Medical Certificate for Jaundice Early Newborn Discharge and

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Medical Certificate for Jaundice Early Newborn Discharge and Powered By Docstoc
					                                                             Early Newborn Discharge and Readmission for Mild and Severe Jaundice                                                                                                                     For more information, contact:
                                                                                                                                                                                                                                                      Jacqueline Grupp-Phelan,
                                                                                                                                                                                                                                                      Department of Pediatrics
                                                                                                                                                                                                                                                      Box 356320
                                                                                                                                                                                                                                                      Seattle, WA 98195
                                                                                                                                                                                                                                                      Tel. 206 543-3209
                                                                                                    Jacqueline Grupp-Phelan, James A. Taylor, Lenna L. Liu and Robert L. Davis                                                                        E-mail jgphelan@u.washington.edu

                                                                                        Department of Health Services, School of Public Health , University of Washington, Seattle, Washington


                                                                                                                       METHODS (con’t)                                                                 RESULTS (con’t)
Abstract                                                                                                               • Cases: 750 babies readmitted within 14 days for jaundice
Objective: A past study showed early newborn discharge places neonates at risk for readmission in
the first 30 days of life. Because a large number of these readmissions were for jaundice, we sought                   • Controls: 3942 babies not readmitted frequency matched on                     Risk for readmission for jaundice after early discharge:
to further explore the relationship of early newborn discharge and readmission for jaundice, and to
see if early discharge was associated with increased severity of jaundice among those readmitted.                        date of birth                                                                 Newborn Stay (Hours)                          Readmitted
Methods: We performed a population-based case-control study using Washington State vital                               • Early discharge             <30 hours post-partum                               Not Readmitted
statistic, birth certificate and hospital discharge abstracts from 1991-95. Cases were 750 infants
readmitted for jaundice in the two first weeks of life, controls were 3,192 infants not readmitted.                    • Late discharge             30 - 72 hours post-partum
Infants with severe medical conditions and those status post cesarean section were excluded.                                                                                                                Early (<30)                503                 1910
“Early” discharge was defined as less than 30 hours and “late” discharge as 30 - 72 hours. We                                                          Study Population
assessed the risk for jaundice readmission and for readmissions classified as brief (2 days) or
prolonged () 2 days and for readmissions classified as uncomplicated or complicated. Logistic                                                           Total Births                                       Late (30-40)               247                 1282
                                                                                                                                                          348,495
regression was used to determine the association between early discharge and readmission for
jaundice.                                                                                                                                                                                              OR=1.34 95% CI 1.10-1.64 (adjusted for year of birth, type of
Results: Of 3,942 infants studied, 750 cases were readmitted for jaundice. Among cases, 503                                                             Readmissions
infants (67%) were readmitted after “early” discharge, while among controls, 1910 (60%) were                                                            42,274 infants                                  payer, infant gender, maternal age, gestational age, and parity.)
readmitted after “early” discharge (Odds Ratio (OR) 1.34, 95%CI 1.10, 1.64, adjusted for birth year,
gestational age, maternal race and age, payer, and infant sex). Newborns discharged early were as                                           Reamission within the first two weeks                      Subset Analyses:
                                                                                                                                                       7,388 cases
likely to have a brief readmission (OR 1.35 95% CI 1.12,1.63) verses a prolonged readmission (OR
1.43 95% CI 1.01, 2.04). Newborns discharged early were as likely to have a non-complicated                                                                                                            A trend toward increased risk for readmission for young maternal
jaundice readmission (OR 1.23 95%CI 0.93, 1.62) verses a complicated jaundice readmission (OR                                            Jaundice as one of the first three diagnoses
1.44 95%CI 1.17,1.78).                                                                                                                                 4,099 cases                                        age: (p =0.11)
Conclusions: While newborns discharged early are at increased risk for readmission for jaundice,
the clinical significance is limited. Mandating longer neonatal stays may not be the most effective                                                    After exclusions
                                                                                                                                                                                                       • Less than 17 years       OR= 2.50 95% CI 1.00,6.41
strategy to prevent readmission for jaundice and its complications.                                                                                       750 cases
                                                                                                                                                       3,942 controls                                  • Older mothers             OR=1.32 95% CI 1.11,1.58

                                                                                                                                                                                                       No increased risk of readmission for the following maternal
                                                                                                             Jaundice Complication Variable:                                                           characteristics:
                                                                                                                kernciterus         exchange transfusion                                               • primip vs. multip       OR=1.29 (1.0,1.7) vs. 1.51 (1.2,1.9)
Objectives                                                                                                      sepsis              death                                                              • unmarried vs. married OR=1.39 (0.9,2.0) vs. 1.37 (1.1,1.6)
• To determine if early neonatal discharge is a risk factor for                                              Analysis
   readmission for jaundice                                                                                  • Unadjusted odds ratios calculated for:                                                  There was no clear difference in risk for readmission after early
• To determine if certain subgroups are at increased risk                                                        risk for readmissions classified as brief (2 days)     vs.                          discharge for infants discharged over a weekend vs. early in the
• To determine if early neonatal discharge increases severity                                                                        prolonged () 2 days                                              week.
   of jaundice                                                                                                     uncomplicated vs. complicated readmission                                           Thurs-Sat                 OR=1.43 95% CI 1.11,1.85
Limitations                                                                                                                                                                                            Sun-Wed                   OR=1.31 95% CI 1.04,1.66
                                                                                                             • Logistic regression used to determine the association between
• Exact time of discharge is not available                                                                      early discharge and readmission for jaundice.
• Breastfeeding and follow up information is not available                                                                                                                                             Length of Stay and Complications
• Laboratory tests not accessible                                                                                                                                                                      Upon readmission for jaundice, infants were at no greater risk for
                                                                                                                                                                                                       longer admissions:
Conclusions                                                                                                                  RESULTS                                                                   LOS 2 days            OR=1.35 95% CI 1.12,1.63
• Newborns discharged early are at increased risk for                                                                                                    Figure 1                                      LOS > 2 days            OR=1.43 95% CI 1.01,2.04
   readmission for jaundice                                                                                        1000
                                                                                                                                           Early versus Late Discharge by Year
• The clinical significance is limited                                                                                      900
                                                                                                                                                                                                       Or for more severe complications:
Implications                                                                                                                800
                                                                                                                                                                                                       Non-severe admission OR=1.23 95% CI 0.93,1.62
Mandating longer neonatal stays may not be the most effective                                                                                                                                          Severe admission       OR=1.44 95% CI 1.17,1.78
                                                                                                                            700
strategy to prevent readmission for jaundice                                                                                600
                                                                                                                                                                                                       Number Needed to Treat Analysis
                                                                                                        Number of Infants




                                                                                                                                                                                               Late
METHODS                                                                                                                     500
                                                                                                                                                                                               Early   385 infants would need to stay > 30 hours to avoid one readmission
• Population based case control study                                                                                       400                                                                        due to early discharge
• Data sources: Washington State Birth Events Record                                                                        300

  Database linked to Hospital Discharge Abstracts                                                                           200
                                                                                                                            100

                                                                                                                             0
                                                                                                                                  1991          1992           1993           1994      1995

				
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