In this study we evaluated the extent of implementation of the 2004 AAP guideline for the management of hyperbilirubinemia in the newborn infant of ≥35 weeks of gestation. The key findings from this study are that implementation of recommendation for follow-up remains incomplete and that many infants may be exposed to the risk of severe hyperbilirubinemia. Although most birth hospitals in the geographic area studied have policies to perform predischarge risk assessment that includes bilirubin measurement, more than half of vaginally delivered and breastfed infants did not receive timely follow-up. The results of our study are similar to those from assessments of newborn follow-up patterns published before the revised AAP guidelines of 2004. Maisels and Kring5
found that despite physician education regarding the importance of evaluating infants within 2 to 3 days of discharge if the hospital stay was <48 hours, 38% of short-stay infants were scheduled to be seen ≥4 days after discharge. Among a national sample of >4000 healthy term infants, Bernstein et al6
found that only 54% of first office visits actually occurred within 7 days after discharge.
Barriers to compliance with guidelines include provider knowledge, attitude, and behavior.7
Although publication of the 2004 AAP guideline for management of hyperbilirubinemia was accompanied by substantial education, some providers may remain unaware. It is possible that some providers may be reassured by a predischarge bilirubin level in a zone that does not predict a high risk for subsequent severe hyperbilirubinemia8
and, thus, delay a follow-up visit. This prioritization may not be appropriate, because some infants at lower risk will develop significant hyperbilirubinemia, and there are additional advantages to an early visit, including lactation support.9
Providers may disagree with the guidelines10
by perceiving them as too stringent or not cost-effective, thinking they are unable to implement the required changes in their practice, or, because kernicterus is a rare event, considering the effect on outcomes too negligible to change their practice. Providers may also experience external barriers to performing recommendations such as financial disincentives, difficulties with care coordination during off hours and weekends, and inadequate access to laboratory services.
Care transitions, such as discharge from birth hospitalization and transfer of care to a medical home in the ambulatory care setting, have been shown to be associated with adverse outcomes. In adults, the potential patient safety risks of care transitions include inaccurate or incomplete transfer of information between providers and from provider to patient, as well as ambivalence about care responsibilities.11–14
Care transitions for newborns exhibit many of the same risks, including incompletely resolved medical conditions such as jaundice or breastfeeding competency, the need for caregiver education and participation, and an often-prolonged time between the birth hospitalization and ambulatory follow-up. In fact, the bimodal distribution of follow-up that we have documented seems to reflect partial compliance with the AAP guidelines but also a continued influence of traditional 1- and 2-week scheduled follow-up visits. In addition, unclear lines of responsibility for the patient15
and deficits in transfer of information between providers may put infants at risk. In our study, the pediatrician who saw the patient at the follow-up visit often did not provide care during the birth hospitalization and, therefore, may not have had complete or accurate information about the patient's condition. As a result, the transition period between the inpatient and outpatient settings is an environment in which deficits may be common and can have potentially severe consequences.
At the local, regional, and national levels, the formidable obstacles to safe newborn care during the first week after birth may be overcome through a combination of regulatory policies and alignment of provider incentives with desired care quality. Maisels and Kring5,16
have demonstrated that local institutional policies promulgated by a local champion, provider education, and reminder systems can significantly improve compliance with early newborn follow-up. The replication of such successes on a national scale requires a comprehensive approach that targets different levels of the health care delivery system (parents, doctor, team practice, hospital, payers of health care) and is tailored to the needs of the newborn as well as the existing practice environment.17
Such interventions are more successful if they actively engage providers and provide tools that facilitate implementation.18–21
The need for such a systems approach has been recognized by the pediatric community.22,23
The AAP's Safe and Healthy Beginnings project, which includes development of a tool kit, is working to facilitate implementation of the 2004 guideline for management of hyperbilirubinemia.24,25
However, tool kits may not be sufficient to drive further improvement in the face of insufficient incentives for provider change.
Payers of health care can support the effectiveness of local quality-improvement efforts by aligning financial incentives and regulatory frameworks with quality objectives.26
Aligning financial incentives with quality means that providers should not be penalized but, rather, encouraged to provide high-quality care. Yet, in many states Medicaid does not encourage early newborn follow-up by adding this visit as a sixth reimbursable well-child visit during the first year of life. Instead, early newborn follow-up visits can be assigned a lower-paying sick-visit reimbursement code. It is possible that financial disincentives contributed to our finding of lower compliance with guidelines for early newborn follow-up for Medicaid-insured patients, leaving the most vulnerable infants poorly protected. Redesigning financial reimbursement policies to encourage guideline-recommended care by paying a premium for high-value visits, such as the early newborn follow-up visit, might invite safer practice.
Our findings must be interpreted within the framework of the study design. The large variation in practice styles may reflect care practices in a pediatric practice association that has not developed system-wide clinical care pathways. Therefore, our findings may not generalize to more tightly managed practice settings or provider networks. However, given that most providers practice outside of tightly managed settings, this study likely provides a realistic picture of practice variation across the country. Indeed, because our study population is largely non-Hispanic white and commercially insured, our results may represent an underestimate of the true quality gap.
A limitation of our study is that data collection relied solely on office records. We did not have access to records for the birth hospitalization for validation. Therefore, we do not know the precise length of birth hospitalization for an individual infant, which might affect the timing of follow-up. We have addressed this weakness in our subgroup analyses of vaginally delivered infants, who are customarily discharged from the hospital within 48 hours of age. Such infants should be followed within 2 days of discharge, particularly if they are breastfed. However, a substantial proportion was seen after the first week of age.
Finally, some pediatricians in our study may have used predischarge bilirubin measurement results to prioritize follow-up. Indeed, infants with a predischarge bilirubin measurement below the 40th percentile (low risk) are unlikely to develop subsequent severe hyperbilirubinemia. However, such cases have occurred22
and have contributed to the current recommendations for routine early follow-up for all infants discharged before 72 hours.