Comprehensive Care a "Better Deal" for High-Risk Infants

A program of comprehensive follow-up care for high-risk infants had better outcomes at lower overall cost estimates than routine follow-up care, according to an article in the Oct. 25 issue of The Journal of the American Medical Association.

"It's rare in medical research to show in a randomized trial that you improve outcomes without increasing costs," said the paper's senior author, Dr. Jon Tyson, Michelle Bain Distinguished Professor of Medicine and Public Health at The University of Texas Health Science Center at Houston. "We believe that the comprehensive care program is a model for how care should be given to really high-risk babies," he said.

Lead author Dr. R. Sue Broyles, associate professor of pediatrics at the University of Texas Southwestern Medical Center at Dallas, Tyson, and colleagues studied 887 high-risk infants in Dallas who were randomly assigned to receive either routine follow-up or comprehensive follow-up care. High-risk infants were defined as either having a very low birth-weight of less than 1000 grams (about 2 pounds, 3 ounces) or those having a weight of up to 3 pounds, 5 ounces who also needed a mechanical ventilator in the first 48 hours after birth. Medicaid covered virtually all children in the study.

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.

Infants assigned to receive comprehensive follow-up care had 48 percent fewer

life-threatening illnesses, 57 percent fewer intensive care admissions, and spent 42 percent fewer days in an intensive care unit.

"Those additional clinic visits and phone calls kept children from getting really sick and needing intensive care," Tyson said.

The estimated average cost per infant for all care received for the one-year period after discharge from the hospital nursery was $6,265 for infants in the comprehensive care group and $9,913 for infants in the routine follow-up group.

Deaths in the two groups were similar (11 in the comprehensive versus 13 in the routine). The paper notes three possible reasons: lack of an effect, inadequate sample size to establish an effect, or an inability to identify all deaths.

Broyles explained that routine follow-up care was available two mornings per week and included well-baby care and care for chronic conditions. Comprehen-sive follow-up care was available five days per week and included routine follow-up plus care for acute illnesses and 24-hour access to a nurse practitioner or physician's assistant supervised by a pediatrician and a neonatologist trained in follow-up care.

Tyson cited two important aspects of comprehensive follow-up: the care-givers had an average 11 years of experience with high-risk infants, and when a family called for help or advice, they virtually always talked to their child's specific caregiver.

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."

The report also notes that "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."

Establishing comprehensive follow-up programs, Tyson noted, requires both experienced personnel and recognition by insurers and Medicaid of the need for such centers.

Tyson also is professor of pediatrics and obstetrics/gynecology and director of the Medical School's Center for Population Health and Evidence-Based Medicine. Other UT-Houston participants included Dr. Chul Ahn, associate professor of internal medicine at the Medical School, who conducted statistical analysis, and Dr. Michael Swint, professor of management and policy sciences, and Dr. Nancy Pomeroy, assistant professor of management and policy sciences, both of the School of Public Health, who provided economic analysis.

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.

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©2006 Texas Medical Center

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