Retrospective Evaluation of Patients Who Leave against Medical Advice in a Tertiary Teaching Care Institute

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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

Stakeholder engagement as a strategy to enhance palliative care involvement in intensive care units: A theory of change approach

BACKGROUND

Adult patients admitted to intensive care units in the terminal phase experience high symptom burden, increased costs, and diminished quality of dying. There is limited literature on palliative care engagement in ICU, especially in lower-middle-income countries. This study explores a strategy to enhance palliative care engagement in ICU through a stakeholder participatory approach.

METHODS

Theory of Change approach was used to develop a hypothetical causal pathway for palliative care integration into ICUs in India. Four facilitated workshops and fifteen research team meetings were conducted virtually over three months. Thirteen stakeholders were purposively chosen, and three facilitators conducted the workshops. Data included workshop discussion transcripts, online chat box comments, and team meeting minutes. These were collected, analysed and represented as theory of change map.

RESULTS

The desired impact of palliative care integration was good death. Potential long-term outcomes identified were fewer deaths in ICUs, discharge against medical advice, and inappropriate admissions; increased referrals to palliative care; and improved patient and family satisfaction. Twelve preconditions were identified, and eleven key interventions were developed. Five overarching assumptions related to contextual factors influencing the outcomes of interventions.

CONCLUSION

Theory of change framework facilitated the identification of proposed mechanisms and interventions underpinning palliative care integration in ICUs.

Role of Sildenafil in Management of Pediatric Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) has high mortality and multiple therapeutic strategies have been used to improve the outcome. Inhaled nitric oxide (INO), a pulmonary vasodilator, is used to improve oxygenation. This study was conducted to determine the role of sildenafil, an oral vasodilator, to improve oxygenation and mortality in pediatric ARDS (PARDS). The prevalence of pulmonary hypertension in PARDS was studied as well. Inclusion criteria included children (1–18 years) with ARDS requiring invasive ventilation admitted to the pediatric intensive care unit of a teaching hospital in Northern India over a 1-year period of time. Thirty-five patients met the inclusion criteria. Cardiologist performed a detailed echocardiogram to determine pulmonary arterial pressure (PAP). Patients with persistent hypoxemia were started on oral sildenafil. The majority (77%) patients had a primary pulmonary etiology of PARDS. Elevated PAP (>25 mm Hg) was detected in 54.3% patients at admission. Sildenafil was given to 20 patients who had severe and persistent hypoxemia. Oxygenation improved in most patients after the first dose with statistically significant improvement in PaO2/FiO2 ratios at both 12 and 24 hours following initiation of therapeutic dosing of sildenafil. Improvement in oxygenation occurred irrespective of initial PAP. Outcomes included a total of 57.1% patients discharged, 28.6% discharged against medical advice (DAMA), and a 14.3% mortality rate. Mortality was related to the severity of PARDS and not the use of sildenafil. This is the first study to determine the effect of sildenafil in PARDS. Sildenafil led to improvement in oxygenation in nearly all the cases without affecting mortality. Due to unavailability of INO in most centers of developing countries, sildenafil may be considered as an inexpensive alternative in cases of persistent hypoxemia in PARDS. We recommend additional randomized controlled trials to confirm the effect of sildenafil in PARDS as determined in this study.

Reducing rates of discharge against medical advice in the neonatal intensive care unit in a tertiary care hospital in South India: a mixed-methods study

OBJECTIVE

To elucidate characteristics among neonates and their mothers who were discharged against medical advice (DAMA), providers' perspectives on DAMA and the effect of an intervention to reduce DAMA in a tertiary care hospital in South India.

METHODS

We conducted a mixed-methods study to identify neonates at risk of DAMA. We reviewed charts of neonates and their mothers who were DAMA and conducted logit regression analysis to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to determine associations with DAMA. We conducted focus group discussions with nurses and doctors. We developed an intervention that included family counselling, supplemental funds for hospital bills and involving family members to reduce DAMA.

RESULTS

Of 10 834 neonates, 179 (1.7%) were DAMA over the study period. Maternal characteristics associated with DAMA included higher previous parity (aOR 1.9, 95% CI 1.1-2.3, P = 0.001). Mothers who received antenatal care had lower odds of DAMA (aOR 0.2, 95% CI 0.1-0.7, P = 0.039). Neonates with lower birth weight (aOR 2.1, 95% CI 1.7-9.4, P = 0.002) and congenital malformations (aOR 3.3, 95% CI 1.1-5.3, P = 0.005) also had higher odds of DAMA. The most commonly cited reasons for DAMA were financial constraints, inadequate counselling and perceived poor prognosis. The average monthly number of neonates who were DAMA decreased from 3.6 (1.6%) to 1.5 (0.6%) after our multi-pronged intervention.

CONCLUSIONS

Neonates with severe illness and poor prognosis had higher odds of DAMA. A multi-pronged intervention demonstrated reductions in the rates of DAMA. This intervention may be trialled in similar settings to reduce DAMA.

Characteristics of trauma patients that leave against medical advice: An eight-year survey analysis using the National Hospital Ambulatory Medical Care Survey, 2009-2016

BACKGROUND

Leaving against medical advice (AMA) is associated with increased readmission rates, fragmented patient care, and healthcare litigation. Understanding the factors associated with trauma patients leaving AMA from acute care settings will help guide better communication with trauma patients and improve patient satisfaction. This study aims to assess the sociodemographic and in-hospital care characteristics of trauma patients that leave AMA from acute care centers across the U.S.

METHODS

We pooled and analyzed eight years of data (2009-2016) from the National Hospital Ambulatory Medical Care Survey. The outcome variable was whether the patient left AMA or not. The main predictors were the triage class, weekend presentation, health insurance status, the presence of chronic diseases, and the receipt of therapeutic and diagnostic procedures. The sociodemographic characteristics -age, sex, and race/ethnicity, were measured as potential confounders in the developed model. We performed logistic regression and reported the unadjusted and adjusted odds of leaving AMA as well as the 95% confidence intervals.

RESULTS

The weighted percent of the trauma patient population that left AMA was 1.8%. The odds of leaving AMA decreased with advancing age, and increased among non-Hispanic Blacks, compared with non-Hispanic Whites. After adjusting for age, race, and gender, the odds of leaving AMA increased among patients that lacked health insurance (AOR: 1.86; 95% CI: 1.51-2.31), and had diagnostic procedures (AOR: 2.79; 95% CI: 2.32-3.36). The odds of leaving AMA reduced among trauma patients who were classified as emergent (AOR: 0.70; 95% CI: 0.50-0.98) and had therapeutic procedures (AOR: 0.39; 95% CI: 0.32-0.47).

CONCLUSION

Predicting trauma patients with increased odds of leaving AMA will inform intentional communication that may reduce leaving AMA rates and improve care.

Effects of Iranian healthcare transformation plan on discharge against medical advice rate and related factors in 2012 and 2016

OBJECTIVE

Discharge against medical advice (DAMA) is a critical problem in hospitals and has several consequences for healthcare systems. The aim of this study was to determine and compare the rate of DAMA and its related factors before and after executing the healthcare transformation plan (HTP) in Iran.

METHODS

In a two-phase, cross-sectional study, the DAMA information of 200 patients in 2016 (after HTP) and the patients of a previous study in 2012 (before HTP) was compared. Samples were randomly selected from the main referral centre in the north-west of Iran. Data were collected using a validated and reliable questionnaire and analysed using the SPSS V.16 software.

RESULTS

In the post-HTP plan period, the rate of DAMA was 3.9%, while this rate was 5.49% in 2012 (p=0.029). A total of 15% (108 out of 721) of patients in the postreform group and 13.5% (101 out of 747) in the prereform group were rehospitalised (p=0.411). The three main categories of reasons for DAMA in 2012 and 2016 were as follows: patient-related factors, 27% vs 45%; staff-related factors, 33% vs 30%; and hospital-related factors (basic amenities), 40% vs 25%. In both periods, the average scores of patient satisfaction were almost the same; however, satisfaction regarding environmental and human factors in hospitals had changed significantly after HTP (p<0.05).

CONCLUSIONS

There was a decrease in the rate of DAMA after HTP in Iran. Considering DAMA as a multifactorial phenomenon, this might be due to the higher relative satisfaction after HTP, indicating an increase in public confidence in general hospitals.

Retrospective Evaluation of Patients Leaving against Medical Advice in aTertiary Care Teaching Hospital

Background

Leaving against medical advice (LAMA) is a worldwide healthcare problem, occurring due to various contributing factors, seen more commonly indeveloping countries like ours.

Aim

To retrospectively study the prevalence of LAMA along with its affectingfactors.

Methods

We screened the hospital record of a tertiary care teaching hospital forone year, after obtaining approval from the institutional ethicalcommittee. Patient demography, disease characteristics and status at thetime of LAMA were noted and statistically analysed.

Results

During the study period, 4.95% patients took LAMA. The mean age was 47.2±21years (range newborn to 103 years) with 2:1 Male: Female ratio. Forty ninepercent of patients resided in rural areas and around 1/3rd were dependenton others for their living. The mean length of stay in hospital was 6.1±9.3days. Around 60% patients required mechanical ventilation and 51% patientshad been explained guarded prognosis. About 53% of patients taking LAMAwere admitted in medical wards, trauma being the most common diagnosis(17.2%). History of alcohol abuse and poisoning with suicidal intent wasseen in 11.47% and 3.9%, respectively.

Conclusion

The number of patients taking LAMA from our country is quite high. This necessitates formulation and implementation of strategies to reduce the prevalence of LAMA discharges like further investigations to look into the causes contributing to patients taking LAMA, attending to substance abuseissues, recognizing psychological factors and strengthening the socialsystems, encouraging insurance cover, helping patients’ treatment expensesthrough charity care and optimizing healthcare delivery and patient centredpolicies.

Key messages

LAMA is a global health issue precipitated by unemployment and alcohol abuse, commonly taken due to financial reasons. This necessitates a strong social system and national health insurance schemes to reduce the cost of treatment.

How to cite this article

Mahajan RK, Gautam PL, et al. Retrospective Evaluation of Patients Leaving against Medical Advice in a Tertiary Care Teaching Hospital. IndianJ Crit Care Med 2019;23(3):139-142.