Against Medical Advice Discharge: A Narrative Review and Recommendations for a Systematic Approach

Holmes, Emily G.; Cooley, Benjamin S.; Fleisch, Sheryl B.; Rosenstein, Donald L.

doi:10.1016/j.amjmed.2020.12.027

Cited by 23 publications

(30 citation statements)

References 39 publications

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“…29 Incomplete treatment at the time of discharge may heighten the risk for symptom worsening. 30 This may be especially true for patients with SUD who may experience withdrawal symptoms that drive them to abruptly leave the programme and, potentially, relapse. 30 Providers’ beliefs about the degree of treatment that should be provided to patients who leave with an irregular discharge may also result in patients leaving without treatment (such as medication supply or scheduled follow-up care).…”

Section: Discussionmentioning

confidence: 99%

“…30 This may be especially true for patients with SUD who may experience withdrawal symptoms that drive them to abruptly leave the programme and, potentially, relapse. 30 Providers’ beliefs about the degree of treatment that should be provided to patients who leave with an irregular discharge may also result in patients leaving without treatment (such as medication supply or scheduled follow-up care). 4,30 Related to this concern, there may also be breakdowns in therapeutic alliance between providers and patients at the time of an irregular discharge.…”

Section: Discussionmentioning

confidence: 99%

“…30 Providers’ beliefs about the degree of treatment that should be provided to patients who leave with an irregular discharge may also result in patients leaving without treatment (such as medication supply or scheduled follow-up care). 4,30 Related to this concern, there may also be breakdowns in therapeutic alliance between providers and patients at the time of an irregular discharge. For example, patients may perceive that their needs were not addressed or feel generally alienated from providers because of stigma.…”

Section: Discussionmentioning

confidence: 99%

“…For example, patients may perceive that their needs were not addressed or feel generally alienated from providers because of stigma. 30 These factors may put patients at a higher risk for adverse outcomes such as suicide because they are then isolated from necessary treatment and related out-patient supports. Aligned with these concerns, we found that the risk for suicide was particularly high in the first 30 days post-discharge (HR = 3.41).…”

Section: Discussionmentioning

confidence: 99%

“…To date, a few studies have evaluated various strategies to prevent irregular discharge, although they have primarily focused on patients with SUD. 30,32,33 For example, using retrospective data from over 35 000 hospital-related treatment encounters for SUD, Thompson et al found that compared with usual care, a substance use intervention team (SUIT) was associated with a significantly greater probability that patients would leave with a regular discharge (HR = 1.16, 95% CI 1.03–1.3). 32 The SUIT intervention focuses on harm reduction and includes interventions such as medication initiation, motivational interviewing, treatment education and processes to facilitate post-discharge care.…”

Section: Discussionmentioning

confidence: 99%

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Association between suicide, external-cause and all-cause mortality and irregular mental health discharge among the US veteran population

et al. 2021

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Background Irregular hospital discharge is highly prevalent among people admitted to hospital for mental health reasons. No study has examined the relationship between irregular discharge, post-discharge mortality and treatment setting (i.e. mortality after patients are discharged from acute in-patient or residential mental health settings). Aims To understand the relationship between irregular discharge and mortality among patients discharged from acute in-patient and residential settings. Method A retrospective study was conducted in members of the US veteran population discharged from acute in-patient or residential settings of the US Department of Veterans Affairs between 2003 and 2018. Multivariate Cox proportional hazards were used to evaluate associations between irregular discharge and suicide, external-cause (as defined by ICD-10 Codes: V01-Y98) and all-cause mortality in the first 30-, 90- and 180-days post-discharge. Results There were over 1.5 million mental health discharges between 2003 and 2018. Patients with an irregular discharge were at increased risk for suicide, external-cause and all-cause mortality in the first 180 days after discharge. In the first 30 days after discharge, patients with irregular discharge had more than three times greater suicide risk than patients with regular discharge (adjusted hazard ratio (HR) = 3.41, 95% CI 2.21–5.25). Suicide risk was higher among patients with irregular discharge in the first 30 days after acute in-patient discharge (adjusted HR = 1.55, 95% CI 1.11–2.16). In both settings, the mortality risk associated with irregular discharge attenuated but remained elevated within 90 and 180 days. Conclusions Irregular discharge after an acute in-patient or residential stay poses a large risk for mortality soon after discharge. Clinicians must identify effective interventions to mitigate harms associated with irregular discharge in these settings.

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Section: Discussionmentioning

confidence: 99%