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Comprehensive Follow-up Care and Life-Threatening Illnesses Among High-Risk Infants
A Randomized Controlled Trial
R. Sue Broyles, MD;
Jon E. Tyson, MD, MPH;
Elizabeth T. Heyne, MS, PA-C;
Roy J. Heyne, MD;
Jackie F. Hickman, RN;
Michael Swint, PhD;
Sally S. Adams, MS, RN, CPNP;
Linda A. West, RN, CPNP;
Nancy Pomeroy, PhD;
Patricia J. Hicks, MD;
Chul Ahn, PhD
JAMA. 2000;284:2070-2076.
Context Inner-city high-risk infants often receive limited and fragmented care, a problem that may increase serious illness.
Objective To assess whether access to comprehensive care in a follow-up clinic is cost-effective in reducing life-threatening illnesses among high-risk, inner-city infants.
Design Randomized controlled trial.
Setting and Participants A total of 887 very-low-birth-weight infants born in a Texas county hospital between January 1988 and March 1996 and followed up in a children's hospital clinic. One hundred four infants who became ineligible or died after randomization but before nursery discharge were excluded from the analysis.
Interventions Infants were randomly assigned to receive routine follow-up care (well-baby care and care for chronic illnesses; n = 441) or comprehensive care (which included the components of routine care plus care for acute illnesses, with 24-hour access to a primary caregiver; n = 446).
Main Outcome Measures Life-threatening illnesses (ie, causing death or hospital admission for pediatric intensive care) occurring between nursery discharge and age 1 year, assessed by blinded evaluators from inpatient charts and state Medicaid and vital statistics records; and hospital costs (estimated from department-specific cost-to-charge ratios).
Results Comprehensive care resulted in a mean of 3.1 more clinic visits and 6.7 more telephone conversations with clinic staff (P<.001 for both). One-year outcomes were unknown for fewer comprehensive-care infants than routine-care infants (9 vs 28; P = .001). Identified deaths were similar (11 in comprehensive care vs 13 in routine care; P = .68). The comprehensive-care group had 48% fewer life-threatening illnesses (33 vs 63; P<.001), 57% fewer intensive care admissions (23 vs 53; P = .003), and 42% fewer intensive care days (254 vs 440; P = .003). Comprehensive care did not increase the mean estimated cost per infant for all care ($6265 with comprehensive care and $9913 with routine care).
Conclusion Comprehensive follow-up care by experienced caregivers can be highly effective in reducing life-threatening illness without increasing costs among high-risk inner-city infants.
Author Affiliations: Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (Drs Broyles, Tyson, and Hicks and Ms Hickman); University of Texas-Houston School of Public Health (Drs Swint and Pomeroy); Children's Medical Center of Dallas (Mss Heyne, Adams, and West and Dr Heyne); and Department of Internal Medicine, University of Texas Houston Medical School (Dr Ahn). Dr Tyson is now director of the Center for Population Health and Evidence-Based Medicine, University of Texas-Houston.
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