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Anyaehie UE, Ede O, Edomwonyi EO, Ekwedigwe HC, Toluse AM, Muoghalu ON, Okoh N, Dabkana TM, Esan O, Ajiboye LO, Shodipo OM, Anikwe IA. Discharge against Medical Advice in Eight Tertiary Hospitals in Nigeria: A Prospective Study. Niger J Clin Pract 2023; 26:1927-1933. [PMID: 38158363 DOI: 10.4103/njcp.njcp_511_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/29/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Discharge against medical advice (DAMA) is when a patient decides to leave the hospital without the consent of the treating physician. It poses serious clinical, ethical, and legal challenges to the individual physician as well as the hospital. AIM To determine the prevalence and reasons for DAMA in orthopedic departments of eight tertiary hospitals in Nigeria. MATERIALS AND METHODS This was a prospective multi-center descriptive study undertaken in eight tertiary Nigerian hospitals. Consecutive patients who requested for DAMA within 1 year of the study and who consented to participate in the study had face-to-face interviews. Data obtained were documented in a questionnaire and analyzed with SPSS version 20. RESULTS The total number of patients studied was 373 with a mean age 34.7 ± 17.5 years. About a quarter of them (25.5%) were between 31 and 40 years. A prevalence rate of 1.9% was found with financial constraint being the predominant reason for DAMA (40.8%). Other reasons include family preference for unorthodox treatment (18.8%) and treatment dissatisfaction (7.0%) among others. CONCLUSION The study findings indicate a low DAMA rate when compared to previous studies in this region. It also indicates that financial constraints, family preference for unorthodox care, and low educational status are major drivers of DAMA. Deepened health insurance and other measures that can reduce the prevalence of DAMA should be prioritized to improve treatment outcomes.
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Affiliation(s)
- U E Anyaehie
- Department of Orthopaedics and Trauma, National Orthopaedic Hospital, Enugu and Institute of Orthopaedics, Plastic and Reconstructive Surgery, Abia State University, Uturu, Nigeria
| | - O Ede
- Consultant Orthopaedic Surgeon, National Orthopaedic Hospital, Enugu, Nigeria
| | - E O Edomwonyi
- Consultant Orthopaedic Surgeon, Irrua Specialist Teaching Hospital, Irrua, Nigeria
| | - H C Ekwedigwe
- Consultant Orthopaedic Surgeon, National Orthopaedic Hospital, Enugu, Nigeria
- Consultant Orthopaedic Surgeon, Alex Ekwueme Federal Teaching Hospital, Abakaliki, Nigeria
| | - A M Toluse
- Consultant Orthopaedic Surgeon, National Orthopaedic Hospital, Lagos, Nigeria
| | - O N Muoghalu
- Consultant Orthopaedic Surgeon, National Orthopaedic Hospital, Enugu, Nigeria
| | - N Okoh
- Consultant Orthopaedic Surgeon, National Orthopaedic Hospital, Kano, Nigeria
| | - T M Dabkana
- Deparment of Orthopaedics and Trauma Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - O Esan
- Honorary Consultant Orthopaedic Surgeon and Traumatologist, Obafemi Awolowo University/Teaching Hospital, Ile Ife, Nigeria
| | - L O Ajiboye
- Consultant Orthopaedic, Spine and Trauma Surgeon, Usman Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - O M Shodipo
- Consultant Orthopaedic Surgeon, Federal Medical Centre Bida, Niger State, Nigeria
| | - I A Anikwe
- Consultant Orthopaedic Surgeon, Alex Ekwueme Federal Teaching Hospital, Abakaliki, Nigeria
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Alrawashdeh M, Rhee C, Klompas M, Larochelle MR, Poland RE, Guy JS, Kimmel SD. Association of Early Opioid Withdrawal Treatment Strategy and Patient-Directed Discharge Among Hospitalized Patients with Opioid Use Disorder. J Gen Intern Med 2023; 38:2289-2297. [PMID: 36788169 PMCID: PMC10406767 DOI: 10.1007/s11606-023-08059-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023]
Abstract
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.
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Affiliation(s)
- Mohammad Alrawashdeh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
- Jordan University of Science and Technology, Irbid, Jordan.
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marc R Larochelle
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- HCA Healthcare, Nashville, TN, USA
| | | | - Simeon D Kimmel
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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Toluse AM, Onibonoje AD, Biala A, Adeyemi TO. Discharge against medical advice: cross-sectional survey from a regional orthopaedic hospital in sub-Saharan Africa. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05836-4. [PMID: 37195464 DOI: 10.1007/s00264-023-05836-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/05/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE Discharge against medical advice (DAMA) is a worldwide phenomenon. It continues to challenge the healthcare system and has profound effects on outcomes of treatment. It is when a patient leaves the hospital against the treating physician's recommendation. The objectives of this study are to identify the prevalence, associated factors, and proffer recommendations to mitigate the anomaly in our local/regional healthcare system. METHODS This was a cross-sectional study with data collected from consecutive patients who sought DAMA at the accident and emergency department of the hospital from October 2020 to March 2022. Data were analyzed using SPSS version 26. Descriptive and inferential statistics were used for data presentation. RESULTS Ninety-nine cases of DAMA out of 4608 patients seen at the Emergency Department during the study period, giving a prevalence rate of 2.14%. 70.7% (70) of these patients were aged 16-44 years with male-to-female ratio of 2.5:1. An estimated half the number of the patients who DAMA were traders 44.4% (44), 14.1% (14) were in paid employment, 22.2% (22) were unskilled workers, and 3% (3) unemployed. Financial constraint was the leading cause in 73 (73.7%) cases. The majority of patients had limited or no formal education, and this was significantly associated with DAMA (P = 0.032). Ninety-two patients (92.6%) sought discharge within 72 h of admission and 89 (89.9%) admitted to leaving to seek alternative methods of care. CONCLUSION DAMA is still a problem in our environment. Comprehensive health insurance must be mandatory for all citizens with improved scope and coverage, especially for trauma victims.
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Affiliation(s)
| | | | - Adebola Biala
- Department of Orthopaedic and Trauma Surgery, National Orthopaedic Hospital, Lagos, Nigeria
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Schranz AJ, Tak C, Wu LT, Chu VH, Wohl DA, Rosen DL. The Impact of Discharge Against Medical Advice on Readmission After Opioid Use Disorder-Associated Infective Endocarditis: a National Cohort Study. J Gen Intern Med 2023; 38:1615-1622. [PMID: 36344644 PMCID: PMC10212894 DOI: 10.1007/s11606-022-07879-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Asher J Schranz
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Casey Tak
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Vivian H Chu
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - David A Wohl
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - David L Rosen
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Alagappan A, Chambers TJG, Brown E, Grecian SM, Lockman KA. 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. BMJ Open 2023; 13:e068801. [PMID: 36972969 PMCID: PMC10069606 DOI: 10.1136/bmjopen-2022-068801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
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.
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Affiliation(s)
- Anand Alagappan
- Acute & General Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Thomas J G Chambers
- Centre for Discovery Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Metabolic Unit, Western General Hospital, Edinburgh, UK
| | - Erik Brown
- Lothian Analytical Services, Waverley Gate, NHS Lothian, Edinburgh, UK
| | | | - Khalida Ann Lockman
- Acute & General Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Acute Medicine, The University of Edinburgh, Edinburgh, UK
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Jumah F, Chotai S, Hilden P, Raju B, Nagaraj A, Agarwalla P, Johnson S, Gupta G, Sun H, Nanda A. Characteristics and Outcomes of Discharge Against Medical Advice and 30-Day Readmissions After Concussion: Analysis of the Nationwide Readmissions Database. Neurosurgery 2022; 91:373-380. [PMID: 35593720 DOI: 10.1227/neu.0000000000002040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/24/2022] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Fareed Jumah
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Silky Chotai
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick Hilden
- Rutgers Neurosurgery Health Outcomes, Policy, and Economics (HOPE) Center, New Brunswick, New Jersey, USA
| | - Bharath Raju
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Anmol Nagaraj
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Pankaj Agarwalla
- Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Stephen Johnson
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Hai Sun
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Anil Nanda
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA.,Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
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Thyagaturu HS, Bolton A, Thangjui S, Kumar A, Shah K, Bondi G, Naik R, Sornprom S, Balla S. Effect of leaving against medical advice on 30-day infective endocarditis readmissions. Expert Rev Cardiovasc Ther 2022; 20:773-781. [PMID: 35984240 DOI: 10.1080/14779072.2022.2115358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- Harshith S Thyagaturu
- Department of Cardiology, Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Alexander Bolton
- University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Sittinun Thangjui
- Department of Internal Medicine and *Department of Infectious Diseases, Bassett Medical Center, Cooperstown, New York, USA
| | - Amudha Kumar
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kashyap Shah
- Department of Internal Medicine, St Luke's University Hospitals, Allentown, Pennsylvania, USA
| | - Gayatri Bondi
- Department of Internal Medicine and *Department of Infectious Diseases, Bassett Medical Center, Cooperstown, New York, USA
| | - Riddhima Naik
- Department of Internal Medicine and *Department of Infectious Diseases, Bassett Medical Center, Cooperstown, New York, USA
| | - Suthanya Sornprom
- Department of Internal Medicine and *Department of Infectious Diseases, Bassett Medical Center, Cooperstown, New York, USA
| | - Sudarshan Balla
- Department of Cardiology, Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia, USA
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Siebenhüner K, Blaser J, Nowak A, Cheetham M, Mueller BU, Battegay E, Beeler PE. Comorbidities Associated with Worse Outcomes Among Inpatients Admitted for Acute Gastrointestinal Bleeding. Dig Dis Sci 2022; 67:3938-3947. [PMID: 34365536 PMCID: PMC8349143 DOI: 10.1007/s10620-021-07197-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 07/25/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Multimorbidity increases healthcare resource utilization. Little is known on specific comorbidity combinations. AIMS To identify comorbidities associated with increased resource utilization among inpatients admitted for gastrointestinal bleeding (GIB). METHODS This retrospective cross-sectional study, 1/2010-5/2018 at the University Hospital Zurich, Switzerland, analyzed electronic health records of patients with upper (UGIB) and lower (LGIB) GIB, focusing on length of stay (LOS) and 30-day readmissions for resource use and clinical outcomes, investigated by multivariable regression adjusted for antithrombotics. RESULTS Of 1101 patients, 791 had UGIB and 310 LGIB, most often melena and bleeding diverticula, respectively. In UGIB, thromboembolic events showed a trend toward 27% increased LOS (1.27; 95% confidence interval [CI] 1.00-1.61), antithrombotics independently associated with 46% increased LOS (1.46; 95% CI 1.32-1.62). Cancer (odds ratio [OR] 2.86; 95% CI 1.68-4.88) independently associated with 30-day readmissions, anemia showed a trend (OR 1.68; 95% CI 1.00-2.84). In LGIB, none of the investigated comorbidities associated with increased LOS, but antithrombotics independently associated with 25% increased LOS (1.25; 95% CI 1.07-1.46). Atrial fibrillation/flutter (OR 2.69; 95% CI 1.06-6.82) and cancer (OR 4.76; 95% CI 1.40-16.20) associated strongly with 30-day readmissions. CONCLUSIONS In both groups, cancer associated with 30-day readmissions, antithrombotics with increased LOS. Thromboembolic events and anemia showed clinically important trends in UGIB. Atrial fibrillation/flutter associated with 30-day readmissions in LGIB. Prospective studies are needed to investigate these complex multimorbid populations and establish appropriate guidelines.
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Affiliation(s)
- K. Siebenhüner
- Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland ,Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland ,Centre of Competence Multimorbidity, University of Zurich, Zurich, Switzerland ,Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - J. Blaser
- Directorate of Research and Education, University Hospital of Zurich, Zurich, Switzerland
| | - A. Nowak
- Department of Endocrinology and Clinical Nutrition, University Hospital Zurich and University of Zurich, Zurich, Switzerland ,Department of Internal Medicine, Psychiatry University Hospital Zurich, Zurich, Switzerland
| | - M. Cheetham
- Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - B. U. Mueller
- Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - E. Battegay
- Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland ,Centre of Competence Multimorbidity, University of Zurich, Zurich, Switzerland ,Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - P. E. Beeler
- Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland ,Department of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Onukwugha E, Gandhi AB, Alfandre D. Discharges against medical advice and 30-day healthcare costs: an analysis of commercially insured adults. J Comp Eff Res 2021; 11:169-177. [PMID: 34783251 DOI: 10.2217/cer-2021-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Prior literature detailing the consequences of a discharge against medical advice (DAMA) has not focused on costs. We examine costs following a DAMA. Materials & methods: This retrospective cohort study utilized the IQVIA PharMetrics® Plus database to identify adults hospitalized during 2007-2015. We compared 30-day postdischarge healthcare costs between matched DAMA and routinely discharged groups. Results: Thirty-day healthcare costs for the DAMA group were US$1078 (95% CI: US$434-1730) higher, driven by inpatient readmissions (US$979; 95% CI: US$415-1543) and emergency department visits (US$79; 95% CI: US$56-102). Costs due to prescription drug fills were lower in the DAMA group. Conclusion: A DAMA was associated with higher 30-day postdischarge healthcare costs compared with routine discharges.
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Affiliation(s)
- Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Aakash Bipin Gandhi
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - David Alfandre
- VA National Center for Ethics in Health Care, US Department of Veterans Affairs and New York University School of Medicine, New York, NY 10010, USA
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Kimmel SD, Kim JH, Kalesan B, Samet JH, Walley AY, Larochelle MR. Against Medical Advice Discharges in Injection and Non-injection Drug Use-associated Infective Endocarditis: A Nationwide Cohort Study. Clin Infect Dis 2021; 73:e2484-e2492. [PMID: 32756935 PMCID: PMC8563193 DOI: 10.1093/cid/ciaa1126] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/30/2020] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Simeon D Kimmel
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
| | - June-Ho Kim
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts, USA
- Ariadne Labs, Harvard T. H. Chan School of Public Health & Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Bindu Kalesan
- Section of Preventative Medicine and Epidemiology, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
- Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Marc R Larochelle
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
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Shaaban AN, Peleteiro B, Martins MRO. Statistical models for analyzing count data: predictors of length of stay among HIV patients in Portugal using a multilevel model. BMC Health Serv Res 2021; 21:372. [PMID: 33882911 PMCID: PMC8061202 DOI: 10.1186/s12913-021-06389-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 04/14/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND This study offers a comprehensive approach to precisely analyze the complexly distributed length of stay among HIV admissions in Portugal. OBJECTIVE To provide an illustration of statistical techniques for analysing count data using longitudinal predictors of length of stay among HIV hospitalizations in Portugal. METHOD Registered discharges in the Portuguese National Health Service (NHS) facilities Between January 2009 and December 2017, a total of 26,505 classified under Major Diagnostic Category (MDC) created for patients with HIV infection, with HIV/AIDS as a main or secondary cause of admission, were used to predict length of stay among HIV hospitalizations in Portugal. Several strategies were applied to select the best count fit model that includes the Poisson regression model, zero-inflated Poisson, the negative binomial regression model, and zero-inflated negative binomial regression model. A random hospital effects term has been incorporated into the negative binomial model to examine the dependence between observations within the same hospital. A multivariable analysis has been performed to assess the effect of covariates on length of stay. RESULTS The median length of stay in our study was 11 days (interquartile range: 6-22). Statistical comparisons among the count models revealed that the random-effects negative binomial models provided the best fit with observed data. Admissions among males or admissions associated with TB infection, pneumocystis, cytomegalovirus, candidiasis, toxoplasmosis, or mycobacterium disease exhibit a highly significant increase in length of stay. Perfect trends were observed in which a higher number of diagnoses or procedures lead to significantly higher length of stay. The random-effects term included in our model and refers to unexplained factors specific to each hospital revealed obvious differences in quality among the hospitals included in our study. CONCLUSIONS This study provides a comprehensive approach to address unique problems associated with the prediction of length of stay among HIV patients in Portugal.
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Affiliation(s)
- Ahmed Nabil Shaaban
- Department of Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, NOVA University of Lisbon, Rua da Junqueira N°100, 1349-008, Lisbon, Portugal.
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
| | - Bárbara Peleteiro
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Maria Rosario O Martins
- Department of Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, NOVA University of Lisbon, Rua da Junqueira N°100, 1349-008, Lisbon, Portugal
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Spooner KK, Saunders JJ, Chima CC, Zoorob RJ, Salemi JL. Increased risk of 30-day hospital readmission among patients discharged against medical advice: a nationwide analysis. Ann Epidemiol 2020; 52:77-85.e2. [DOI: 10.1016/j.annepidem.2020.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
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Oyemolade TA, Adeleye AO, Ogunyileka OC, Arogundade FM, Olusola AJ, Aribisala OO. Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study. Surg Neurol Int 2020; 11:290. [PMID: 33033652 PMCID: PMC7538796 DOI: 10.25259/sni_559_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/26/2020] [Indexed: 12/02/2022] Open
Abstract
Background: In low-resource regions of the world, discharge against medical advice (DAMA) is one empiric contributory factor to poor in-hospital outcome that is not often mentioned. This study aims to investigate the determinants of DAMA from a rural neurosurgical service in a developing country. Methods: This was a prospective observational study of all patients who discharged against medical advice in our service between November 2018 and October 2019. Results: There were 88 patients, 67 (76.1%) males, in the study, (M:F = 3.2:1), representing 17.4% of our patient population in the study period. The peak incidence was in the 20–29 years age group which accounted for 37.5% of the cases. About 55% of the patients presented directly to our center; 31.8% were referred from other hospitals, while 3.4% came from traditional caregivers and 1.1% from religious homes. Head injury was the most common indication for presentation (76.1% of the cases). The duration of hospital stay ranged from 2 h to 14 days. Majority of the patients (87.5%) left the hospital within 8 h of presentation. The reason for DAMA was financial constraints in 50% of cases, inadequate health literacy in 20.5%, financial constraints and poor health literacy together in 12.5%, religious misgivings in 4.5%, and traditional belief in 2.3%. Neurotrauma was predictive of early DAMA (P = 0.001). Conclusion: The rate of DAMA was high in our study. Financial constraints with other socioeconomic limitations were the most common causes of DAMA in our environment.
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Affiliation(s)
| | - Amos Olufemi Adeleye
- Department of Neurological Surgery, University College Hospital, University of Ibadan, Ibadan, Oyo state, Nigeria
| | | | | | - Ayodele J Olusola
- Department of Surgery, Federal Medical Center Owo, Owo, Ondo state, Nigeria
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Leaving Against Medical Advice After Emergency General Surgery: Avoiding a Two-Hit Effect. J Surg Res 2020; 257:278-284. [PMID: 32866668 DOI: 10.1016/j.jss.2020.06.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/04/2020] [Accepted: 06/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Emergency general surgery has higher adverse outcomes than elective surgery. Patients leaving the hospital against medical advice (AMA) have a greater risk for readmission and complications. We sought to identify clinical and demographic characteristics along with hospital factors associated with leaving AMA after EGS operations. METHODS A retrospective review of the Nationwide Inpatient Sample was performed. All patients who underwent an EGS procedure accounting for >80% of the burden of EGS-related inpatient resources were identified. 4:1 propensity score analysis was conducted. Regression analyses determined predictive factors for leaving AMA. RESULTS 546,856 patients were identified. 1085 (0.2%) patients who underwent EGS left AMA. They were more likely to be men (59% versus 42%), younger (median age 51 y, IQR [37.61] versus 54, IQR [38.69]), qualify for Medicaid (26% versus 13%) or be self-pay (17% versus 9%), and be within the lowest quartile median household income (40% versus 28%) (all P < 0.05). After applying 4:1 propensity score matching, individuals who were self-pay (OR 3.15, 95% CI 2.44-4.06) or insured through Medicare (OR 2.75, 95% CI 2.11-3.57) and Medicaid (OR 3.58, 95% CI 2.83-4.52) had increased odds of leaving AMA compared with privately insured patients. In addition, history of alcohol (OR 2.21, 95% CI 1.65-2.98), drug abuse (OR 4.54, 95% CI 3.23-6.38), and psychosis (OR 2.31, 95% CI 1.65-3.23) were associated with higher likelihood for leaving AMA. CONCLUSIONS Patients undergoing EGS have a high risk of complications, and leaving AMA further increases this risk. Interventions to encourage safe discharge encompassing surgical, psychiatric, and socioeconomic factors are warranted to prevent a two-hit effect and compound postoperative risk.
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Kavanagh A, Donnelly J, Dunne N, Maher T, Nichol M, Creedon J. Factors associated with requests for premature discharge and the decision to support a service user through the discharge against medical advice process. Int J Ment Health Nurs 2020; 29:716-724. [PMID: 32134182 DOI: 10.1111/inm.12706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2020] [Indexed: 11/27/2022]
Abstract
In the Irish mental healthcare system, voluntarily admitted service users can request to leave hospital at any time. Following engagement with treating clinicians, service users remain as voluntary inpatients, are discharged, discharge themselves against medical advice, or are detained under legislation for the purposes of assessment. While detention conflicts with the principle of autonomy and a human rights-based approach, premature discharge is often associated with negative outcomes including reduced time to readmission, poorer quality of life, increased costs, and suicide. This study is a retrospective review of clinical records to identify factors associated with requests for premature discharge. Considerations of clinicians making the decision to detain the person or to support them through the discharge against medical advice process were also elucidated. Data were collected from clinical records of service users who requested discharge and were subsequently discharged against medical advice or detained involuntarily. Discharge against medical advice represented 3.5% of all discharges. The most frequent reasons for requests for discharge against medical advice were dissatisfaction with treatment, lack of engagement due to addiction, and leaving without notifying staff. Requests for discharge against medical advice frequently occurred out of hours, and nurses were the clinicians most likely to receive such requests.
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Affiliation(s)
- Adam Kavanagh
- St. Patrick's Mental Health Services, Dublin 8, Ireland
| | | | - Niall Dunne
- St. Patrick's Mental Health Services, Dublin 8, Ireland
| | - Tom Maher
- St. Patrick's Mental Health Services, Dublin 8, Ireland
| | | | - John Creedon
- St. Patrick's Mental Health Services, Dublin 8, Ireland
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Chaudhary F, Albeiruti R, Alqahtani F, Alhajji M, Lerfald N, Hutson W. Temporal Trends and Predictors of Pancreatitis Patients Who Leave Against Medical Advice: A Nationwide Analysis. Gastroenterology Res 2020; 13:58-65. [PMID: 32362964 PMCID: PMC7188362 DOI: 10.14740/gr1272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
Background Acute pancreatitis is the leading gastrointestinal cause of hospital admissions. Our study aims to determine the trends and predictors of discharge against medical advice (AMA). Methods We utilized the Nationwide Inpatient Sample (2003 - 2016) to identify patients admitted with pancreatitis. We compared in-hospital complications and determined predictors of discharge AMA using a multivariate logistic regression. Results A total of 7,158,894 patients were admitted with pancreatitis. Of those, 199,351 left AMA. Discharge AMA increased over time from 2.3% to 3.2%. Patients who left AMA were more likely to be younger, male, black, and a lower socioeconomic status (SES). They had a greater prevalence of depression, cirrhosis, smoking, drug abuse, and human immunodeficiency virus (HIV) infection. Alcohol use was the most likely etiology of pancreatitis among those leaving AMA. In a multivariate regression, patients more likely to leave AMA included: age 18 - 44, male, and black. Patients with a history of depression, drug abuse, and HIV infection were also more likely to be discharged AMA. Conclusions Discharges AMA increased over time. Predictors of AMA include patients who are younger, male, black, lower socioeconomic status, and have a history of depression, HIV infection, alcohol and drug use. Future studies are necessary to examine the reasons for discharge AMA among this population.
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Affiliation(s)
- Fahad Chaudhary
- Department of Medicine, West Virginia University, Morgantown, WV, USA.,They contributed equally to the manuscript
| | - Ridwaan Albeiruti
- Department of Medicine, West Virginia University, Morgantown, WV, USA.,They contributed equally to the manuscript
| | - Fahad Alqahtani
- Division of Cardiology, West Virginia University, Morgantown WV, USA
| | - Mohamed Alhajji
- Division of Cardiology, West Virginia University, Morgantown WV, USA
| | - Nathan Lerfald
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - William Hutson
- Section of Digestive Diseases, West Virginia University, Morgantown, WV, USA
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Haines K, Freeman J, Vastaas C, Rust C, Cox C, Kasotakis G, Fuller M, Krishnamoorthy V, Siciliano M, Alger A, Montgomery S, Agarwal S. "I'm Leaving": Factors That Impact Against Medical Advice Disposition Post-Trauma. J Emerg Med 2020; 58:691-697. [PMID: 32171476 DOI: 10.1016/j.jemermed.2019.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Discharge against medical advice (AMA) is an important, yet understudied, aspect of health care-particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs. OBJECTIVE The goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment. METHODS We performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status. RESULTS Uninsured (odds ratio [OR] 2.72; 95% confidence interval [CI] 2.58-2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37-2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02-1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52-0.75), Asian (OR 0.59; 95% CI 0.49-0.69), and Hispanic (OR 0.80; 95% CI 0.75-0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury. CONCLUSIONS Insurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.
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Affiliation(s)
- Krista Haines
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer Freeman
- Department of Surgery, Texas Health Harris Methodist Hospital, Fort Worth, Texas
| | - Cory Vastaas
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Clay Rust
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher Cox
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
| | - George Kasotakis
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew Fuller
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
| | - Michelle Siciliano
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Amy Alger
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Sean Montgomery
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Jasperse N, Grigorian A, Delaplain P, Jutric Z, Schubl SD, Kuza CM, Nahmias J. Predictors of discharge against medical advice in adult trauma patients. Surgeon 2019; 18:12-18. [PMID: 31056431 DOI: 10.1016/j.surge.2019.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients who leave against medical advice (AMA) have higher readmission rates and mortality. However, little is known about the characteristics of trauma patients that leave AMA. The purpose of this study was to identify predictors for leaving AMA in adult trauma patients. METHODS The Trauma Quality Improvement Program database was queried between 2010 and 2016 for patients ≥18 years of age presenting after trauma. Two groups were compared: those who left AMA and those that did not. Bivariate analysis using Chi-squared and Mann-Whitney U tests was performed. A multivariable logistic regression analysis was performed to identify predictors for leaving AMA. RESULTS Of 1,403,466 trauma patients identified, 10,659 (0.76%) left AMA. Patients that left AMA were younger (median age, 48 vs. 53 years-old, p < 0.001), more often male (82.1% vs. 62.8%, p < 0.001), more likely to be black (23.6% vs. 14.9%, p < 0.001), and more likely to be uninsured (27.0% vs. 12.3%, p < 0.001). Patients leaving AMA were more likely to test positive for alcohol (36.1% vs. 17.4%, p < 0.001) or drug use (36.0% vs. 17.2%, p < 0.001) at time of admission. On multivariable logistic regression, the strongest predictors for leaving AMA were: no insurance (OR 2.00, CI 1.88-2.14, p < 0.001), alcohol use (OR 1.85, CI 1.74-1.96, p < 0.001) or drug use (OR 1.83, CI 1.72-1.94, p < 0.001), male gender (OR 1.83, CI 1.71-1.97, p < 0.001), and stab mechanism of injury (OR 1.58, CI 1.43-1.73, p < 0.001). CONCLUSION In adult trauma patients, male gender, stab mechanism of injury, being uninsured, and alcohol/drug use were strong predictors of leaving AMA. The risk factors identified may help in developing strategies aimed at preventing trauma patients from leaving AMA.
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Affiliation(s)
- Nathan Jasperse
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Patrick Delaplain
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Zeljka Jutric
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Sebastian D Schubl
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Catherine M Kuza
- University of Southern California, Department of Anesthesiology, Los Angeles, CA, USA
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
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Patel B, Prousi G, Shah M, Secheresiu P, Garg L, Agarwal M, Patil S, Gupta R, Feldman B. Thirty-Day Readmission Rate in Acute Heart Failure Patients Discharged Against Medical Advice in a Matched Cohort Study. Mayo Clin Proc 2018; 93:1397-1403. [PMID: 30005815 DOI: 10.1016/j.mayocp.2018.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/10/2018] [Accepted: 04/26/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the readmission rate in patients with acute heart failure (AHF) discharged against medical advice (AMA). METHODS We performed a retrospective analysis using the 2014 National Readmission Database. Patients admitted with a primary diagnosis of AHF were selected. Only those discharged to home and who left AMA were included in the study. The primary outcome was 30-day readmission. We compared the readmission rates among those discharged AMA vs routinely discharged patients using propensity score matching (PSM) to address imbalance in variables between the 2 groups. We matched 3 routinely discharged patients to 1 patient who left AMA. RESULTS We identified 273,489 patients with AHF, of whom 116,869 qualified for further study analysis. A total of 2014 patients (1.7%) were in the AMA group and 114,855 (98.3%) were in the routinely discharged group. After PSM, 6042 routinely discharged patients were matched with 2014 patients from the AMA group. The standard mean difference for each variable was less than 10% postmatching. The 30-day readmission rate among those who left AMA was higher than among those routinely discharged (33% vs 20.1%; P<.001). Heart failure (44.8%) was the most common cause of readmission in the AMA group. Patients who left AMA were more likely to be readmitted to a different hospital compared with those routinely discharged (37.4 vs 23.1%; P<.001). They also had a high rate of leaving AMA during the readmission (18 vs 2%; P<.001). CONCLUSION Patients with AHF discharged AMA had a significantly higher 30-day readmission rate than did the routinely discharged group.
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Affiliation(s)
- Brijesh Patel
- Department of Cardiology, Lehigh Valley Hospital Network, Allentown, PA.
| | - George Prousi
- Department of Internal Medicine, Lehigh Valley Hospital Network, Allentown, PA
| | - Mahek Shah
- Department of Cardiology, Lehigh Valley Hospital Network, Allentown, PA
| | - Paul Secheresiu
- Department of Internal Medicine, Lehigh Valley Hospital Network, Allentown, PA
| | - Lohit Garg
- Department of Cardiology, Lehigh Valley Hospital Network, Allentown, PA
| | - Manyoo Agarwal
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Shantanu Patil
- Department of Medicine, SSM Health St Mary's Hospital, St Louis, MO
| | - Rahul Gupta
- Department of Internal Medicine, New York Medical College, Valhalla, NY
| | - Bruce Feldman
- Department of Cardiology, Lehigh Valley Hospital Network, Allentown, PA
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Ramakrishnan N, Ranganathan L, Abraham BK, Rajagopalan S, Venkataraman R. What Happens to Patients Discharged Against Medical Advice? Indian J Crit Care Med 2018; 22:580-584. [PMID: 30186008 PMCID: PMC6108291 DOI: 10.4103/ijccm.ijccm_101_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Discharge against medical advice (DAMA) when requested by family members of patients in Indian Critical Care Units (CCUs) leads to loss of follow-up and unknown patient outcomes. Exclusion of these patients from research analysis and quality audits confounds these results. We hence explored the proportion of patients leaving DAMA, reasons, and their outcomes at 30 and 90 days. Methods This was a prospective study of CCU patients admitted from July 2013 to February 2014. All patients, who were DAMA during this period, were included in this study. Demographics, APACHE data, and outcomes were collected and compared to patients discharged regularly during the same period. Outcomes of DAMA patients at 30 and 90 days were gathered by telephone follow-up. Results Among the 663 patients admitted to the CCU, 15.1% (100 patients) were DAMA. The baseline APACHE score of the DAMA group was higher than the regular discharge group (29.5 ± 8.6 vs. 26.1 ± 10.3; P = 0.002). During the 30-day follow-up, 23% were alive, 56% dead, and 21% could not be contacted. At 90 days, mortality was 62% and survivors decreased to 14%. Common reasons for DAMA were - wanting to take the patient to another hospital (21%), reluctance for further treatments (12%), financial constraints (9%), and overall poor prognosis (7%). Conclusion A significant proportion of patients in the CCU get DAMA despite high severity of illness. Understanding the outcomes of these patients will help refine CCU quality audit reports and research study results.
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Affiliation(s)
| | - Lakshmi Ranganathan
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Babu K Abraham
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
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Ashrafi E, Nobakht S, Keykaleh MS, Kakemam E, Hasanpoor E, Sokhanvar M. Discharge against medical advice (DAMA): Causes and predictors. Electron Physician 2017; 9:4563-4570. [PMID: 28848631 PMCID: PMC5557136 DOI: 10.19082/4563] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 02/06/2017] [Indexed: 11/30/2022] Open
Abstract
Background and aim DAMA is a result of patient dissatisfaction, which increases the rate of readmission, mortality, and complications. In this study, the causes and predictors of DAMA in Shahid Labbafinejad Hospital of Tehran were determined. Methods The descriptive and analytical study was conducted in 2016 from the information of 1,168 hospitalized patients in the period of 2015 and the first half of 2016. Patients’ information was collected using checklists and through clinical records, nursing unit reports, and telephone calls. The collected data were analyzed using SPSS-v18 software and by employing chi-square test and logistic regression modeling. Results The DAMA rate was estimated at 3.27%. Among the causes of DAMA, the high rates were related to personal problems (39.04%) and going to other centers (34.93%), and the lowest level was related to dissatisfaction with the physician (3.08%). Age groups (19–37, OR=2.17), (38–56 years, OR=1.70), and (57–75, OR=1.62), gender (male, OR=1.47), locations (Tehran city, OR=0.61) and (Tehran Province, OR=0.63) were predictors of DAMA (p<0.05). Conclusions The importance of DAMA requires practical measures such as creating a suitable environment for patients, providing consulting services for youth, improving staff relations, providing assistance for patients in need, and removing accommodation problems of patients and their companions to reduce the DAMA.
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Affiliation(s)
- Ensieh Ashrafi
- M.Sc. in Health Services Management, Shahid Labbafinejad Hospital, Social Security Organization (SSO), Tehran, Iran
| | - Samin Nobakht
- M.Sc. in Health Services Management, Department of Health Management, Tehran Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Meysam Safi Keykaleh
- Ph.D. Student in Health in Disaster and Emergencies, School of Health, Safety and Environment, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Edris Kakemam
- Ph.D. Student in Health Services Management, Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Edris Hasanpoor
- Ph.D. Candidate in Health Services Management, Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mobin Sokhanvar
- Ph.D. Candidate in Health Services Management, Iranian Center of Excellence in Health Management (ICeHM), Tabriz University of Medical Sciences, Tabriz, Iran
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Spooner KK, Salemi JL, Salihu HM, Zoorob RJ. Discharge Against Medical Advice in the United States, 2002-2011. Mayo Clin Proc 2017; 92:525-535. [PMID: 28291588 DOI: 10.1016/j.mayocp.2016.12.022] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/30/2016] [Accepted: 12/14/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To describe the national frequency, prevalence, and trends of discharge against medical advice (DAMA) among inpatient hospitalizations in the United States and identify differences across patient- and hospital-level characteristics, overall and in clinically distinct diagnostic subgroups. PATIENTS AND METHODS We conducted a retrospective, cross-sectional analysis of inpatient hospitalizations (≥18 years), discharged between January 1, 2002, and December 31, 2011, using the Nationwide Inpatient Sample. Descriptive statistics, multivariable logistic, and joinpoint regression were used for statistical analyses. RESULTS Between January 1, 2002, and December 31, 2011, more than 338,000 inpatient hospitalizations were discharged against medical advice each year, with a 1.9% average annual increase in prevalence over the decade (95% CI, 0.8%-3.0%). Temporal trends in DAMA varied by principal diagnosis. Among patients hospitalized for mental health- or substance abuse-related disorders, there was a -2.3% (95% CI, -3.8% to -0.8%) average annual decrease in the rate of DAMA. A statistically significant temporal rate change was not observed among hospitalizations for pregnancy-related disorders. Multivariable regression revealed several patient and hospital characteristics as predictors of DAMA, including lack of health insurance (odds ratio [OR], 3.78; 95% CI, 3.62-3.94), male sex (OR, 2.40; 95% CI, 2.36-2.45), and northeast region (OR, 1.91; 95% CI, 1.72-2.11). Other predictors included age, race/ethnicity, income, primary diagnosis, severity of illness, and hospital location/type and size. CONCLUSION Rates for DAMA have increased in the United States, and key differences exist across patient and hospital characteristics. Early identification of vulnerable patients and preventive measures such as improved patient-provider communication may reduce DAMA.
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Affiliation(s)
- Kiara K Spooner
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX.
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Hamisu M Salihu
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Roger J Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
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Soltani M, Mirzaei M, Amin A, Emami M, Aryanpoor R, Shamsi F, Sarebanhassanabadi M. Predictors of Adverse Outcomes of Patients with Chest Pain and Primary Diagnosis of Non-Cardiac Pain at the Time of Discharge from Emergency Department: A 30-Days Prospective Study. Ethiop J Health Sci 2016; 26:305-10. [PMID: 27587928 PMCID: PMC4992770 DOI: 10.4314/ejhs.v26i4.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Chest pain is a common symptom for referring patients to emergency departments (ED). Among those referred, some are admitted to hospitals with a definite or tentative diagnosis of acute coronary syndrome and some are discharged with primary diagnosis of non-cardiac chest pain. This study aimed at investigating 30 days' adverse outcomes of patients discharged from ED of a major heart center in Iran. Methods Out of 1638 chest pain admissions to the centre during 2010–2011, 962 patients (mean age= 50.9±15.9 years) who were admitted to Afshar Heart Center's ED with chest pain as their chief complaint, and discharged with primary diagnosis of non-cardiac chest pain, were followed for any adverse cardiac events 30 days post discharge. The adverse events were: unstable angina, non-ST-elevated myocardial infarction (NSTEMI), ST elevated myocardial infarction (STEMI), coronary revascularization (percutaneous angioplasty, coronary artery bypass grafting) and death. Results Adverse cardiac events, including acute coronary syndrome (ACS), revascularization and death were observed in 30 patients (3.1%) including: acute MI n=5 (0.5%, sudden cardiac death inn=1 (0.1%, coronary revascularization in n=8 (0.8%) and hospitalization due to unstable angina/NSTEMI in n=16 (1–7%). Adverse events were seen more frequently in patients with history of hypertension, dyslipidemia and previous coronary artery disease. In univariate analysis, the chance of postdischarge adverse cardiac events was higher in patients with hypertension (OR=9.36, CI=3.24–27.03), previous coronary artery disease (OR= 3.8, CI=1.78–8.0), dyslipidemia (OR=3.5, CI=1.7–7.38) and discharge against medical advice (OR=2.85, CI= 1.37–5.91). Conclusion The extent of adverse cardiac events in patients with a primary diagnosis of non-cardiac chest pain within 30 days of discharge was significant, mandating nation-wide registries to provide better care for these patients.
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Affiliation(s)
- Mohammadhossien Soltani
- Yazd Cardiovascular Research Centre, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Masoud Mirzaei
- Yazd Cardiovascular Research Centre, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Ahmad Amin
- Rajaie Cardiovascular, Medical and Research Center, Tehran. Iran
| | - Mahmoud Emami
- Yazd Cardiovascular Research Centre, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | - Farimah Shamsi
- Department of Epidemiology and Biostatistics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Tawk R, Dutton M. Racial Differences in Length of Stay for Patients Who Leave Against Medical Advice from U.S. General Hospitals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 13:ijerph13010095. [PMID: 26729149 PMCID: PMC4730486 DOI: 10.3390/ijerph13010095] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 12/14/2015] [Accepted: 12/29/2015] [Indexed: 01/13/2023]
Abstract
There is a paucity of published literature on the length of hospital stays (LOS) for patients who leave against medical advice (AMA) and on the factors that predict their LOS. The purpose of the study is to examine the relationship between race and the LOS for AMA patients after adjusting for patient and hospital characteristics. National Hospital Discharge Survey (NHDS) data were used to describe LOS for AMA patients aged 18 years or older. Patient characteristics included age, sex, race, marital status, insurance, and diagnosis (ICD-9-CM). Hospital characteristics consisted of ownership, region and bed size. LOS was the major outcome measure. Using data from all years 1988–2006, the expected time to AMA discharge was first examined as a function of race, then adjusting for year terms, patient and hospital characteristics, and major medical diagnoses and mental illness. The unadjusted effect of race on the expected time of leaving AMA was about twice the adjusted effect. After controlling for the other covariates, the expected time to AMA discharge is 20% shorter for Blacks than Whites. The most significant predictors included age, insurance coverage, mental illness, gender, and region. Factors identified in this study offer insights into directions for evidence based- health policy to reduce AMA discharges.
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Affiliation(s)
- Rima Tawk
- Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA.
| | - Matthew Dutton
- Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA.
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MOHSENI M, ALIKHANI M, TOURANI S, AZAMI-AGHDASH S, ROYANI S, MORADI-JOO M. Rate and Causes of Discharge against Medical Advice in Iranian Hospitals: A Systematic Review and Meta-Analysis. IRANIAN JOURNAL OF PUBLIC HEALTH 2015; 44:902-12. [PMID: 26576368 PMCID: PMC4645761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 04/19/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Discharge against Medical Advice (DAMA) is a problem for hospitals which may result in increasing readmissions, morbidities, inabilities, deaths and health care costs. This study, aimed to investigate the rate and causes of DAMA in Iranian hospitals. METHODS A systematic review and meta-analysis study was conducted in 2014. Required data were collected through searching for key words included: "Discharge Against Medical Advice", "Leaving against medical advice", "causes*", "hospital" and their Persian equivalents, over databases including PubMed, OVID, Google Scholar, Embase, Scopus, Magiran, scientific information database (SID). The reference lists of the articles, certain relevant journals and web sites in this field were also searched. RESULTS Out of 913 articles initially retrieved, finally 17 articles were incorporated into the study. There were 244858 individuals studied in the articles. Using a random effects model, the rate of DAMA in Iranian hospitals was estimated at 7.9% (6.3%-9.8%). While the highest rate of DAMA was associated with patients in departments of psychiatry (12%), the lowest rate was related to patients in departments of pediatrics (3.7). DAMA was in men more than women (P<0.05) Patient's perception of feeling of wellbeing, financial problems, family problems, the lack of attention from physicians and nurses, inappropriate behavior with patients by hospital team and the lack of timely care were mentioned as main causes for DAMA. CONCLUSION The rate of DAMA in Iranian hospitals is relatively high. Thus effective initiatives in this area are required.
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Affiliation(s)
- Mohammad MOHSENI
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahtab ALIKHANI
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Sogand TOURANI
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Saber AZAMI-AGHDASH
- Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sanaz ROYANI
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad MORADI-JOO
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Prospective evaluation of cases of discharge against medical advice in Abuja, Nigeria. ScientificWorldJournal 2015; 2015:314817. [PMID: 25821850 PMCID: PMC4363576 DOI: 10.1155/2015/314817] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 02/14/2015] [Indexed: 11/20/2022] Open
Abstract
Background. Discharge against medical advice (DAMA) is a global clinical phenomenon contributing significantly to adverse patients' outcome. Literatures abound on self-discharges in specific medical subpopulations. However, multidisciplinary studies on this subject in our region are few. Aim. To prospectively evaluate cases of DAMA in a wholesale multidisciplinary perspective at Federal Staff Medical Centre, Abuja, and suggest strategies to reduce it. Patients and Methods. All consecutive patients who DAMA from our medical centre between June 2013 and May 2014 were included in the study. Data harvested from the standard proforma were analyzed using IBM SPSS version 19.0. Results. We recorded an overall DAMA rate of 2.1%. The majority of the patients were paediatric cases (n = 63, 44.6%) while closed long bone fractures represented the leading diagnosis (n = 35, 24.8%). The most commonly cited reasons for leaving the hospital were financial constraints (n = 46, 32.6%) and seeking alternative therapy (n = 25, 17.7%). Conclusion. The DAMA rate in our study is comparable to some urban hospitals elsewhere. However, the leading reasons for this phenomenon are unacceptable in the current medical best practice. Thus, strengthening the Health Insurance Scheme, strict control of traditional medical practices, and focused health education are recommended strategies to reduce DAMA.
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Jafari S, Joe R, Elliot D, Nagji A, Hayden S, Marsh DC. A Community Care Model of Intravenous Antibiotic Therapy for Injection Drug Users with Deep Tissue Infection for "Reduce Leaving Against Medical Advice". Int J Ment Health Addict 2015; 13:49-58. [PMID: 25685126 PMCID: PMC4320270 DOI: 10.1007/s11469-014-9511-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Deep tissue infection is a serious sequela that often demands intravenous (IV) antibiotic treatment. With respect to IV drug users (IDU's), research and lived experience demonstrates a trend of failed treatment outcomes, most notably associated with leaving hospital against medical advice (LAMA) prior to treatment completion, increased adverse outcomes and patient hardship. This paper examines an alternative model for delivering and completing IV antibiotic treatment to IDU's in a community care setting. A retrospective study was designed to review client characteristics. A total of 33 in-depth interviews were conducted with clients, clinicians and with staff. The impact of treatment adherence and completion, as well as client satisfaction of care was explored. A total of 165 patients were admitted during the study period. Osteomyelitis was the primary cause for IV antibiotics. Risk of leaving AMA was significantly lower for community model (p value <0.0000). Qualitative narrative analysis is also described with respect to satisfaction, stigma and the need for better models of care. With lower rates of LAMA a community model ought to be considered on a wider scale for provision of comprehensive support for populations with complex underlying health needs.
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Affiliation(s)
- Siavash Jafari
- Addiction Medicine Program, Vancouver Coastal Health Authority, Vancouver, BC Canada
| | - Ronald Joe
- Addiction Medicine Program, Vancouver Coastal Health Authority, Vancouver, BC Canada
| | - Danielle Elliot
- Department of Social Sciences, York University, 4700 Keele Street, Toronto, ON M3J 1P3 Canada
| | - Ashnoor Nagji
- Addiction Medicine Program, Vancouver Coastal Health Authority, Vancouver, BC Canada
| | - Sargent Hayden
- Addiction Medicine Program, Vancouver Coastal Health Authority, Vancouver, BC Canada
| | - David C. Marsh
- Community Engagement, Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6 Canada
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Abdelaziz OS, Elwany MN, Abbassy MA, Mostafa MS. Profile of Road Traffic Accidents–related Head Injuries in Alexandria During the Egyptian Revolution 2011. ACTA ACUST UNITED AC 2015. [DOI: 10.1097/wnq.0000000000000077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gili-Miner M, Béjar-Prado L, Gili-Ortiz E, Ramírez-Ramírez G, López-Méndez J, López-Millán JM, Sharp B. Alcohol use disorders among surgical patients: unplanned 30-days readmissions, length of hospital stay, excessive costs and mortality. Drug Alcohol Depend 2014; 137:55-61. [PMID: 24529967 DOI: 10.1016/j.drugalcdep.2014.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 01/07/2014] [Accepted: 01/09/2014] [Indexed: 10/25/2022]
Abstract
AIMS Alcohol use disorders (AUD) have been associated with an increased risk of unplanned hospital readmissions (URA). We analyzed in a sample of 87 Spanish Hospitals if surgical patients with AUD had a higher risk of URA and if among patients with URA, those with AUD had an excess length of hospital stay, higher hospital expenses and increased risk of mortality. METHOD We analyzed data of patients who underwent surgical operations during the period between 2008 and 2010. URA was defined as unplanned readmissions during the first 30 days after hospital departure. The primary outcome was risk of URA in patients with AUD. Secondary outcomes were mortality, excess length of stay and over expenditure. RESULTS A total of 2,076,958 patients who underwent surgical operations were identified: 68,135 (3.3%) had AUD, and 62,045 (3.0%) had at least one URA. Among patients with AUD 4212 (6.2%) had at least one URA and among patients without AUD 57,833 (2.9%) had at least one URA. Multivariable analysis demonstrated that AUD was an independent predictor of developing URA (Odds ratio: 1.56; 95% CI: 1.50-1.62). Among surgical patients with URA, those with AUD had longer lengths of hospital stay (2.9 days longer), higher hospital costs (2885.8 Euros or 3858.3 US Dollars), higher risk of death (OR: 2.16, 95% CI: 1.92-2.44) and higher attributable mortality (11.2%). CONCLUSIONS Among surgical patients, AUD increase the risk of URA, and among patients with URA, AUD heighten the risk of in-hospital death, and cause longer hospital stays and over expenditures.
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Affiliation(s)
- Miguel Gili-Miner
- Unidad de Gestión Clínica de Medicina Preventiva, Vigilancia y Promoción de la Salud, Hospital Universitario Virgen Macarena, Av. Dr. Fedriani s/n, 41070 Seville, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Av. Sánchez Pizjuán s/n, 41007 Seville, Spain.
| | - Luis Béjar-Prado
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Av. Sánchez Pizjuán s/n, 41007 Seville, Spain
| | - Enrique Gili-Ortiz
- Unidad de Gestión Clínica de Anestesiología y Bloque Quirúrgico, Hospital Universitario Virgen Macarena, Av. Dr. Fedriani s/n, 41070 Seville, Spain
| | - Gloria Ramírez-Ramírez
- Unidad de Gestión Clínica de Medicina Preventiva, Vigilancia y Promoción de la Salud, Hospital Universitario Virgen Macarena, Av. Dr. Fedriani s/n, 41070 Seville, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Av. Sánchez Pizjuán s/n, 41007 Seville, Spain
| | - Julio López-Méndez
- Unidad de Gestión Clínica de Medicina Preventiva, Vigilancia y Promoción de la Salud, Hospital Universitario Virgen Macarena, Av. Dr. Fedriani s/n, 41070 Seville, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Av. Sánchez Pizjuán s/n, 41007 Seville, Spain
| | - José-Manuel López-Millán
- Unidad de Gestión Clínica de Anestesiología y Bloque Quirúrgico, Hospital Universitario Virgen Macarena, Av. Dr. Fedriani s/n, 41070 Seville, Spain
| | - Brett Sharp
- Unidad de Gestión Clínica de Diagnóstico por la Imagen, Hospital Universitario Virgen de Rocío, Av. Manuel Siurot s/n, 41013 Seville, Spain
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Yong TY, Fok JS, Hakendorf P, Ben-Tovim D, Thompson CH, Li JY. Characteristics and outcomes of discharges against medical advice among hospitalised patients. Intern Med J 2014; 43:798-802. [PMID: 23461391 DOI: 10.1111/imj.12109] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 02/17/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Discharge against medical advice (DAMA) occurs when an in-patient chooses to leave the hospital before discharge is recommended by the treating clinicians. The long-term outcomes of patients who DAMA are not well documented. AIM The objective of this long-term and hospital-wide study is to examine characteristics of patients who DAMA, their rates of readmission and mortality after self-discharge. METHODS Administrative data of admissions to Flinders Medical Centre between July 2002 and June 2011 were used to compare readmissions and mortality among patients who DAMA with those who did not. The outcomes were adjusted for age, gender, emergency admission status, comorbidity, mental health diagnoses, and alcohol and substance abuse. RESULTS In the study period, 1562 episodes (1.3%) of 121,986 admissions to Flinders Medical Centre were DAMA. Compared with those who did not leave against medical advice, these patients were younger, more often male, more likely of indigenous ethnicity and had less physical comorbidity, but greater mental health comorbidity. Half of the DAMA group stayed less than 3 days. In multivariate analysis, the relative risk for 7-day, 28-day and 1-year readmission in the DAMA group was 2.36 (95% confidence interval (CI), 1.99-2.81; P < 0.001), 1.66 (95% CI, 1.44-1.92; P < 0.001) and 1.31 (95% CI, 1.19-1.45; P < 0.001), respectively, compared with standard discharges. Furthermore, DAMA was associated with twofold (P = 0.02), 1.4-fold (P = 0.025) and 1.2-fold (P = 0.049) increase in 28-day, 1-year and up-to-9-year mortality, respectively, compared with non-DAMA. CONCLUSIONS Patients who self-discharged against medical advice carry a significant risk of readmission and mortality. Patients with characteristics of 'at risk of DAMA' should have greater attention paid to their care before and especially after any premature discharge.
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Affiliation(s)
- T Y Yong
- Department of General Medicine, Flinders Medical Centre; Faculty of Health Science, Flinders University, Adelaide, South Australia, Australia
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Beck CA, Southern DA, Saitz R, Knudtson ML, Ghali WA. Alcohol and drug use disorders among patients with myocardial infarction: associations with disparities in care and mortality. PLoS One 2013; 8:e66551. [PMID: 24039695 PMCID: PMC3770618 DOI: 10.1371/journal.pone.0066551] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 05/10/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Because alcohol and drug use disorders (SUDs) can influence quality of care, we compared patients with and without SUDs on frequency of catheterization, revascularization, and in-hospital mortality after acute myocardial infarction (AMI). METHODS This study employed hospital discharge data identifying all adult AMI admissions (ICD-9-CM code 410) between April 1996 and December 2001. Patients were classified as having an SUD if they had alcohol and/or drug (not nicotine) abuse or dependence using a validated ICD-9-CM coding definition. Catheterization and revascularization data were obtained by linkage with a clinically-detailed cardiac registry. Analyses (controlling for comorbidities and disease severity) compared patients with and without SUDs for post-MI catheterization, revascularization, and in-hospital mortality. RESULTS Of 7,876 AMI unique patient admissions, 2.6% had an SUD. In adjusted analyses mortality was significantly higher among those with an SUD (odds ratio (OR) 2.02; 95%CI: 1.10-3.69), while there was a trend toward lower catheterization rates among those with an SUD (OR 0.75; 95%CI: 0.55-1.01). Among the subset of AMI admissions who underwent catheterization, the adjusted hazard ratio for one-year revascularization was 0.85 (95%CI: 0.65-1.11) with an SUD compared to without. CONCLUSIONS Alcohol and drug use disorders are associated with significantly higher in-hospital mortality following AMI in adults of all ages, and may also be associated with decreased access to catheterization and revascularization. This higher mortality in the face of poorer access to procedures suggests that these individuals may be under-treated following AMI. Targeted efforts are required to explore the interplay of patient and provider factors that underlie this finding.
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Affiliation(s)
- Cynthia A. Beck
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
- Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
| | - Danielle A. Southern
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Richard Saitz
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | | | - William A. Ghali
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
- Institute for Public Health (IPH), University of Calgary, Calgary, Alberta, Canada
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Abdulateef H, Al Amri M, Sayyed RF, Al Ansari K, Lariego G, Al Hammadi Z. Discharge against medical advice in a pediatric emergency center in the State of Qatar. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2012. [DOI: 10.5339/jemtac.2012.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Stern TW, Silverman BC, Smith FA, Stern TA. Prior discharges against medical advice and withdrawal of consent: what they can teach us about patient management. Prim Care Companion CNS Disord 2012; 13:10f01047blu. [PMID: 21731846 DOI: 10.4088/pcc.10f01047blu] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Macrohon BC. Pediatrician's perspectives on discharge against medical advice (DAMA) among pediatric patients: a qualitative study. BMC Pediatr 2012; 12:75. [PMID: 22709143 PMCID: PMC3407506 DOI: 10.1186/1471-2431-12-75] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 06/18/2012] [Indexed: 11/27/2022] Open
Abstract
Background The phenomenon of discharge against medical advice (DAMA) among pediatric patients places pediatricians in a dilemma between respect for the parent’s decision and the desire to provide complete care for the vulnerable child-patient. Little has been written about factors that affect a pediatrician’s decision to allow a parent to discharge his child against medical advice. This qualitative study aims to answer the question of how pediatric residents in a tertiary government hospital perceive and decide on a DAMA request from a parent or primary caregiver. Methods Using a focus group discussion approach, 11 pediatric residents from a government-run tertiary hospital were recruited for the study. The session was digitally recorded and dominant themes were coded and identified. Results There were three prominent themes that arose in the discussion: variability of definitions of DAMA, factors considered before “allowing” the patient to be DAMA, and the implications of a DAMA request on their performance as pediatricians. Definitions vary from one resident to another based on the main reason for DAMA (terminal, cultural, or financial). A conflict was noted in the definition of Home per Request (HPR) versus DAMA. Factors that influence a pediatrician to sign out a case as DAMA include: their ability to do something about the reason given for the DAMA request, the condition of the patient when the DAMA request was given, their impression of the kind of care that the parents provide, and their legal liabilities. Pediatric residents generally maintain a positive attitude towards the parents who request for DAMA and in the event of readmission, accept the patient into their care again. The occurrence of a variety of definitions and subcategories for DAMA may cause confusion among the pediatricians and should be clarified. The familiarity with cultural traditions contributes to their ability to handle situations that may lead to DAMA but this should always be considered in the context of the pediatrician’s legal liabilities. The attitude of being helpful in spite of readmission after DAMA is an important attribute to be encouraged among new trainees. Conclusion In most reviews about the phenomenon of DAMA, patient characteristics have been identified that make them prone to request for DAMA however; physicians also experience a complex process of decision-making in DAMA situations. It is therefore vital for every training institution to include ethical, legal and moral aspects of learning into their training programs especially in dealing with cases of DAMA.
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Affiliation(s)
- Bernadette C Macrohon
- Department of Pediatrics, Zamboanga City Medical Center, Zamboanga City, Philippines.
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Walley AY, Paasche-Orlow M, Lee EC, Forsythe S, Chetty VK, Mitchell S, Jack BW. Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis. J Addict Med 2012; 6:50-6. [PMID: 21979821 PMCID: PMC6034987 DOI: 10.1097/adm.0b013e318231de51] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Hospital discharge may be an opportunity to intervene among patients with substance use disorders to reduce subsequent hospital utilization. This study determined whether having a substance use disorder diagnosis was associated with subsequent acute care hospital utilization. METHODS We conducted an observational cohort study among 738 patients on a general medical service at an urban, academic, safety-net hospital. The main outcomes were rate and risk of acute care hospital utilization (emergency department visit or hospitalization) within 30 days of discharge. The main independent variable was presence of a substance use disorder primary or secondary discharge diagnosis code at the index hospitalization. RESULTS At discharge, 17% of subjects had a substance use disorder diagnosis. These patients had higher rates of recurrent acute care hospital utilization than patients without substance use disorder diagnoses (0.63 vs 0.32 events per subject at 30 days, P < 0.01) and increased risk of any recurrent acute care hospital utilization (33% vs 22% at 30 days, P < 0.05). In adjusted Poisson regression models, the incident rate ratio at 30 days was 1.49 (95% confidence interval, 1.12-1.98) for patients with substance use disorder diagnoses compared with those without. In subgroup analyses, higher utilization was attributable to those with drug diagnoses or a combination of drug and alcohol diagnoses, but not to those with exclusively alcohol diagnoses. CONCLUSIONS Medical patients with substance use disorder diagnoses, specifically those with drug use-related diagnoses, have higher rates of recurrent acute care hospital utilization than those without substance use disorder diagnoses.
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Affiliation(s)
- Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA 02118, USA.
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Manouchehri J, Goodarzynejad H, Khoshgoftar Z, Sheikh Fathollahi M, Aghamohammadi Abyaneh M. Discharge against Medical Advice among Inpatients with Heart Disease in Iran. J Tehran Heart Cent 2012; 7:72-7. [PMID: 23074641 PMCID: PMC3466903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 02/27/2012] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Discharge against medical advice (DAMA) is a relatively common problem worldwide. We sought to determine the prevalence of and reasons for DAMA among inpatients of our cardiac center. METHODS From a total of 20289 discharges from our cardiac teaching hospital, 992 (4.9%) patients at a minimum age of 18 years were cases of DAMA. After excluding 49 cases due to missing data, we retrospectively analyzed our prospectively collected data from 943 patients, who were DAMA cases. Patients' characteristics, including demographic details, reason for discharge, insurance status, and length of stay before discharge, were examined. RESULTS The mean age of the study patients was 60.7 ± 13.0 (range, 18-94 years) with a male-to-female ratio of 2.1/1. Lack of consent to surgery or other invasive procedures was the reason cited for DAMA in 31% of the patients, followed by personal or family issues (17%). No reason for DAMA was reported in 26 (2.8%) of the patients. Women compared to men were more likely to cite "lack of consent to surgery or invasive procedures" as the reason for DAMA (p value = 0.005), whereas men more prevalently stated "personal or family issues" as the reason for DAMA (18.7% vs. 12.7%, p value = 0.022). CONCLUSION The most frequent self-reported reason for DAMA in our cardiac patients was lack of consent to surgery or invasive procedures. This may be because of fear of undergoing invasive procedures such as revascularization. Explaining the stages of a given invasive procedure to patients and comparing its risks versus benefits may lessen impulsive decision-making and DAMA.
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Affiliation(s)
| | - Hamidreza Goodarzynejad
- Corresponding Author: Hamidreza Goodarzynejad, Research Department, University of Medical Sciences, Tehran Heart Center, North Kargar Street, Tehran, Iran. 1411713138. Tel: +98 21 88029245. Fax: +98 21 88029731. E-mail:
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Choi M, Kim H, Qian H, Palepu A. Readmission rates of patients discharged against medical advice: a matched cohort study. PLoS One 2011; 6:e24459. [PMID: 21931723 PMCID: PMC3169593 DOI: 10.1371/journal.pone.0024459] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 08/10/2011] [Indexed: 11/18/2022] Open
Abstract
Objective We compared the readmission rates and the pattern of readmission among patients discharged against medical advice (AMA) to control patients discharged with approval over a one-year follow-up period. Methods A retrospective matched-cohort study of 656 patients(328 were discharged AMA) who were followed for one year after their initial hospitalization at an urban university-affiliated teaching hospital in Vancouver, Canada that serves a population with high prevalence of addiction and psychiatric disorders. Multivariate conditional logistic regression was used to examine the independent association of discharge AMA on 14-day related diagnosis hospital readmission. We fit a multivariate conditional negative binomial regression model to examine the readmission frequency ratio between the AMA and non-AMA group. Principal Findings AMA patients were more likely to be homeless (32.3% vs. 11%) and have co-morbid conditions such as psychiatric illnesses, injection drug use, HIV, hepatitis C and previous gastrointestinal bleeding. Patients discharged AMA were more likely to be readmitted: 25.6% vs. 3.4%, p<0.001 by day 14. The AMA group were more likely to be readmitted within 14 days with a related diagnosis than the non-AMA group (Adjusted Odds Ratio 12.0; 95% Confidence Interval [CI]: 3.7–38.9). Patients who left AMA were more likely to be readmitted multiple times at one year compared to the non-AMA group (adjusted frequency ratio 1.6; 95% CI: 1.3–2.0). There was also higher all-cause in-hospital mortality during the 12-month follow-up in the AMA group compared to non-AMA group (6.7% vs. 2.4%, p = 0.01). Conclusions Patients discharged AMA were more likely to be homeless and have multiple co-morbid conditions. At one year follow-up, the AMA group had higher readmission rates, were predisposed to multiple readmissions and had a higher in-hospital mortality. Interventions to reduce discharges AMA in high-risk groups need to be developed and tested.
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Affiliation(s)
- Mark Choi
- Department of Medicine, University of British Columbia, Vancouver BC, Canada
| | - Haerin Kim
- Department of Medicine, University of British Columbia, Vancouver BC, Canada
| | - Hong Qian
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, British Columbia, Canada
| | - Anita Palepu
- Department of Medicine, University of British Columbia, Vancouver BC, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, British Columbia, Canada
- * E-mail:
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Discharge against medical advice from emergency department: results from a tertiary care hospital in Tehran, Iran. Eur J Emerg Med 2011; 17:318-21. [PMID: 19898241 DOI: 10.1097/mej.0b013e3283334ef1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Discharge against medical advice (AMA) depends on both patient population and hospital-related factors. No previous study has examined AMA discharges in Iran. The aim of this study was to determine the prevalence of AMA discharges and the associated factors in Iranian emergency department-admitted patients. In this prospective cross-sectional study, we studied 915 consecutive patients admitted to the emergency department of a major referral center in Iran. Patients were divided into two groups: those who left hospital AMA and those discharged with medical approval. Patients' characteristics in AMA and non-AMA groups along with reasons associated with AMA discharges were examined. Of 880 patients included, 178 (20.2%) were discharged AMA. Male sex, younger age, and a history of drug or alcohol abuse were not associated with AMA discharges. Lack of health insurance was found more frequently in patients discharged AMA (46.1 vs. 34.8%). Most AMA patients (63.0%) have been staying in hospital for less than 12 h. The most common reason stated by the patients for AMA discharge was dissatisfaction with care or diagnostic and therapeutic procedures (38.2%). This study identifies marked differences in prevalence and potential predictors of AMA discharges in Iran compared with what has been described in the literature. The high prevalence of AMA discharges after emergency admission in a developing country such as Iran calls for effective approaches to reduce the prevalence as well as further investigation into the responsible factors.
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de Wit M, Zilberberg MD, Boehmler JM, Bearman GM, Edmond MB. Outcomes of Patients with Alcohol Use Disorders Experiencing Healthcare-Associated Infections. Alcohol Clin Exp Res 2011; 35:1368-73. [DOI: 10.1111/j.1530-0277.2011.01475.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Patients who left against medical advice (AMA) may be at higher risk for a hospital readmission if the unauthorized discharge was premature. The objective of this study is to examine the relationship between discharges AMA from nonfederal acute care hospitals and cardiovascular disease (CVD) hospital readmissions while addressing bias due to potential confounding, selection, and hospital-level clustering. METHODS This cross-sectional study used hospital discharge data covering the period between 2000 and 2005. The outcome variables captured readmissions for a CVD-related condition following an index CVD-related discharge. The covariate of interest was an indicator for a discharge AMA in the index hospitalization. The relationship between discharges AMA and 7-day, 31-day, and 180-day readmissions was examined using multivariate models with adjustment for clustering and selection bias. RESULTS The sample included 348,572 patients, of which 7001 (2%), 19,779 (6%), and 48,855 (14%) were readmitted within 7, 31, and 180 days, respectively. The percentage of patients who were readmitted (7 days; 31 days; 180 days) was higher among the AMA group versus the non-AMA group (2.2% vs. 1%, P < 0.002; 1.3% vs. 1%, P < 0.001; 1.2% vs. 1%, P = 0.02). The adjusted odds of a CVD-related readmission to the same hospital within 7 days, 31 days, and 180 days were 154% (P < 0.001), 51% (P < 0.001), and 19% (P = 0.004) higher, respectively, for patients who left AMA. Results were robust in examining readmissions to any hospital as well as corrections for observable selection bias through propensity score analysis. CONCLUSIONS A discharge AMA among patients with a discharge diagnosis for CVD during the index hospitalization was predictive of CVD-related readmissions. The strength of the association between a discharge AMA and readmission was greatest within the first week after discharge.
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Sclar DA, Robison LM. Hospital admission for schizophrenia and discharge against medical advice in the United States. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2010; 12. [PMID: 20694117 DOI: 10.4088/pcc.09m00827yel] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 05/13/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Hospital discharge against medical advice may leave a patient at risk for adverse health outcomes and/or readmission, yet little is known regarding its occurrence, especially among patients with mental illness. The objective of this study was to discern the prevalence of, and predictive factors for, being discharged against medical advice among hospitalized patients with a primary diagnosis of schizophrenia. METHOD The 2004 US Healthcare Cost and Utilization Project Nationwide Inpatient Sample was used to discern demographic predictors, length of stay, and costs for discharge against medical advice relative to discharge with medical approval. Inpatient discharges from US community hospitals for patients of all ages with The International Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes 295.0-295.9 were included. Conditional logistic regression was used to discern factors predictive of discharge against medical advice, and least squares mean analysis was used to examine differences in length of stay and mean cost per day relative to discharge with medical approval. Least squares means were adjusted for age (continuous), sex, race, region, payer, hospital setting, and bed size. RESULTS Within the study population, 1.6% of patients admitted for schizophrenia were discharged against medical advice (n = 3,382/210,722). Patients discharged against medical advice were significantly more likely to be younger (OR = 0.985, 95% CI, 0.982-0.987) and male (OR = 1.421, 95% CI, 1.321-1.529). Race was not a significant factor. Mean +/- SE length of stay for discharge against medical advice was 5.0 +/- 0.24 days, as compared to 8.7 +/- 0.06 days for patients discharged with medical approval (P < .0001). Mean cost per day was significantly higher for discharge against medical advice ($1,886.02 +/- 49.67 vs $1,565.79 +/- 13.42, P < .0001). CONCLUSIONS Although the percentage of patients discharged against medical advice was small, the numeric magnitude on a nationwide basis was substantial. The adjusted mean length of stay for discharge against medical advice was significantly reduced, while cost per day was significantly higher. Discharge against medical advice represents a challenge to the provision of care for patients with schizophrenia and may contribute to increased use of primary and specialty outpatient services, rehospitalization rates, morbidity, and mortality.
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Affiliation(s)
- David A Sclar
- Pharmacoeconomics and Pharmacoepidemiology Research Unit, Department of Health Policy and Administration, and Department of Pharmacotherapy and Department of Statistics , Washington State University, Pullman; and Washington Institute for Mental Illness Research and Training, Spokane.
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Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care 2010; 19:420-4. [PMID: 20538627 DOI: 10.1136/qshc.2009.036269] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is limited information in the literature about reasons for discharges against medical advice (DAMA) as supplied by patients and providers. Information about the reasons for DAMA is necessary for identifying workable strategies to reduce the likelihood and health consequences of DAMA. The objective of this study is to identify the reasons for DAMA based on patient and multicategory provider focus-group interviews (FGIs). METHODS Patients who discharged against medical advice between 2006 and 2008 from a large, academic medical centre along with hospital providers reporting contact with patients who left against medical advice were recruited. Three patient-only groups, one physician-only group and one nurse/social worker group were held. Focus-group interviews were transcribed, and a thematic analysis was performed to identify themes within and across groups. Participants discussed the reasons for patient DAMA and identified potential solutions. RESULTS Eighteen patients, five physicians, six nurses and four social workers participated in the FGIs. Seven themes emerged across the separate patient, doctor, nurse/social worker FGIs of reasons why patients leave against medical advice: (1) drug addiction, (2) pain management, (3) external obligations, (4) wait time, (5) doctor's bedside manner, (6) teaching hospital setting and (7) communication. Solutions to tackle DAMA identified by participants revolved mainly around enhanced communication and provider education. CONCLUSIONS In a large, academic medical centre, the authors find some differences and many similarities across patients and providers in identifying the causes of and solutions to DAMA, many of which relate to communication.
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Affiliation(s)
- Eberechukwu Onukwugha
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, 220 Arch Street, Baltimore, MD 21201, USA.
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Sitorus RS, Moll AC, Suhardjono S, Simangunsong LS, Riono P, Imhof S, Völker-Dieben HJM. The Effect of Therapy Refusal Against Medical Advice in Retinoblastoma Patients in a Setting Where Treatment Delays are Common. Ophthalmic Genet 2009; 30:31-6. [PMID: 19172508 DOI: 10.1080/13816810802464320] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Characteristics of patients with cirrhosis who are discharged from the hospital against medical advice. Clin Gastroenterol Hepatol 2009; 7:786-92. [PMID: 19345284 DOI: 10.1016/j.cgh.2009.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 03/06/2009] [Accepted: 03/21/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients discharged from hospital against medical advice are at risk of adverse health outcomes. The frequency and predictors of self-discharge in cirrhotic patients have not been examined. METHODS By using the 1993-2005 US Nationwide Inpatient Sample, we identified 581,380 cirrhotic patients who had been admitted to hospitals. The proportion discharged against medical advice and predictors of self-discharge were analyzed by using regression models with adjustments for clinical factors, including illness severity. RESULTS Of the patients with cirrhosis identified, 2.8% left their hospital against medical advice. Self-discharge was most common in patients with alcoholic cirrhosis (4.2%) and hepatitis B or C ( approximately 3%) and least common among those with chronic cholestasis (0.4%). Independent predictors of self-discharge included male sex, younger age, non-private insurance, and admission to urban, nonteaching hospitals. Patients undergoing surgery and those with more comorbidities were less likely to leave against medical advice, whereas those with human immunodeficiency virus, drug and alcohol abuse, or psychosis were more likely to leave against medical advice. Self-discharge was less common among patients with hepatic decompensation (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.76-0.82), primary liver cancer (OR, 0.49; 95% CI, 0.41-0.59), or prior transplantation (OR, 0.37; 95% CI, 0.25-0.55). Length of stay and hospital charges were lower in patients discharged against medical advice (P < .0001). CONCLUSIONS Approximately 1 in 36 hospitalized cirrhotic patients leave hospital against medical advice. Self-discharge is most common among patients with alcoholic cirrhosis, lower socioeconomic status, psychiatric disorders, substance abuse, and less severe liver disease. These findings might assist in the prevention of self-discharge and, ultimately, improve health outcomes in patients with cirrhosis.
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Abstract
Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem. This article reviews the prevalence, costs, predictors, and potential interventions for this clinical problem. Between 1% and 2% of all medical admissions result in an AMA discharge. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Interventions to reduce the rate of AMA discharges have not been systematically studied. This article offers suggestions for interventions based on studies in other areas of clinical care as well as the psychiatric AMA discharge literature. Studies for this review were identified by searching the relevant MeSH heading (discharge) and key words (against medical advice, leave, elope, hospital, and self-discharge) in PubMed databases and selecting all English-language articles from 1970 through 2008 that included data on adult medical inpatients.
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Affiliation(s)
- David J Alfandre
- Department of Veterans Affairs National Center for Ethics in Health Care, 423 E 23rd St (10E), New York, NY 10021, USA.
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Abstract
Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem. This article reviews the prevalence, costs, predictors, and potential interventions for this clinical problem. Between 1% and 2% of all medical admissions result in an AMA discharge. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Interventions to reduce the rate of AMA discharges have not been systematically studied. This article offers suggestions for interventions based on studies in other areas of clinical care as well as the psychiatric AMA discharge literature. Studies for this review were identified by searching the relevant MeSH heading (discharge) and key words (against medical advice, leave, elope, hospital, and self-discharge) in PubMed databases and selecting all English-language articles from 1970 through 2008 that included data on adult medical inpatients.
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Affiliation(s)
- David J Alfandre
- Department of Veterans Affairs National Center for Ethics in Health Care, 423 E 23rd St (10E), New York, NY 10021, USA.
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Alfandre D. From "I'm not staying!" to "I'm not leaving!": ethics, communication, and empathy in complicated medical discharges. THE MOUNT SINAI JOURNAL OF MEDICINE, NEW YORK 2008; 75:466-71. [PMID: 18828170 DOI: 10.1002/msj.20067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- David Alfandre
- Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health 2007; 97:2204-8. [PMID: 17971552 DOI: 10.2105/ajph.2006.100164] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined hospital- and patient-related factors associated with discharge against medical advice (termed self-discharge) after emergency admission to acute-care hospitals. METHODS We analyzed data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project using logistic regression models to assess the relationship between self-discharge and a set of patient and hospital characteristics. RESULTS Of 3,039,050 discharges in the sample, 43 678 were against medical advice (1.44%). In multivariable modeling, predictors of self-discharge included having Medicaid insurance (adjusted odds ratio [AOR]=3.32; 95% confidence interval [CI]=3.22, 3.42), having Medicare insurance (AOR=1.64; 95% CI=1.59, 1.70), urban location (AOR=1.66; 95% CI=1.61, 1.72), medium (AOR=1.25; 95% CI=1.20, 1.29) or large (AOR=1.08, 95% CI=1.05, 1.12) hospital (defined by the number of beds), shorter hospital stay (OR=0.84; 95% CI=0.84, 0.85), and African American race (AOR=1.10; 95% CI=1.07, 1.14). Teaching hospitals had fewer self-discharges (AOR=0.90; 95% CI=0.88, 0.92). Other predictors of discharge against medical advice included age, gender, and income. CONCLUSIONS Approximately 1 in 70 hospital discharges in the United States are against medical advice. Both hospital and patient characteristics were associated with these decisions.
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Affiliation(s)
- Said A Ibrahim
- Center for Health Equity Research and Promotion, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pa 15240, USA.
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Fiscella K, Meldrum S, Franks P. Post partum discharge against medical advice: who leaves and does it matter? Matern Child Health J 2007; 11:431-6. [PMID: 17334926 DOI: 10.1007/s10995-007-0194-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 02/07/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine risk factors and sequela for post partum discharge against medical advice. METHODS We conducted cross-sectional analyses of hospital discharge data linked to American Hospital Association data for women discharged following a live birth for California, Florida, and New York in the years 1998-2000. We examined rates, risk factors, hospital readmission rate and mortality (California only), associated with discharge against medical advice after controlling for patient and hospital characteristics. RESULTS Post partum discharge against medical advice averaged 0.10%. Rates were lowest among women following uncomplicated cesarean and vaginal births (0.07%), intermediate following complicated vaginal birth (0.21%) and highest following complicated cesarean birth (0.29%). African American race, lower income, public health insurance, no health insurance, or greater comorbidity, particularly drug abuse or psychotic illness, discharge from a hospital in California or New York (compared to Florida), and location in medium or large metropolitan areas, were associated with significantly higher rates of discharge against advice. Asian or Hispanic race or ethnicity and delivery at an obstetrical specialized hospital were associated with lower risk. Patients discharged against medical advice in California were significantly more likely to be re-admitted within 30 days (adjusted odds ratio 2.7; 95% confidence interval [CI] 1.8-3.9), though none died during the period. CONCLUSIONS Discharge against medical advice among post partum patients is uncommon, but occurs primarily among vulnerable women with psychosocial and medical risk factors. Thus, discharge against medical advice may help identify women who may benefit from additional maternal and/or child services.
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Affiliation(s)
- Kevin Fiscella
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, 1381 South Ave, Rochester, NY 14620, USA.
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