Effectiveness of individualized counseling in reducing leave against medical advice among neurosurgical patients in the emergency department

Abstract

Objective: Leave against medical advice (LAMA) in the emergency department (ED) is a significant challenge in low- and middle-income countries, often leading to higher rates of readmission, increased mortality, and disrupted continuity of care. This study aimed to evaluate the effectiveness of individualized counseling in reducing LAMA incidents among neurosurgical patients in the ED. Materials and Methods: This quality improvement study employed a prospective case-control design to compare LAMA rates between patients who received individualized counseling and those who did not. A “nursing-coordinator program” was introduced, focusing on patient communication and engagement. Trained staff followed a standardized checklist to address the concerns of patients and their caregivers, providing “individualized counseling.” Data collected after the intervention were compared with retrospective pre-intervention data, and the results were analyzed. Results: A total of 554 patients, ranging from 1 to 94 years of age, were included in the study, with 60.5% being male. Among the 353 patients who received the “individualized counseling” intervention, 60 opted for LAMA (study group), compared to 49 LAMA cases out of 201 patients who did not receive counseling (control group). The LAMA rate significantly decreased from 24.4% to 16.9% post-intervention (P = 0.035). The “individualized counseling” intervention effectively reduced LAMA due to factors such as misinformation about disease severity (P = 0.009), economic constraints (P < 0.001), and poor prognosis (P < 0.001). However, it was less effective for reasons like proximity to home (P = 0.007), inadvisable transfers for personal reasons (P = 0.023), and family problems (P = 0.293). Conclusions: This study demonstrates that individualized counseling is an effective intervention for reducing LAMA among neurosurgical patients in the ED. By addressing non-medical factors often overlooked due to inadequate counseling, this quality improvement strategy can help prevent vulnerable patients from prematurely terminating their treatment.