Physician Practices in Against Medical Advice Discharges.
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ABSTRACT: Background
Patients discharged against medical advice (AMA) have disproportionately high health care costs and increased morbidity, mortality, and hospital readmissions. Although patient risk factors for discharge AMA are known, there are little data regarding physician discharge practices surrounding AMA discharges.Methods
We performed a cross-sectional analysis of patients discharged AMA from a large, urban, academic medical center. Our study predictors included patient demographics and admission characteristics: primary service team, time of discharge, documentation of anticipated AMA discharge, and length of stay. The primary outcomes were physician discharge practices including a scheduled follow-up appointment, documentation of informed consent, documentation of a risk/benefit discussion, and notification of the attending physician. Our coprimary outcome was the incidence of 30-day hospital readmission.Results
Among AMA discharges, 33% had follow-up appointments scheduled upon discharge. There was documentation of a risk/benefit discussion (69%), informed consent (63%), and notification of the attending physician (72%) in most discharges. Physician discharge practices were not associated with 30-day hospital readmission.Conclusions
Adherence to discharge best practices in AMA discharges was inconsistent and suboptimal, particularly for scheduling follow-up appointments, but was not associated with hospital readmission. Our results highlight the difficulty in facilitating safe transitions of care for patients discharged AMA.
SUBMITTER: Tummalapalli SL
PROVIDER: S-EPMC7218753 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description: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.
| S-EPMC2664598 | biostudies-other
Project description:BackgroundAmong 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.MethodsWe 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.ResultsWe 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).ConclusionsAMA 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.
| S-EPMC8563193 | biostudies-literature
Project description:BackgroundPhysicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases.ObjectiveTo review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA.DesignRetrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010.ParticipantsPatients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010.Main measuresPercent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible.Key resultsOf 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1-5 scale, in which 5 is "always" inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was "so they will reconsider staying in the hospital" (84.8% residents, 66.7% attendings, p = 0.008)ConclusionsContrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.
| S-EPMC3378751 | biostudies-literature
Project description:ObjectiveTo study characteristics and outcomes of patients with stroke, traumatic brain injury (TBI), and epilepsy with discharge against medical advice (DAMA).Data sources/study settingRetrospective analysis of the 2013 Nationwide Readmissions Database, a nationally representative inpatient administrative dataset.Study designAssociations between predictors and DAMA at index admission were analyzed using adjusted logistic models. We examined 30-day all-cause readmissions.Data collection methodsPatients aged ≥18 years at index admission for International Classification of Diseases-9 diagnosis code of epilepsy, TBI, or stroke were included.Principal findingsDischarge against medical advice occurred in 1998/58278 patients (3.43 percent) in the epilepsy group, 1762/211 213 (0.83 percent) in the stroke group, and 1289/74 652 (1.73 percent) in the TBI group. Factors consistently associated with increased likelihood of DAMA included lower age, male sex, non-Medicare and nonprivate insurance, lower socioeconomic status, and behavioral risk factors (smoking history, alcohol history, and drug use). The crude 30-day all-cause readmission rate for those with DAMA from their index admission was 16.4 percent for the stroke cohort, 13.9 percent for epilepsy, and 13.4 percent for TBI. DAMA at index admission was significantly associated with increased risk of 30-day all-cause readmission among all groups (adjusted odds ratio 1.79, 95% CI: 1.65-1.94, P < .0001).ConclusionsAge, sex, insurance status, socioeconomic status, and behavioral factors were associated with DAMA in neurological patients. Further research is needed to develop interventions to reduce DAMA in high-risk groups.
| S-EPMC7518816 | biostudies-literature
Project description:ImportanceAlthough discharges against medical advice (DAMA) are associated with greater morbidity and mortality, little is known about current racial and ethnic disparities in DAMA from the emergency department (ED) nationally.ObjectiveTo characterize current patterns of racial and ethnic disparities in rates of ED DAMA.Design, setting, and participantsThis cross-sectional study used data from the Nationwide Emergency Department Sample on all hospital ED visits made between January to December 2019 in the US.Main outcomes and measuresThe main outcome was odds of ED DAMA for Black and Hispanic patients compared with White patients nationally and in analysis adjusted for sociodemographic factors. Secondary analysis examined hospital-level variation in DAMA rates for Black, Hispanic, and White patients.ResultsThe study sample included 33 147 251 visits to 989 hospitals, representing the estimated 143 million ED visits in 2019. The median age of patients was 40 years (IQR, 22-61 years). Overall, 1.6% of ED visits resulted in DAMA. DAMA rates were higher for Black patients (2.1%) compared with Hispanic (1.6%) and White (1.4%) patients, males (1.7%) compared with females (1.5%), those with no insurance (2.8%), those with lower income (<$27 999; 1.9%), and those aged 35 to 49 years (2.2%). DAMA visits were highest at metropolitan teaching hospitals (1.8%) and hospitals that served greater proportions of racial and ethnic minoritized patients (serving ≥57.9%; 2.1%). Odds of DAMA were greater for Black patients (odds ratio [OR], 1.45; 95% CI, 1.31-1.57) and Hispanic patients (OR, 1.16; 95% CI, 1.04-1.29) compared with White patients. After adjusting for sociodemographic characteristics (age, sex, income, and insurance status), the adjusted OR (AOR) for DAMA was lower for Black patients compared with the unadjusted OR (AOR, 1.18; 95% CI, 1.09-1.28) and there was no difference in odds for Hispanic patients (AOR, 1.03; 95% CI, 0.92-1.15) compared with White patients. After additional adjustment for hospital random intercepts, DAMA disparities reversed, with Black and Hispanic patients having lower odds of DAMA compared with White patients (Black patients: AOR, 0.94 [95% CI, 0.90-0.98]; Hispanic patients: AOR, 0.68 [95% CI, 0.63-0.72]). The intraclass correlation in this secondary analysis model was 0.118 (95% CI, 0.104-0.133).Conclusions and relevanceThis national cross-sectional study found that Black and Hispanic patients had greater odds of ED DAMA than White patients in unadjusted analysis. Disparities were reversed after patient-level and hospital-level risk adjustment, and greater between-hospital than within-hospital variation in DAMA was observed, suggesting that Black and Hispanic patients are more likely to receive care in hospitals with higher DAMA rates. Structural racism may contribute to ED DAMA disparities via unequal allocation of health care resources in hospitals that disproportionately treat racial and ethnic minoritized groups. Monitoring variation in DAMA by race and ethnicity and hospital suggests an opportunity to improve equitable access to health care.
| S-EPMC10685883 | biostudies-literature
Project description:PurposeTo determine characteristics of smokers discussing e-cigarette use with their physician and receiving recommendations from their physician to use e-cigarettes for smoking cessation.MethodsUS adult smokers who had visited a physician in the previous 12 months (n = 2671) were surveyed. Logistic generalized estimating equation models were used to assess the characteristics of smokers who (1) talked to a physician about e-cigarettes, and (2) received physician advice to use e-cigarettes for smoking cessation.Results15% (n = 406) of smokers who visited a physician talked with their physician about e-cigarettes. Among those asked whether their physician recommend e-cigarettes for smoking cessation (n = 257), 61% responded affirmatively. Current e-cigarette users were more likely to talk to their physicians about e-cigarettes (nondaily users vs never users: OR, 2.70; 95% CI, 1.79-4.05; daily users vs never users: OR, 4.29; 95% CI, 2.34-7.84) and have their physician recommend e-cigarettes for smoking cessation (daily users vs never users: OR, 9.40; 95% CI, 2.54-34.71).ConclusionsThe majority of smokers who talk to their physician about e-cigarettes report that they received advice to use e-cigarettes to quit smoking, despite limited evidence for their efficacy. More studies are needed to better understand e-cigarette recommendations in clinical settings.
| S-EPMC6143900 | biostudies-literature
Project description: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.To prospectively evaluate cases of DAMA in a wholesale multidisciplinary perspective at Federal Staff Medical Centre, Abuja, and suggest strategies to reduce it.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.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%).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.
| S-EPMC4363576 | biostudies-other
Project description:BackgroundPolicies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination.ObjectivesWe examine whether and how practices use commercial EMRs to support coordination tasks and identify work-around practices have created to address new coordination challenges.Design, settingSemi-structured telephone interviews in 12 randomly selected communities.ParticipantsSixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders.ResultsSix major themes emerged: (1) EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging; (2) EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange; (3) managing information overflow from EMRs is a challenge for clinicians; (4) clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination; (5) realizing EMRs' potential for facilitating coordination requires evolution of practice operational processes; (6) current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).ConclusionsThere is a gap between policy-makers' expectation of, and clinical practitioners' experience with, current electronic medical records' ability to support coordination of care. Policymakers could expand current health information technology policies to support assessment of how well the technology facilitates tasks necessary for coordination. By reforming payment policy to include care coordination, policymakers could encourage the evolution of EMR technology to include capabilities that support coordination, for example, allowing for inter-practice data exchange and multi-provider clinical decision support.
| S-EPMC2839331 | biostudies-literature
Project description:ObjectiveTo determine the proportion of physician practices in the United States that currently meets medical home criteria.Data source/study setting2007 and 2008 National Ambulatory Medical Care Survey.Study designWe mapped survey items to the National Committee on Quality Assurance's (NCQA's) medical home standards. After awarding points for each "passed" element, we calculated a practice's infrastructure score, dividing its cumulative total by the number of available points. We identified practices that would be recognized as a medical home (Level 1 [25-49 percent], Level 2 [50-74 percent], or Level 3 [infrastructure score ≥75 percent]) and examined characteristics associated with NCQA recognition.ResultsForty-six percent (95 percent confidence interval [CI], 42.5-50.2) of all practices lack sufficient medical home infrastructure. While 72.3 percent (95 percent CI, 64.0-80.7 percent) of multi-specialty groups would achieve recognition, only 49.8 percent (95 percent CI, 45.2-54.5 percent) of solo/partnership practices meet NCQA standards. Although better prepared than specialists, 40 percent of primary care practices would not qualify as a medical home under present criteria.ConclusionAlmost half of all practices fail to meet NCQA standards for medical home recognition.
| S-EPMC3393004 | biostudies-literature
Project description:BackgroundAlcohol-related hepatitis is one of the most severe manifestations of alcohol-related liver disease and has been associated with significant morbidity, mortality and financial burden. Patients with alcohol use disorders are at risk of leaving against medical advice (LAMA); however, there is currently a lack of data in the literature to show which patients are at higher risk. In this study, we investigated the specific demographic factors and comorbidities associated with LAMA.MethodsPatients with a primary or secondary discharge diagnosis of alcohol-related hepatitis (ICD10-CM codes K70.4 and K70.1) between January 2016 and December 2019 were included in this study. Demographics, comorbidities, complications and interventions were studied in for patients who LAMA. Multivariate analysis was conducted to elucidate factors contributing to the increased risk of alcohol-related hepatitis.ResultsA total of 538,750 patients were admitted with a diagnosis of alcohol-related hepatitis. Of these, 31,500 (5.84%) patients LAMA. Older age, Hispanic race, private insurance, and higher income status were associated with a lower risk of LAMA, while younger age, African American race, lack of insurance and being in the lowest income quartile were associated with the highest risk.ConclusionsOur findings demonstrated that significant differences exist between patients with alcohol-related hepatitis who LAMA and those who remain hospitalized until discharge. We believe that this study will help healthcare providers identify patients at risk of LAMA, and help promote the targeted education of specific subgroups to improve their understanding of their disease state and decrease adverse events.
| S-EPMC9399570 | biostudies-literature