Discharge Against Medical Advice in the United States, 2002-2011

Trends and predictors of leaving before medically advised in US emergency departments from 2016 to 2021

BACKGROUND

Leaving before medically advised (BMA) is a significant issue in the US healthcare system, leading to adverse health outcomes and increased costs. Despite previous research, multi-year studies using up-to-date nationwide emergency department (ED) data, are limited. This study examines factors associated with leaving BMA from EDs and trends over time, before and during the COVID-19 pandemic.

METHODS

We conducted a pooled, cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2021. Multivariable logistic regression and interrupted time series (ITS) analyses were used to identify factors associated with leaving BMA and to examine trends over time, respectively.

RESULTS

Out of 721.0 million ED visits, 5.9 million (0.8 %) resulted in leaving BMA. Factors associated with higher odds of leaving BMA included public or no insurance coverage (Medicare: AOR = 1.74, 95 % CI = 1.12-2.70; Medicaid/CHIP/State-based: AOR = 1.86, 95 % CI = 1.40-2.45; Uninsured/Self-pay: AOR = 1.51, 95 % CI = 0.99-2.29), alcohol or substance use disorders (AOR = 2.19, 95 % CI = 1.77-2.70), arrival by ambulance (AOR = 1.68, 95 % CI = 1.31-2.15), and being male (AOR = 1.32, 95 % CI = 1.09-1.62). Conversely, hospital admissions (AOR = 0.11, 95 % CI = 0.05-0.21) and trauma or overdose related visits (AOR = 0.54, 95 % CI = 0.44-0.67) were associated with lower odds of leaving BMA. The COVID-19 pandemic significantly increased the odds of leaving BMA (AOR = 1.44, 95 % CI = 1.06-1.95), with an overall increase of 53.6 % in BMA-related ED visits observed post-March 2020 relatively to the previous years, particularly in the fourth quarters of 2020 and 2021 and second and third quarters of 2020.

CONCLUSIONS

In this study, several demographics, socio-economic, and clinical characteristics were associated with higher incidences of leaving ED BMA. The COVID-19 pandemic also exacerbated BMA rates. These findings highlight the need for targeted interventions to improve patient-provider communication and ED triage efficiency, especially in resource-constrained facilities serving lower-income individuals.

Leaving Against Medical Advice: What's a Nurse to Do?

ABSTRACT

Each year approximately 1% to 2% of patient acute care discharges in United States hospitals are described as against medical advice (AMA). AMA discharges are associated with higher patient morbidity, increased risk of readmission, and higher mortality. Most discussions dealing with AMA discharge tend to focus on physicians. However, nurses have a pivotal role in the care process and in ensuring the safety of patients. The aim of this paper is to increase awareness regarding nurses' ethical responsibilities when confronting AMA discharges. We highlight nurses' leadership role in discharge planning and argue that they have moral obligations to promote as safe a discharge as possible. Such obligations are consistent with nursing codes of ethics, according to which nurses have a primary moral duty to promote patients' well-being. Moreover, nurses' training, expertise, and scope of practice place them in an ideal situation to address problems related to AMA discharges. We also offer suggestions that can contribute to helping nurses to fulfill their ethical responsibilities in this context.

Discharge Against Medical Advice Among Schizophrenia Patients in Germany: A Multicenter Cross-Sectional Study

BACKGROUND

The objective of this study was to investigate the prevalence of discharge against medical advice (DAMA) among schizophrenia patients in Germany and to identify factors associated with the risk of DAMA.

METHODS

This multicenter cross-sectional study was based on data from the IQVIA hospital database, which contains records from 36 hospitals across Germany. This study included all hospitalizations for patients with a primary or secondary diagnosis of schizophrenia between January 2019 and December 2023. Multivariable logistic regression analyses adjusted for age, sex, primary or secondary schizophrenia diagnosis, as well as codiagnoses, were conducted to assess the associations between demographic and clinical variables and DAMA.

RESULTS

A total of 7663 hospitalization cases (mean age: 49.5 years, 40.6% female) were included in the study. The DAMA rate was 31.1% in patients with schizophrenia as the primary diagnoses and 6.0% in patients with schizophrenia as a secondary diagnosis. Younger age (i.e., adjusted odds ratio (aOR): 7.44; 95% CI: 4.35-12.73 in the age group 18-30; aOR: 6.63; 95% CI: 3.89-11.29 in the age group 31-40; aOR: 5.59; 95% CI: 3.28-9.54 in the age group 41-50), schizophrenia as the primary diagnosis (aOR: 3.61; 95% CI: 3.05-4.26), alcohol-related disorders (aOR: 1.68; 95% CI: 1.38-2.04), and cannabis-related disorders (aOR: 1.43; 95% CI: 1.18-1.72) were significantly associated with an increased risk of DAMA.

CONCLUSIONS

This study highlights the high prevalence of DAMA among hospitalized schizophrenia patients and identifies the important factors (i.e., younger age, alcohol-related disorders, and cannabis-related disorders) associated with DAMA risk. Additional studies are recommended for further exploration into the reasons for DAMA.

Early Leaves from Inpatient Care Among Individuals with Traumatic Life Events in Ontario, Canada

Psychological trauma is a prevalent mental health concern, with most individuals experiencing at least one traumatic event in their lifetime. Early leaves from inpatient settings are a pertinent challenge among persons who have experienced trauma and may reflect unmet care needs. This study examined patterns of early leaves among persons with trauma from inpatient care in Ontario, Canada. All records for individuals who have experienced trauma with an index admission of over 72 h between January 1, 2015 and December 31, 2019 were included (N = 11,043). Logistic regression using generalized equation estimation was used to assess the association between demographic and clinical characteristics, substance use, social relationships, staff dynamics, and control interventions with the outcome of early leaves. In the final model, alcohol (OR: 1.83, 95% CI: 1.27-2.64), other substances (OR: 2.15, 95% CI: 1.34-3.46), and poly substance use (OR: 2.46, 95% CI: 1.82-3.31) all increased the odds of early leaves after considering possible facility effects, and after adjusting for other demographic and clinical factors. Being older, employed, and having mood disorders reduced odds of early leaves. Early leaves are important within treatment planning, particularly in relation to addressing complex traumas. While challenges related to substance use may be driving some of the early leaves, there may also be challenges to providing complex care within acute mental health settings. Further exploration of policies and practices to prevent early leaves are necessary, including the potential need for longer-term specialized treatment programs.

Patients Discharged "Against Medical Advice" More than Once: A Cross-Sectional Descriptive Analysis of a Vulnerable Population

BACKGROUND

Patients who have been discharged "against medical advice" (AMA) are at increased risk of morbidity and mortality, but there is little research about patients who have had more than one AMA discharge.

OBJECTIVE

We aimed to describe the socio-demographic and clinical characteristics of patients with more than one AMA discharge.

DESIGN

We conducted a cross-sectional, retrospective chart review of a sample of adult patients who were discharged AMA more than once between 2016 and 2021 and abstracted detailed characteristics of this sample.

PATIENTS

A total of 81 patients were discharged AMA more than once during the study period.

MAIN MEASURES

We reviewed demographics, health insurance, substance use and mental health diagnoses, psychiatric consultations, documentation of prior AMA discharges, admitting medical service, length of stay, number of hospitalizations during the study period, and readmission within 30 days of the first AMA discharge. We also noted the presence of relevant psychosocial stressors.

KEY RESULTS

Among 81 patients reviewed, the average age was 41 years (range 19-76). Most were unmarried (n = 72, 89%) and most had public insurance or were uninsured (n = 74, 91%). More than half (n = 52, 64%) had a readmission within 30 days. The average number of hospitalizations in the study period was 10 (range 2-47). These patients had a high burden of psychosocial stressors including financial stress (56, 69%), housing insecurity (n = 40, 49%), and grief or loss of social support (n = 20, 25%).

CONCLUSIONS

Patients who have been discharged AMA more than once represent a vulnerable population with significant unmet needs.

Medical Detention of Incapacitated Patients

Inpatients with impaired decision-making capacity may attempt to leave the hospital prematurely. When no surrogate decision-maker is available, clinical teams often lack a legal basis to keep these patients. Provisions for emergency treatment and involuntary psychiatric holds are unsuitable and insufficient to address the problem. Clinicians need explicit legal authority to temporarily detain and treat incapacitated and unrepresented patients. Physician and hospital associations should lobby state legislatures to create new statutes for medical incapacity modeled after mental health laws.

Incidence of Discharge Against Medical Advice in Queensland Hospital Emergency Departments Among Indigenous Patients from 2016 to 2021

BACKGROUND

The incidence of discharge against medical advice (DAMA) in emergency departments (EDs) among Indigenous people is a growing concern in Australia. This study aimed to determine the incidence of ED DAMA in public hospitals in Queensland (QLD) from 2016 to 2021 and investigate the disparities in ED DAMA between Indigenous and non-Indigenous patients. The study also assessed the impact of the COVID-19 pandemic on the incidence of ED DAMA.

METHODS

A descriptive epidemiological study was conducted using aggregated data from QLD public hospital EDs. The data was retrieved from Clinical Excellence QLD, Healthcare Improvement Unit, in the QLD Health Open Data Portal for the period 1 January 2016 to 31 December 2021. Incidence rates and unadjusted odds ratios were calculated and compared using the chi-square test to identify differences between Indigenous and non-Indigenous patients.

RESULTS

The annual incidence of DAMA in EDs was 7.7% among Indigenous patients, compared to 4.8% among non-Indigenous patients, with the highest rate (8.9%) reported in 2021 among Indigenous patients. The incidence of ED DAMA was higher for Indigenous patients in major cities (20.0%) than in very remote areas (7.4%). Patients in triage categories 4 (10.0%) and 3 (7.3%) accounted for the vast majority of ED DAMA events among Indigenous patients. The acute group A hospitals had the highest incidence of ED DAMA (10.9% for Indigenous patients and 6.5% for non-Indigenous patients). The COVID-19 pandemic had no impact on the incidence of ED DAMA.

CONCLUSION

Indigenous patients experience a disparity in ED DAMA incidence. Addressing this issue requires collaborative efforts from healthcare providers, policymakers, and community organizations.

Leaving Against Medical Advice From Children's Hospitals

BACKGROUND

Leaving the hospital against medical advice (AMA) reflects a breakdown in the family-clinician relationship and creates ethical dilemmas in inpatient pediatric care. There are no national data on frequency or characteristics of leaving AMA from US children's hospitals.

METHODS

We performed a retrospective cohort study of hospital discharges for children under 18 years old from January 1, 2018 to December 31, 2022 in 43 children's hospitals in the Pediatric Health Information System (PHIS) database. The primary outcome was leaving AMA. Exposures were demographic, geographic, and clinical characteristics. We used multivariable mixed effects logistic regression models to assess independent factors associated with leaving AMA and all-cause 14-day hospital readmission.

RESULTS

Among 3 672 243 included inpatient encounters, 2972 (0.08%) ended in leaving AMA. Compared with non-Hispanic white patients, non-Hispanic Black patients had higher odds of leaving AMA (adjusted odds ratio [aOR] 1.31 [95% confidence interval (CI) 1.19-1.44]), whereas Hispanic patients (aOR 0.66 [95% CI 0.59-0.75]) had lower odds of leaving AMA. Hospitalizations for patients with noncommercial insurance were more likely to end in leaving AMA. Leaving AMA was associated with increased odds of 14-day inpatient readmission (aOR 1.41 [95% CI 1.24-1.61]) compared with patients who did not leave AMA. There was substantial interhospital variability in standardized rates of leaving AMA (range 0.18-2.14 discharges per 1000 inpatient encounters).

CONCLUSIONS

Approximately 1 in 1235 inpatient encounters ended in leaving AMA. Non-Hispanic Black patients had increased odds of leaving AMA. Leaving AMA was associated with increased odds of 14-day readmission.

In-hospital outcomes in people with autism and epilepsy - A population-based study

Autism is a common comorbid diagnosis in those with epilepsy. Understanding the health needs and outcomes in patients with this dual diagnosis is important for optimizing healthcare outcomes. We compared hospital-level variables amongst patients with co-occurring autism and epilepsy, to those with epilepsy alone. Non-elective hospital admissions amongst patients with epilepsy alone and co-occurring autism and epilepsy were identified in the 2003-14 National Inpatient Sample (NIS) using previously validated ICD-9-CM case definitions. One patient with co-occurring epilepsy and autism was matched to three epilepsy patients for age and sex. Multinomial logistic regressions were performed to examine outcomes of interest. Compared to those with epilepsy alone (n = 27,762), patients with autism and epilepsy (n = 9254) had a higher odds of transfer to another facility (OR = 1.09, p = 0.048), in-hospital mortality (OR = 1.36, p = 0.011), longer mean length of stay (5.63 days vs. 5.12 days, p < 0.0001), and septicemia (4.21 % vs. 3.08 %, p < 0.0001). Distributions of demographics, insurance type, socioeconomic status, and comorbidities significantly differed between both groups. Our findings demonstrate that patients with comorbid autism and epilepsy are a unique population with health outcomes significantly differing from those with epilepsy alone. Given the effect that dual diagnosis has on hospital trajectory, focused treatment plans must be adopted to optimize care and hospital outcomes in these patients.

Discharge Against Medical Advice: The Causes, Consequences and Possible Corrective Measures

Patients who discharge themselves against medical advice comprise 1%-2% of hospital admissions. Discharge against medical advice (DAMA) is defined as when a hospitalised patient chooses to leave the hospital before the treating medical team recommends discharge. The act of DAMA impacts on both the patient, the staff and their ongoing care. Specifically, this means that the patient's medical problems maybe inadequately assessed or treated. Patients who decide to DAMA tend to be young males, from a lower socioeconomic background and with a history of mental health or substance misuse disorder. DAMA has an associated increased risk of morbidity and mortality. In this review of studies across Western healthcare settings, specifically adult medical inpatients, we will review the evidence and seek to address the causes, consequences and possible corrective measures in this common scenario.

Risk Factors for Leaving Against Medical Advice in Patients Admitted for Upper Extremity Orthopedic Procedures

INTRODUCTION

Patients who leave against medical advice (AMA) face increased risks of negative health outcomes, presenting a challenge for healthcare systems. This study examines demographic and hospital course factors associated with patients leaving AMA after an upper extremity (UE) orthopaedic procedure.

METHODS

We analyzed 262,912 patients who underwent UE orthopaedic procedures between 2011 and 2020, using the Healthcare Cost and Utilization Project database. We then compared demographic and hospital course factors between patients who left AMA and those who did not leave AMA.

RESULTS

Of 262,912 UE orthopaedic patients, 0.45% (1,173) left AMA. Those more likely to leave AMA were aged 30 to 49 (OR, 5.953, P < 0.001), Black (OR, 1.708, P < 0.001), had Medicaid (OR, 3.436, P < 0.001), and were in the 1st to 25th income percentile (OR, 1.657, P < 0.001). Female patients were less likely to leave AMA than male patients (OR, 0.647, P < 0.001). Patients leaving AMA had longer stays (3.626 versus 2.363 days, P < 0.001) and longer recovery times (2.733 versus 1.977, P < 0.001).

CONCLUSION

We found that male, Black, younger than 49 years old, Medicaid-insured, and lowest income quartile patients are more likely to leave AMA after UE orthopaedic treatment.

Factors associated with pediatric trauma patients leaving against medical advice

BACKGROUND

Discharge against medical advice (AMA) leads to worse patient outcomes, increased readmission rates, and higher cost. However, AMA discharge has received limited study, particularly in pediatric trauma patients. Our objective was to explore the risk factors associated with leaving AMA in pediatric trauma patients.

METHODS

We performed a retrospective analysis on pediatric trauma patients from 2017 to 2019 using the National Trauma Data Bank. We examined patient characteristics including age (<18 years), race, sex, Glasgow Coma Scale, trauma type, primary payment methods, and Abbreviated Injury Scale. Multiple Logistic Regression models were utilized to determine characteristics associated with leaving AMA.

RESULTS

Of the 224,196 pediatric patients included in the study, 238 left AMA (0.1%). Our study showed black pediatric trauma patients were more likely to leave AMA compared to nonblack patients (OR 1.987, 95% CI 1.501 to 2.631). Patients with self-pay coverage were more likely to leave AMA than those with other insurance coverages (OR 1.759, 95% CI 1.183 to 2.614). Blunt trauma patients were more likely to leave AMA than those with penetrating trauma (OR 1.683, 95% CI 1.216 to 2.330). Every one-year increase in age led to 15% increase in odds of AMA discharge (OR 1.150, 95% CI 1.115 to 1.186). Pediatric patients with severe abdominal injuries were less likely to leave AMA compared to those with mild abdominal injuries (OR 0.271, 95% CI 0.111 to 0.657). Patients with severe lower extremity injury were less likely to leave AMA compared to those with mild lower extremity injuries (OR 0.258, 95% CI 0.127 to 0.522).

CONCLUSION

Race, insurance, injury type, and age play a role in AMA discharge of pediatric trauma patients. Black pediatric trauma patients have ∼ double the AMA discharge rate of nonblack patients. AMA discharge remains relevant, and addressing racial and socioeconomic factors provide opportunities for future interventions in pediatric trauma care.

LEVEL OF EVIDENCE

III, retrospective study.

Quantitative Analysis of Characteristics Associated with Patient-Directed Discharges, Representations, and Readmissions: a Safety-Net Hospital Experience

BACKGROUND

No clinical tools currently exist to stratify patients' risks of patient-directed discharge (PDD).

OBJECTIVE

This study aims to identify trends and factors associated with PDD, representation, and readmission.

DESIGN

This was an IRB-approved, single-centered, retrospective study.

PARTICIPANTS

Patients aged > 18, admitted to medicine service, were included from January 1st through December 31st, 2019. Patients admitted to ICU or surgical services were excluded.

MAIN MEASURES

Demographics, insurance information, medical history, social history, rates of events occurrences, and discharge disposition were obtained.

KEY RESULTS

Of the 16,889 encounters, there were 776 (4.6%) PDDs, 4312 (25.5%) representations, and 2924 (17.3%) readmissions. Of those who completed PDDs, 42.1% represented and 26.4% were readmitted. Male sex, age ≤ 45, insurance type, homelessness, and substance use disorders had higher rates of PDD (OR = 2.0; 4.2; 4.5; 6.2; 5.2; p < 0.0001, respectively). Patients with homelessness, substance use disorders, mental health disorders, or prior history of PDD were more likely to represent (OR = 3.6; 2.0; 2.0; 1.5; p < 0.0001, respectively) and be readmitted (OR = 2.2; 1.6; 1.9; 1.5; p < 0.0001, respectively). Patients aged 30-35 had the highest PDD rate at 16%, but this was not associated with representations or readmissions. Between July and September, the PDD rate peaked at 5.5% and similarly representation and readmission rates followed. The rates of subsequent readmissions after PDDs were nearly two-fold compared to non-PDD patients in later half of the year. 51% of all subsequent readmissions occur within 7 days of PDD, compared to 34% in the non-PDD group (OR = 2.0; p < 0.0001). Patients with primary diagnosis of abscess had 16% PDDs.

CONCLUSIONS

Factors associated with PDD include male, younger age, insurance type, substance use, homelessness, and primary diagnosis of abscess. Factors associated with representation and readmission are homelessness, substance use disorders, mental health disorders, and prior history of PDD. Further research is needed to develop a risk stratification tool to identify at-risk patients.

A 15-year review of characteristics and outcomes of patients leaving against medical advice

PURPOSE

Discharging against medical advice can have significant, detrimental effects on burn patient outcomes as well as higher hospital readmission rates and healthcare expenditures. The goal of this study is to identify characteristics of patients who left against medical advice and suggest solutions to mitigate these factors. Data were collected at our American Burn Association verified Burn Unit over a 15-year period.

RESULTS

Between 2007 and 2022, 37 patients were identified as having left against medical advice from the burn unit. The average patient age was 37 years old with 64.9% being male, and 70.2% were identified as having a substance abuse history. The majority (51.4%) had Medicaid or State health insurance, 29.7% had no insurance, and 18.9% had private insurance. The mechanism of injury was most commonly frostbite (43.2%). The majority sustained < 1% total body surface area injuries. Most (83.7%) had social work and/or case management involved during their admission, and all (100%) had their involvement if the length of admission was greater than one day. Over half (59.5%) returned to the ED within 2 weeks with complications.

CONCLUSIONS

This study found that patients discharging against medical advice from the burn unit suffered from smaller injuries, often due to cold related injuries. These patients had comorbid substance abuse or psychiatric histories, and the majority had Medicaid or state health insurance. Recruiting interdisciplinary care members, including social work, psychiatry, and addiction medicine, early may help these patients by encouraging completion of their hospital care and setting up crucial follow-up care.

Discharges against medical advice: time to take another look. A retrospective review of discharges against medical advice focused on prevention

BACKGROUND

Discharges against medical advice (DAMA) increase the risk of death.

METHODS

We retrieved DAMA from five hospitals within a large health system and reviewed 10% of DAMA from the academic site between 2016 and 2021.

RESULTS

DAMA increased at the onset of the pandemic. Patients who discharged AMA multiple times accounted for a third of all DAMA. Detailed review was completed for 278 patients who discharged AMA from the academic site. In this sample, women comprised 52% of those who discharged AMA multiple times. Relative to the proportion of all discharges from the academic site during the study period, Black patients were overrepresented among DAMA (21% vs. 34%, p < .05). Patients with multiple AMA discharges were younger, more likely to be unmarried, or have substance use disorders (SUD) than those who discharged AMA once. The most common reason for requesting premature discharge noted in n = 77, 28% of instances was related to patient obligations outside the hospital. Hospital policies and procedures contributed in n = 29, 10% of instances. Reasons for requesting premature discharge and documentation of key safety processes were similar by gender and race however the sample may be underpowered to detect differences. Capacity was evaluated in 109 (39%). Among those who consumed alcohol (n = 81 (29%)) or had SUDs (n = 112 (40%)), information on the amount or timing of last use was missing in n = 39 (48%) and n = 74 (66%), respectively. Critical tools to manage illness were provided in 45 (16%) of DAMA reviewed.

CONCLUSIONS

Drivers of AMA discharge may differ by AMA discharge frequency. Recognition of the common reasons for requesting premature discharge may help destigmatize AMA discharges and also identifies early assessments by social work colleagues as an important prevention strategy. Opportunities also exist in anticipating and preventing withdrawal symptoms and in revising hospital practices that contribute to DAMA.

Self-discharge during treatment for acute recreational drug toxicity: an observational study from emergency departments in seven European countries

BACKGROUND

Self-discharge is a risk factor for readmission and excess mortality. We assess the rate of self-discharge from the emergency department (ED) among presentations for acute recreational drug toxicity and identify factors associated with self-discharge.

METHODS

From the Euro-DEN Plus database of presentations to the ED with acute recreational drug toxicity, we extracted data from 11 centres in seven European countries from 2014 to 2017. Self-discharge was defined as taking one's own discharge or escaping from the ED before being medically cleared. We used multiple logistic regression analyses to look for factors associated with self-discharge.

RESULTS

Among 15,135 included presentations, 1807 (11.9%) self-discharged. Self-discharge rates varied from 1.7 to 17.1% between centres. Synthetic cannabinoids were associated with self-discharge, adjusted odds ratio 1.44 (95% confidence interval 1.10-1.89), as were heroin, 1.44 (1.26-1.64), agitation, 1.27 (1.10-1.46), and naloxone treatment, 1.27 (1.07-1.51), while sedation protected from self-discharge, 0.38 (0.30-0.48).

CONCLUSION

One in eight presentations self-discharged. There was a large variation in self-discharge rates across the participating centres, possibly partly reflecting different discharge procedures and practices. Measures to improve the management of agitation and cautious administration of naloxone to avoid opioid withdrawal symptoms may be approaches worth exploring to reduce self-discharge.

The Color of Autonomy: Examining Racial Inequity in Coercive Institutional Practices

Two articles recently published in this journal identified racial inequities in routine psychiatric practice. This Open Forum discusses the need for a paradigm shift in inequities research. The two articles reviewed here, one by Shea and colleagues on racial-ethnic inequities in inpatient psychiatric civil commitment and one by Garrett and colleagues on racial-ethnic disparities in psychiatric decisional capacity consultations, are examples of the new research gaze. Four topics are identified for enhancing understanding of racism and other forms of structural exclusion in psychiatric practice: medical authority and power imbalance between providers and patients, involuntary psychiatric commitment and requests for decisional capacity consultations as strategic research events, limited use of theory, and limitations of the literature on psychiatric inequities.

Race and Ethnicity and Emergency Department Discharge Against Medical Advice

Importance

Although discharges against medical advice (DAMA) are associated with greater morbidity and mortality, little is known about current racial and ethnic disparities in DAMA from the emergency department (ED) nationally.

Objective

To characterize current patterns of racial and ethnic disparities in rates of ED DAMA.

Design, Setting, and Participants

This cross-sectional study used data from the Nationwide Emergency Department Sample on all hospital ED visits made between January to December 2019 in the US.

Main Outcomes and Measures

The main outcome was odds of ED DAMA for Black and Hispanic patients compared with White patients nationally and in analysis adjusted for sociodemographic factors. Secondary analysis examined hospital-level variation in DAMA rates for Black, Hispanic, and White patients.

Results

The study sample included 33 147 251 visits to 989 hospitals, representing the estimated 143 million ED visits in 2019. The median age of patients was 40 years (IQR, 22-61 years). Overall, 1.6% of ED visits resulted in DAMA. DAMA rates were higher for Black patients (2.1%) compared with Hispanic (1.6%) and White (1.4%) patients, males (1.7%) compared with females (1.5%), those with no insurance (2.8%), those with lower income (<$27 999; 1.9%), and those aged 35 to 49 years (2.2%). DAMA visits were highest at metropolitan teaching hospitals (1.8%) and hospitals that served greater proportions of racial and ethnic minoritized patients (serving ≥57.9%; 2.1%). Odds of DAMA were greater for Black patients (odds ratio [OR], 1.45; 95% CI, 1.31-1.57) and Hispanic patients (OR, 1.16; 95% CI, 1.04-1.29) compared with White patients. After adjusting for sociodemographic characteristics (age, sex, income, and insurance status), the adjusted OR (AOR) for DAMA was lower for Black patients compared with the unadjusted OR (AOR, 1.18; 95% CI, 1.09-1.28) and there was no difference in odds for Hispanic patients (AOR, 1.03; 95% CI, 0.92-1.15) compared with White patients. After additional adjustment for hospital random intercepts, DAMA disparities reversed, with Black and Hispanic patients having lower odds of DAMA compared with White patients (Black patients: AOR, 0.94 [95% CI, 0.90-0.98]; Hispanic patients: AOR, 0.68 [95% CI, 0.63-0.72]). The intraclass correlation in this secondary analysis model was 0.118 (95% CI, 0.104-0.133).

Conclusions and Relevance

This national cross-sectional study found that Black and Hispanic patients had greater odds of ED DAMA than White patients in unadjusted analysis. Disparities were reversed after patient-level and hospital-level risk adjustment, and greater between-hospital than within-hospital variation in DAMA was observed, suggesting that Black and Hispanic patients are more likely to receive care in hospitals with higher DAMA rates. Structural racism may contribute to ED DAMA disparities via unequal allocation of health care resources in hospitals that disproportionately treat racial and ethnic minoritized groups. Monitoring variation in DAMA by race and ethnicity and hospital suggests an opportunity to improve equitable access to health care.

Discharge Against Medical Advice After Hospitalization for Sepsis: Predictors, 30-Day Readmissions, and Outcomes

BACKGROUND

Sepsis is a leading cause of death worldwide. However, little has been known concerning the status of discharge against medical advice (DAMA) in sepsis patients.

OBJECTIVE

To identify factors associated with DAMA, evaluate the association of DAMA with 30-day unplanned readmission and readmitted outcomes after sepsis hospitalization.

METHODS

Using the National Readmission Database, we identified sepsis patients who discharged routinely or DAMA in 2017. Multivariable models were used to identify factors related to DAMA, evaluate the association between DAMA and readmission, and elucidate the relationship between DAMA and outcomes in patients readmitted within 30 days.

RESULTS

Among 1,012,650 sepsis cases, patients with DAMA accounted for 3.88% (n = 39,308). The unplanned 30-day readmission rates in patients who discharged home and DAMA were 13.08% and 27.21%, respectively. Predictors of DAMA in sepsis included Medicaid, diabetes, smoking, drug abuse, alcohol abuse, and psychoses. DAMA was statistically significantly associated with 30-day (odds ratio [OR] 2.18, 95% confidence interval [CI] 2.09-2.28), 60-day (OR 1.98, 95% CI 1.90-2.06), and 90-day (OR 1.88, 95% CI 1.81-1.96) readmission. DAMA is also associated with higher mortality in patients readmitted within 30 days (OR 1.38, 95% CI 1.17-1.63), whereas there were no statistically significant differences in length of stay and costs between patients who discharged home or DAMA.

CONCLUSIONS

DAMA occurs in nearly 3.88% of sepsis patients and is linked to higher readmission and mortality. Those at high risk of DAMA should be early identified to motivate intervention to avoid premature discharges and associated adverse outcomes.

Critical care for patients with substance use disorders

PURPOSE OF REVIEW

To examine the impact of substance use disorders (SUDs) on critical illness and the role of critical care providers in treating SUDs. We discuss emerging evidence supporting hospital-based addiction treatment and highlight the clinical and research innovations needed to elevate the standards of care for patients with SUDs in the intensive care unit (ICU) amidst staggering individual and public health consequences.

RECENT FINDINGS

Despite the rapid increase of SUDs in recent years, with growing implications for critical care, dedicated studies focused on ICU patients with SUDs remain scant. Available data demonstrate SUDs are major risk factors for the development and severity of critical illness and are associated with poor outcomes. ICU patients with SUDs experience mutually reinforcing effects of substance withdrawal and pain, which amplify risks and consequences of delirium, and complicate management of comorbid conditions. Hospital-based addiction treatment can dramatically improve the health outcomes of hospitalized patients with SUDs and should begin in the ICU.

SUMMARY

SUDs have a significant impact on critical illness and post-ICU outcomes. High-quality cohort and treatment studies designed specifically for ICU patients with SUDs are needed to define best practices and improve health outcomes in this vulnerable population.

Identifying Risk Factors for AMA Discharge After Injury at a Level 1 Trauma Center

BACKGROUND

Discharging a patient against medical advice (AMA) is used to describe when a patient opts to leave the hospital prior to a physician's recommendation while acknowledging the risks of doing so. There are limited published data that identify risk factors for patients leaving AMA, particularly after trauma.

OBJECTIVE

This study sought to delineate risk factors for AMA discharge after trauma.

METHODS

Trauma patients who left AMA at our ACS-verified level 1 trauma center were retrospectively included (2021-2022) without exclusions. Demographics, clinical/injury data, and outcomes were collected. The primary outcome was patient-stated reason for leaving AMA. Study variables were summarized with descriptive statistics.

RESULTS

During the study period, 262 (8%) of 3218 admitted trauma patients left AMA. Psychiatric disease was present in most patients (n = 197, 75%), including substance abuse (n = 146, 56%), and alcohol abuse (n = 95, 36%). Common patient-stated reasons for leaving AMA were inability/unwillingness to wait for procedure, imaging, or placement (n = 56, 22%); and psychiatric disease other than alcohol/substance abuse (n = 39, 15%). Of the patients who left AMA, 29% (n = 77) returned to the hospital 30 days, and 13% (n = 35) were readmitted.

CONCLUSION

Patients who leave AMA are at elevated risk of returning to the hospital, which incurs additional costs in already resource-constrained systems. These findings provide impetus for early identification of high-risk patients and efforts to decrease wait times for imaging, procedures, and placement. These actions may mitigate AMA discharges and their resultant impact on patients and hospitals.

Association of Early Opioid Withdrawal Treatment Strategy and Patient-Directed Discharge Among Hospitalized Patients with Opioid Use Disorder

BACKGROUND

Medical hospitalizations for people with opioid use disorder (OUD) frequently result in patient-directed discharges (PDD), often due to untreated pain and withdrawal.

OBJECTIVE

To investigate the association between early opioid withdrawal management strategies and PDD.

DESIGN

Retrospective cohort study using three datasets representing 362 US hospitals.

PARTICIPANTS

Adult patients hospitalized between 2009 and 2015 with OUD (as identified using ICD-9-CM codes or inpatient buprenorphine administration) and no PDD on the day of admission.

INTERVENTIONS

Opioid withdrawal management strategies were classified based on day-of-admission receipt of any of the following treatments: (1) medications for OUD (MOUD) including methadone or buprenorphine, (2) other opioid analgesics, (3) adjunctive symptomatic medications without opioids (e.g., clonidine), and (4) no withdrawal treatment.

MAIN MEASURES

PDD was assessed as the main outcome and hospital length of stay as a secondary outcome.

KEY RESULTS

Of 6,715,286 hospitalizations, 127,158 (1.9%) patients had OUD and no PDD on the day of admission, of whom 7166 (5.6%) had a later PDD and 91,051 (71.6%) patients received some early opioid withdrawal treatment (22.3% MOUD; 43.4% opioid analgesics; 5.9% adjunctive medications). Compared to no withdrawal treatment, MOUD was associated with a lower risk of PDD (adjusted odds ratio [aOR] = 0.73, 95%CI 0.68-0.8, p < .001), adjunctive treatment alone was associated with higher risk (aOR = 1.13, 95%CI: 1.01-1.26, p = .031), and treatment with opioid analgesics alone was associated with similar risk (aOR 0.95, 95%CI: 0.89-1.02, p = .148). Among those with PDD, both MOUD (adjusted incidence rate ratio [aIRR] = 1.24, 95%CI: 1.17-1.3, p < .001) and opioid analgesic treatments (aIRR = 1.39, 95%CI: 1.34-1.45, p < .001) were associated with longer hospital stays.

CONCLUSIONS

MOUD was associated with decreased risk of PDD but was utilized in < 1 in 4 patients. Efforts are needed to ensure all patients with OUD have access to effective opioid withdrawal management to improve the likelihood they receive recommended hospital care.

Analysis of factors affecting discharge with the personal consent of hospitalized patients: A cross-sectional study

Background and Aims

Discharge by personal satisfaction is a condition in which the patient leaves the hospital before completing the care period against medical advice. Thus, this study aims to identify and analyze the reasons for discharge with the personal satisfaction of hospitalized patients.

Methods

The study was descriptive-analytical being performed in 2021. The study population was 2869 discharged inpatients with personal satisfaction. Sampling was done by random and census. The data were collected using a checklist and a researcher-made questionnaire whose validity and reliability were confirmed. The data were analyzed using SPSS24 by K-Score test for qualitative and variance for quantitative variables.

Results

The discharge rate by personal satisfaction was 7.01%, the average age was 42 years, and the average length of stay was 4 days. Further, 57.1% of patients were female, 63.7% were married, and 21% were babies. A total of 22.77% of the patients were discharged with the father's consent, of which 13.2% were re-admitted. The most common reasons for the discharge were feeling of recovery (47.2%), the hospital being educational (30%), and dissatisfaction with the services of doctors (51.6%). Discharge with personal satisfaction had a significant relationship with the length of hospitalization (p < 0.001) and type of hospital (p = 0.04).

Conclusion

The feeling of recovery, the educational nature of the hospital, and dissatisfaction with the services of doctors were the most common reasons for discharge with personal satisfaction. Therefore, monitoring the provision of services, establishing proper patient-doctor communication, and increasing the awareness of patients and parents could reduce this type of discharge and its consequences.

Appropriateness of Empirical Antibiotic Therapy in Hospitalized Patients with Bacterial Infection: A Retrospective Cohort Study

Objective

The incidence of inappropriate and excessive empirical antibiotic therapy is unclear. The aim of this study was to determine the prevalence of different empirical antibiotic therapy prescriptions, related factors, and outcomes in hospitalized patients with bacterial infection.

Methods

A retrospective cohort study was performed and patients with bacterial infection who were admitted between October 1, 2019, and September 30, 2020, were included. Multivariable analysis was performed by the logistic regression model.

Results

A total of 536 (42.6%) of the 1257 included patients received inappropriate empirical antibiotic therapy (IEAT), and 368 (29.3%) patients received appropriate but unnecessarily broad-spectrum empirical antibiotic therapy (AUEAT). MDRO (adjusted OR 2.932 [95% CI 2.201~3.905]; p < 0.001) and fever on admission (adjusted OR 0.592 [95% CI 0.415~0.844]; p = 0.004) were correlates of IEAT; sepsis (adjusted OR 2.342 [95% CI 1.371~3.999]; p = 0.002), age (adjusted OR 1.019 [95% CI 1.008~1.030]; p < 0.001), MDRO (adjusted OR 0.664 [95% CI 0.469~0.941]; p = 0.021), and urinary tract infection (adjusted OR 0.352 [95% CI 0.203~0.611]; p < 0.001) were correlates of AUEAT. Patients who received AUEAT were more likely to have a poor prognosis (63 [17.8%] vs 101 [27.4%]; p = 0.002). Both IEAT (median [IQR], 24,971 [13,135-70,155] vs 31,489 [14,894-101,082] CNY; p = 0.007) and AUEAT (median [IQR], 24,971 [13,135-70,155] vs 30,960 [16,475-90,881] CNY; p = 0.002) increased hospital costs. 45.3% (570/1257) of patients were infected with MDRO and 62.9% of them received IEAT.

Conclusion

Inappropriate and excessive empirical antibiotic use was widely prevalent among hospitalized patients. Either inappropriate or excessive use of antibiotics may increase the burden of healthcare costs, the latter of which may be associated with poor prognosis. Clinicians need to be more judicious in choosing antibiotic(s). The MDRO epidemic was severe, especially in patients who received IEAT. It is imperative to take effective measures to improve the current situation of antibiotic abuse and antimicrobial resistance.

The risk factors, consequences, and interventions of discharge against medical advice - A narrative review

Discharge against medical advice (DAMA) represents an increasingly burdensome public health issue that leads to worse outcomes for patients and high costs to society. While the rate of patients who DAMA is higher within certain institutions and geographic locations, the problem is present across all healthcare systems. DAMAs are often challenging as they occur suddenly and can be unsatisfactory. An opportunity exists to better meet the needs of this patient population; however, many providers are unsure of how they can prevent a DAMA. In this review, we discuss the broader impact, associated factors, the most common reasons, the consequences, and the prevention strategies for DAMA. Further research is needed to create tools for stratifying patients most likely to DAMA. Early identification and appropriate interventions for these patients will allow for safe discharges.

Characteristics of home oxygen therapy for preterm infants with bronchopulmonary dysplasia in China: results of a multicenter cohort study

BACKGROUND

Home oxygen therapy (HOT) is indicated upon discharge in some preterm infants with severe bronchopulmonary dysplasia (BPD). There is a lack of evidence-based consensus on the indication for HOT among these infants. Because wide variation in the institutional use of HOT exists, little is known about the role of regional social-economic level in the wide variation of HOT.

METHODS

This was a secondary analysis of Chinese Neonatal Network (CHNN) data from January 1, 2019 to December 31, 2019. Infants at gestational ages < 32 weeks, with a birth weight < 1500 g, and with moderate or severe BPD who survived to discharge from tertiary hospitals located in 25 provinces were included in this study. Infants with major congenital anomalies and those who were discharged against medical advice were excluded.

RESULTS

Of 1768 preterm infants with BPD, 474 infants (26.8%) were discharged to home with oxygen. The proportion of HOT use in participating member hospitals varied from 0 to 89%, with five of 52 hospitals' observing proportions of HOT use that were significantly greater than expected, with 14 hospitals with observing proportions significantly less than expected, and with 33 hospitals with appropriate proportions. We noted a negative correlation between different performance groups of HOT and median GDP per capita (P = 0.04).

CONCLUSIONS

The use of HOT varied across China and was negatively correlated with the levels of provincial economic levels. A local HOT guideline is needed to address the wide variation in HOT use with respect to different regional economic levels in countries like China.

Hospital readmissions and mortality following discharge against medical advice: a five-year retrospective, population-based cohort study in Veneto region, Northeast Italy

OBJECTIVES

The aim of this study was to examine the odds of readmission and mortality after discharge against medical advice (DAMA) in the Veneto region of Northeast Italy, drawing on data from the regional archives of emergency department records and hospital discharge records.

DESIGN

A retrospective cohort study.

SETTING

Hospital discharges, Veneto region, Italy.

PARTICIPANTS

All patients discharged after being admitted to a public or accredited private hospital between January 2016 and 31 January 2021 in the Veneto region were considered. A total of 3 574 124 index discharges were examined for inclusion in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Readmission and overall mortality at 30 days after the index discharge against admission.

RESULTS

In our cohort, 7.6‰ of patients left hospital against their doctor's advice (n=19 272). These DAMA patients were more likely to be younger (mean age: 45.5 vs 55.0), foreign (22.1% vs 9.1%). The adjusted odds of readmission after DAMA was 2.76 (CI 95% 2.62-2.90) at 30 days (9.5% DAMA vs 4.6% not-DAMA), and the highest readmission rate was recorded in the first 24 hours after the index discharge. Mortality was higher for DAMA patients after adjusting for patient-level and hospital-level characteristics (with adjusted ORs of 1.40 for in-hospital mortality and 1.48 for overall mortality).

CONCLUSIONS

The present study shows that DAMA patients are more likely to die and to need hospital readmission than patients discharged by their doctors. DAMA patients should be more committed to a proactive and diligent postdischarge care.

The Impact of Discharge Against Medical Advice on Readmission After Opioid Use Disorder-Associated Infective Endocarditis: a National Cohort Study

BACKGROUND

Hospitalizations for infective endocarditis (IE) associated with opioid use disorder (O-IE) have increased in the USA and have been linked to high rates of discharge against medical advice (DAMA). DAMA represents a truncation of care for a severe infection, yet patient outcomes after DAMA are unknown.

OBJECTIVE

This study aimed to assess readmissions following O-IE and quantify the impact of DAMA on outcomes.

DESIGN

A retrospective study of a nationally representative dataset of persons' inpatient discharges in the USA in 2016 PARTICIPANTS: A total of 6018 weighted persons were discharged for O-IE, stratified by DAMA vs. other discharge statuses. Of these, 1331 (22%) were DAMA.

MAIN MEASURES

The primary outcome of interest was 30-day readmission rates, stratified by discharge type. We also examined the total number of hospitalizations during the year and estimated the effect of DAMA on readmission.

KEY RESULTS

Compared with non-DAMA, those experiencing DAMA were more commonly female, resided in metropolitan areas, lower income, and uninsured. Crude 30-day readmission following DAMA was 50%, compared with 21% for other discharge types. DAMA was strongly associated with readmission in an adjusted logistic regression model (OR 3.72, CI 3.02-4.60). Persons experiencing DAMA more commonly had ≥2 more hospitalizations during the period (31% vs. 18%, p<0.01), and were less frequently readmitted at the same hospital (49% vs 64%, p<0.01).

CONCLUSIONS

DAMA occurs in nearly a quarter of patients hospitalized for O-IE and is strongly associated with short-term readmission. Interventions to address the root causes of premature discharges will enhance O-IE care, reduce hospitalizations and improve outcomes.

How does discharge against medical advice affect risk of mortality and unplanned readmission? A retrospective cohort study set in a large UK medical admissions unit

OBJECTIVES

To assess the frequency of discharge against medical advice (DAMA) in a large UK teaching hospital, explore factors which increase the risk of DAMA and identify how DAMA impacts patient risk of mortality and readmission.

DESIGN

Retrospective cohort study.

SETTING

Large acute teaching hospital in the UK.

PATIENTS

36 683 patients discharged from the acute medical unit of a large UK teaching hospital between 1 January 2012 and 31 December 2016.

MEASUREMENTS

Patients were censored on 1 January 2021. Mortality and 30-day unplanned readmission rates were assessed. Deprivation, age and sex were taken as covariates.

RESULTS

3% of patients discharged against medical advice. These patients were younger (median age (years) (IQR)): planned discharge (PD) 59 (40-77); DAMA 39 (28-51), predominantly of male sex (PD 48%; DAMA 66%) and were of greater social deprivation (in three most deprived quintiles PD 69%; DAMA 84%). DAMA was associated with increased risk of death in patients under the age of 33.3 years (adjusted HR 2.6 (1.2-5.8)) and increased incidence of 30-day readmission (standardised incidence ratio 1.9 (1.5-2.2)).

LIMITATIONS

Readmission to acute hospitals outside of the local health board may have been missed. We were unable to include information regarding comorbidity or severity of presentation.

CONCLUSIONS

These data highlight the vulnerability of younger patients who DAMA, even in a free-at-the-point-of-delivery healthcare setting.

A step-by-step approach to patients leaving against medical advice (AMA) in the emergency department

OBJECTIVES

Patients leaving against medical advice (AMA) can be distressing for emergency physicians trying to navigate the medical, social, psychological, and legal ramifications of the situation in a fast-paced and chaotic environment. To guide physicians in fulfilling their obligation of care, we aimed to synthesize the best approaches to patients leaving AMA.

METHODS

We conducted a scoping review across various fields of work, research context and methodology to synthesize the most relevant strategies for emergency physicians attending patients leaving AMA. We searched Medline, CINAHL, PSYCHO Legal Source, PsycINFO, PsycEXTRA, Psychological and Behavioural Sciences collection, SocIndex and Scopus. Search strategies included controlled vocabulary (i.e., MESH) and keywords relevant to the subject chosen by a team of four people, including two specialized librarians.

RESULTS

The literature review included 34 relevant papers about approaches to patients leaving AMA: 8 case presentations, 4 ethical case analyses, 10 legal letters, 4 reviews and 8 original studies. The main identified strategies were prioritizing a patient-centered approach, proposing alternative discharge and reducing harm while properly documenting the encounter.

CONCLUSION

A systematic approach to patients leaving AMA could help improve patient care, support physicians and decrease stigmatization of this population. We advocate that emergency physicians should receive training on how to approach patients leaving AMA to limit the impact on this vulnerable population.

Characteristics and Outcomes of Discharge Against Medical Advice and 30-Day Readmissions After Concussion: Analysis of the Nationwide Readmissions Database

BACKGROUND

Little is known about the impact of discharge against medical advice (DAMA) in patients admitted with concussion.

OBJECTIVE

To explore the prevalence of DAMA and its effect on 30-day readmissions and cost in concussion using a nationally representative sample.

METHODS

The Nationwide Readmissions Database was queried for concussion admissions and their disposition at discharge between 2010 and 2014. Included patients were ≥18 years old who were admitted with concussion and had <1 hour loss of consciousness. We excluded in-hospital deaths or discharge dispositions other than home or against medical advice. Univariate and multivariate analyses were performed to determine characteristics associated with DAMA and 30-day readmissions.

RESULTS

A total of 38 919 index admissions were identified, which resulted in 998 (2.6%) DAMA. In multivariate analysis, characteristics associated with DAMA included younger age (odds ratio [OR] = 0.84, 95% CI 0.80-0.88), male sex (1.47, 1.22-1.76), an Elixhauser comorbidity index >3 (1.67, 1.15-1.60), and assault (2.02, 1.48-2.75) and fall injuries (1.28, 1.03-1.60). The highest-income quartile was negatively associated with DAMA (0.91, 0.73-1.13). In multivariate analysis, DAMA (1.63, 1.29-2.06), higher comorbidity index (2.61, 2.22-3.06), and self-inflicted mode of injury (2.28, 1.30-4.02) were independently associated with 30-day readmission. The most common indication for readmission in both routine and DAMA groups was traumatic injury (21.1% and 24.5%, respectively).

CONCLUSION

DAMA is an independent risk factor for readmission in patients admitted for concussion. The variables associated with DAMA identified in this study can be used to design patient-centered interventions that can be implemented to reduce DAMA and its impact on clinical outcomes in patients with traumatic brain injury.

Effect of leaving against medical advice on 30-day infective endocarditis readmissions

BACKGROUND

: The burden of against medical advice (AMA) discharges on the readmission rate of infective endocarditis (IE) patients has been largely ignored.

METHODS

We used the National Readmissions Database, years 2016 to 2019, to identify IE patients and categorized them into those who left AMA (IE AMA) and those who were discharged to home or skilled nursing facility (SNF)/other facility (IE non-AMA). The primary outcome was 30-day all-cause readmissions difference per AMA status.

RESULTS

Of 26,481 patients with IE who met the inclusion criteria, 4,310 (16.3%) left the hospital AMA. IE AMA patients were younger (mean years; 43.7 vs 34.2; p < 0.01) and had a higher prevalence of injection drug use (IDU) (89.4% vs 45.2%; p < 0.01) but fewer comorbidities compared to IE non-AMA. In adjusted analyses, IE AMA had higher hazards for 30-day readmissions compared to IE non-AMA [hazards ratio (HR): 3.1 (2.9 - 3.5); p < 0.01].

CONCLUSION

IE AMA are at increased risk of 30-day readmissions and higher resource utilization at the time of readmission compared to IE non-AMA. Considering the high prevalence of IDU in IE AMA, the role of mental health to curb the burden of IE readmissions is an area of further research.

Leave events among Aboriginal and Torres Strait Islander people: a systematic review

BACKGROUND

Leave events are a public health concern resulting in poorer health outcomes. In Australia, leave events disproportionally impact Aboriginal and Torres Strait Islander people. A systematic review was conducted to explore the causes of leave events among Aboriginal and Torres Strait Islander people and strategies to reduce them.

METHODS

A systematic review was conducted using Medline, Web of Science, Embase and Informit, a database with a strong focus on relevant Australian content. Additionally, we examined the references of the records included, and performed a manual search using Google, Google scholar and the Australia's National Institute for Aboriginal and Torres Strait Islander Health Research. Two independent reviewers screened the records. One author extracted the data and a second author reviewed it. To appraise the quality of the studies the Mixed Methods Appraisal Tool was used as well as the Aboriginal and Torres Strait Islander Quality Appraisal Tool. A narrative synthesis was used to report quantitative findings and an inductive thematic analysis for qualitative studies and reports.

RESULTS

We located 421 records. Ten records met eligibility criteria and were included in the systematic review. From those, four were quantitative studies, three were qualitative studies and three reports. Five records studied data from the Northern Territory, two from Western Australia, two from New South Whales and one from Queensland. The quantitative studies focused on the characteristics of the patients and found associations between leave events and male gender, age younger than 45 years and town camp residency. Qualitative findings yielded more in depth causes of leave events evidencing that they are associated with health care quality gaps. There were multiple strategies suggested to reduce leave events through adapting health care service delivery. Aboriginal and Torres Strait Islander representation is needed in a variety of roles within health care provision and during decision-making.

CONCLUSION

This systematic review found that multiple gaps within Australian health care delivery are associated with leave events among Aboriginal and Torres Strait Islander people. The findings suggest that reducing leave events requires better representation of Aboriginal and Torres Strait Islander people within the health workforce. In addition, partnership with Aboriginal and Torres Strait Islander people is needed during the decision-making process in providing health services that meet Aboriginal and Torres Strait Islander cultural needs.

Adverse Discharge Outcomes Associated With the Medicare Hospital Readmissions Reduction Program Among Commercially Insured Adults

ABSTRACT

It is unknown if changes in the rate of discharges against medical advice (DAMA) are related to the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP). We performed an interrupted time series analysis of monthly DAMA rates per 1,000 discharges of all enrolled individuals 18-64 years old with a hospitalization between January 1, 2006, and December 31, 2015, in a commercially insured population. We performed a segmented linear regression with two interruptions: (1) April 2010 to coincide with the passage of the HRRP and (2) October 2012 to coincide with the implementation of HRRP penalties. There were 1,087,812 discharges representing 668,823 individuals over 120 months. The downward trend in monthly DAMA rates was reversed significantly after April 2010 with a sustained 0.1 increase in the monthly rate that continued after the implementation of penalties in October 2012. Allowing for the two interruptions, there was a statistically significant positive trend (0.10; 0.06-0.13, p < .01) in April 2010. Relative to the first interruption, there was no statistically significant change in the slope in October 2012; the estimated slope was -0.04 (-0.08 to 0.002). Monthly DAMA rates increased in anticipation of and after HRRP implementation, suggesting a potential relationship between the HRRP and DAMA.

Against Medical Advice Discharges in Injection and Non-injection Drug Use-associated Infective Endocarditis: A Nationwide Cohort Study

BACKGROUND

Among those with injection drug use-associated infective endocarditis (IDU-IE), against medical advice (AMA) discharge is common and linked to adverse outcomes. Understanding trends, risk factors, and timing is needed to reduce IDU-IE AMA discharges.

METHODS

We identified individuals ages 18-64 with International Classification of Diseases, 9thRevision, diagnosis codes for infective endocarditis (IE) in the National Inpatient Sample, a representative sample of United States hospitalizations from January 2010 to September 2015. We plotted unadjusted quarter-year trends for AMA discharges and used multivariable logistic regression to identify factors associated with AMA discharge among IE hospitalizations, comparing IDU-IE with non-IDU-IE.

RESULTS

We identified 7259 IDU-IE and 23 633 non-IDU-IE hospitalizations. Of these hospitalizations, 14.2% of IDU-IE and 1.9% of non-IDU-IE resulted in AMA discharges. More than 30% of AMA discharges for both groups occurred before hospital day 3. In adjusted models, IDU status (adjusted odds ratio [AOR], 3.92; 95% confidence interval [CI], 3.43-4.48)] was associated with increased odds of AMA discharge. Among IDU-IE, women (AOR, 1.21; 95% CI, 1.04-1.41) and Hispanics (AOR, 1.32; 95% CI, 1.03-1.69) had increased odds of AMA discharge, which differed from non-IDU-IE. Over nearly 6 years, odds of AMA discharge increased 12% per year for IDU-IE (AOR, 1.12; 95% CI, 1.07-1.18) and 6% per year for non-IDU-IE (AOR, 1.06; 95% CI. 1.00-1.13).

CONCLUSIONS

AMA discharges have risen among individuals with IDU-IE and non-IDE-IE. Among those who inject drugs, AMA discharges were more common and increases sharper. Efforts that address the rising fraction, disparities, and timing of IDU-IE AMA discharges are needed.

Irregular hospital discharge from acute inpatient and residential mental health treatment settings in a large integrated healthcare system

OBJECTIVE

Irregular discharge is a concern among mental health populations and associated with poor outcomes. Little is known about the relationship between irregular discharge and treatment setting. Because care processes differ between acute inpatient and residential settings, it is important to evaluate irregular discharge in these settings.

METHOD

A retrospective study was conducted in patients with mental health conditions admitted to acute inpatient or residential mental health settings in the Department of Veterans Affairs, 2003-2019. Logistic regression and multivariate Cox proportional hazards were used to evaluate factors associated with irregular discharge risk in the first 90- days of admission.

RESULTS

Among 1.8 million discharges, 7.4% had an irregular discharge within 90- days of admission. Younger age was a central predictor of risk. Irregular discharge rates were four-fold higher in residential versus acute settings. When accounting for length of stay (LOS) across settings, there was a modest higher risk of irregular discharge from acute versus residential settings (HR = 1.06, 95% Confidence Interval 1.04-1.07).

CONCLUSIONS

Patients are at high risk for irregular discharge from acute and residential settings when they are young. LOS is an important determinant of irregular discharge risk.. Interventions are needed to address drivers of irregular discharge.

Factors Influencing Early Readmission after Discharge against Medical Advice from the Emergency Department

Discharge against medical advice (DAMA) and readmissions are important issues worldwide and can lead to adverse clinical outcomes, financial burden, and exposure of healthcare workers to unintended medical disputes. This study aimed to identify factors that affect readmissions within 48 h after DAMA. This retrospective study utilized the medical records of patients who visited an emergency medical center in Korea for treatment and were readmitted during a 10-year period. Factors predicting readmission after being DAMA were identified using logistic regression analysis. The total number of patients who were DAMA during the study period was 5445, of which 351 were readmitted to the emergency department within 48 h (6.4%). Factors influencing readmission included medical aid (odds ratio (OR) = 2.02, 95% confidence interval (CI): 1.46–2.83) and foreign worker insurance (OR = 2.07, 95% CI: 1.04–4.09) as their health insurance, as well as presenting for readmission by car (OR = 1.41, 95% CI: 1.08–1.82). Healthcare workers should treat patients who are DAMA and those who are likely to return with a more careful and preventative management strategy so that potential clinical, legal, and economic impacts of DAMA can be mitigated.

Against Medical Advice Discharge: A Narrative Review and Recommendations for a Systematic Approach

Approximately 1%-2% of hospitalizations in the United States result in an against medical advice discharge. Still, the practice of discharging patients against medical advice is highly subjective and variable. Discharges against medical advice are associated with physician distress, patient stigma, and adverse outcomes, including increased morbidity and mortality. This review summarizes discharge against medical advice research, proposes a definition for against medical advice discharge, and recommends a standard approach to a patient's request for discharge against medical advice.

Association between discharges against medical advice and readmission in patients treated for drug injection-related skin and soft tissue infections

BACKGROUND

The prevalence of injection drug use (IDU)-related skin and soft tissue infections (SSTI) in Philadelphia has been steadily increasing since 2013. Patients seeking treatment for these infections are more likely to be discharged against medical advice (AMA), increasing the likelihood that they will end antibiotic treatment prematurely and require additional medical interventions.

METHODS

The research team performed a nested case-control study using the Pennsylvania Health Care Cost Containment Council database for Philadelphia residents hospitalized for SSTI and substance use-related diagnoses between 2013 and 2018. The primary outcome was readmission in the same or following quarter. The study examined the impact of discharge AMA on readmission along with clinical characteristics including diagnoses for anxiety, bipolar disorder, depression, schizophrenia, diabetes, and polydrug use.

RESULTS

There were 8265 hospitalizations for IDU-related SSTI and 316 (6%) were readmitted to the hospital at least once in the same or following quarter. In total, 23.4% of cases and 13% of controls left AMA. In the final multivariable regression model, AMA discharge (AOR 2.04, 95% CI 1.46-2.86), anxiety (AOR 1.44, 95% CI 1.01-2.05), diabetes (AOR 2.02, 95% CI 1.46-2.81), and polydrug use (AOR 2.11, 95% CI 1.52-2.92) were associated with higher odds of readmission.

CONCLUSIONS

Our study demonstrates that readmissions for IDU-related SSTI are associated with recent discharge AMA. As IDU-related SSTI and polydrug use continue to rise, premature antibiotic treatment completion will impact more people, leading to worse health outcomes and additional strain on the health care system.

Discharge Against Medical Advice in Acute Ischemic Stroke: the Risk of 30-Day Unplanned Readmission

BACKGROUND

Discharge against medical advice may be associated with more readmissions.

OBJECTIVE

To evaluate DAMA in patients with acute ischemic stroke (AIS) and identify the relationship between DAMA and 30-day unplanned readmissions.

DESIGN

A retrospective cohort study.

PARTICIPANTS

The National Readmission Database was used to identify inpatients with a primary diagnosis of AIS who were either discharged home or DAMA between 2010 and 2017 in the USA.

MEASURES

Demographic features, hospital type, comorbidities, stroke risk factors, severity indices, and treatments were compared between patients discharged routinely and DAMA. Multivariable logistic regression was used to evaluate predictors of DAMA, and a double robust inverse probability of treatment weighting method was used to assess the association between DAMA and 30-day unplanned readmissions.

KEY RESULTS

Overall, 1,335,484 patients with AIS were included, of whom 2.09% (n = 27,892) were DAMA. The prevalence of DAMA in AIS patients increased from 1.65 in 2010 to 2.57% in 2017. The rates of 30-day unplanned readmissions for DAMA and non-DAMA patients were 16.81% and 7.78%, respectively. Patients with drug abuse, alcohol abuse, smoking, prior stroke, psychoses, and intravenous thrombolysis had greater odds of DAMA. DAMA was associated with all-cause readmissions (OR, 2.04; 95% CI, 2.01-2.07) and remained a strong predictor for transient ischemic attack/stroke-specific and cardiac-specific causes of readmissions.

CONCLUSIONS

Although the DAMA rate is low in AIS patients, DAMA is a risk factor for all-cause and recurrent stroke-specific readmissions. Future studies are needed to address issues around compliance and engagement with health care to reduce DAMA.

Hospital Outcomes in Uninsured Patients With Disease and Disorders of Nervous System: A National Cohort Study During a Decade in the United States

Objectives

Health insurance is associated with better outcomes in the admitted patient population, even after adjusting for other factors such as race and socioeconomic status. However, the literature is limited on the relationship between insurance status and hospital outcomes in patients hospitalized with the disease of nervous system.

Methods

This cross-sectional study used the Nationwide Inpatient Sample (NIS) database to achieve the results. All Major Diagnostic Category (MDC) codes from patients discharged for disease and disorders of nervous system between the years 2005 to 2014 were queried and analyzed for the impact of lack of insurance on patient outcome.

Results

Among 4,737,999 discharges, 5.6% had no insurance. The hospital mortality rate among uninsured and insured patients was 4.1% and 3.7%, respectively (P<0.001). In the multivariate analysis, hospital mortality of uninsured patients was higher in the elderly (aOR: 4.74[CI:4.52-4.97], P<0.001), those with comorbidities (aOR: 2.23[CI:2.18-2.27], P<0.001), Asians (aOR: 1.16[CI:1.12-1.20]. P<0.001), in rural areas (aOR: 1.44[ 95%CI:1.41-1.48], P<0.001) and those in the lowest household income quartile (aOR: 1.03[CI:1.01-1.05], P<0.001). The average length of stay (LOS) was shorter for the uninsured (4.79±8.26 vs 4.96±7.55 days, P<0.001).

Conclusions

The findings suggest that lack of health insurance is correlated with hospital mortality in patients hospitalized with disease and disorders of nervous system, with an increased disparity in vulnerable populations.

Chronic Pancreatitis Patients Who Leave Against Medical Advice: Prevalence, Trend, and Predictors

BACKGROUND AND AIMS

Leaving against medical advice (LAMA) is an unfortunate occurrence in 1-2% of all hospitalized patients and is associated with worse outcomes. While this has been investigated across multiple clinical conditions, studies on patients with chronic pancreatitis (CP) are lacking. We aimed to determine the prevalence and determinants of this event among patients with CP.

METHODS

The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS), 2007-2014, was used in the study. Patients with LAMA were identified, and the temporal trend of LAMA was estimated and compared among patients with and without CP. We then extracted patients with a discharge diagnosis of CP from the recent years of HCUP-NIS (2012-2014) and described the characteristics of LAMA in these patients. Multivariate logistic regression models were used to evaluate predictors of LAMA.

RESULTS

3.39% of patients with CP discharged against medical advice. LAMA rate in CP patients was higher and increased more steeply at quadruple the rate of those without. More likely to self-discharge were patients who were young, males, non-privately insured, or engaged in alcohol and substance abuse, likewise were those with psychosis and those admitted on a weekend or non-electively. The northeast and for-profit hospitals also had higher odds of LAMA. However, patients transferred from other healthcare facilities have reduced LAMA odds. Among all patients with CP, those with LAMA had shorter length of stay (2.74 [2.62-2.85] days vs. 5.78 [5.71-5.83] days) and lower hospitalization cost $23,271 [$22,171-$24,370] versus $45,472 [$44,381-$46,562] compared to the no-LAMA group.

CONCLUSION

LAMA occurs in approximately 1 in 29 patients with CP and is increasing at almost quadruple the rate of those without. Clinicians need to pay closer attention to the identified at-risk groups for ameliorative targeted interventions.

Why Do Patients Leave against Medical Advice? Reasons, Consequences, Prevention, and Interventions

Background: A patient decides to leave the hospital against medical advice. Is this an erratic eccentric behavior of the patient, or a gap in the quality of care provided by the hospital? With a significant and increasing prevalence of up to 1–2% of all hospital admissions, leaving against medical advice affects both the patient and the healthcare provider. We hereby explore this persistent problem in the healthcare system. We searched Medline and PubMed within the last 10 years, using the keywords “discharge against medical advice,” “DAMA,” “leave against medical advice,” and “AMA.” We retrospectively reviewed 49 articles in our project. Ishikawa fishbone root cause analysis (RCA) was employed to explore reasons for leaving against medical advice (AMA). This report presents the results of the RCA and highlights the consequences of discharge against medical advice (DAMA). In addition, the article explores preventive strategies, as well as interventions to ameliorate leaving AMA.

Multi-Level Predictors of Discharges Against Medical Advice: Identifying Contributors to Variation Using an All-Payer Database

ABSTRACT

There is increasing evidence of the role of non-patient-level factors on discharge against medical advice (DAMA), but limited quantitative information regarding the extent of their impact. This study quantifies the contribution of discharge-level and hospital-level factors to the variation in DAMA. We grouped variables from the 2014 National Inpatient Sample data and ran incremental mixed-effects logit models with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICCs), and evaluated the incremental change in ICC. The final sample included 2,687,430 discharges. 12.8% of the identified variation in the probability of DAMA was associated with the hospital, and 1.2% of the variation was associated with the census division in which the hospital was located. The final, fully-adjusted model had 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions because of the addition of patient demographics. Even after adjusting for measured patient-level characteristics, there was a contribution of non-patient-level factors to DAMA outcomes. The findings identify a role for a multi-level approach to addressing DAMA.

Discharge against medical advice among neurological patients: Characteristics and outcomes

OBJECTIVE

To study characteristics and outcomes of patients with stroke, traumatic brain injury (TBI), and epilepsy with discharge against medical advice (DAMA).

DATA SOURCES/STUDY SETTING

Retrospective analysis of the 2013 Nationwide Readmissions Database, a nationally representative inpatient administrative dataset.

STUDY DESIGN

Associations between predictors and DAMA at index admission were analyzed using adjusted logistic models. We examined 30-day all-cause readmissions.

DATA COLLECTION METHODS

Patients aged ≥18 years at index admission for International Classification of Diseases-9 diagnosis code of epilepsy, TBI, or stroke were included.

PRINCIPAL FINDINGS

Discharge against medical advice occurred in 1998/58278 patients (3.43 percent) in the epilepsy group, 1762/211 213 (0.83 percent) in the stroke group, and 1289/74 652 (1.73 percent) in the TBI group. Factors consistently associated with increased likelihood of DAMA included lower age, male sex, non-Medicare and nonprivate insurance, lower socioeconomic status, and behavioral risk factors (smoking history, alcohol history, and drug use). The crude 30-day all-cause readmission rate for those with DAMA from their index admission was 16.4 percent for the stroke cohort, 13.9 percent for epilepsy, and 13.4 percent for TBI. DAMA at index admission was significantly associated with increased risk of 30-day all-cause readmission among all groups (adjusted odds ratio 1.79, 95% CI: 1.65-1.94, P < .0001).

CONCLUSIONS

Age, sex, insurance status, socioeconomic status, and behavioral factors were associated with DAMA in neurological patients. Further research is needed to develop interventions to reduce DAMA in high-risk groups.