that such variation likely has not resulted in variation in health outcomes.
Our study differs from previous work in this area in several important ways. First, it was conducted after the implementation of federal and state laws mandating insurance coverage of up to 48-hour hospital stays after uncomplicated delivery. We are not aware of any other randomized trials that have addressed postnatal or postpartum care after uncomplicated deliveries conducted after the aforementioned legislation. In fact, we are not aware of any rigorously designed randomized studies of early postpartum care for well newborns after uncomplicated vaginal delivery since the 1980s, and all of these used multiple home visits rather than the single visit in this study.16,17,36,37 This study also is unique in that it specifically addresses services provided after short stays. We are not aware of other controlled studies since the legislation took effect that focus on services after short stays (rather than focusing primarily on LOS). Finally, other studies of group visits have assigned patients to either group or traditional one-on-one visits.9,38 In this study, group visits were part of hospital-based follow-up, but mothers had the option of attending a group visit, an individual visit, or both.
It is important to note the relevance of our study for another reason, namely, that short postpartum LOSs are likely to remain common. Although LOSs may have increased as a result of the legislation,39 large numbers of newborns still are going home after stays of <48 hours. Recent data from a statewide, population-based survey in California showed that in 1999, 44.2% of vaginally delivered healthy term newborns had stays of 0-1 nights (A. Galbraith, University of California, San Francisco, personal communication, March 2, 2001). Hospital stays of <48 hours after normal vaginal delivery of <48 hours are likely to remain common in the United States, and it is likely, therefore, that improvements in postpartum services will focus on postdischarge services.5
First-time mothers in this study generally chose the group visits, and experienced mothers chose the individual visit. Newborn Club staff believed that experienced mothers chose individual visits because they no longer felt the need to get all of the information provided in group visits. However, not all experienced mothers requested individual visits with a physician but often requested individual visits with the Newborn Club nurse, with whom they may have established a relationship after the birth of a previous child. Thus, our observations reflect a situation in which individuals are allowed to self-select the service that they believe best fits their needs. This is a realistic situation in that clinicians in the KPMCP and elsewhere believe that attending a group visit rather than an individual visit should be optional.40 It seems likely that other health plans also would emphasize giving their members similar options.
Limitations
It is important to keep in mind that our study focused on a socioeconomically low-risk population in an integrated health care setting. More than two thirds of the mothers had at least some college education, more than 90% had a high school degree, and the majority had annual household incomes of >$60 000. Furthermore, the KMPCP has an unusually high degree of integration between hospital and outpatient services, and the mothers in this study had ready access to multiple services. These included telephone advice nurses and urgent care clinics that may play a significant role in keeping rates of adverse outcomes low. Although our population was ethnically diverse, our results cannot necessarily be generalized to more socioeconomically disadvantaged populations, to families who receive care in less integrated settings, or to settings in which screening for risk is less careful. Additional research involving such populations and settings is needed. Furthermore, we did not test an arm with no follow-up care because our previous work20,41,42 and national guidelines43 suggest that failing to provide follow-up visits is bad clinical practice. We have heard anecdotal reports that many mothers and newborns in the United States are not receiving early postpartum follow-up. The consequences of this practice should be studied, and appropriate action should be taken.
The study's sample size had better than 85% power to identify a
relative difference of 10% in the combined outcome measure between
groups, but it had more limited power to identify differences between
subgroups. It had only 6% power to detect a 20% relative difference
in newborn rehospitalization rates. It has far less power to detect
differences for more rare outcomes such as severe dehydration, which
has an incidence of 2.6 per 1000 live births, or severe
hyperbilirubinemia (total serum bilirubin 
24.9 mg/dL), which has an
incidence of 1.4 per 1000 live births.44,45 To detect a
20% relative reduction in a newborn rehospitalization rate of 2% with
80% power, more than 17 000 newborns would be needed in each group.
Our ability to gauge patient satisfaction suffers from some limitations as well. Many mothers did not respond to all questions reported in Tables 3 and 4, raising the question of whether they may not have understood some of the questions.
Future Research
It is both disappointing and discouraging that breastfeeding discontinuation was high in both arms of this trial, a result similar to what we found in our previous 2 studies.14,20 This suggests that to improve breastfeeding rates, future studies should not focus simply on the type of any single postpartum visit; rather, it may be more useful to study what knowledge mothers actually absorb in any given educational context, how this knowledge is applied, and how much one can expect from a single encounter. Reisinger and Bires10 showed that the amount of time that pediatricians devote to individual anticipatory guidance topics is brief, often lasting only a few seconds. Group visits may have a distinct advantage over one-on-one visits because they give mothers more time to absorb and discuss information. However, serial group visits, as suggested by Taylor et al,46 may have stronger effects than the single group that visit we studied here.
| |
CONCLUSION |
|---|
|
Top
Abstract
Methods
Results
Discussion
Conclusion
References
|
|---|
For low-risk mothers and newborns in this integrated health maintenance organization, group visits and home visits on the third or fourth postpartum hospital day had equivalent clinical outcomes. Group visits were less costly than home visits but were associated with lower maternal satisfaction. For home visits, the value of increased maternal satisfaction will need to be weighed against their additional cost. Decisions among alternative postpartum follow-up services ideally should incorporate the perspectives of all parties in these decisions, including clinicians, insurers, and the mothers and families themselves. Future research also must explore the limited effectiveness of current strategies with respect to desirable outcomes such as continuation of breastfeeding.
| |
ACKNOWLEDGMENTS |
|---|
This project was supported by Grant MCJ #R40 MC 0010303 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services; Grant #9003 from the Sidney Garfield Memorial Fund; Grant #970005 from the Innovation Program of The Permanente Medical Group, Inc.; and Grant #1998-6861 from the David and Lucile Packard Foundation's Center for the Future of Children.
We thank Susan Egerter, PhD, and Kristen Marchi, MPH, of the Department of Family and Community Medicine at the University of California, San Francisco, for their thoughtful advice on the design and interpretation of this study. We greatly appreciate the efforts of Nancy G. Jensvold, MPH, during the initiation of this project and the study nurses (Kim Banks, RN; Rosemary Eddington, RN; Eileen Fulk, RN; and Linda Hoeber, RN) and interviewers (Julie Holsopple, Regina Mason, Nydia Medina, Diana Reiss-Koncar, and Ayawnna Smith). The study could not have succeeded without the generous assistance received from the Kaiser Permanente Santa Clara Home Health department and nurses (Jeanne Davis, RN, MS; Bing Tenorio, RN; Vickie Johnson, RN; Fran Koperniak; Faith Blicharz, RN; Sandra Skoda; Vanette Braddock, RN; Deseree Arcangel-Primo; Angeles Cayabyab, RN; Nancy Cullen; Jane DeMaestri, RN; Bev Curry; Yilei Hsu, RN; Julie Vaday; Susan Lee, RN; Jennifer Lu, RN; and Mary Lou Serrano, RN) and from the staff of the Kaiser Permanente Santa Clara Newborn Club (Leslie Krauss, RN; Kim Gilderoy; Claire Langdon, RN; Mikala Perez; Jovita Penegra, RN; and Kathy Prows, RN). Donna McGill, RN, Susan Perry, RN, and Daniel Faletti also provided valuable input. We also thank Francis J. Crosson, MD, for his sponsorship; Joe Selby, MD, MPH, for advice and support throughout the study; Andy L. Avins, MD, MPH, for reviewing the manuscript; and Emily M. Breed for editing the manuscript.
| |
FOOTNOTES |
|---|
Received for publication Dec 13, 2000; accepted Apr 13, 2001.
Reprint requests to (G.J.E) 3505 Broadway Ave, Oakland, CA 94611. E-mail: gabriel.escobar{at}kp.org
| |
ABBREVIATIONS |
|---|
KPMCP, Kaiser Permanente Medical Care Program; LOS, length of stay.
| |
REFERENCES |
|---|
|
Top
Abstract
Methods
Results
Discussion
Conclusion
References
|
|---|
effect
on scheduling of follow-up visits by pediatricians.
Pediatrics
1997;
100:72-74 Early Postpartum
Follow-up Clinic. Unpublished final report. Santa Clara, CA:
Kaiser Permanente Medical Care Program, Northern California Region,
Innovation Program; 19972000 grams at birth: a population-based study.
Pediatrics
2000;
106:256-263 This article has been cited by other articles:
 |
|
 |
|
  M. Heisler Overview of Peer Support Models to Improve Diabetes Self-Management and Clinical Outcomes Diabetes Spectr, October 1, 2007; 20(4): 214 - 221. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. J. Madlon-Kay and S. E. Asche Factors That Influence the Receipt of Well Baby Care in the First 2 Weeks of Life. J Am Board Fam Med, May 1, 2006; 19(3): 258 - 264. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Jaber, A. Braksmajer, and J. S. Trilling Group visits: a qualitative review of current research. J Am Board Fam Med, May 1, 2006; 19(3): 276 - 290. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Heisler and J. D. Piette "I Help You, and You Help Me": Facilitated Telephone Peer Support Among Patients With Diabetes The Diabetes Educator, November 1, 2005; 31(6): 869 - 879. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G J Escobar, J D Greene, P Hulac, E Kincannon, K Bischoff, M N Gardner, M A Armstrong, and E K France Rehospitalisation after birth hospitalisation: patterns among infants of all gestations Arch. Dis. Child., February 1, 2005; 90(2): 125 - 131. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Labarere, N. Gelbert-Baudino, A.-S. Ayral, C. Duc, M. Berchotteau, N. Bouchon, C. Schelstraete, J.-P. Vittoz, P. Francois, and J.-C. Pons Efficacy of Breastfeeding Support Provided by Trained Clinicians During an Early, Routine, Preventive Visit: A Prospective, Randomized, Open Trial of 226 Mother-Infant Pairs Pediatrics, February 1, 2005; 115(2): e139 - e146. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. M. Paul, T. A. Phillips, M. D. Widome, and C. S. Hollenbeak Cost-Effectiveness of Postnatal Home Nursing Visits for Prevention of Hospital Care for Jaundice and Dehydration Pediatrics, October 1, 2004; 114(4): 1015 - 1022. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Committee on Fetus and Newborn Hospital Stay for Healthy Term Newborns Pediatrics, May 1, 2004; 113(5): 1434 - 1436. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. C. Beal, J. P. T. Co, D. Dougherty, T. Jorsling, J. Kam, J. Perrin, and R. H. Palmer Quality Measures for Children's Health Care Pediatrics, January 1, 2004; 113(1/S1): 199 - 209. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J.-M. Guise, V. Palda, C. Westhoff, B. K. S. Chan, M. Helfand, and T. A. Lieu The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the US Preventive Services Task Force Ann. Fam. Med, July 1, 2003; 1(2): 70 - 78. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. M. Taveras, A. M. Capra, P. A. Braveman, N. G. Jensvold, G. J. Escobar, and T. A. Lieu Clinician Support and Psychosocial Risk Factors Associated With Breastfeeding Discontinuation Pediatrics, July 1, 2003; 112(1): 108 - 115. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 OTHER ARTICLES NOTED (Nov 01 to 18 Oct 02) Evid. Based Nurs., January 1, 2003; 6(1): e1 - 1. [Full Text] [PDF]
|
|
| ||||||||||||||||
