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Discharge against medical advice from hospitalizations for substance use disorders: The potential impact of the Affordable Care Act.

ABSTRACT: OBJECTIVES:To explore whether the Affordable Care Act (ACA) enactment is associated with changes in the proportion of discharge against medical advice (DAMA) among hospitalizations due to substance use disorders (SUDs). METHODS:Data were drawn from the 2012-2015 National Inpatient Samples. The sample comprised hospitalizations with a principal diagnosis of SUD (i.e., SUD-involved hospitalization) for patients aged 18-64 years (unweighted N?=?287,629). Interrupted time series analyses were conducted to evaluate the effect of the ACA on monthly proportions of DAMA among SUD-involved hospitalizations. RESULTS:Overall, approximately 11% of SUD-involved hospitalizations were DAMA. DAMA was most frequently found among hospitalizations for primary opioid use disorder (pre-ACA: 16.4%; post-ACA: 17.2%). Despite the increase in the Medicaid coverage after ACA enactment, there was no significant change in the proportion of DAMA before and after ACA periods across various demographic groups and clinical conditions. Time series analyses also indicated no significant trend effect on the proportion of DAMA during the pre- and post-ACA months. CONCLUSIONS:As many as 1 in 10 SUD-involved hospitalizations were considered as DAMA. Concerted efforts are needed to enhance insurance benefits for SUDs and patients' knowledge of SUD treatment benefits in order to increase SUD treatment engagement and completion and to reduce DAMA, especially for substance-using patients with Medicaid or opioid use disorder.

SUBMITTER: Zhu H

PROVIDER: S-EPMC6508559 | biostudies-literature | 2019 Apr

REPOSITORIES: biostudies-literature

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Discharge against medical advice from hospitalizations for substance use disorders: The potential impact of the Affordable Care Act.

Zhu He H Wu Li-Tzy LT

Drug and alcohol dependence 20190216

<h4>Objectives</h4>To explore whether the Affordable Care Act (ACA) enactment is associated with changes in the proportion of discharge against medical advice (DAMA) among hospitalizations due to substance use disorders (SUDs).<h4>Methods</h4>Data were drawn from the 2012-2015 National Inpatient Samples. The sample comprised hospitalizations with a principal diagnosis of SUD (i.e., SUD-involved hospitalization) for patients aged 18-64 years (unweighted N = 287,629). Interrupted time series analy ...[more]

PMID: 30802735

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Project description:BackgroundPractitioners expected the Affordable Care Act (ACA) to increase availability of health services and access to treatment for Americans with substance use disorders (SUDs). Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services. Understanding these relationships can inform future healthcare policy.MethodsWe conducted a longitudinal analysis of patients with SUDs newly enrolled in the Kaiser Permanente Northern California health system in 2014 (N = 6957). Analyses examined the likelihood of service utilization (primary care, specialty SUD treatment, psychiatry, inpatient, and emergency department [ED]) over three years after SUD diagnosis, and associations with enrollment mechanisms (ACA Exchange vs. other), deductibles (none, $1-$999 [low] and ≥$1000 [high]), membership duration, psychiatric comorbidity, and demographic characteristics. We also evaluated whether the enrollment mechanism moderated the associations between deductible limits and utilization likelihood.ResultsService utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2-3. Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees. Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment. Exchange enrollment compared to other mechanisms was associated with less ED use. Psychiatric comorbidity was associated with greater use of all services. Nonwhite patients were less likely to initiate SUD and psychiatry treatment.ConclusionsHigher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange. The role of insurance factors, psychiatric comorbidity and race/ethnicity in health services for people with SUDs are important to consider as health policy evolves.

Project description:ImportanceHospital readmissions contribute to higher expenditures and may sometimes reflect suboptimal patient care. Individuals discharged against medical advice (AMA) are a vulnerable patient population and may have higher risk for readmission.ObjectivesTo determine odds of readmission and mortality for patients discharged AMA vs all others, to characterize patient and hospital-level factors associated with readmissions, and to quantify their overall cost burden.Design, setting, and participantsNationally representative, all-payer cohort study using the 2014 National Readmissions Database. Eligible index admissions were nonobstetrical/newborn hospitalizations for patients 18 years and older discharged between January 2014 and November 2014. Admissions were excluded if there was a missing primary diagnosis, discharge disposition, length of stay, or if the patient died during that hospitalization. Data were analyzed between January 2018 and June 2018.ExposuresDischarge AMA and non-AMA discharge.Main outcomes and measuresThirty-day all-cause readmission and in-hospital mortality rate.ResultsThere were 19.9 million weighted index admissions, of which 1.5% resulted in an AMA discharge. Within the AMA cohort, 85% were younger than 65 years, 63% were male, 55% had Medicaid or other (including uninsured) coverage, and 39% were in the lowest income quartile. Thirty-day all-cause readmission was 21.0% vs 11.9% for AMA vs non-AMA discharge (P < .001), and 30-day in-hospital mortality was 2.5% vs 5.6% (P < .001), respectively. Individuals discharged AMA were more likely to be readmitted to a different hospital compared with non-AMA patients (43.0% vs 23.9%; P < .001). Of all 30-day readmissions, 19.0% occurred within the first day after AMA discharge vs 6.1% for non-AMA patients (P < .001). On multivariable regression, AMA discharge was associated with a 2.01 (95% CI, 1.97-2.05) increased adjusted odds of readmission and a 0.80 (95% CI, 0.74-0.87) decreased adjusted odds of in-hospital mortality compared with non-AMA discharge. Nationwide readmissions after AMA discharge accounted for more than 400 000 inpatient hospitalization days at a total cost of $822 million in 2014.Conclusions and relevanceIndividuals discharged AMA have higher odds of 30-day readmission at significant cost to the health care system and lower in-hospital mortality rates compared with non-AMA patients. Patients discharged AMA are also more likely to be readmitted to different hospitals and to have earlier bounce-back readmissions, which may reflect dissatisfaction with their initial episode of care.

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Discharge against medical advice from hospitalizations for substance use disorders: The potential impact of the Affordable Care Act.

Publications

Discharge against medical advice from hospitalizations for substance use disorders: The potential impact of the Affordable Care Act.

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