Multi-Level Predictors of Discharges Against Medical Advice: Identifying Contributors to Variation Using an All-Payer Database

Abstract

There is increasing evidence of the role of non–patient-level factors on discharge against medical advice (DAMA), but limited quantitative information regarding the extent of their impact. This study quantifies the contribution of discharge-level and hospital-level factors to the variation in DAMA. We grouped variables from the 2014 National Inpatient Sample data and ran incremental mixed-effects logit models with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICCs), and evaluated the incremental change in ICC. The final sample included 2,687,430 discharges. 12.8% of the identified variation in the probability of DAMA was associated with the hospital, and 1.2% of the variation was associated with the census division in which the hospital was located. The final, fully-adjusted model had 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions because of the addition of patient demographics. Even after adjusting for measured patient-level characteristics, there was a contribution of non–patient-level factors to DAMA outcomes. The findings identify a role for a multi-level approach to addressing DAMA.

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

“…First, these findings add to evidence that a non-patient-level factor may be associated with DAMA and play a role in its increasing prevalence over time. Previous studies have identified other non-patient-level factors that are associated with DAMA, including a hospital's quality metrics, 39 location, 40 and teaching status. 41 Our findings may be relevant in the design of system-level interventions to reduce DAMA, including policy changes.…”

Is It Time for the Mental Health Field to Consider Unplanned Discharge a Key Metric of Patient Safety?

“…Experts emphasize that unplanned discharge is a system-level problem that cannot be solely attributed to behaviors or characteristics of individual patients (Alfandre, 2019; White et al, 2005). This concern has been borne out in the literature where studies have found that rates of AMA discharge vary based on hospital characteristics such as urban location, medium hospital size, and for-profit status (Onukwugha et al, 2021). Available studies, however, have generally focused their attention on acute medical wards and have not considered whether unplanned discharge rates also vary based on mental health treatment settings including acute inpatient and residential settings.…”