Do longer postpartum stays reduce newborn readmissions? Analysis using instrumental variables.

OBJECTIVE: To determine the effect of postpartum length of stay on newborn readmission. DATA SOURCES: Secondary data set consisting of newborns born in Washington state in 1989 and 1990. The data set contains information about the characteristics of the newborn and its parents, physician, hospital, and insurance status. STUDY DESIGN: Analysis of the effect of length of stay on the probability of newborn readmission using hour of birth and method of delivery as instrumental variables (IVs) to account for unobserved heterogeneity. Of approximately 150,000 newborns born in Washington in 1989 and 1990, 108,551 (72 percent) were included in our analysis. PRINCIPAL FINDINGS: Newborns with different lengths of stay differ in unmeasured characteristics, biasing estimates based on standard statistical methods. The results of our analyses show that a 12-hour increase in length of stay is associated with a reduction in the newborn readmission rate of 0.6 percentage points. This is twice as large as the estimate obtained using standard statistical (non-IV) methods. CONCLUSION: An increase in the length of postpartum hospital stays may result in a decline in newborn readmissions. The magnitude of this decline in readmissions may be larger than previously thought.

Infant mortality and early postpartum discharge.

OBJECTIVE: To assess additional risk of newborn death owing to early discharge. METHODS: This was a historical cohort study using Washington State linked birth certificates, death certificates, and hospital discharge records that covered 47,879 live births in 1989 and 1990. Logistic regression was used to assess risk of death within the first year of life after early discharge (less than 30 hours after birth) compared with later discharge (30-78 hours after birth). RESULTS: Newborns discharged early were more likely to die within 28 days of birth (odds ratio [OR] 3.65; 95% confidence interval [CI] 1.56, 8.54), between 29 days and 1 year (OR 1.61; 95% CI 1.10, 2.36), and any time within the first year (OR 1.84; 95% CI, 1.31, 2.60) of life than newborns sent home later. Newborns discharged early also were more likely to die of heart-related problems (OR 3.72; CI 1.25, 11.04) and infections (OR 4.72; CI 1.13, 19.67) within 1 year of birth than newborns discharged later. CONCLUSION: Newborns discharged within 30 hours of birth are at increased risk of death within the first year of life.

Can medical savings accounts for the nonelderly reduce health care costs?

OBJECTIVE: To understand how medical savings account (MSA) legislation for the nonelderly would affect health care costs. DESIGN: Economic policy evaluation based on the RAND Health Expenditures Simulation Model. SETTING: National probability sample of nonelderly noninstitutionalized households. PARTICIPANTS: Persons in 23 157 sampled households from the 1993 Current Population Survey. INTERVENTIONS: Medical savings account legislation would allow all Americans who are covered only by a catastrophic health care plan to set up a tax-exempt account that they can use to pay medical bills not covered by their health insurance. The interventions we evaluate differ in the deductibles of the catastrophic plan and in whether the employee or employer funds the MSA. MAIN OUTCOME MEASURES: Changes in national health expenditures and net societal benefits of health care. RESULTS: If all insured nonelderly Americans switched to MSAs, their health care expenditures would decline by between 0% and 13%, depending on how the MSAs are designed. However, not all nonelderly Americans would choose MSAs; taking into account selection patterns, health spending would change by + 1% to -2%. CONCLUSIONS: Medical savings account legislation would have little impact on health care costs of Americans with employer-provided insurance. However, depending on the size of the catastrophic limit, waste from the excessive use of generously insured care could be reduced, and MSAs would be attractive to both sick and healthy people.