A randomized comparison of home visits and hospital-based group follow-up visits after early postpartum discharge

Objective. Short postpartum stays are common. Current guidelines provide sc ant guidance on how routine follow-up of newly discharged mother-infant pai rs should be performed. We aimed to compare 2 short-term (within 72 hours o f discharge) follow-up strategies for low-risk mother-infant pairs with pos tpartum length of stay (LOS) of <48 hours: home visits by a nurse and hospi tal-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 middl e class population. Mother-infant pairs that met LOS and risk criteria were randomized to the control arm (hospital-based followup) or to the interven tion arm (home nurse visit). Clinical utilization and costs were studied us ing computerized databases and chart review. Breastfeeding continuation, ma ternal depressive symptoms, and maternal satisfaction were assessed by mean s of telephone interviews at 2 weeks postpartum. Results. During a 17-month period in 1998 to 1999, we enrolled and randomiz ed 1014 mother-infant pairs (506 to the control group and 508 to the interv ention group). There were no significant differences between the study grou ps with respect to maternal age, race, education, household income, parity, previous breastfeeding experience, early initiation of prenatal care, or p ostpartum LOS. There were no differences with respect to neonatal LOS or Ap gar 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 individ ual visit, 4 had a home health and a hospital-based follow-up, 13 had no fo llow-up within 72 hours, and 4 were lost to follow-up. With respect to outc omes within 2 weeks after discharge, there were no significant differences in newborn or maternal hospitalizations or urgent care visits, breastfeedin g discontinuation, maternal depressive symptoms, or a combined clinical out come measure indicating whether a mother-infant pair had any of the above o utcomes. However, mothers in the home visit group were more likely than tho se 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 h ome visit group also gave higher ratings on overall satisfaction with the n ewborn's posthospital care (71% vs 59%), as well as with their own posthosp ital care (63% vs 55%). The estimated cost of a postpartum home visit to th e mother and the newborn was $265. In contrast, the cost of the hospital-ba sed group visit was $22 per mother-infant pair; the cost of an individual 1 5-minute visit with a registered nurse was $52; the cost of a 15-minute ind ividual 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 car e organization, home visits compared with hospital-based follow-up and grou p visits were more costly but achieved comparable clinical outcomes and wer e associated with higher maternal satisfaction. Neither strategy is associa ted with significantly greater success at increasing continuation of breast feeding. This study had limited power to identify group differences in reho spitalization and may not be generalizable to higher-risk populations witho ut comparable access to integrated hospital and outpatient care.