Letter: Characteristics and Outcomes of Discharge Against Medical Advice and 30-Day Readmissions After Concussion: Analysis of the Nationwide Readmissions Database.

Abstract

To the Editor: We read with immense interest the article by Jumah et al1 titled as “Characteristics and Outcomes of Discharge Against Medical Advice (DAMA) and 30-Day Readmissions After Concussion: Analysis of the Nationwide Readmissions Database.” It was indeed a fascinating and compelling study which attempted to assess the prevalence of DAMA and its effect on 30-day readmissions and cost in concussion using a nationally representative sample. The authors state that this is the first study to date to analyze DAMA in patients with mild traumatic brain injury (mTBI) and hence is a stepping stone in this arena. Prevalence rates reported (2.6%) were in accordance with other studies and so were the factors associated with DAMA: young men, an Elixhauser comorbidity index >3, and injuries due to assault and/or fall while higher income had a negative association with DAMA. Thirty-day readmission had an independent association with DAMA, higher comorbidity index, and self-inflicted mode of injury. Most frequently encountered cause of readmission was TBI in both routine and DAMA groups. This study can act as a reference to design interventions that can be implemented in real time at health care facilities to reduce DAMA and readmission rate and consequently morbidity and mortality associated with TBI. Although the study is very engrossing and interesting, we were hoping the authors would shed some light on a few areas that could have given more insight about the issue. The study strictly included only patients with mTBI to make sure of the patient's ability to choose DAMA, thereby excluding other patients with TBI. This was very thoughtful of the authors; however, the medical decision-making capacity of a patient with TBI, even if mild, is significantly affected for at least 1 month from injury as compared with a healthy control or patients with other mild illnesses2 and hence we feel that this might have led to confounded results. In addition, what would have been an interesting factor to study is the relationship between DAMA and patient's educational status .3 The authors have reported assault to have a significant association with DAMA. In many cases, women are a victim of assault and thereby female sex should have had an association with DAMA which was contradictory to the observed relation of male sex to DAMA. The study also failed to take into account the role of factors such as sociocultural beliefs of the patients, their family conditions, and their relation with the health care provider. This was most probably due to absence of such variables in the Nationwide Readmissions Database that was used to conduct this study. In addition, patients with mTBI have more emergency department visits which could not be captured by Nationwide Readmissions Database and hence readmission rates might have been confounded. Many studies have shown the negative impact of sociocultural practices on patients' health as they interfere with the scientific process of providing health care to the patients, especially in Asian and African communities.4 Having a child/elderly member at home to take care of or no one to accompany the patients during the stay in the hospitals could be some of the familial reasons for patients to leave against medical advice. Inclusion of ethnicity, gender identity, and the immigration status of the patients and their effect on DAMA would have been a novel addition to the study. Discrimination by the health care providers on the basis of patients' ethnicity and/or sex identity creates differences between the health care providers and the patients. Therefore, patients may feel secluded and disrespected which might be a probable cause of DAMA. For instance, African American patients were found to have 2-fold higher odds of DAMA as compared with White patients.5 Paperwork at the time of admission and the financial constraints create an obstacle for the illegal immigrants forcing them to seek health care facilities somewhere else leading to DAMA. Further analysis of these factors would have been very insightful for the readers. Such findings would also help guide health care entities to adopt a holistic approach toward reducing DAMA and improving the health outcomes.