Improving Quality in Against Medical Advice Discharges—More Empirical Evidence, Enhanced Professional Education, and Directed Systems Changes

Alfandre, David

doi:10.1002/jhm.2678

Cited by 6 publications

(9 citation statements)

References 16 publications

(22 reference statements)

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“…Improved understanding of the factors associated with DAMA beyond those available in large secondary population-based datasets such as the NIS may also help inform efforts to improve continuity of care. For example, further more detailed exploration of DAMA risk factors may find that outreach by social workers, public health agencies and other community-based partners may reduce DAMA among those living with epilepsy [23,24].…”

Section: Discussionmentioning

confidence: 99%

A nationally representative study on discharge against medical advice among those living with epilepsy

Agarwal

Lin

et al. 2021

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A retrospective cross-sectional study was performed using the 2003-2014 National Inpatient Sample database. ICD-9-CM diagnosis codes were used to identify admissions of patients with epilepsy. Following outcomes were examined among epilepsy patients: proportion and predictors of DAMA, 12-year DAMA trends and causes of admissions. Results: In 2014, of the 187,850 admissions in patients with epilepsy, 3783 (2.01 %) were DAMA. Male sex, Black race, younger age, lower household income, Medicaid/self-pay/other as primary payer, lower Elixhauser comorbidities index, weekend admission, non-elective admission, hospital in northeast region, and urban nonteaching hospital were all associated with DAMA. There was a significant increase in the proportion of DAMA in people with epilepsy from 2003 to 2014 (1.13 %-2.01 %, p < 0.0001). The top reasons of admissions for epilepsy patients who were DAMA were: epilepsy/convulsion (21.02 %), alcohol-(8.86 %) and substance-related disorders (3.75 %), and diabetes mellitus with complications (3.33 %). Conclusions: Our findings provide opportunities to understand DAMA among those living with epilepsy, which is more prevalent in socially-disadvantaged populations. This study highlight the need to develop electronic medical records-based prediction tools that could be used at the point-of-care to enable the early identification of people at risk for DAMA, since it is often likely preventable. Future mixed methods studies are recommended to identify facilitators of DAMA and strategies for prevention.

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Section: Discussionmentioning

confidence: 99%

A nationally representative study on discharge against medical advice among those living with epilepsy

Agarwal

Lin

et al. 2021

Seizure

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“…A study on clinician attitudes towards patient behaviours found that a history of DAMA is considered to be a negative red-flag patient behaviour 7. Healthcare providers often see designating a discharge as ‘against medical advice’ as a way of distancing themselves from the unsafe discharge plan, thus avoiding any potential blame for poor downstream outcomes 8. Once a patient has declared their intention to leave against medical advice, healthcare providers dutifully outline the risks of this decision and ask the patients to sign paperwork that aims to put the responsibility of the decision and its outcomes predominantly on the patient’s shoulders.…”

Section: Current Perceptions Of Discharge Against Medical Advicementioning

confidence: 99%

“…DAMA is related to a complex interplay of numerous patient, provider and system factors, many of which remain to yet be elucidated. Many healthcare providers and institutions believe that they are fulfilling their legal and ethical responsibilities by designating a discharge as against medical advice 8. However, liability protection is conferred because of proper execution of discharge process and documentation of informed declination of care, as opposed to specific designation as ‘against medical advice’ 8.…”

Section: Shared Patient–system Responsibility Model To Generate Systementioning

confidence: 99%

“…Many healthcare providers and institutions believe that they are fulfilling their legal and ethical responsibilities by designating a discharge as against medical advice 8. However, liability protection is conferred because of proper execution of discharge process and documentation of informed declination of care, as opposed to specific designation as ‘against medical advice’ 8. In fact, some advocate now that designating a discharge as against medical advice is paternalistic, signifies low value care, stigmatises patients and is a move away from patient-centred shared decision-making 25.…”

Section: Shared Patient–system Responsibility Model To Generate Systementioning

confidence: 99%

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

et al. 2019

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“…These findings can help guide the implementation of appropriate patient-and system-level interventions to optimize DAMA prevention and mitigate the associated utilization burden on the healthcare system in the postdischarge period. 26,27 Our findings should be interpreted with certain limitations in mind. First, this study used data based on a commercially insured sample of patients and may not be generalizable to pub-licly insured or uninsured samples.…”

Section: Discussionmentioning

confidence: 86%

Healthcare Resource Utilization Following a Discharge Against Medical Advice: An Analysis of Commercially Insured Adults

Gandhi

Onukwugha

McRae

et al. 2020

Journal of Hospital Medicine

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BACKGROUND: A 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. METHODS: This 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). RESULTS: Of 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). CONCLUSION: The 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.

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Improving Quality in Against Medical Advice Discharges—More Empirical Evidence, Enhanced Professional Education, and Directed Systems Changes

Cited by 6 publications

References 16 publications

A nationally representative study on discharge against medical advice among those living with epilepsy

A nationally representative study on discharge against medical advice among those living with epilepsy

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

Healthcare Resource Utilization Following a Discharge Against Medical Advice: An Analysis of Commercially Insured Adults

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