Characteristics of patients with acute traumatic brain injury discharged against medical advice in a Level 1 urban trauma centre

Association of Homelessness with Before Medically Advised Discharge After Surgery

BACKGROUND

Before medically advised (BMA) discharge, which refers to patients leaving the hospital at their own discretion, is associated with higher rates of readmission and death in other settings. It is not known if housing status is associated with this phenomenon after surgery.

METHODS

We identified all admitted adults who underwent an operation by one of 11 different surgical services at a single tertiary care hospital between January 2013 and June 2022. Chi-square tests and t-tests were used to compare demographic and clinical features between BMA discharges and standard discharges. Multivariable logistic regression was used to evaluate the association between housing status and BMA discharge, adjusting for demographic and admission characteristics. Documented reasons for BMA discharge were also abstracted from the medical record.

RESULTS

Of 111,036 patient admissions, 242 resulted in BMA discharge (0.2%). After adjusting for observable confounders, patients experiencing homelessness had substantially higher odds of BMA discharge after surgery (adjusted odds ratio 4.4, 95% confidence interval 3.0-6.4; p < 0.001) when compared to housed. Patients who underwent emergency surgery, patients with a documented substance use disorder, and those insured by Medicaid also had significantly higher odds of BMA discharge. System- or provider-related reasons (including patient frustration with the hospital environment, challenges in managing substance dependence, and perceived inadequacy of paint control) were documented in 96% of BMA discharges for patients experiencing homelessness (vs. 66% in housed patients).

CONCLUSION

BMA discharge is more common in patients experiencing homelessness after surgery even after adjusting for observable confounding characteristics. Deeper understanding of the drivers of BMA discharge in patients experiencing homelessness through qualitative methods are critical to promote more equitable and effective care.

Traumatic Brain Injury in Cameroon: A Prospective Observational Study in a Level I Trauma Centre

Background and Objective: About 14 million people will likely suffer a traumatic brain injury (TBI) per year by 2050 in sub-Saharan Africa. Studying TBI characteristics and their relation to outcomes can identify initiatives to improve TBI prevention and care. The objective of this study was to define the features and outcomes of TBI patients seen over a 1-year period in a level-I trauma centre in Cameroon. Materials and Methods: Data on demographics, causes, clinical aspects, and discharge status were collected over a period of 12 months. The Glasgow Outcome Scale-Extended (GOSE) and the Quality-of-Life Questionnaire after Brain Injury (QoLIBRI) were used to evaluate outcomes six months after TBI. Comparisons between two categorical variables were done using Pearson's chi-square test. Results: A total of 160 TBI patients participated in the study. The age group 15-45 years was most represented (78%). Males were more affected (90%). A low educational level was seen in 122 (76%) cases. Road traffic incidents (RTI) (85%), assaults (7.5%), and falls (2.5%) were the main causes of TBI, with professional bike riders being frequently involved (27%). Only 15 patients were transported to the hospital by ambulance, and 14 of these were from a referring hospital. CT-imaging was performed in 78% of cases, and intracranial traumatic abnormalities were identified in 64% of cases. Financial constraints (93%) was the main reason for not performing a CT scan. Forty-six (33%) patients were discharged against medical advice (DAMA) due to financial constraints. Mortality was 14% (22/160) and high in patients with severe TBI (46%). DAMA had poor outcomes with QoLIBRI. Only four patients received post-injury physical therapy services. Conclusions: TBI in Cameroon mainly results from RTIs and commonly affects young adult males. Lack of pre-hospital care, financial constraints limiting both CT scanning and medical care, and a lack of acute physiotherapy services likely influenced care and outcomes adversely.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Traumatic brain injury in the homeless: health, injury mechanisms, and hospital course

Primary ObjectiveEstablished literature demonstrates that homeless individuals experience both greater disease burden and risk of experiencing traumatic brain injury (TBI) than the general population. Similarly, shared risk factors for both homelessness and/or TBI may exacerbate the risk of repetitive neurotrauma within homeless populations.Research DesignWe leveraged a state-wide trauma registry, the Pennsylvania Trauma Outcome Study (PTOS), to characterize 609 patients discharged to homeless (58% TBI, 42% orthopedic injury (OI)) in comparison to 609 randomly sampled adult patients discharged to home.Methods and ProceduresWe implemented Chi-square tests to examine preexisting health conditions (PECs), hospital course, and injury mechanisms for both patient groups.Main Outcomes and ResultsHomelessness affects a greater proportion of nonwhite patients, and homeless patients present for care with increased frequencies of psychiatric and substance use PECs, and alcohol-positive TBI. Furthermore, assault impacts a larger proportion of homeless patients, and the window for overnight assault risk resulting in TBI is extended for these patients compared to patients discharged to home.ConclusionGiven the shifting conceptualization of TBI as a chronic condition, identifying homeless patients on admission to trauma centers, rather than retrospectively at discharge, can enhance understanding of the challenges facing the homeless as they age with both a complex neurotrauma history and multimorbidity.

Trauma in adults experiencing homelessness

BACKGROUND

Homeless individuals suffer a greater burden of health problems than the general population. This study aimed to describe the epidemiology of physical trauma among homeless patients presenting to an urban major trauma center and to ascertain any differences in the nature, injury severity and outcomes among homeless compared to domiciled patients.

METHODS

A retrospective matched cohort study that included adults who met inclusion criteria for The Alfred Hospital Trauma Registry between 01 July 2010 and 31 March 2017 was conducted. Primary homelessness was identified using the International Statistical Classification of Diseases, 10th Revision Coding Z59.0 and/or 'No fixed abode' address data. Homeless and domiciled patients were matched at a 1:2 ratio on age, sex, month and year of injury. The primary outcome variable was the Injury Severity Score (ISS). Secondary outcomes were hospital length of stay (LOS), mortality, emergency department (ED) disposition, hospital disposition, discharge processes and trauma registry recidivism.

RESULTS

Of 25,920 cases in the trauma registry, 147 (0.6%) were identified as homeless, comprising 131 unique homeless individuals who were matched with 262 domiciled patients. The median (Inter-Quartile Range) ISS among homeless patients was 5(2-10), compared to 9(4-17) for domiciled patients (p < 0.001). Homeless patients had significantly lower odds of sustaining an injury with ISS>12 (OR 0.5, 95% CI: 0.3-0.8, p = 0.001). Homeless patients were treated more often than domiciled patients for assault (32.1% vs 9.5%), intentional self-harm (10.7% vs 2.7%), and penetrating injury (16.0% vs 6.5%). Homeless patients had higher rates of psychiatry admissions (9.2% vs 0.8%), positive blood alcohol concentration (30.5% vs 13.7%), and higher odds of discharging against medical advice (DAMA)(OR 2.0, 95% CI: 1.1-3.6 p = 0.02). There were no differences in LOS (p = 0.51), mortality (p = 0.19), ED disposition (p = 0.64) or trauma registry recidivism (p = 0.09).

CONCLUSION

Among injured patients who presented at an urban trauma center, homelessness was associated with higher odds of assault, intentional self-harm, penetrating injury, psychiatry admissions, DAMA but lower ISS than domiciled patients. Variable definitions of homelessness and lack of standardized documentation in the medical record should be addressed to ensure these vulnerable patients are identified and linked with peripheral services.

Refusal of emergency medical care: An analysis of patients who left without being seen, eloped, and left against medical advice

OBJECTIVE

Emergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.

METHODS

This prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.

RESULTS

Among 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).

CONCLUSION

ED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.

Predictors of discharge against medical advice in adult trauma patients

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.

Whatever happens to trauma patients who leave against medical advice?

BACKGROUND

Although trauma patients are frequently discharged against medical advice (AMA), the fate of these patients remains mostly unknown.

METHODS

Patients with traumatic injuries were identified in the California State Inpatient Database, 2007 to 2011. Readmission characteristics of patients discharged AMA were compared with patients discharged home.

RESULTS

There were 203,756 (75.65%) patients discharged home and 4,480 (1.66%) discharged AMA. Compared with those discharged home, patients discharged AMA had significantly higher 30-day readmission rates (17.12% vs 6.75%), rates of multiple readmissions (3.83% vs 1.12%), and likelihood of being readmitted at different hospitals (44.83% vs 33.82%) (all P < .001). The commonest reasons for readmission in patients discharged AMA were psychiatric conditions [adjusted odds ratio: 1.67 (1.21 to 2.27)].

CONCLUSIONS

Discharge AMA is associated with multiple readmissions and higher rates of readmissions at different hospitals. Early identification of vulnerable patients and improved modalities to prevent discharge AMA among these patients may reduce the negative outcomes associated with discharge AMA among trauma patients.