Patient Satisfaction in a Managed Care Organization

ABSTRACT & COMMENTARY

To determine the relationship between postpartum length of stay after a normal vaginal delivery and patient satisfaction, Gazmararian and colleagues conducted a telephone survey of women enrolled in a large managed care organization with approximately 4.5 million members throughout the United States. The survey of 59 questions was completed by 5201 women—a response rate of 71.3%. Most of the study subjects were white, married, multiparous, of higher socioeconomic status, lived in the South, and were at least 25 years old. Just more than 60% of the women were discharged within 24 hours after a normal delivery, and nearly 95% went home with their infants. A postpartum stay more than 48 hours after delivery was most often associated with a medial complication of pregnancy such as hypertension and/or diabetes, labor lasting more than nine hours, or delivery of a preterm or low birthweight infant.

Most of the women believed their postpartum care could be improved. Nearly 61% stated that they did not receive enough information about important issues such as the normal physiologic and emotional changes expected after delivery, breast feeding and infant care, and warning signs indicating maternal or infant problems. More than half of the women, 56.4%, thought their postpartum stay was shorter than what was needed. Of mothers who were sent home within 24 hours, only one-third said that length of stay was "about right" When asked if they would be willing to go home within 24 hours after a future delivery, nearly 60% said they would if additional services were available including a 24-hour hotline, a follow-up home health visit or telephone call by a health care provider, and housekeeping services. The maternal length of stay was not statistically associated with maternal and newborn readmissions. Overall, only 4% of newborns were readmitted, the rate ranging from 2.9% for those women discharged after 48 hours to 4.4% for those women who went home within 24 hours. Only 1.6% of mothers were readmitted to the hospital. Women who were discharged within 24 hours after delivery were less likely to be readmitted (1.5%) as compared to women who went home more than 48 hours after delivery (2.9%).

Gazmararian et al conclude that, while most women feel that a postpartum stay of 24 hours is too short, they would be willing to go home within one day after delivery if important support services were provided. (Gazmararian JA et al. Health Affairs 1997;16:198-208.)

COMMENT BY STEVEN G. GABBE, MD

In response to increasing pressures by insurance companies to cut the costs of health care and reduce lengths of stay postpartum, 29 states and Congress have passed laws requiring managed care organizations to cover a 48-hour stay after a vaginal delivery and a 96-hour stay after a cesarean delivery. When this legislation was enacted, few studies were available to determine whether shorter lengths of stay were safe or met the needs of mothers and their infants. This important study by Gazmararian et al confirms that a length of stay less than 24 hours after a normal vaginal delivery is not associated with increased risks to the mother or newborn. Overall, only 1.6% of women and 4% of newborns were readmitted. On the other hand, most women said their length of stay was too short. Why? Most often, patients said they needed more rest; they did not feel well; they required more information on infant care and self-care; they did not have adequate support at home; and they did not feel comfortable caring for their infant. The additional services patients felt were necessary to be discharged within 24 hours centered on follow-up and availability of an around-the-clock telephone hotline to respond to their questions.

The characteristics of the patients who participated in this study must be kept in mind. They had received early and adequate prenatal care. Nearly all were married. Most were college educated and employed. Future research should focus on the impact of a short length of postpartum stay on outcomes for women and their infants from less advantaged socioeconomic groups.