A program that provided more comprehensive follow-up care for high-risk infants, including 24-hour access to care, had better outcomes and lower overall costs estimates when compared with routine follow-up care, according to an article in the October 25 issue of The Journal of the American Medical Association (JAMA), a theme issue on access to care.
R. Sue Broyles, M.D., from the University of Texas Southwestern Medical Center at Dallas, and colleagues studied 887 high-risk infants who were randomly assigned to receive either routine follow-up or comprehensive follow-up care. For the purpose of this study the researchers defined high-risk infants as either having a very-low-birth-weight (less than 1000 grams or less than approximately 2 pounds, 3 ounces) or having a weight between 1001 grams and 1500 grams (between approximately 2 pounds, 3 ounces and 3 pounds, 5 ounces) who needed a mechanical ventilator (a device that supports breathing) in the first 48 hours after birth.
The researchers found that comprehensive care resulted in an average of 3.1 more clinic visits and 6.7 more telephone conversations with clinic staff. The number of deaths in the two groups were similar (11 in the comprehensive care group versus 13 in the routine care group), but high-risk infants assigned to receive comprehensive follow-up care had 48 percent fewer life-threatening illnesses (33 versus 63), had 57 percent fewer intensive care admissions (23 versus 53), and spent 42 percent fewer days in an intensive care unit (254 versus 440 days).
The estimated average cost per infant for all care received for the 1-year period after discharge from the hospital nursery was $6,265 for infants in the comprehensive care group and $9,913 for infants who received routine follow-up care.
The authors note: “Our findings demonstrate that comprehensive follow-up care provided by highly experienced caregivers can be highly effective in reducing life-threatening illnesses without increasing the overall costs of care for high-risk inner-city infants. Follow-up clinics that serve such infants should consider developing a comprehensive-care program.”
Routine follow-up care was available two mornings per week and included well-baby care (for example, immunizations, social services, and assessment of the child's development) and care for chronic conditions. Comprehensive follow-up care was available five days per week and included all the components of routine follow-up care plus care for acute illnesses (illnesses with a sudden onset) and 24-hour access to a nurse practitioner or physician's assistant.
Citing previous studies, the authors note: “Neonatal follow-up programs were originally developed to survey the outcome of high-risk infants, assess the effects of perinatal insults [medical problems that were discovered around the time of birth] and care, and identify infants needing referral for care of ongoing problems. Unfortunately, this approach has often been associated with a substantial loss to follow-up among families of lower socioeconomic status. Moreover, this approach does not address the needs of very-low-birth-weight infants of any socioeconomic situation who lack access to a physician skilled in managing the pulmonary, gastrointestinal, nutritional, neurological, developmental and other problems common among these infants. Some follow-up programs now provide well-baby care and care for chronic illnesses. However, care for acute illnesses typically is not provided. Without prompt, effective treatment, minor illnesses or complications may quickly become life-threatening in these vulnerable infants. This problem is likely to contribute to their increased mortality, morbidity and cost of care throughout infancy.”
(JAMA. 2000;284:2070-2076)
Editor's Note: Financial support was provided by a grant from the Agency for Healthcare Research and Quality and by funds provided by the North Texas Chapter of the National Foundation March of Dimes. Media Advisory: To contact R. Sue Broyles, M.D., call Brian Cofer at 214-648-3404.
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