Public standards and patients' control: how to keep electronic medical records accessible but private.
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Computer Security↗
Biomedical subjects
K D Mandl
Publications and source records attributed to K D Mandl.
The personal internetworked notary and guardian.
In this paper, we propose a secure, distributed and scaleable infrastructure for a lifelong personal medical record system. We leverage on existing and widely available technologies, like the Web and public-key cryptography, to define an architecture that allows patients to exercise full control over their medical data. This is done without compromising patients' privacy and the ability of other interested parties (e.g. physicians, health-care institutions, public-health researchers) to access the data when appropriately authorized. The system organizes the information as a tree of encrypted plain-text XML files, in order to ensure platform independence and durability, and uses a role-based authorization scheme to assign access privileges. In addition to the basic architecture, we describe tools to populate the patient's record with data from hospital databases and the first testbed applications we are deploying.
Computer Security↗
Growth and determinants of access in patient e-mail and Internet use.
OBJECTIVES: To measure the rate of access to and use of the Internet and e-mail, to determine sociodemographic predictors of access, and to measure the change in Internet and e-mail access over a 1-year interval. DESIGN: Survey study. Comparison of data with those from a similar survey from 1998. SETTING: Emergency department of a large urban pediatric teaching hospital. PARTICIPANTS: Primary caretakers of pediatric patients or the patients themselves if aged 16 years or older. MAIN OUTCOME MEASURES: Use of and access to the Internet or e-mail. RESULTS: We surveyed 214 individuals: 72.8% use or have access to the Internet, e-mail, or both, an increase from 52.2% in the 1998 survey (P<.001), and 48.5% regularly use the Internet or e-mail, compared with 43.1% in 1998 (P = .32). Outside the home, access is primarily at work (52.2%), schools (8.9%), public libraries (11.5%), and friends' and relatives' houses (16.7%). Internet use and access are linearly correlated with income (r = 0.43; P<.001). White patients are more likely to have access (odds ratio, 2.6; 95% confidence interval, 1.3-5.4; P<.001) than black or Asian patients, whereas those of Hispanic ethnicity are less likely to have access (odds ratio, 0.20; 95% confidence interval, 0.09-0.43; P<.001). However, after adjustment for race and Hispanic ethnicity, only income was a significant predictor of family access to the Internet and e-mail. CONCLUSIONS: During the past year, many patients have gained access to the Internet and e-mail, although rates of regular use have remained steady. This access is often from outside the home. Furthermore, access is directly related to income and is unevenly distributed across racial and ethnic groups.
Adolescent↗
Parents as direct contributors to the medical record: validation of their electronic input.
STUDY OBJECTIVES: We assessed the validity and completeness of data in the past medical history (PMH) obtained electronically from parents and examined effects of the human-computer interface and sociodemographic variables on electronic parental report. METHODS: We compared parents' electronic report of PMH data with a criterion standard, structured face-to-face interview by a pediatrician blinded to the electronic data. The electronic medical record interface enabled parents to provide 5 elements of the PMH: birth status, allergies, current medications, immunization status, and previous hospitalizations. The setting was the emergency department waiting room in an academic, urban children's hospital; parents of infants up to 12 months old participated. Outcome measures were validity of the PMH data obtained using the electronic medical record interface and odds of having an invalid or incomplete response using the electronic medical record interface. RESULTS: One hundred parents were enrolled (69.4% of eligible subjects). Study subjects did not differ from nonenrollees on demographic variables and visit characteristics. The validity of the electronic medical record interface data was high across the PMH elements (94% to 99%). Two demographic features predicted invalid response: parental primary language other than English or Spanish (odds ratio [OR] 11.4, 95% confidence interval CI 1.7 to 76.3), and Asian ethnicity (OR 14. 6, 95% CI 1.2 to 182.4). Incomplete responses were predicted by limited previous experience with computers; computer-naive subjects had an eightfold increased odds of skipping a question (OR 7.9, 95% CI 1.8 to 34.6). CONCLUSION: Parents are accurate independent reporters of their infants' general PMH using the electronic medical record interface. Their participation in care may be enhanced by allowing them to contribute medical information directly to the electronic medical record.
Attitude to Computers↗
Four strategies for the management of esophageal coins in children.
OBJECTIVE: To compare clinical outcomes and costs under 4 strategies for the management of esophageal coins in children. METHODS: We developed a decision analysis model of 4 possible strategies for managing esophageal coins: 1) endoscopic removal under general anesthesia; 2) esophageal bougienage, 3) an outpatient 12- to 24-hour observation period to allow spontaneous coin passage; and 4) an inpatient observation period. Probabilities of success and complication rates for endoscopy and esophageal bougienage were obtained from published data. The probability of spontaneous coin passage was derived from chart review data at our institution. Costs were calculated from charges using a cost-to-charge ratio of.72. Hypothetical patients included in the model were those with a single esophageal coin presenting within 24 hours of ingestion, with no respiratory compromise on presentation and with no previous history of esophageal disease. Strategy-specific outcomes were overall complication rate and total cost in dollars per patient. Sensitivity analyses were performed to account for variations in the data. RESULTS: The esophageal bougienage strategy resulted in no complications and a total cost per patient of $382, which represents a marginal advantage of $2915 per patient compared with the endoscopic removal strategy. On sensitivity analysis over the range of success and complication rates of bougienage, this strategy maintained a considerable decrease in both overall complications and total cost per patient compared with all other strategies. Both outpatient and inpatient observation strategies had overall complication rates of 4.2% compared with the complication rate of 5.8% for the endoscopy strategy. The total cost per patient under these strategies was $2439 for the outpatient and $3141 for the inpatient strategy, representing a marginal advantage of $858 and $156 per patient, respectively, compared with the endoscopy strategy. Both observation strategies maintained a lower overall complication rate compared with endoscopy in the sensitivity analysis. The outpatient observation strategy maintained a marginal advantage of $645 to $1257 per patient compared with endoscopy; however, the inpatient observation strategy total cost per patient surpassed that of endoscopy at a spontaneous passage rate <23%. CONCLUSIONS: Given the high success and low complication rates reported for esophageal bougienage, substantial savings in overall complications and costs would be expected with the use of this procedure. With spontaneous passage rates >23%, either an outpatient or an inpatient observation strategy would reduce costs and complications, compared with endoscopic removal of all esophageal coins.
Child↗
Costs and effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children.
BACKGROUND: A protocol of ultrasonography (US) followed by computed tomography with rectal contrast (CTRC) has been shown to be 94% accurate in the diagnosis of acute appendicitis in children. OBJECTIVE: To evaluate the changes in patient management and costs of a protocol using US and CTRC in the evaluation of appendicitis in children. DESIGN, SETTING, AND SUBJECTS: Prospective cohort study of 139 children between 3 and 21 years of age who had equivocal clinical findings for acute appendicitis seen in the emergency department of a large, urban pediatric teaching hospital between July 1998 and December 1998. PROTOCOL: Children with equivocal clinical presentations for acute appendicitis were prospectively evaluated with US. Patients with positive findings for acute appendicitis went directly to the operating room. Patients with negative or equivocal findings on US underwent CTRC. Surgical management plans were recorded before imaging, after US, and after CTRC. MAIN OUTCOME MEASURES: Surgical management plans before and after the imaging protocol as well as total hospital direct and indirect costs incurred or saved by each change in management were determined. Costs were obtained through the hospital's cost database and by ratios of costs to charges. RESULTS: Of the 139 children, the protocol resulted in a beneficial change in management in 86 children (61.9%), no change in management in 50 children (36.0%) and an incorrect change in management in 3 children (2.1%). US alone resulted in a beneficial change in management decision in 12/31 children (38.7%), while US followed by CTRC resulted in a beneficial change in management in 74/108 children (68.5%). The protocol resulted in a total cost savings of $78 503.99 or $565/patient. CONCLUSION: A protocol of US followed by CTRC in children with negative or equivocal US examinations results in a high rate of beneficial change in management as well as in total cost savings in children with equivocal clinical presentations for suspected appendicitis.
Adolescent↗
Time to detection of positive cultures in 28- to 90-day-old febrile infants.
OBJECTIVE: To determine the time to detection of positive blood, urine, and cerebrospinal fluid (CSF) cultures among febrile 28- to 90-day-old infants. STUDY DESIGN: Retrospective cohort of consecutive 28- to 90-day-old infants presenting with a temperature of >/=38 degrees C to an urban pediatric emergency department. Positive cultures and times to detection were noted. Patients were categorized as being at high risk for serious bacterial illness (SBI) based on clinical and laboratory criteria. RESULTS: Of the 3166 febrile infants seen in the emergency department during the study, 2733 had blood (86%), 2517 had urine (80%), and 2361 had CSF (75%) specimens obtained for culture, and 2190 had all 3 cultures (69%) sent. There were 224 positive cultures in 214 patients; of these, 191 had all 3 cultures (89%) sent. Subsequent analyses were confined to those who had all 3 cultures sent. The detected rate of SBI was 8.7% (191/2190). There were 28 positive blood cultures (1. 3%), 165 positive urine cultures (7.5%), and 8 positive CSF cultures (.4%). Median time to detection of positive cultures was 16 hours for blood, 16 hours for urine, and 18 hours for CSF. Four blood cultures (.1%), 20 urine cultures (.9%), and 0 CSF cultures were noted to have growth of a pathogen >24 hours after the specimen was obtained. All 4 blood cultures and 17 of 20 urine cultures with growth noted after 24 hours occurred among high-risk patients. CONCLUSIONS: The risk of identifying SBI after 24 hours is 1.1% among all 28- to 90-day-old febrile infants and.3% in low-risk infants.
Bacterial Infections↗
Effect of a reduced postpartum length of stay program on primary care services use by mothers and infants.
OBJECTIVE: To determine the impact of reduced postpartum length of stay (LOS) on primary care services use. METHODS. DESIGN: Retrospective quasiexperimental study, comparing 3 periods before and 1 period after introducing an intervention and adjusting for time trends. SETTING: A managed care plan. INTERVENTION: A reduced obstetrical LOS program (ROLOS), offering enhanced education and services. PARTICIPANTS: mother-infant dyads, delivered during 4 time periods: February through May 1992, 1993, and 1994, before ROLOS, and 1995, while ROLOS was in effect. INDEPENDENT MEASURES: Pre-ROLOS or the post-ROLOS year. OUTCOME MEASURES: Telephone calls, visits, and urgent care events during the first 3 weeks postpartum summed as total utilization events. RESULTS: Before ROLOS, LOS decreased gradually (from 51.6 to 44.3 hours) and after, sharply to 36.5 hours. Although primary care use did not increase before ROLOS, utilization for dyads increased during ROLOS. Before ROLOS, there were between 2.37 and 2.72 utilization events per day; after, there were 4.60. Well-child visits increased slightly to.98 visits per dyad, but urgent visits did not. CONCLUSION: This program resulted in shortened stays and more primary care use. There was no increase in infant urgent primary care utilization. Early discharge programs that incorporate and reimburse for enhanced ambulatory services may be safe for infants; these findings should not be extrapolated to mandatory reduced LOS initiatives without enhancement of care.
Adult↗
Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children.
CONTEXT: Limited computed tomography with rectal contrast (CTRC) has been shown to be 98% accurate in the diagnosis of appendicitis in the adult population, but data are lacking regarding the accuracy and effectiveness of this technique in diagnosing pediatric appendicitis. OBJECTIVE: To determine the diagnostic value of a protocol involving ultrasonography and CTRC in the diagnosis and management of appendicitis in children and adolescents. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 139 children and adolescents aged 3 to 21 years (2 patients were older than 18 years) who had equivocal clinical findings for acute appendicitis and who presented to the emergency department of a large, urban, pediatric teaching hospital between July and December 1998. Interventions Children were first evaluated with pelvic ultrasonography. If the result was definitive for appendicitis, laparotomy was performed; if ultrasonography was negative or inconclusive, CTRC was obtained. Patients who did not undergo laparotomy had telephone follow-up at 2 weeks and medical records of all patients were reviewed 4 to 6 months after study completion. MAIN OUTCOME MEASURES: Specificity, sensitivity, positive predictive value, negative predictive value, and accuracy of tests based on final diagnoses; surgeons' estimated likelihood of appendicitis on a scale of 1 to 10 for each case and their case management plans before imaging, after ultrasonography, and after CTRC. RESULTS: A total of 108 patients underwent both ultrasonography and CTRC examinations. The protocol had a sensitivity of 94%, specificity of 94%, positive predictive value of 90%, negative predictive value of 97%, and accuracy of 94%. A normal appendix was identified by ultrasonography in 2 (2.4%) of 83 patients without appendicitis and by CTRC in 62 (84%) of 74 patients. A negative ultrasonography result did not change the surgeons' clinical confidence level in excluding appendicitis (P= .06), while a negative CTRC result did have a significant effect (P<.001). Positive results obtained for either ultrasonography or CTRC significantly affected surgeons' estimated likelihood of appendicitis (P=.001 and P<.001, respectively). Ultrasonography resulted in a beneficial change in patient management in 26 (18.7%) of 139 children while CTRC correctly changed management in 79 (73.1%) of 108. CONCLUSIONS: These data show that CTRC following a negative or indeterminate ultrasonography result is highly accurate in the diagnosis of appendicitis in children.
Adolescent↗
The spontaneous passage of esophageal coins in children.
OBJECTIVES: To determine the likelihood of spontaneous passage of esophageal coins to the stomach in children and to determine the effect of initial coin location on spontaneous passage. DESIGN: Retrospective review of medical records and radiographs. SUBJECTS: Consecutive patients 18 years or younger presenting during a 24-month period (October 1995 to September 1997) whose evaluation revealed an esophageal coin. SETTING: The emergency department of a large, urban academic children's hospital. MAIN OUTCOME MEASURES: Independent measures were time between ingestion and radiographs, initial location of the coin, and categorization of case as "simple" (patients without a history of esophageal disease or surgery, with a single esophageal coin lodged less than 24 hours, and with no respiratory compromise on presentation) or "complex." Dependent measures were spontaneous passage of the coin to the stomach and the time to passage. RESULTS: A total of 116 cases were included in the analysis, of which 84 were simple and 32 complex. Among the 84 simple cases, the coin was initially located in the proximal third of the esophagus in 54 (64%), the middle third in 7 (8%), and the distal third in 22 (26%). For the 32 complex cases, the initial location of the coin was the proximal third of the esophagus in 27 (84%) and the middle third in 5 (16%). Subsequent radiographs were obtained in the emergency department in 58 (69%) of the simple cases. Among these cases, spontaneous passage of the coin to the stomach occurred in 16 (28% [95% confidence interval, 21%-41%]). By initial coin location, spontaneous passage in this group occurred in 22% (7/32) of proximal, 33% (2/6) of middle, and 37% (7/19) of distal esophageal coins (P >.05). Subsequent radiographs were obtained in 14 (44%) of the complex cases; no coin had passed spontaneously to the stomach in these patients (0% [95% confidence interval, 0%-20%]). CONCLUSIONS: Children with a single esophageal coin seen within 24 hours of ingestion, who have no history of esophageal disease and no respiratory compromise on presentation, have a 28% chance of spontaneous passage of the coin to the stomach. Coins in the upper as well as the lower esophagus pass spontaneously. Observing these children for 12 to 24 hours prior to invasive procedures will reduce complications and costs.
Adolescent↗
Infant health care use and maternal depression.
OBJECTIVE: To determine whether women who frequently bring their neonates for problem-oriented primary care visits or emergency department visits are at elevated risk of having depressive symptoms. DESIGN: Analysis of 2 prospective cohort studies of mothers and their infants: (1) a telephone interview study of mothers and infants after birth at an urban teaching hospital (the hospital cohort) and (2) the 1988 National Maternal and Infant Health Survey, a nationally representative sample of women who had live births in 1988. PARTICIPANTS: A total of 1015 women in the hospital cohort surveyed at 3 and 8 weeks post partum and 6779 women with data from the national survey. MAIN OUTCOME MEASURE: Depressive symptoms above the Center for Epidemiologic Studies Depression Scale cutoff score of 15. RESULTS: After controlling for sociodemographic variables and parity, women exhibited high levels of depressive symptoms if their infants had more than 1 problem-oriented primary care visit (hospital cohort: odds ratio, 2.0 [95% confidence interval, 1.1-4.3]; national survey cohort: odds ratio, 2.0 [95% confidence interval, 1.5-3.0]). Women were more likely to have high levels of depressive symptoms if their infants had even 1 emergency department visit (hospital cohort: odds ratio, 3.2 [95% confidence interval, 1.5-6.9]). Frequent well-child visits were not associated with maternal depressive symptoms. CONCLUSIONS: Neonatal health care use patterns predict women at risk for postpartum depression. Recognition of these signature patterns of service use by pediatric health care providers may facilitate early diagnosis and treatment of postpartum depression and improve outcomes for women and their families.
Adolescent↗
Effect of computed tomography on patient management and costs in children with suspected appendicitis.
OBJECTIVE: Children evaluated in the emergency department for possible appendicitis are often admitted for observation, despite the widespread availability of accurate diagnostic studies, particularly computed tomography (CT). We sought to establish effective and efficient strategies for using CT to diagnose and manage children with possible appendicitis. DESIGN: Retrospective chart review and decision analysis. Setting. Emergency department of a large, urban tertiary care pediatric teaching hospital. PATIENTS: All patients admitted from January 1996 to August 1997 for suspected appendicitis. METHOD OF ANALYSIS: Three modeled strategies were empirically applied to the retrospective cohort of patients admitted for observation. Outcomes and costs under the modeled strategies were compared with those under current practice. The three strategies were: 1) to obtain CT scans on all patients and discharge those with normal findings; 2) to obtain CT scans and admit all patients; 3) to selectively obtain CT scans on those patients with a peripheral white blood cell count >10 000/mm(3) (10 x 10(9)/L) and admit all. The sensitivity and specificity of CT for diagnosing appendicitis were determined empirically from the data. A sensitivity analysis was performed. MAIN OUTCOME MEASURES: The number of preoperative inpatient observation days, total hospital costs, and the rates of both missed appendicitis and negative laparotomies. RESULTS: Of 609 patients hospitalized for possible appendicitis, 287 went directly to the operating room and 14 patients had known perforation and abscess. Three hundred eight children were observed and comprised the study cohort. Of the cohort, 112 (36.4%) underwent appendectomy and 26 (23.2%) of these had a normal appendix at pathology. Three patients were discharged from the hospital after observation and were subsequently readmitted with appendicitis (missed appendicitis). Among the 75 patients who had CT performed, the sensitivity and specificity of CT were both 97%. Under the current practice strategy, the cohort collectively accumulated 487 inpatient observation days and incurred a per patient cost of $5831. All three CT strategies would have reduced the total number of inpatient observation days, operations, negative laparotomies, as well as the per patient cost. The strategy of obtaining CT scans on all patients and then admitting them had the lowest rate of missed appendicitis. The additional cost of preventing each case of missed appendicitis under this strategy compared with the strategy of obtaining CT scans and sending home those with negative findings was $150,304. Even at the lowest reported sensitivity and specificity of CT in the literature, the ordering of the three strategies remained constant and continued to reduce total cost per patient. CONCLUSION: Compared with current practice, diagnostic strategies using CT could reduce costs and improve diagnosis, management, and outcomes for children with appendicitis.
Appendicitis↗
Data quality and the electronic medical record: a role for direct parental data entry.
INTRODUCTION: The paper and electronic medical record (EMR) have evolved with little scientific inquiry into what effect the informant (clinician or patient) has on the validity of the recorded information. We have previously reported on an electronic interview program that facilitated parents' direct reporting of past medical history data. We sought to define additional data elements that parents could report electronically and to compare parents' electronically entered data to that charted by physicians using the current EMR system. METHODS: A convenience sample of parents was recruited to enter data on history of present illness (HPI) and review of systems (ROS) elements using an electronic interview. Data from the electronic parental interview and information abstracted from the physician EMR were compared to data derived from a face-to-face criterion standard interview. Validity, sensitivity and specificity of each mode of data entry were calculated. RESULTS: 100 of 140 eligible parents (71.4%) participated. Validity of information from the electronic interview was comparable to that charted by emergency physicians for HPI regarding fever and ROS questions. Sensitivity of parents' electronic interview was superior to physicians' charting for ROS elements specific to hydration status. CONCLUSIONS: Improved sensitivity for detection of historical risk factors for illness can be achieved by augmenting the pediatric EMR with a section for direct parental direct data input. Direct parental data input to the EMR should be considered to improve the quality of documentation for medical histories.
Emergency Medicine↗
Healthconnect: clinical grade patient-physician communication.
A critical mass of Internet users is leading to a wide diffusion of electronic communications within medical practice. Unless implemented with substantial forethought, these new technological linkages could disturb delicate balances in the doctor-patient relationship, threaten the privacy of medical information, widen social disparity in health outcomes, and even function as barriers to access. The American Medical Informatics Association (AMIA) recently published recommendations to guide computer-based communications between clinicians and patients. This paper describes the motivations for and the design of HealthConnect, a web-based patient-doctor communications tool currently in use at Children's Hospital, Boston. Structural and process-oriented features of HealthConnect, as they relate to promotion of adherence with the Guidelines, are discussed.
Communication↗
Electronic patient-physician communication: problems and promise.
A critical mass of Internet users will soon enable wide diffusion of electronic communication within medical practice. E-mail between physicians and patients offers important opportunities for better communication. Linking patients and physicians through e-mail may increase the involvement of patients in supervising and documenting their own health care, processes that may activate patients and contribute to improved health. These new linkages may have profound implications for the patient-physician relationship. Although the federal government proposes regulation of telemedicine technologies and medical software, communications technologies are evolving under less scrutiny. Unless these technologies are implemented with substantial forethought, they may disturb delicate balances in the patient-physician relationship, widen social disparities in health outcomes, and create barriers to access to health care. This paper seeks to identify the promise and pitfalls of electronic patient-physician communication before such technology becomes widely distributed. A research agenda is proposed that would provide data that are useful for careful shaping of the communications infrastructure. The paper addresses the need to 1) define appropriate use of the various modes of patient-physician communication, 2) ensure the security and confidentiality of patient information, 3) create user interfaces that guide patients in effective use of the technology, 4) proactively assess medicolegal liability, and 5) ensure access to the technology by a multicultural, multilingual population with varying degrees of literacy.
Communication↗
Social equity and access to the World Wide Web and E-mail: implications for design and implementation of medical applications.
INTRODUCTION: The distribution and types of Internet connectivity will determine the equity of access by patient populations to emerging health technologies. We sought to measure the rates, types, and predictors of access in a patient population targeted for Web-based medical services. METHODS: Design. Cross sectional in-person interview. Setting. Emergency department of a large urban pediatric teaching hospital. Subjects. Primary caretakers of patients or patients at least 16 years old. Procedure and measures. Subjects were asked about access to e-mail and the Internet as well as about willingness to use and concerns about Web-based services. Views of equity and access and sociodemographic data were also elicited. RESULTS: 132 subjects were enrolled in the study. Of respondents, 67.2% use a computer and 36.4% can access the Internet or e-mail from home. Including Internet connections and/or e-mail accounts at work, school and public libraries, 50.7% of the sample has access. Forty percent of families have e-mail accounts. The rate at which families have connectivity is primarily correlated with income (r = 0.6, p < 0.01). At all income levels, rates of access to the World Wide Web are higher than to e-mail. White patients are much more likely to have e-mail (OR 5.0, 95% CI 2.4-10.8) and Web access (OR 3.6, 95% CI 1.7-7.5). CONCLUSIONS: Connectivity is directly correlated with income and distributed unevenly across racial and ethnic groups. World Wide Web access is more prevalent than e-mail accounts, and both are often obtained outside the home. Design of health applications should account for these attributes of patient access.
Caregivers↗
Linking multiple heterogeneous data sources to practice guidelines.
The BiliLIGHT system is a World Wide Web (Web) based system that integrates an interactive clinical practice guideline with real-time patient-data retrieval from remote heterogeneous data sources to help clinicians manage newborn jaundice at the point of care in three clinical settings. We briefly describe the system, how actual information exchange of medical data across institutional boundaries was achieved, and how the data were connected to a CPG. In particular, we examine the requirements for patient identification, exchange protocols, authentication, and a standard vocabulary.
Computer Systems↗
Maternal and infant health: effects of moderate reductions in postpartum length of stay.
BACKGROUND: The Newborns' and Mothers' Health Protection Act of 1996 prohibits payers from restricting "benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours." The law recognizes the basic right of women and physicians to make decisions about aptness of discharge timing. OBJECTIVE: To provide data as a basis for decisions about aptness of discharge timing by studying the effect of voluntary, moderate reductions in length of postpartum hospital stay on an array of maternal and infant health outcomes. DESIGN: A prospective cohort study. Patients were surveyed by telephone at 3 and 8 weeks postpartum. SETTING: A teaching hospital where 38% of the patients are in a managed care health plan with a noncompulsory reduced stay program offering enhanced prepartum and postpartum services, including home visits. PATIENTS: Consecutive mothers discharged after vaginal delivery during a 3-month period. MAIN OUTCOME MEASURES: The outcomes were health services use within 21 days, breast-feeding, depression, sense of competence, and satisfaction with care. Multivariate analyses adjusted for sociodemographic factors, payer status, services, and social support. RESULTS: Of 1364 eligible patients, 1200 (88%) were surveyed at 3 weeks; of these 1200, 1015 (85%) were resurveyed at 8 weeks. The mean length of stay was 41.9 hours (SD, 12.2 hours). Of patients going home in 30 hours or less, 60.8% belonged to a managed care health plan. The length of stay was not related to the outcomes, except that women hospitalized shorter than 48 hours had more emergency department visits than those staying 40 to 48 hours (adjusted odds ratio, 5.78; 95% confidence interval, 1.19-28.05). CONCLUSIONS: When adequate postpartum outpatient care is accessible, a moderately shorter length of postpartum stay after an uncomplicated vaginal delivery had no adverse effect on an array of outcomes. Researchers and policy makers should seek to better define the content of postpartum services necessary for achieving optimal outcomes for women and newborns; funding should be available to provide such services, regardless of the setting in which they are provided.
Adolescent↗