Discharge against medical advice among neurological patients: Characteristics and outcomes.
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ABSTRACT: Objective
To study characteristics and outcomes of patients with stroke, traumatic brain injury (TBI), and epilepsy with discharge against medical advice (DAMA).Data sources/study setting
Retrospective analysis of the 2013 Nationwide Readmissions Database, a nationally representative inpatient administrative dataset.Study design
Associations between predictors and DAMA at index admission were analyzed using adjusted logistic models. We examined 30-day all-cause readmissions.Data collection methods
Patients aged ≥18 years at index admission for International Classification of Diseases-9 diagnosis code of epilepsy, TBI, or stroke were included.Principal findings
Discharge 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).Conclusions
Age, 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.
SUBMITTER: Raja A
PROVIDER: S-EPMC7518816 | biostudies-literature |
REPOSITORIES: biostudies-literature
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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: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.
| S-EPMC7290410 | biostudies-literature
Project description:BackgroundDischarge against medical advice may be associated with more readmissions.ObjectiveTo evaluate DAMA in patients with acute ischemic stroke (AIS) and identify the relationship between DAMA and 30-day unplanned readmissions.DesignA retrospective cohort study.ParticipantsThe National Readmission Database was used to identify inpatients with a primary diagnosis of AIS who were either discharged home or DAMA between 2010 and 2017 in the USA.MeasuresDemographic features, hospital type, comorbidities, stroke risk factors, severity indices, and treatments were compared between patients discharged routinely and DAMA. Multivariable logistic regression was used to evaluate predictors of DAMA, and a double robust inverse probability of treatment weighting method was used to assess the association between DAMA and 30-day unplanned readmissions.Key resultsOverall, 1,335,484 patients with AIS were included, of whom 2.09% (n = 27,892) were DAMA. The prevalence of DAMA in AIS patients increased from 1.65 in 2010 to 2.57% in 2017. The rates of 30-day unplanned readmissions for DAMA and non-DAMA patients were 16.81% and 7.78%, respectively. Patients with drug abuse, alcohol abuse, smoking, prior stroke, psychoses, and intravenous thrombolysis had greater odds of DAMA. DAMA was associated with all-cause readmissions (OR, 2.04; 95% CI, 2.01-2.07) and remained a strong predictor for transient ischemic attack/stroke-specific and cardiac-specific causes of readmissions.ConclusionsAlthough the DAMA rate is low in AIS patients, DAMA is a risk factor for all-cause and recurrent stroke-specific readmissions. Future studies are needed to address issues around compliance and engagement with health care to reduce DAMA.
| S-EPMC8131431 | biostudies-literature
Project description:BackgroundA discharge against medical advice (DAMA) is associated with adverse health outcomes. Its association with postdischarge healthcare resource utilization (HcRU) outside an inpatient setting is unknown. This information can help us understand how a DAMA may affect healthcare-seeking behavior following a hospital stay. We evaluated the relationship between a DAMA and 30-day postdischarge HcRU.MethodsThis retrospective cohort study uses a 10% random sample of enrollees in the IQVIA PharMetrics® Plus database. We included individuals aged 18 to 64 years with an inpatient admission during 2007-2015 and continuous insurance coverage. We defined comparison groups as DAMA and routine discharge. Both groups were matched on baseline covariates. We quantified the association between a DAMA and 30-day HcRU, as well as 90-day for sensitivity analysis, with use of generalized linear models for binary outcomes (inpatient readmissions, emergency department [ED] visits) and count outcomes (physician office visits, nonphysician outpatient encounters, prescription drug fills).ResultsOf the 457,530 individuals in the unmatched sample, 2,245 (0.5%) had a DAMA. In the matched sample, a DAMA was positively associated with an ED visit (adjusted odds ratio, 2.28; 95% confidence interval, 1.90-2.72) but not with an inpatient readmission. There were no differences between groups based on the count outcomes. A DAMA was positively associated with 90-day HcRU (ie, inpatient readmission, ED visit, and prescription drug fills).ConclusionThe relationship between a DAMA and HcRU varied with the HcRU category and postdischarge time interval. This examination of HcRU in the inpatient and outpatient settings provides important information about outcomes following a DAMA.
| S-EPMC8034675 | biostudies-literature
Project description:IntroductionDischarge against medical advice (DAMA) is an unexpected event for patients and healthcare personnel. The study aimed to assess the prevalence of DAMA in neonates along with characteristics of neonates who got DAMA and, causes and predictors of DAMA.Methods and findingsThis case-control study was carried out in Special Care Newborn Unit (SCANU) at Chittagong Medical College Hospital from July 2017 to December 2017. Clinical and demographic characteristics of neonates with DAMA were compared with that of discharged neonates. The causes of DAMA were identified by a semi-structured questionnaire. Predictors of DAMA were determined using a logistic regression model with a 95% confidence interval. A total of 6167 neonates were admitted and 1588 got DAMA. Most of the DAMA neonates were male (61.3%), term (74.7%), outborn (69.8%), delivered vaginally (65.7%), and had standard weight at admission (54.3%). A significant relationship (p < 0.001) was found between the variables of residence, place of delivery, mode of delivery, gestational age, weight at admission, and day and time of outcome with the type of discharge. False perceptions of wellbeing (28.7%), inadequate facilities for mothers (14.5%), and financial problems (14.1%) were the prevalent causes behind DAMA. Predictors of DAMA were preterm gestation (AOR 1.3, 95% CI 1.07-1.7, p = 0.013), vaginal delivery (AOR 1.56, 95% CI 1.31-1.86, p < 0.001), timing of outcome after office hours (AOR 477.15, 95% CI 236-964.6, p < 0.001), and weekends (AOR 2.55, 95% CI 2.06-3.17, p < 0.001). Neonates suffering from sepsis (AOR 1.4, 95% CI 1.1-1.7, p< 0.001), Respiratory Distress Syndrome (AOR 3.1, 95% CI 1.9-5.2, p< 0.001), prematurity without other complications (AOR 2.1, 95% CI 1.45-3.1, p < 0.001) or who were referred from north-western districts (AOR 1.48, 95% CI 1.13-1.95, p = 0.004) had higher odds for DAMA.ConclusionsIdentification of predictors and reasons behind DAMA may provide opportunities to improve the hospital environment and service related issues so that such vulnerable neonates can complete their treatment. We should ensure better communication with parents, provide provision for mothers' corner, especially for outborn neonates, maintain a standard ratio of neonates and healthcare providers, and adopt specific DAMA policy by the hospital authority.
| S-EPMC10118186 | 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: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: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.
| S-EPMC6508559 | biostudies-literature
Project description:BackgroundPatients 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.MethodsWe 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.ResultsAmong 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.ConclusionsAdherence 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.
| S-EPMC7218753 | 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