Leaving Against Medical Advice From In-patients Departments Rate, Reasons and Predicting Risk Factors for Re-visiting Hospital Retrospective Cohort From a Tertiary Care Hospital

Abstract

Background: Approximately 1% to 2% of hospitalized patients get discharged or leave from the hospital against medical advice and up to 26% in some centers. They have higher readmission rate and risk of complications than patients who receive complete care. In this study we aimed to determine the rate of leave against medical advice (LAMA) and reasons for the same across different in-patient departments of a tertiary care hospital. Methods: Retrospective cohort study on patients admitted in all departments at our institute over a 1-year period. All patients who were admitted to an in-patient ward at the hospital and who left against medical advice by submitting a duly filled LAMA form were included. Univariate and multivariate logistic regression models with forward selection methods were employed. Revisit to hospital within 30 days; to clinic or emergency department was outcome variable for regression. Results: From June 2015 to May 2016 there were 429 LAMA patients, accounting for 0.7% of total admissions. Females were 223 (52%) compared to males 206 (48%). Finances were quoted as the most common reason for LAMA by 174 (41%) patients followed by domestic problems 78 (18%). Internal medicine was the service with the highest number of LAMA patients ie, 153 (36%) followed by Pediatric medicine with 73 (17%). Of the 429 patients, 147 (34%) patients revisited the hospital within 30 days. Sixty-one percent of these ‘bounced-back’ LAMA patients had worsening or persistence of same problem, or new problem/s had developed. In unadjusted bivariate logistic model, patients who were advised for follow-up during discharge against medical advice were four times more likely to revisit the hospital. Patients who were married had an increased odd of revisiting the hospital. Conclusion: Financial reasons are the most common stated reasons to LAMA. Patients who LAMA are at a high risk of clinical worsening and ‘bouncing back.’ This is the first study from our region on in-patient LAMA rates, to our knowledge. The results can be used for planning measures to reduce LAMA rates and its consequences.

Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study

“…[ 29 ] and Hasan et al . [ 25 ] More than one- third (37.5%) of our patients were between 20 and 29 years. The predominance of patients in the economically productive age groups and the aforementioned male predominance in this study may be due to the predominance of neurotrauma patients in our study population since it is known that trauma is the leading cause of neurosurgical diseases in these groups.…”

“…[ 13 , 24 , 25 , 29 ] Poor socioeconomic status and lack of health insurance are probable reasons for this. [ 26 , 28 , 29 , 40 ] Our figure of about 63% regarding the contribution of economic hardships for the cause of DAMA is higher than 32.9% reported by Jimoh et al .,[ 29 ] 40.6% by Hasan et al .,[ 25 ] and 48% by Fadare et al .,[ 24 ] but similar to 61.1% in the study by Lakhotia et al . [ 31 ] The variation between our figures and that of Fadare et al .…”

Characteristics of trauma patients that leave against medical advice: An eight-year survey analysis using the National Hospital Ambulatory Medical Care Survey, 2009–2016

“…Further, negotiating with patients to complete the recommended treatment becomes vital as the patient and the healthcare system are negatively affected by leaving AMA. 2,5,10,33 Leaving AMA is associated with increased readmission rates, fragmented patient care, and healthcare litigation. 2,5,10,33 A qualitative study that assessed physician and patients' notes on reasons for requesting and denying discharge, respectively, identified the role of strained patient-physician communication in decisions to leave AMA.…”

“…2,5,10,33 Leaving AMA is associated with increased readmission rates, fragmented patient care, and healthcare litigation. 2,5,10,33 A qualitative study that assessed physician and patients' notes on reasons for requesting and denying discharge, respectively, identified the role of strained patient-physician communication in decisions to leave AMA. 34 The possibility exists that involving medical social workers to serve as trained advocates for patient completion of care may reduce the leaving AMA rates.…”

“…2,3 While this proportion represents a small percentage of the patients' load in the U.S., 2,4 decisions to leave AMA affect the individual, the caregivers, and the healthcare system. 5 Leaving AMA is associated with stigma, and incomplete medical care, 1,5 resulting in increased likelihood to be admitted in a different equidistant hospital, fragmented care, 6 and increased cost of care. 7 The most common reasons for leaving AMA are financial constraints, socioeconomic status, dissatisfaction with treatment, and poor communication with healthcare professionals.…”