Fifty percent of infants receive extended newborn care or are
taken to a hospital for inpatient or outpatient care (including
emergency room care) at least once in the first year of life.
Extended newborn care or later inpatient hospitalization other
than normal newborn care was experienced by 23 percent of Medicaid
and 13 percent of non-Medicaid infants. For 1993 this care resulted
in charges of $260 million for all infants and $147 million for
Medicaid infants.
The population for this report is Missouri resident live births.
Excluded were the four percent of births that took place in out-of-state
or military hospitals, or died within a week of birth. Services
provided to these infants were studied linking patient abstract
reports provided by hospitals to the Missouri Department of Health
to the appropriate birth certificate. Over 93 percent of records
could be linked. Hospital utilization data included are records
for admissions or visits that took place within a year of birth,
including all inpatient stays, except for newborn stays of less
than seven days, and outpatient services including emergency room
(ER) care, observation, outpatient surgery, CT scans, and magnetic
resonance imaging. Two common outpatient services notincluded
in this report are x-ray and laboratory services provided by a
hospital on an outpatient basis, where the recipient was not an
ER patient (e.g., a physician referral for chest x-rays).
Hospital services were classified as follows: 1) extended newborn
stay (seven days or more; 2) inpatient readmission, defined as
an inpatient hospitalization at any age following dismissal from
hospital care after birth; 3) ER visits; and 4) all other outpatient
visits. When an infant was transferred directly from one hospital
to another (e.g., a premature infant born at a community hospital
and transferred to a children's hospital), data from all hospitals
were collated and the infant was considered to have a single hospitalization.
Infants brought to the hospital as ER patients but admitted as
inpatients were counted as both ER and inpatients; the same was
true for other outpatient encounters that resulted in inpatient
admission (5.3 percent of infant ER visits and 1.1 percent of
other outpatient encounters resulted in inpatient admission).
In this report Medicaid statistics refer to Medicaid status at
birth, as reported on the birth certificate. This is not totally
reliable as an indicator of Medicaid status later in infancy,
since infants can gain or lose Medicaid eligibility, but its use
allows development of population-based statistics, and Medicaid
status at birth is highly consistent with principal payment source
listed in hospital records (85 percent agreement).
The number of admissions/visits by type of service, race, and
Medicaid status are presented in Table 1, with the number of times
each infant used each service. Extended newborn stays were required
for 4,461 (6.2 percent) of 72,119 births, more frequently for
black than white infants (10.2 vs. 5.3 percent), and for infants
of mothers who were on Medicaid at birth than non-Medicaid infants
(8.0 vs. 4.9 percent, respectively). Low birth weight (<2,500
g) infants accounted for over half of extended newborn stays.
There were 11,654 inpatient readmissions (16.2 per 100 births),
with black, Medicaid, and low-birth-weight births more likely
to be readmitted. Overall, 10.1 percent of infants born in 1993
were readmitted as inpatients one time in the first year of life
and 2.3 percent more than once.
Emergency room visits were by far the hospital service most frequently
used by infants. There were 71,195 ER visits, almost one per
birth; 42 percent of infants were seen in an ER in the first year
of life; 19.8 percent had one ER visit, 17.3 percent had 2-4 visits,
and 5.0 percent were taken to emergency rooms five or more times
within the first year.
There were 5,958 outpatients visits other than ER visits (8.3
per 100 births). This was the only service used more frequently
by white than black infants, and with similar frequency by Medicaid
and non-Medicaid infants.
Data on average and total charges, and average stay for inpatients,
are also listed in Table 1. Extended newborn stays averaged 21.7
days and $34,892 charge per stay, for a total of $155.6 million
in charges. Inpatient readmissions averaged 4.2 days and $6,980
per stay, for a total of $81.3 million in charges. ER visits
cost $219 on average, for a total of $15.6 million; other outpatient
visits averaged $1,309 per visit, for a total of $7.8 million.
Inpatient readmissions were concentrated among younger infants;
48 percent of readmissions were for infants younger than 3 months
and 70 percent for infants younger than 6 months. The age distribution
for ER and other outpatient encounters was relatively even by
age.
In addition to higher crude rates of inpatient and ER utilization
for black and Medicaid infants, higher crude ratesof inpatient
readmission and ER visits were also observed for infants whose
newborn hospitalization lasted seven days or longer (primarily
low birth weight infants and infants with birth defects), firstborn
infants, and infants whose mothers were less than 20 or unmarried,
had education less than 12 years, had late or no prenatal care
(beginning after the fourth month), smoked during pregnancy, or
lived in rural areas (outside the St. Louis, Kansas City, Springfield,
Columbia, St. Joseph, and Joplin metropolitan areas).
Because many of these factors are highly correlated, the tendency
to use inpatient readmission and ER services was examined by multivariate
logistic regression. In Table 2 the adjusted relative risk (RR)
for one or more inpatient readmissions and that for one or more
ER visits are presented for each variable listed above with a
95 percent confidence interval.
The factor associated with the highest RR of inpatient readmission
was extended newborn stay. After adjusting for other covariates,
infants whose initial hospitalization exceeded six days were 2.19
times as likely to have a subsequent admission than those with
shorter stays. The risk factors next in importance for readmission
were Medicaid status at birth (1.46) and rural residence (1.43).
Black infants had an adjusted RR of 1.17, statistically significant
but smaller than the crude difference between black and white
rates. Statistically significant increased risks for readmission
were also found for infants of teen mothers (1.28); mothers with
low education (1.28), unmarried mothers (1.17); and mothers who
smoked during pregnancy (1.13). After adjusting for all other
variables, firstborn infants had a lower risk of inpatient readmission
(0.77, or 23 percent less likely to be readmitted), while late
or no prenatal care was not a statistically significant risk factor
for inpatient readmission, because the 95 percent confidence interval
includes 1.0.
For ER visits, the highest RR was for Medicaid status at birth
(3.09). Black infants were 57 percent more likely to be treated
in an ER, and infants of teen mothers, unmarried mothers, and
mothers with low education had RRs of 1.42-1.45. Maternal smoking
in pregnancy was associated with a 30 percent higher risk for
one or more ER visit, and extended newborn stays with a 21 percent
increased risk. Small but statistically significant elevated
risks were also seen for firstborn infants (1.05 RR) and rural
residents (1.05). Afteradjusting for other covariates, infants
of women receiving late or no prenatal care were less likely to
be seen in an ER (0.86 RR, or 14 percent less likely).
Principal diagnosis for inpatient readmissions and ER visits is
presented in Table 3. Respiratory system diseases accounted for
40.9 percent of inpatient readmissions, primarily upper respiratory
infections, pneumonia, and influenza, and 10.6 percent of readmissions
had infectious and parasitic disease principal diagnoses. The
perinatal conditions diagnosis category included the principal
diagnoses of 9.3 percent of infant readmissions; this category
includes perinatal jaundice, prematurity, and respiratory conditions
and infections specific to the perinatal period. Birth defects
were the principal diagnosis for 6.8 percent of readmissions.
For emergency room visits, respiratory diseases were also the
leading principal diagnosis (32 percent), followed by otitis media
(20.2 percent). Infectious and parasitic diseases (8.6 percent)
and digestive system disorders (8.2 percent) were also important
causes of ER visits. Injuries and poisonings accounted for the
7.4 percent of ER visits, with 42 percent of these cases listing
a fall as the cause of injury.
These data suggest many hospital encounters by infants are preventable,
that in many cases the illness itself could be prevented, and
in other cases a lower level of care could adequately meet the
needs of sick infants.
Infants who begin life healthy have less need for hospital services
in the first year of life, as evidenced by lower risk for inpatient
readmission and ER visits among infants who did not require extended
newborn stays. Low maternal age and education and unmarried status
are associated with low birth weight and other indicators of newborn
morbidity and also with later hospital utilization. Smoking during
pregnancy (which may also indicate postnatal exposure to tobaccosmoke)
is certainly preventable, and is associated with increased newborn
and later morbidity. That some infants' illnesses could have
been treated in a physician's office at an earlier, less serious
stage before an ER visit or inpatient hospitalization became necessary
is a reasonable conjecture, but not demonstrable with available
data.
The data suggest that for many hospital encounters, particularly
ER visits, infants could have been treated in lower-level settings,
such as physician's offices or urgent care centers. Study of
the principal diagnoses assigned to ER visits indicates a high
proportion are for routine and relatively minor conditions, such
as otitis media and upper respiratory infection. Use of an emergency
room rather than a lower-level care setting may reflect real or
perceived lack of options for treatment, lack of a primary care
provider, inability to pay for services in another setting, or
over-estimation of the seriousness of an infant's illness. That
Medicaid and uninsured persons tend to depend upon emergency rooms
for routine, non-emergency care has been discussed elsewhere.1
High readmission rates among infants in rural areas suggests
that they have less access to some services that can be provided
in outpatient settings in urban areas.
Data included in this report are for infants born in 1993. Since
that time managed care, with its emphasis on obtaining services
from a primary care provider, has become an increasingly common
component of both Medicaid and private insurance plans. When
data for more recent births become available, the effect of managed
care can be studied, and may show significant changes in infant
utilization of hospital services.
1Gadomski, A, et al. Diverting Managed Care Medicaid Patients
From Pediatric Emergency Department Use. Pediatrics. 95
(2): 170-177. 1995.
Table 1
Hospital Utilization by Infants by Type of Service, Race,
Birth Weight, and Medicaid Status at Birth:
Missouri 1993 Birth Cohort
Rate per 100 births (Number)
| Extended Newborn Stay | Inpatient Readmission |
Emergency Room Visit | Other Outpatient Visit |
| Total Admissions/Visits |
| Total | 6.2 | (4,461) | 16.2 | (11,654) | 98.7 | (71,195) | 8.3 | (5,958) |
| White | 5.3 | (3,105) | 15.0 | (8,737) | 83.7 | (48,775) | 8.8 | (5,122) |
| Black | 10.2 | (1,284) | 22.0 | (2,766) | 170.3 | (21,506) | 6.0 | (762) |
| Non-Medicaid* | 4.9 | (2,093) | 11.4 | (4,843) | 44.0 | (18,730) | 8.2 | (3,476) |
| Medicaid* | 8.0 | (2,353) | 23.1 | (6,776) | 178.2 | (52,331) | 8.4 | (2,464) |
Normal birth
weight | 3.0 | (2,428) | 14.8 | (9,883) | 96.4 | (64,492) | 7.9 | (5,290) |
| Low birth weight | 46.5 | (2,023) | 33.9 | (1,770) | 128.4 | (6,695) | 12.8 | (666) |
| Admissions/Visits per Infant |
| None | 93.8 | (67,658) | 87.6 | (63,121) | 58.0 | (41,834) | 93.0 | (67,047)
|
| 1 | 6.2 | (4,461) | 10.1 | (7,292) | 19.8 | (14,295) | 6.3 | (4,545)
|
| 2-4 | -- | -- | 2.2 | (1,597) | 17.3 | (12,479) | 0.7 | (497)
|
| 5+ | -- | -- | 0.1 | (99) | 5.0 | (3,511) | 0.04 | (30)
|
| Average stay (days) | 21.7 | 4.2 | - | -
|
| Average charge | $34,892 | $6,980 | $219 | $1,309
|
| Total charges (millions) | $155.6 | $81.3 | $15.6 | $7.8
|
*Medicaid status at birth. Source of data is the birth certificate.
Table 2
Adjusted Relative Risk for One or More Inpatient Readmission and Emergency Room (ER)
Visits* for Selected Characteristics: Missouri 1993 Birth Cohort
| | Inpatient Readmission | Emergency Room Visit |
| Total Births | Adjusted Relative Risk | 95% Confidence Interval |
Adjusted Relative Risk | 95% Confidence Interval |
| Black | 12,630 | 1.17 | (1.09-1.25) | 1.57 | (1.50-1.65) |
| Extended newborn stay | 4,461 | 2.19 | (2.03-2.37) | 1.21 | (1.13-1.29) |
| Medicaid at birth | 29,362 | 1.46 | (1.38-1.55) | 3.09 | (2.97-3.22) |
| First born | 28,961 | 0.77 | (0.73-0.81) | 1.05 | (1.02-1.09) |
| Maternal characteristics at birth |
| Rural resident | 15,941 | 1.43 | (1.35-1.51) | 1.05 | (1.01-1.09)
|
| Age <20 | 10,257 | 1.28 | (1.20-1.38) | 1.45 | (1.37-1.54)
|
| Unmarried | 23,655 | 1.17 | (1.10-1.24) | 1.44 | (1.38-1.50)
|
| Education <12 | 14,730 | 1.28 | (1.20-1.35) | 1.42 | (1.35-1.49)
|
| Late/no prenatal care | 7,646 | 0.95 | (0.88-1.02) | 0.86 | (0.82-0.91)
|
| Smoker | 16,025 | 1.13 | (1.07-1.20) | 1.30 | (1.25-1.35)
|
| Total births | 72,119
|
*Risk of one or more inpatient readmission or ER visit for listed
characteristic in relation to births without that characteristic (e.g.,
risk for blacks compared to non blacks), after adjusting for all other
listed characteristics, using mulitvariate logistic regression.
Table 3
Inpatient Readmissions and Emergency Room Visits by Principal Diagnosis:
Missouri 1993 Birth Cohort
| Percent of Total (Number)
|
| Principal Diagnosis | Inpatient Readmission | Emergency Room Visit |
| All admissions | 100.0 | (11,654) | 100.0 | (71,195)
|
| Infectious and Parasitic Diseases | 10.6 | (1,238) | 8.6 | (6,099)
|
| Intestional infectious diseases | 2.7 | (309) | 1.7 | (1,225)
|
| Endocrine, Nutritional, Metabolic | 3.9 | (450) | 0.4 | (292)
|
| Volume depletion | 3.1 | (361) | 0.3 | (227)
|
| Nervous System & Sense Organs | 3.3 | (379) | 22.7 | (16,145)
|
| Otitis media | 1.2 | (138) | 20.2 | (14,365)
|
| Circulatory System | 0.6 | (72) | 0.2 | (145)
|
| Respiratory System | 40.9 | (4,769) | 32.0 | (22,785)
|
| Acute upper resp infections | 22.0 | 2,566) | 23.0 | (16,145)
|
| Pneumonia and influenza | 14.3 | (1,671) | 3.6 | (2,552)
|
| Chronic bronchitis & asthma | 3.3 | (380) | 2.5 | (1,808)
|
| Digestive System | 7.2 | (844) | 8.2 | (5,843)
|
| Noninfectious gastroenteritis | 2.5 | (296) | 4.9 | (3,465)
|
| Genitourinary System | 2.6 | (303) | 0.7 | (512)
|
| Skin & Subcutaneous Tissue | 0.9 | (109) | 3.1 | (2,199)
|
| Musculoskeletal | 0.2 | (26) | 0.2 | (131)
|
| Congenital Anomalies | 6.8 | (789) | 0.3 | (186)
|
| Perinatal Conditions | 9.3 | (1,082) | 1.4 | (996)
|
| Perinatal jaundice | 3.6 | (414) | 0.4 | (265)
|
| Ill-defined Conditions | 8.7 | (1,013) | 9.1 | (6,493)
|
| Fever | 2.9 | (339) | 2.7 | (1,912)
|
| Injury and Poisoning | 3.3 | (387) | 7.4 | (5,303)
|
| Other & Unknown Diagnosis | 1.7 | (193) | 5.7 | (4,066)
|
Provisional Vital Statistics for January 1997
LIVE BIRTHS increased slightly in January as 7,142 Missouri
babies were born compared with 6,963 one year earlier.
Cumulative births show a slight decrease for the 12 months ending
with January. However, provisional calendar year 1996 data indicates
a slight increase from 72,804 in 1995 to 73,600 in 1996.
DEATHS show little change between 1996 and 1997 figures.
Provisional 1996 deaths total 53,600 compared with 54,222 in
1995.
The NATURAL INCREASE for Missouri in January was 1,418
persons (7,142 births minus 5,724 deaths). This represents a
slight increase from 1,234 in January 1996.
MARRIAGES and DISSOLUTIONS OF MARRIAGE decreased
in January and also for the 12 months ending with January. Provisional
1996 figures show 45,000 marriages and 26,400 dissolutions for
a marriage to divorce ratio of 1.70.
INFANT DEATHS increased in January as 61 Missouri infants
died compared with 39 in January 1996. The provisional infant
death rate for 1996 was 7.5 per 1,000 live births compared with
7.4 in 1995.
Provisional Resident Vital Statistics for the State of Missouri
| January | 12 months ending with January |
Provisional |
|
| Item | Number | Rate* | Number | Rate* | 1996 |
| 1996 | 1997 | 1996 | 1997 | 1995 | 1996 | 1997 | 1994 | 1995 | 1996 | 1997 | Number | Rate |
| Live births | 6,963 | 7,142 | 15.3 | 16.1 | 74,704 | 73,486 | 72,722 | 14.8 | 14.2 | 13.8 | 13.6 | 73,600 | 13.7
|
| Deaths | 5,729 | 5,724 | 12.6 | 12.9 | 52,674 | 54,195 | 54,088 | 10.7 | 10.0 | 10.2 | 10.1 | 53,600 | 10.0
|
| Natural increase | 1,234 | 1,418 | 2.7 | 3.2 | 22,030 | 19,291 | 18,634 | 4.2 | 4.2 | 3.6 | 3.5 | 20,000 | 3.7
|
| Marriages | 2,835 | 2,657 | 6.2 | 6.0 | 45,013 | 45,977 | 44,728 | 8.4 | 8.5 | 8.6 | 8.3 | 45,000 | 8.4
|
| Dissolutions | 2,629 | 2,080 | 5.8 | 4.0 | 25,853 | 26,419 | 26,225 | 5.1 | 5.0 | 5.0 | 4.8 | 26,400 | 4.9
|
| Infant deaths | 39 | 61 | 5.5 | 7.2 | 600 | 534 | 578 | 8.6 | 8.0 | 7.3 | 7.9 | 550 | 7.5
|
Population base
(in thousands) | -- | -- | 5,359 | 5,395 | -- | -- | -- | 5,237 | 5,279 | 5,322 | 5,362 | -- | 5,359
|
*Rates for live births, deaths, natural increase, marriages and
dissolutions are computed on the number per 1000 estimated population.
The infant death rate is based on the number of infant deaths per 1000
live births. Rates are adjusted to account for varying lengths of
monthly reporting periods.
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