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      Discharge against Medical Advice among Inpatients with Heart Disease in Iran

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          Abstract

          Background

          Discharge against medical advice (DAMA) is a relatively common problem worldwide. We sought to determine the prevalence of and reasons for DAMA among inpatients of our cardiac center.

          Methods:

          From a total of 20289 discharges from our cardiac teaching hospital, 992 (4.9%) patients at a minimum age of 18 years were cases of DAMA. After excluding 49 cases due to missing data, we retrospectively analyzed our prospectively collected data from 943 patients, who were DAMA cases. Patients’ characteristics, including demographic details, reason for discharge, insurance status, and length of stay before discharge, were examined.

          Results:

          The mean age of the study patients was 60.7 ± 13.0 (range, 18–94 years) with a male-to-female ratio of 2.1/1. Lack of consent to surgery or other invasive procedures was the reason cited for DAMA in 31% of the patients, followed by personal or family issues (17%). No reason for DAMA was reported in 26 (2.8%) of the patients. Women compared to men were more likely to cite “lack of consent to surgery or invasive procedures” as the reason for DAMA (p value = 0.005), whereas men more prevalently stated “personal or family issues” as the reason for DAMA (18.7% vs. 12.7%, p value = 0.022).

          Conclusion:

          The most frequent self-reported reason for DAMA in our cardiac patients was lack of consent to surgery or invasive procedures. This may be because of fear of undergoing invasive procedures such as revascularization. Explaining the stages of a given invasive procedure to patients and comparing its risks versus benefits may lessen impulsive decision-making and DAMA.

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          Most cited references 26

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          Factors associated with patients who leave acute-care hospitals against medical advice.

          We examined hospital- and patient-related factors associated with discharge against medical advice (termed self-discharge) after emergency admission to acute-care hospitals. We analyzed data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project using logistic regression models to assess the relationship between self-discharge and a set of patient and hospital characteristics. Of 3,039,050 discharges in the sample, 43 678 were against medical advice (1.44%). In multivariable modeling, predictors of self-discharge included having Medicaid insurance (adjusted odds ratio [AOR]=3.32; 95% confidence interval [CI]=3.22, 3.42), having Medicare insurance (AOR=1.64; 95% CI=1.59, 1.70), urban location (AOR=1.66; 95% CI=1.61, 1.72), medium (AOR=1.25; 95% CI=1.20, 1.29) or large (AOR=1.08, 95% CI=1.05, 1.12) hospital (defined by the number of beds), shorter hospital stay (OR=0.84; 95% CI=0.84, 0.85), and African American race (AOR=1.10; 95% CI=1.07, 1.14). Teaching hospitals had fewer self-discharges (AOR=0.90; 95% CI=0.88, 0.92). Other predictors of discharge against medical advice included age, gender, and income. Approximately 1 in 70 hospital discharges in the United States are against medical advice. Both hospital and patient characteristics were associated with these decisions.
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            What happens to patients who leave hospital against medical advice?

            Patients who leave hospital against medical advice (AMA) may be at risk of adverse health outcomes and readmission. In this study we examined rates of readmission and predictors of readmission among patients leaving hospital AMA. We prospectively studied 97 consecutive patients who left the general medicine service of an urban teaching hospital AMA. Each patient was matched according to age, sex and primary diagnosis with a control patient who was discharged routinely. Readmission rates were examined using Kaplan-Meier analysis. Regression models were used to test the hypothesis that readmissions among patients discharged AMA followed a biphasic curve. Patients who left AMA were much more likely than the control patients to be readmitted within 15 days (21% v. 3%, p < 0.001). Readmissions occurred at an accelerated pace during the first 15 days, followed by a 75-day period during which readmissions occurred at a rate comparable to that among the control patients. Among the patients who left AMA, being male and having a history of alcohol abuse were significant predictors of readmission within 15 days; however, these characteristics were common among the patients who left AMA. In the Cox proportional hazard models, leaving AMA was the only significant predictor of readmission (adjusted hazard ratio 2.5, 95% confidence interval 1.4-4.4). The significantly increased risk of readmission among general medicine patients who leave hospital AMA is concentrated in the first 2 weeks after discharge. However, it is difficult to identify which patients will likely be readmitted.
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              Leaving hospital against medical advice among HIV-positive patients.

              Hospital discharge against medical advice, especially among substance-abusing populations, is a frustrating problem for health care providers. Because of the high prevalence of injection drug use among HIV-positive patients admitted to hospital in Vancouver, we explored the factors associated with leaving hospital against medical advice in this population. We reviewed records for all HIV/AIDS patients admitted to St. Paul's Hospital, Vancouver, between Apr. 1, 1997, and Mar. 1, 1999. After identifying the first ("index") admission during this period, we followed the patients' records for 1 year. Multivariate models were applied to identify the determinants of discharge against medical advice and to estimate the impact of such discharge on readmission rate, readmission frequency and length of stay in hospital. Of 981 index admissions among HIV/AIDS patients, 125 (13%) of the patients left the hospital against medical advice. Departure on the day on which welfare cheques were issued and a history of injection drug use were significant predictors of leaving against medical advice. After adjusting for sex, age, severity of illness, injection drug use and homelessness, we found that patients leaving against medical advice were readmitted more frequently than those who were formally discharged (frequency ratio 1.25, 95% confidence interval [CI] 1.11-1.42), were more likely to be readmitted with a related diagnosis within 30 days (odds ratio 5.00, 95% Cl 3.04-8.24) and had significantly longer lengths of stay in the follow-up period. Discharge against medical advice among HIV-positive patients was associated with frequent readmissions with the same diagnosis. Preventing such discharges is likely to benefit patients (by improving their health status) and the health care system (by reducing unnecessary readmissions).
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                Author and article information

                Journal
                J Tehran Heart Cent
                J Tehran Heart Cent
                JTHC
                The Journal of Tehran Heart Center
                Tehran University of Medical Sciences
                1735-5370
                2008-2371
                Spring 2012
                2012
                31 May 2012
                : 7
                : 2
                : 72-77
                Affiliations
                Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
                Author notes
                [* ]Corresponding Author: Hamidreza Goodarzynejad, Research Department, University of Medical Sciences, Tehran Heart Center, North Kargar Street, Tehran, Iran. 1411713138. Tel: +98 21 88029245. Fax: +98 21 88029731. E-mail: hami_nag@ 123456yahoo.com .
                Article
                jthc-7-72
                3466903
                23074641
                Copyright © Tehran Heart Center, Tehran University of Medical Sciences

                This is an open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0), which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.

                Categories
                Original Article

                Cardiovascular Medicine

                iran, heath care surveys, patient discharge, heart diseases

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