Discharge against medical advice: ‘deviant’ behaviour or a health system quality gap?

Ambasta, Anshula; Santana, Maria; Ghali, William A.; Tang, Karen

doi:10.1136/bmjqs-2019-010332

Cited by 18 publications

(17 citation statements)

References 21 publications

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“…These are consistent with global literature which have associated leave events with the profile of a young male patient of low socioeconomic status and medical comorbidities related to substance use disorder and mental health disease [2,[31][32][33][34]. Unfortunately, research focused on describing the characteristics of patients who leave against medical advice has served to perpetuate the notion that leave events are a deviant behaviour observed in individuals with certain characteristics [35] which can result in patient stigmatisation, and reduced access to care [35,36]. This deflects the attention from the quality gaps on the health care delivery models that disproportionally impact Aboriginal and Torres Strait Islander people [35,37].…”

Section: Discussionsupporting

confidence: 84%

“…Unfortunately, research focused on describing the characteristics of patients who leave against medical advice has served to perpetuate the notion that leave events are a deviant behaviour observed in individuals with certain characteristics [35] which can result in patient stigmatisation, and reduced access to care [35,36]. This deflects the attention from the quality gaps on the health care delivery models that disproportionally impact Aboriginal and Torres Strait Islander people [35,37]. The qualitative findings of our review revealed in depth some of the causes behind the high representation of leave events among Aboriginal and Torres Strait Islander people and strategies to overcome these.…”

Section: Discussionmentioning

confidence: 99%

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Leave events among Aboriginal and Torres Strait Islander people: a systematic review

et al. 2022

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Background Leave events are a public health concern resulting in poorer health outcomes. In Australia, leave events disproportionally impact Aboriginal and Torres Strait Islander people. A systematic review was conducted to explore the causes of leave events among Aboriginal and Torres Strait Islander people and strategies to reduce them. Methods A systematic review was conducted using Medline, Web of Science, Embase and Informit, a database with a strong focus on relevant Australian content. Additionally, we examined the references of the records included, and performed a manual search using Google, Google scholar and the Australia’s National Institute for Aboriginal and Torres Strait Islander Health Research. Two independent reviewers screened the records. One author extracted the data and a second author reviewed it. To appraise the quality of the studies the Mixed Methods Appraisal Tool was used as well as the Aboriginal and Torres Strait Islander Quality Appraisal Tool. A narrative synthesis was used to report quantitative findings and an inductive thematic analysis for qualitative studies and reports. Results We located 421 records. Ten records met eligibility criteria and were included in the systematic review. From those, four were quantitative studies, three were qualitative studies and three reports. Five records studied data from the Northern Territory, two from Western Australia, two from New South Whales and one from Queensland. The quantitative studies focused on the characteristics of the patients and found associations between leave events and male gender, age younger than 45 years and town camp residency. Qualitative findings yielded more in depth causes of leave events evidencing that they are associated with health care quality gaps. There were multiple strategies suggested to reduce leave events through adapting health care service delivery. Aboriginal and Torres Strait Islander representation is needed in a variety of roles within health care provision and during decision-making. Conclusion This systematic review found that multiple gaps within Australian health care delivery are associated with leave events among Aboriginal and Torres Strait Islander people. The findings suggest that reducing leave events requires better representation of Aboriginal and Torres Strait Islander people within the health workforce. In addition, partnership with Aboriginal and Torres Strait Islander people is needed during the decision-making process in providing health services that meet Aboriginal and Torres Strait Islander cultural needs.

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Section: Discussionsupporting

confidence: 84%

Section: Discussionmentioning

confidence: 99%

Leave events among Aboriginal and Torres Strait Islander people: a systematic review

et al. 2022

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“…It remains to be established whether the patterns of ‘missingness’ from health care described in our research are associated causally with adverse health outcomes. These findings should however encourage policymakers, health service planners and clinicians to consider the role and contribution that ‘missingness’ in health care should make to improving patient safety and care [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

‘Missingness’ in health care: Associations between hospital utilization and missed appointments in general practice. A retrospective cohort study

et al. 2021

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Objectives Are multiple missed appointments in general practice associated with increased use of hospital services and missingness from hospital care? This novel study explores this in a population representative sample for the first time. Design, setting, participants A large, retrospective cohort (n = 824,374) of patient records from a nationally representative sample of GP practices, Scotland, 2013–2016. Requested data were extracted by a Trusted Third Party for the NHS, anonymised and linked to a unique patient ID, in the NHS Safehaven for analysis using established NHS Scotland linkage. We calculated the per-patient number of GP missed appointments from individual appointments and investigated the likelihood of hospital appointment or admission outcomes using a negative binomial model offset by number of GP appointments made. These models also controlled for age, sex, Scottish Index of Multiple Deprivation (SIMD) and number of long- term conditions (LTCs). Main outcome measures Hospital attendance: Outpatient clinic attendances; hospital admissions; Emergency Department (ED) attendances. Hospital missingness: ‘Did not attend’ (DNAs) outpatient clinic appointments, ‘irregular discharges’ from admissions, and ‘left before care completed’ ED care episodes. Results Attendance: Patients in the high missed GP appointment (HMA) category were higher users of outpatient services (rate ratio (RR) 1.90, 95% confidence intervals (CI) 1.88–1.93) compared to those who missed none (NMA) with a much higher attendance risk at mental health services (RR 4.56, 95% CI 4.31–4.83). HMA patients were more likely to be admitted to hospital; general admissions (RR 1.67, 95% CI 1.65–1.68), maternity (RR 1.24, 95% CI 1.20–1.28) and mental health (RR 1.23, 95% CI 1.15–1.31), compared to NMA patients. Missing GP appointments was not associated with ED attendance; (RR 1.00, CI 0.99–1.01). Missingness: HMA patients were at greater risk of missing outpatient appointments (RR 1.62, 95% CI 1.60–1.64) than NMA patients; with a much higher risk of non-attendance at mental health services (RR 7.83, 95% CI 7.35–8.35). Patients were more likely to leave hospital before their care plan was completed-taking ‘irregular discharges’ (RR 4.56, 95% CI 4.31–4.81). HMA patients were no more at risk of leaving emergency departments ‘without care being completed’ (RR1.02, 95 CI 0.95–1.09). Conclusions Patients who miss high numbers of GP appointments are higher users of outpatient and inpatient hospital care but not of emergency departments, signalling high treatment burden. The pattern of ‘missingness’ is consistent from primary care to hospital care: patients who have patterns of missing GP appointments have patterns of missing many outpatient appointments and are more likely to experience ‘irregular discharge’ from in-patient care. Missingness from outpatient mental health services is very high. Policymakers, health service planners and clinicians should consider the role and contribution of ‘missingness’ in health care to improving patient safety and care.

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“…22 Patients may choose to decline further recommended inpatient care, but from a quality perspective, the healthcare system and its healthcare providers may influence this decision-making process and thus serve as a potential intervention point. 23 In this study, we hypothesize that a health system factor is associated with the increasing trend of DAMA. We use the Medicare Hospital Readmissions Reduction Program (HRRP), which was authorized with the passage of the Patient Protection and Affordable Care Act (ACA) in 2010 as the relevant health system factor.…”

Section: Introductionmentioning

confidence: 92%

Adverse Discharge Outcomes Associated With the Medicare Hospital Readmissions Reduction Program Among Commercially Insured Adults

2021

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It is unknown if changes in the rate of discharges against medical advice (DAMA) are related to the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP). We performed an interrupted time series analysis of monthly DAMA rates per 1,000 discharges of all enrolled individuals 18-64 years old with a hospitalization between January 1, 2006, and December 31, 2015, in a commercially insured population. We performed a segmented linear regression with two interruptions: (1) April 2010 to coincide with the passage of the HRRP and (2) October 2012 to coincide with the implementation of HRRP penalties. There were 1,087,812 discharges representing 668,823 individuals over 120 months. The downward trend in monthly DAMA rates was reversed significantly after April 2010 with a sustained 0.1 increase in the monthly rate that continued after the implementation of penalties in October 2012. Allowing for the two interruptions, there was a statistically significant positive trend (0.10; 0.06-0.13, p , .01) in April 2010. Relative to the first interruption, there was no statistically significant change in the slope in October 2012; the estimated slope was 20.04 (20.08 to 0.002). Monthly DAMA rates increased in anticipation of and after HRRP implementation, suggesting a potential relationship between the HRRP and DAMA.

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Discharge against medical advice: ‘deviant’ behaviour or a health system quality gap?

Cited by 18 publications

References 21 publications

Leave events among Aboriginal and Torres Strait Islander people: a systematic review

Leave events among Aboriginal and Torres Strait Islander people: a systematic review

‘Missingness’ in health care: Associations between hospital utilization and missed appointments in general practice. A retrospective cohort study

Adverse Discharge Outcomes Associated With the Medicare Hospital Readmissions Reduction Program Among Commercially Insured Adults

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