Dataset Information

Against medical advice discharges in injection and non-injection drug use-associated infective endocarditis: A nationwide cohort study.

ABSTRACT:

Background

Among 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.

Methods

We 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 to non-IDU-IE.

Results

We identified 7,259 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% 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)].

Conclusion

AMA 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.

SUBMITTER: Kimmel SD

PROVIDER: S-EPMC8563193 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundDespite high morbidity and mortality, patients with injection drug use associated infective endocarditis (IDU-IE) lack standardized care, and experience prolonged hospitalization and variable substance use disorder (SUD) management. Our study's objective was to elicit perspectives of health care workers (HCWs) who deliver care to this population by understanding their perceived patient, provider, and system-level resources and barriers.MethodsThis qualitative study included interviews of HCWs providing care to patients with IDU-IE from January 2017 to December 2019 at a single Midwest academic center. Based on electronic medical record queries to determine high and low rates of referral to SUD treatment, HCWs were selected using stratified random sampling followed by convenience sampling of non-physician HCWs and a patient. Study participants were recruited via email and verbal consent was obtained. The final sample included 11 hospitalists, 3 specialists (including 2 cardiovascular surgery providers), 3 case managers, 2 social workers, 1 nurse, and 1 patient. Qualitative semi-structured interviews explored challenges and resources related to caring for this population. Qualitative Data Analysis (QDA) Minor Lite was used for thematic data using an inductive approach.ResultsThree major thematic categories emerged relative to patient-level barriers (e.g., pain control, difficult patient interactions, social determinants of health), provider-level barriers (e.g., inequity, expectations for recovery, varying levels of hope, communication style, prescribing medication for SUD), and system-level barriers (e.g., repeat surgery, placement, resources for SUD and mental health). The need to address underlying SUD was a prominent theme.ConclusionPractical steps we can take to improve treatment for this population include training and coaching HCWs on a more person-centered approach to communication and transparent decision-making around pain management, surgery decisions, and expectations for SUD treatment.