prophylaxis in a sizable proportion of neonates in an average NICU; and it provides no information on cost-effectiveness. These data do suggest that flucon-azole can be safely used in VLBW infants (with ap-propriate concerns for drug-drug interactions), and that it can reduce rectal colonization. The authors plainly acknowledge that this study is preliminary and more work must be done. Their final conclusion is important and should be adhered to: routine flu-conazole prophylaxis is not presently justified in VLBW infants.
Michael N. Neely, MD*‡ John R. Schreiber, MD* Department of Pediatrics Case Western Reserve University *Division of Pediatric Infectious Diseases
‡Division of Pediatric Clinical Pharmacology and Critical Care
Rainbow Babies and Children’s Hospital Cleveland, OH 44106
REFERENCES
1. Edmond MB, Wallace SE, McClish DK, Pfaller MA, Jones RN, Wenzel RP. Nosocomial bloodstream infections in United States hospitals: a three-year analysis.Clin Infect Dis.1999;29:239 –244
2. Saiman L, Ludington E, Pfaller M, et al. Risk factors for candidemia in Neonatal Intensive Care Unit patients. The National Epidemiology of Mycosis Survey Study Group.Pediatr Infect Dis J.2000;19:319 –324 3. Kossoff EH, Buescher ES, Karlowicz MG. Candidemia in a neonatal
intensive care unit: trends during fifteen years and clinical features of 111 cases.Pediatr Infect Dis J.1998;17:504 –508
4. Kicklighter SD, Springer SC, Cox T, Hulsey TC, Turner RB. Fluconazole for prophylaxis against candidal rectal colonization in the very low birth weight infant.Pediatrics.2001;107:293–298
5. Pappu-Katikaneni LD, Rao KP, Banister E. Gastrointestinal colonization with yeast species and Candida septicemia in very low birth weight infants.Mycoses.1990;33:20 –23
6. Baley JE, Kliegman RM, Boxerbaum B, Fanaroff AA. Fungal coloniza-tion in the very low birth weight infant.Pediatrics.1986;78:225–232 7. Winston DJ, Pakrasi A, Busuttil RW. Prophylactic fluconazole in liver
transplant recipients. A randomized, double-blind, placebo-controlled trial.Ann Intern Med.1999;131:729 –737
8. Goodman JL, Winston DJ, Greenfield RA, et al. A controlled trial of fluconazole to prevent fungal infections in patients undergoing bone marrow transplantation.N Engl J Med.1992;326:845– 851. See comments 9. Eggimann P, Francioli P, Bille J, et al. Fluconazole prophylaxis prevents intra-abdominal candidiasis in high- risk surgical patients. Crit Care Med.1999;27:1066 –1072. See comments
10. Slavin MA, Osborne B, Adams R, et al. Efficacy and safety of flucon-azole prophylaxis for fungal infections after marrow transplantation—a prospective, randomized, double-blind study. J Infect Dis.1995;171: 1545–1552
11. Huang YC, Li CC, Lin TY, et al. Association of fungal colonization and invasive disease in very low birth weight infants.Pediatr Infect Dis J. 1998;17:819 – 822
12. Wenzl TG, Schefels J, Hornchen H, Skopnik H. Pharmacokinetics of oral fluconazole in premature infants.Eur J Pediatr.1998;157:661– 662 13. Schwarze R, Penk A, Pittrow L. Treatment of candidal infections with
fluconazole in neonates and infants.Eur J Med Res.2000;5:203–208 14. Groll AH, Piscitelli SC, Walsh TJ. Clinical pharmacology of systemic
antifungal agents: a comprehensive review of agents in clinical use, current investigational compounds, and putative targets for antifungal drug development.Adv Pharmacol.1998;44:343–500
15. Lacroix D, Sonnier M, Moncion A, Cheron G, Cresteil T. Expression of CYP3A in the human liver— evidence that the shift between CYP3A7 and CYP3A4 occurs immediately after birth.Eur J Biochem.1997;247: 625– 634
16. Saxen H, Hoppu K, Pohjavuori M. Pharmacokinetics of fluconazole in very low birth weight infants during the first two weeks of life.Clin Pharmacol Ther.1993;54:269 –277
17. el-Mohandes AE, Johnson-Robbins L, Keiser JF, Simmens SJ, Aure MV. Incidence of Candida parapsilosis colonization in an intensive care nursery population and its association with invasive fungal disease.
Pediatr Infect Dis J.1994;13:520 –524
18. Price MF, LaRocco MT, Gentry LO. Fluconazole susceptibilities of Can-dida species and distribution of species recovered from blood cultures over a 5-year period.Antimicrob Agents Chemother.1994;38:1422–1427 19. Huttova M, Hartmanova I, Kralinsky K, et al. Candida fungemia in
neonates treated with fluconazole: report of forty cases, including eight with meningitis.Pediatr Infect Dis J.1998;17:1012–1015
20. Driessen M, Ellis JB, Muwazi F, De Villiers FP. The treatment of sys-temic candidiasis in neonates with oral fluconazole.Ann Trop Paediatr. 1997;17:263–271
21. Driessen M, Ellis JB, Cooper PA, et al. Fluconazole vs. amphotericin B for the treatment of neonatal fungal septicemia: a prospective random-ized trial.Pediatr Infect Dis J.1996;15:1107–1112
What Lessons Should We Learn
From Drive-Through Deliveries?
ABBREVIATIONS. NMHPA, Newborns’ and Mothers’ Health Protection Act; SACIM, Secretary’s Advisory Committee on Infant Mortality; MCO, managed care organization.
T
he first victim of the managed care backlash was rapid postpartum discharge, more com-monly known as a “drive-through delivery.” The issue was framed as a morality play, with cor-porate greed on one side and the health and safety of mothers and infants on the other. When a few hor-rific anecdotes were added to this mix, legislators understandably concluded that drive-through deliv-eries were an abusive practice that needed to be halted. Between 1995 and 1997, 40-odd states and Congress enacted legislation requiring insurers to defer to physician preferences as to an appropriate postpartum length of stay, or to cover a minimum of 48 hours (vaginal delivery) or 96 hours (cesarean section) of postpartum hospitalization.1Physician groups and individual physicians played a major role in the enactment of these laws, through testimony, lobbying, and critical commen-tary in news articles and medical journals. In testi-mony before Congress, the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the American Medical Association denounced drive-through deliveries. Pediatrics pub-lished an inflammatory commentary titled Early Dis-charge in the End: Maternal Abuse, Child Neglect, and Physician Harassment,2 and the New England
Journal of Medicine published a slightly less inflam-matory piece titled Women and Children First.3This tone carried over into the political sphere; when legislation was debated in Congress, Senators from across the political spectrum condemned drive-through deliveries as “unconscionable” (Senators DeWine and Helms), and “scary” (Senator Biden), and suggested it was simply “common sense” for an insurance policy to include the mandated coverage
Received for publication Sep 25, 2000; accepted Sep 25, 2000.
Address correspondence to David A. Hyman, MD, JD, University of Mary-land School of Law, 515 W Lombard St, Baltimore, MD 21201. E-mail: [email protected]
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad-emy of Pediatrics.
(Senator Bradley).4Riding this tide of bipartisan en-thusiasm, the Newborns’ and Mothers’ Health Pro-tection Act (NMHPA) passed the Senate 98 – 0, and took effect on January 1, 1998.5
The result of this state and federal legislation was the immediate reversal of a steady 25-year trend of decreases in the length of postpartum hospitaliza-tion. Between 1970 and 1995, the length of a postpar-tum hospitalization declined from 3.9 days to 1.7 days after a vaginal delivery, and from 7.8 days to 3.6 days after a cesarean section.6 One-day stays ac-counted for 7.6% of vaginal deliveries in 1980, 21.2% of vaginal deliveries in 1990, and almost 47% of vaginal deliveries in 1995.7After legislation was en-acted, these trends reversed, and postpartum lengths of stay began increasing. In 1998, the latest year for which figures are available, average postpartum hos-pitalization in the United States was 2.1 days after a vaginal delivery and 3.7 days after a cesarean deliv-ery.7
The NMHPA required the Secretary of Health and Human Services to appoint an Advisory Panel to study the issue of postpartum care, and prepare pe-riodic reports on the subject. This issue ofPediatrics
includes a summary of the recommendations in the first interim report, prepared by the Secretary’s Ad-visory Committee on Infant Mortality (SACIM).8The report includes 5 recommendations and 8 questions requiring further study. The first 3 recommendations are the most critical ones; SACIM recommends that: 1) the policy focus should be broadened beyond length of stay to “the full range of preconception, prenatal, postnatal, and postpartum services needed for optimal health,” 2) the goal should be reframed from the prevention of rare and catastrophic events to “optimal newborn and maternal health in the short- and long-term,” and 3) we should focus on “ensur[ing] the delivery of health care needed after leaving the hospital, regardless of length of stay.” The report understatedly notes that it may prove difficult to implement these recommendations in a coverage and delivery market in which clinical effec-tiveness, patient satisfaction, and cost-effectiveness are important considerations.
The most interesting feature of the report is that it offers no praise for the coverage provisions man-dated by the NMHPA and analogous state legisla-tion. Although the report asserts that the NMHPA is an “important achievement,” it provides absolutely no evidence to support that claim. Indeed, the report implicitly criticizes the legislation for its focus on the number of hours of postpartum hospital care, instead of the “needs of the mother and newborn and . . . the content and quality of the care they receive.” If any-thing, the SACIM report is a striking repudiation of the tactics and goals of critics of drive-through de-liveries.
Consider the anecdotal bad outcomes that were used to make the case that legislation was necessary. The SACIM report is clear that the issue is not and should not be only the prevention of such “rare and catastrophic events.” Regardless, even if the focus is the prevention of such events, research has made it clear that extended postpartum hospitalizations as
such have at most a limited nexus with the detection and prevention of problems likely to result in a cat-astrophic event.9 –31 Extended postpartum hospital-ization is also a singularly inefficient way of address-ing the problem of maternal inexperience, which is an important factor in many of the bad outcomes.1
Worse still, because of the way the legislation was designed, it did nothing about the real issues at stake, including the availability of postdischarge ser-vices, the quality of services rendered before, during, and after postpartum hospitalization, the distortions created by hospitals’ use of per-diem pricing, and the manner in which managed care organizations (MCOs) make coverage decisions.1 The net result was thus the worst of all worlds—legislation that eliminates the incentive for MCOs to develop and cover appropriate postdischarge care and under-mines the incentives for them to engage in appropri-ately visible cost-containment, while simultaneously giving the public a false sense of security about the merits of the existing care and coverage—positions that are the precise opposite of what any sensible policy in this area should accomplish.
What lessons should we learn from drive-through deliveries? First, although sound bites are helpful in making the case for a policy change, they have a distinct tendency to crowd out the issue they were intended to dramatize. Once the problem was framed as “drive-through deliveries,” the real issues at stake never made it onto the policy agenda. Sec-ond, beware of quick fixes. Most policy issues are issues because they do not have an obviously “right” solution— or because the obvious solutions cause more problems than they solve. Third, be alert to the self-interest of those advocating policy changes. It was hardly a coincidence that most of the providers advocating for extended postpartum hospitalizations were in the business of providing hospital-based ser-vices—just as it was hardly a coincidence that a majority of the states excluded Medicaid recipients and state employees from the ambit of their legisla-tion.1,32Fourth, when legislators and the public look to the medical profession for guidance on such mat-ters, they are entitled to expertise—not political gamesmanship or self-interest masquerading as tech-nical knowledge. It is particularly troubling that rep-resentatives of the organized medicine used anec-dotes and personal testimonials to help make the case against drive-through deliveries when the avail-able empirical research did not support that position. Finally, legislators should consider mandating the preparation of postenactment reports, like the one contained in this issue of Pediatrics, as a matter of routine. Once the rhetoric and passions have cooled, a dispassionate look at the data can be quite produc-tive. In this instance, the SACIM report makes it clear that the NMHPA and analogous state legislation were aimed at the wrong target.
David A. Hyman, MD, JD
University of Maryland School of Law Baltimore, MD 21201
COMMENTARIES 407
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REFERENCES
1. Hyman, DA. Drive-through deliveries: is consumer protection just what the doctor ordered?N C Law Rev.1999;78:5–99
2. Charles S, Prystowsky B. Early discharge, in the end: maternal abuse, child neglect, and physician harassment.Pediatrics.1995;96:746 –747 3. Annas G. Women, and children first.N Engl J Med.1995;333:1647–1651. 4. 142 Cong Rec S9904-S9913 (daily ed. September 5, 1996)
5. Pub L No. 104-204, 110 Stat 2935, codified at 29 USCA 1185, 42 USCA 300gg-4, -51 (1996)
6. Curtin SC, Kozak LJ. Decline in US cesarean delivery rate appears to stall.Birth.1998;25:259 –262
7. Popovik JR, Kozak LJ. National Hospital Discharge Survey: Annual Summary, 1998. National Center for Health Statistics.Vital Health Stat. 2000;13(148)
8. Eaton AP. Early postpartum discharge: recommendations from a pre-liminary report to Congress.Pediatrics. 2001;107:000 – 000
9. Britton JR, Britton HL, Beebe SA. Early discharge of the term newborn: a continued dilemma.Pediatrics.1994;94:291–295
10. Beebe SA, Britton JR, Britton HL, Fan P, Jepson B. Neonatal mortality and length of newborn hospital stay.Pediatrics.1995;98:231–235 11. Braveman PA. Short hospital stay for mothers and newborns.J Fam
Pract.1996;42:523–525
12. Braveman P, Egerter S, Pearl M, Marchi K, Miller C. Early discharge of newborns and mothers: a critical review of the literature.Pediatrics. 1995;96:716 –726
13. Kessel W, Kiely M, Nora AH, Sumaya CV. Early discharge: in the end, it is judgment.Pediatrics.1995; 96:739 –742
14. Lee K, Perlman M, Ballantyne M, Elliot I, To T. Association between duration of neonatal hospital stay and readmission rate.J Pediatr.1995; 127:758 –766
15. Sinai LN, Kim SC, Casey R. Phenylketonuria screening: effect of early newborn discharge,Pediatrics. 1995; 96:605– 608
16. General Accounting Office.Maternity Care: Appropriate Follow-Up Ser-vices Critical With Short Hospital Stays. Washington, DC: General Ac-counting Office; 1996. Publ. No. GAO/HEHS-96-207
17. Soskolne EI, Schumacher R, Fyock C, Young ML, Schork A. The effect of early discharge and other factors on readmission rates of newborns. Arch Pediatr Adolesc Med.1996;150:373–379
18. Bragg EJ, Rosenn BM, Khoury JC, Miodovnik M, Siddiqi TA. The effect of early discharge after vaginal delivery on neonatal readmission rates. Obstet Gynecol.1997;89:930 –933
19. Braveman P, Kessel W, Egerter S, Richmond J. Early discharge and evidence-based practice: good science and good judgment.JAMA.1997; 278:334 –336
20. Edmonson MB, Stoddard JJ, Owens LM. Hospital readmission with feeding-related problems after early postpartum discharge of normal newborns.JAMA. 1997;278:299 –303
21. Gazmararian JA, Koplan JP, Cogswell ME, Bailey CM, Davis NA, Cutler CM. Maternity experiences in a managed care organization.Health Aff. 1997;16:198 –208
22. Grullon KE, Grimes DA. The safety of early postpartum discharge: a review and critique.Obstet Gynecol.1997;90:860 – 865
23. Liu LL, Clemens CJ, Shay DK, Davis RL, Nocavk AH. The safety of newborn early discharge: The Washington State Experience. JAMA. 1997;278:293–298
24. Maisels MJ, Kring E. Early discharge from the newborn nursery— effect on scheduling of follow-up visits by pediatricians.Pediatrics.1997;100: 72–74
25. Maisels MJ, Kring E. Length of stay, jaundice, and hospital readmission. Pediatrics.1998;101:995–998
26. Britton JR. Postpartum early hospital discharge and follow-up practices in Canada and the United States.Birth.1998;25:161–168
27. Marbella AM Chetty VK, Layde PM. Neonatal hospital lengths of stay, readmissions, and charges.Pediatrics.1998;101:32–36
28. Meikle SF, Lyons E, Hulac P, Orleans P. Rehospitalizations And outpa-tient contacts of mothers and neonates after hospital discharge after vaginal delivery.Am J Obstet Gynecol.1998;179:166 –171
29. Kotagal, UR, Atherton HD, Eshett R, Schoettker PJ, Perlstein PH. Safety of early discharge for Medicaid newborns.JAMA.1999;282:1150 –1156 30. Lock M, Ray JG. Higher neonatal morbidity after routine early hospital discharge: are we sending newborns home too early?Can Med Assoc J. 1999;161:249 –253
31. Danielsen B, Castles AG, Damberg CL, Gould JB. Newborn discharge timing and readmissions: California: 1992–1995.Pediatrics.2000;106:31–39 32. Declercq E, Simmes D. The politics of “drive-through deliveries”: put-ting early postpartum discharge on the legislative agenda. Milbank Q. 1997;75:175–202
Serious Firearm Injury Prevention
Does Make Sense
ABBREVIATIONS. AAP, American Academy of Pediatrics; ASK, Asking Saves Kids (campaign).
T
he policy statement “Firearm Injuries Affecting the Pediatric Population” that appeared in the April 2000 issue of this journal reaffirmed the position of the American Academy of Pediatrics (AAP) that firearm injuries and deaths in children represent a public health problem.1 Most impor-tantly, the statement outlined 2 effective measures to achieve absence of guns in the home.• A ban on handguns and semiautomatic weapons; and
• Anticipatory guidance by pediatricians, including asking questions about guns when obtaining pa-tient histories and urging parents who possess guns, especially handguns, to remove them from the home.
The support of these 2 measures was placed in the context of other violence prevention activities, sup-port for safety and design regulations that would treat guns as other consumer products, engineering efforts to decrease the chances that a child could fire a gun, and support for a national surveillance data system on morbidity and mortality associated with firearms.
The recent publication of Healthy People 2010
clearly cites the prevention of violence and injury as 1 of 5 health system indicators.2The Surgeon Gener-al’sReport on Youth Violence Preventionto be released later this year underscores the importance of vio-lence prevention.3For the first time, AAP recommen-dations for preventive pediatric health care list vio-lence prevention anticipatory guidance in the periodicity table, extending from the prenatal period through adolescence.4There can be no question that violence and its prevention are seen as part of the domain of physicians. Understandingly, however, the AAP policy statement on firearm injuries has raised many questions on the practicality of the pro-posed interventions.
DOES THE POLICY STATEMENT MAKE SENSE? The data provided by the policy statement clearly define the firearm injury problem as one of the lead-ing causes of death and injury for children; a prob-lem requiring a comprehensive approach to its pre-vention. The public health model is such an approach. Viewing gun violence as a public health problem requires problem definition, identification of risks, and suggestions for interventions and eval-uations. The public health approach to other injury
Received for publication Nov 13, 2000; accepted Nov 13, 2000.
Reprint requests to (D.L.) Mount Sinai School of Medicine, One Gustave L. Levy Pl, Box 1198, New York, NY 10029-6574.
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad-emy of Pediatrics.
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