Rate Of Discharge Against Medical Advice Research Articles

Discharge against Medical Advice in Eight Tertiary Hospitals in Nigeria: A Prospective Study.

Discharge against medical advice (DAMA) is when a patient decides to leave the hospital without the consent of the treating physician. It poses serious clinical, ethical, and legal challenges to the individual physician as well as the hospital. To determine the prevalence and reasons for DAMA in orthopedic departments of eight tertiary hospitals in Nigeria. This was a prospective multi-center descriptive study undertaken in eight tertiary Nigerian hospitals. Consecutive patients who requested for DAMA within 1 year of the study and who consented to participate in the study had face-to-face interviews. Data obtained were documented in a questionnaire and analyzed with SPSS version 20. The total number of patients studied was 373 with a mean age 34.7 ± 17.5 years. About a quarter of them (25.5%) were between 31 and 40 years. A prevalence rate of 1.9% was found with financial constraint being the predominant reason for DAMA (40.8%). Other reasons include family preference for unorthodox treatment (18.8%) and treatment dissatisfaction (7.0%) among others. The study findings indicate a low DAMA rate when compared to previous studies in this region. It also indicates that financial constraints, family preference for unorthodox care, and low educational status are major drivers of DAMA. Deepened health insurance and other measures that can reduce the prevalence of DAMA should be prioritized to improve treatment outcomes.

Factors Associated With a Discharge Against Medical Advice From an Emergency Department in Adult Patients With Appendicitis

BackgroundDelays in care can lead to worsened outcomes with acute appendicitis. To get timely treatment, patients must consent. ObjectiveTo determine if there are racial and socioeconomic differences in discharge against medical advice (DAMA) rates from an emergency department after the diagnosis of acute appendicitis. MethodsPatients were identified retrospectively from the 2019 National Emergency Department Sample. The inclusion criteria were patients 18 years of age or older with acute appendicitis. Rates were compared using chi-square or Fisher's exact test. Odds ratios were determined using multiple logistic regression. A p value of 0.05 was used to determine statistical significance. ResultsThe overall rate of DAMA was low (0.37%). Black patients had the highest rate, and White patients had the lowest (0.72% and 0.28%, respectively, p < 0.001). When controlling for covariates, Black patients also had a higher odds ratio (OR) for DAMA (OR 1.96, 95% confidence interval [CI] 1.29–2.97). Male patients had a higher unadjusted rate (0.47% vs. 0.26% in females, p < 0.001) and were at increased risk (OR 1.78, 95% CI 1.32–2.41). Patients between 30 and 65 years old had an increased risk (OR 1.48, 95% CI 1.10–2.0). Patients with government insurance or no insurance had higher rates than private insurance (0.57% and 0.56% vs. 0.23% respectively, p < 0.001). ConclusionRace, insurance status, age, and male sex were all associated with increase in DAMA. Risk stratifying patients can help to determine how to best employ mitigations strategies. Reducing DAMA may be the next area for improving reducing disparities in appendicitis care.

Clinical features related to alcohol co-ingestion of deliberate self-poisoning patients visiting the emergency department

Purpose: Alcohol is one of the most commonly co-ingested agents in deliberate self-poisoning (DSP) cases presenting at the emergency department (ED). The increased impulsivity, aggressiveness, and disinhibition caused by alcohol ingestion may have different clinical features and outcomes in cases of DSP. This study investigates whether alcohol co-ingestion affects the clinical features and outcomes of DSP patients in the ED. Methods: This was a single-center retrospective study. We investigated DSP cases who visited our ED from January 2010 to December 2016. Patients were classified into two groups: with (ALC+) or without (ALC–) alcohol co-ingestion. The clinical features of DSP were compared by considering the co-ingestion of alcohol, and the factors related to discharge against medical advice (AMA) of DSP were analyzed. Results: A total of 689 patients were included in the study, with 272 (39.5%) in the ALC+ group. Majority of the ALC+ group patients were middle-aged males (45-54 years old) and arrived at the ED at night. The rate of discharge AMA from ED was significantly higher in the ALC+ group (130; 47.8%) compared to the ALC– group (p=0.001). No significant differences were obtained in the poisoning severity scores between the two groups (p=0.223). Multivariate analysis revealed that alcohol co-ingestion (odds ratio [OR]=1.42; 95% confidence interval [CI], 1.01-1.98), alert mental status (OR=1.65; 95% CI, 1.17-2.32), past psychiatric history (OR=0.04; 95% CI, 0.01-0.28), age &gt;65 years (OR=0.42; 95% CI, 0.23-0.78), and time from event to ED arrival &gt;6 hrs (OR=0.57; 95% CI, 0.37-0.88) were independent predictive factors of discharge AMA (p=0.043, p=0.004, p=0.001, p=0.006, and p=0.010, respectively). Conclusion: Our results determined a high association between alcohol co-ingestion and the outcome of discharge AMA in DSP patients. Emergency physicians should, therefore, be aware that DSP patients who have co-ingested alcohol may be uncooperative and at high risk of discharge AMA.

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

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.

Discharge Against Medical Advice (DAMA) Among Inpatients with Cardiac Problems in CCH

Background: The instance of a patient already in hospital wishing to leave against clinician’s advice is referred to as self-discharge or discharge against medical advice. DAMA is a relatively common problem in health care systems. Because lengths of stay (LOS) are commonly several days, these patients often remain acutely ill at the time of self-discharge, and they may remain exposed to the risk of inappropriately treated medical problem, resulting in the need for readmission. It is not surprising that DAMA poses a major problem for many clinicians who treat inpatients, particularly those with cardiac problems because incomplete therapy in conditions such as ischemic heart disease may exert a negative impact on health outcome. Additionally, consequent care will be probably associated with more challenges and higher overall costs over time. Avoiding DAMA is, thus, likely to be beneficial for both patients and health systems. Methods: Study Design -Non-experimental, cross-sectional research design which will identify the reasons influencing DAMA among inpatients with cardiac problems is CCH. The study will describe the reasons by using a quantitative method. Setting of the study - The research will be conducted in Cardiac Center Hail, Ha’il Region, Kingdom of Saudi Arabia, and will focus on inpatient departments. Sample - In order to get accurate result of study, all discharged patients will be asked to participate in this study optionally. Data collection procedures - After getting approval from ethical committee in CCH and Hail Health Cluster, the questionnaires will be kept in nursing station, and explanation of a purpose of study will be demonstrated to all participants. Then, a collection box of questionnaires will be provided in the nursing office. Thereafter, data will be stored within one week from distribution to be ready for analysis. Data analysis - The ‘Patient Satisfaction Survey - DAMA form’ was designed on the basis of the reasons cited by patients in the past for self-discharge and the potential reasons are provided in this form. Demographic information was comprised of such biological characteristics as age, gender, and nationality. Finally, the prospectively collected data were analysed. The data are presented as n = % for the quantitative variables and are summarized by absolute frequencies and percentages for the categorical variables. Results: For approximately 45-day period, there were 102 discharges, of which 19 (18.63%) were cases of DAMA. Analysis was conducted in 17 patients after the exclusion of 2 patients due to missing data. Modes of admission were the emergency department, hospital transfer, and routine or elective admissions. The most prevalent reason cited by the study was feeling well (88.24%), followed by the desire to be transferred to other hospital (5.88%) and financial problems (5.88%). The baseline characteristics of the DAMA cases, for male and female separately, are depicted in Table 1. The range age of study population is above 18 to over 60 years with a male to female ratio of 16:1. Nearly one third of the study patients were in the age group of 51-60 years. The most common age group was 51-60 years in the men and over 60 years in the women. Conclusion: The most frequent self-reported reasons for DAMA in inpatient cardiac patients included feeling well, desire to be transferred to another hospital and financial problems respectively. We believe that explaining the importance of proper medical treatment and benefits versus risks of medication compliance may lessen impulsive decision of DAMA. Providing strategies for decreasing the rate of DAMA by analysing the current circumstances and developing effective interventions may benefit both patients (improving their health) and health care systems (decreasing unnecessary readmissions). There will be a continuous monitoring of the patient satisfaction survey both in regular and monthly basis by the Nursing Service Department. Proper coordination with social health workers, medical and nursing staff will be done. Multidisciplinary collaboration through regular committee meetings shall be implemented.

Discharge against medical advice among infants with 24-31 weeks' gestation admitted to Chinese neonatal intensive care units: A multicenter cohort study.

BackgroundPrevious studies demonstrated high rates of discharge against medical advice (DAMA) among very preterm infants (VPIs) in China.ObjectivesThe aim of this study was to investigate the concurrent incidence, variation, and predictors of DAMA, along with the effect of DAMA on mortality of VPIs in China using data from the Chinese Neonatal Network (CHNN).MethodsAll infants born at 24–31 completed weeks’ gestation and admitted to 57 CHNN neonatal intensive care units (NICUs) in 2019 were included for this cohort study, excluding infants with major congenital anomalies. Patient information was prospectively collected using the CHNN database. Multivariable log-linear regression analysis was used to assess the association of perinatal factors and DAMA.ResultsA total of 9,442 infants born at 24–31 completed weeks’ gestation and admitted to 57 CHNN participating sites in 2019 were included in the study. Overall, 1,341 infants (14.2%) were discharged against medical advice. Rates of DAMA decreased with increasing gestational age (GA), and infants with lower GA were discharged earlier. DAMA infants had significantly higher rates of necrotizing enterocolitis, severe brain impairment, and bronchopulmonary dysplasia than non-DAMA infants. A total of 58.2% DAMA infants were predicted to die after discharge. The attributable risk percentage of mortality among DAMA infants was 92.4%. Younger maternal age, lower gestational age, small for gestational age, and Apgar score ≤3 at 5 min were independently associated with an increased risk of DAMA, while infants with antenatal steroids were less likely to be DAMA.ConclusionThe rate of DAMA in preterm infants between 24 and 31 weeks’ gestation remained high in China with a significant impact on the mortality rates. Continuous efforts to reduce DAMA would result in substantial improvement of outcomes for VPIs in China.

Profile and Outcome of DAMA among Paediatric Patients from a Tertiary Care Centre of a Non Profit Private Teaching Institute at Gujarat, India

Introduction: The problem of Discharge Against Medical Advice (DAMA) has been reported globally, including in patients of the paediatric age group. Even the Indian subcontinent faces such problems, whether, it is the private sector or public sector. Terminal illness, low affordability, social reason are a few of the common reasons for this DAMA problem. Aim: To know the outcome and demographic profile of DAMAs among paediatric patients at a tertiary care teaching institute. Materials and Methods: This mix-method, prospective descriptive study was conducted in Department of Paediatrics, Pramukhswami Medical College and Shree Krishna Hospital, Karamsad, Gujarat, India, from March 2020 to February 2021. Contact details of patients, whose parents took DAMA from the hospital, were retrieved from the Electronic Health Record system. Interviews were recorded and the required information was gathered. Median (interquartile range), frequency, percentage and proportion of age, sex, diagnosis, and reasons of DAMAs derived. Results: Out of a total of 1752 registered paediatric patients (1 month to 18 years), 74 patients were given DAMA, of which 42 consented to interview. The mean age was 70.36±67.9 months and 65% were males. Amongst these 42, 31(73.81%) were taken to home and 11 (26.19%) to another hospital; 20 (47.62%) patients died. Among the rest, 6 (14.28%) had morbidity. Total deaths were 20, out of which six died within one hour, another four died within 24 hours, two died within 7 days and rest eight were died any time after 7 days till contacted. Family or social reason was the top cause of DAMA, whereas, poor prognosis with or without affordability issues was next. Among all diagnoses, nearly half of the cases were infectious/ inflammatory, 10% tumour/malignancy, and 6.14% trauma/ head injuries. Conclusion: DAMA rate was not high in this study. But this was not preventable in majority of the cases as poor prognosis as well as family or social reasons were the major causes of DAMA.

National survey on discharge against medical advice among patients with musculoskeletal trauma in Nigeria

Background: Patients in our environment sometimes discharge themselves against medical advice. Many of them do this due to the cost of treatment and a belief in the efficacy of traditional bone setters (TBS). This is the first multi-center study in our environment comparing the differences across ethnic groups, religions, and geographical regions. Aim: The study aimed to hightlight the burden of DAMA among patients with musculoskeletal injuries. Patients, Materials and Methods: This was a health facility-based cross-sectional study of patients with musculoskeletal injuries who presented to the Accident and Emergency departments of five selected health facilities across Nigeria over a six-month period. Results: A total of 601 patients were enrolled in this study. One hundred and ninety-four (32.3%) respondents discharged themselves against medical advice and the major reason given for the discharge against medical advice (DAMA) was the cost of treatment (49.1%) and a preference for the care given by TBS by relatives (33.5%) and the respondents (29.8%). The educational status of respondents, ethnic group, and access to health insurance, duration of admission, and frequency of fractures were predictors of DAMA. Respondents with postgraduate qualifications were much less likely to DAMA, adjusted odds ratio 0.36; confidence interval: 0.15–0.86, P = 0.021. Furthermore, respondents from Ibibio, Fulani, and Tiv ethnic groups were 3.79, 2.58, and 2.56 times more likely to DAMA, respectively. Respondents with health insurance coverage were less likely to DAMA. Conclusion: The prevalence rate of DAMA amongst patients with musculoskeletal trauma in Nigerian tertiary hospitals is relatively high. The predictors of DAMA identified in this study call for improvements in education and mandatory health insurance cover. From the findings in this study, reducing out-of-pocket costs to patients may be the most important step in improving access to orthodox treatment of musculoskeletal injuries. Further studies are suggested to determine why some ethnic nationalities had a higher prevalence of DAMA.

Neonatal morbidity and mortality: A 5-year analysis at federal medical centre, Gusau, Zamfara State, Northwest Nigeria

Objectives: Neonatal morbidity and mortality have remained embarrassingly high in Nigeria compared to some countries in Sub-Saharan Africa. Nigeria ranked first in the burden of neonatal deaths in Africa. Therefore, there is need to know causes of newborn diseases and deaths in our neonatal unit. The objective of the study was to describe the morbidity and mortality of newborns admitted into Special Care Baby Unit of Federal Medical Centre, Gusau, Nigeria over a 5-year period. Material and Methods: This is a retrospective study covering January 2012 to December 2016. The case folders of all newborns admitted during this period were retrieved and the following information were extracted: Sex of babies, diagnoses, outcome in terms of discharges, deaths, referrals, and discharge against medical advice (DAMA). Results: A total of 3,553 neonates were admitted during the period under review. The sex ratio for males and females was 1.4:1, respectively. The major diagnoses were neonatal sepsis (NNS) 36.5%, birth asphyxia 25.6%, and prematurity 16.1%. Mortality rate was 6.6% with major contributions from birth asphyxia (35.6%), prematurity (28.1%), and NNS (12.0%). DAMA rate was 1.7%. Conclusion: This study has shown that NNS, birth asphyxia, and prematurity are the dominant causes of morbidity and mortality. These are largely preventable.

The causes of discharge against medical advice and suggestions for its reduction in Tabriz Sina Medical Center (phenomenological study)

Objectives: Patient satisfaction is an issue that has attracted increasing attention to the health industry today. Discharge against medical advice (DAMA) is one of the symptoms of patient dissatisfaction that has adverse effects on patient treatment and increases hospital costs. The purpose of this study was to identify the causes of DAMA by patients admitted to Sina educational and therapeutic center (one of the teaching hospitals of Tabriz University of Medical Sciences) and finally to provide strategies for reducing DAMA. Material and Methods: This study is qualitative research with a phenomenological approach. The data gathering tool is in-depth interviews. The study population consisted of all patients who completed the DAMA form in 2017 and left the hospital with their satisfaction. The sampling method was purposeful and interviewing. The method of analysis is thematic analysis. Results: Final findings indicate that the rate of DAMA in Sina training and medical center has a significant proportion that needs intervention and evaluation. Most of the patients in this study were male, non-native of Tabriz, admitted to surgery, discharged in the morning shift, as well as average stay over 2 days. The reasons for DAMA after an interview with patients were classified into three themes: (1) Problems with the patient, (2) problems with care issues, and (3) problems with hospital facilities. Conclusion: The most common reasons for DAMA in Sina educational and medical center were problems related to the patient.

The pandemic’s effect on discharge against medical advice from the emergency department

Background/Aim: Reasons for discharge against medical advice (DAMA) may vary according to countries' conditions and environmental or individual factors. Patients who choose to leave the hospital against the doctors’ recommendations are at risk of inadequate treatment and increased rehospitalization risk. The COVID-19 disease has come to the fore with a pandemic and the atmosphere of fear and panic it creates. We aimed to investigate the effect of fear of the pandemic on DAMA. Methods: This study was conducted in the emergency department (ED) of a tertiary hospital in Turkey. The characteristics of all patients who were discharged against medical advice and their reasons over six months at the beginning of the pandemic were examined prospectively. Results: A total of 263 patients left the ED on various excuses against medical advice between February 6-August 31, 2020 (DAMA rate: 2.4‰). The most common complaint of patients discharged against medical advice was abdominal pain (27%). The top 3 most common causes of DAMA were the fear of being infected by COVID-19 (36.5%), the thought of being neglected (12.2%), and the month of Ramadan (11.4%). Conclusion: The pandemic is an important reason for DAMA. Patients leave the hospital against medical advice with an avoidance-avoidance conflict during the COVID-19 pandemic. Defining dirty and clean areas within the emergency services with sharp boundaries and informing patients may prevent DAMA due to the fear of being infected with COVID-19. Physicians do not ignore the risk of progression to worse clinical outcomes in patients who discontinue treatment due to the pandemic.

Prevalence, causes, and predictors of discharge against medical advice (DAMA) in an emergency setting: an updated systematic review and meta-analysis

Background: The prevalence of discharge against medical advice (DAMA) ranges from 1% to 2% in inpatient admissions and may reach up to 25.9% in some hospitals. The aim of this meta-analysis was to assess the prevalence, causes, and predictors of DAMA in the emergency departments. Methods: We conducted a systematic electronic database search for suitable studies from inception till 20th January 2020 in nine databases. Meta-analysis was used to pool the results. Results: Of the total 180 records screened, we included 14 studies. The overall prevalence rate of DAMA was 6.3% [95% confidence intervals (CI) = 3.41%-11.63%]. The most common cause of DAMA was not being content with the treatment or not agreeing with the diagnosis/treatment (19.93%; 95% CI = 11.02%-33.34%), followed by long waiting time (8.6%; 95% CI = 0.97%-47.45%) and financial problems (7.15%; 95% CI = 1.45-28.78). Regarding predictors, the reported significant unadjusted predictors were local emergency center [Odds ratios (OR) = 1.23%; 95% CI = 1.21-1.24%; p-value < 0.001], regional emergency center (OR = 0.83%; 95% CI = 0.82%- 0.84%; p-value < 0.001), and non-urgent triage (OR = 12.74%; 95% CI = 1.13%-143.97%; p-value = 0.040). In the same context, the significant adjusted predictors were ≤40 years (males) (OR = 3.94%; 95% CI = 1.31%-11.83%; p-value = 0.014), male gender (youth and middle-aged) (OR = 1.2%; 95% CI = 1.19%-1.21%; p-value < 0.001), and Male gender (aged group) (OR = 1.09%; 95% CI = 1.07%-1.11%; p-value < 0.001). Conclusion: DAMA prevalence in emergency departments is high. More attention should be devoted to those patients in relation to the possible DAMA causes for decreasing negative consequences resulted from committing DAMA.

Initiation of Buprenorphine/Naloxone on Rates of Discharge Against Medical Advice.

Objective: Evidence shows that patients with opioid use disorder (OUD) have an increased rate of discharge against medical advice (DAMA) as well as higher rates of hospital readmission. Therefore, the objective of this study was to determine if inpatient initiation of buprenorphine/naloxone in patients with OUD is associated with decreased rates of DAMA. Methods: This was a single center retrospective cohort study conducted at a level 1, academic medical center. The study included patients with OUD admitted to the Internal Medicine service from January through May of both 2018 and 2019 for an admitting diagnosis other than opioid withdrawal. The primary endpoint was rate of DAMA among OUD patients not initiated on opioid agonist therapy compared to those initiated on buprenorphine/naloxone. The secondary endpoint was the association between factors of the initiation process on rates of DAMA. Patients were excluded if they were discharged in less than 24 hours or received intermittent administration of buprenorphine/naloxone. Results: The rate of DAMA in OUD patients not initiated on buprenorphine/naloxone was 13.85% compared to 2.56% in those initiated on buprenorphine/naloxone (P = .048). Conclusion: In OUD patients initiated on buprenorphine/naloxone, the rate of DAMA was significantly lower than those who were not. This data supports the importance of optimizing the opportunity to initiate buprenorphine/naloxone in the acute care setting to minimize withdrawal symptoms therefore reducing the rate of DAMA. Ultimately increasing the ability to adequately treat the primary reason for admission and potentially decreasing readmission rates. Further studies are needed to evaluate this impact as this study is limited to a small sample size therefore lacking adequate power.

Analysis of Reasons for Orthopaedic Walkouts from the Emergency Department in a Private Tertiary Care Centre.

Introduction:A small proportion of patients presenting to the Emergency department (ED) of any hospital tend to take discharge against medical advice (DAMA) due to several patient related or hospital/service related reasons. Amongst these, orthopaedic patients are a special group due to their inability to mobilise independently due to injuries and have treatment needs which involve higher costs. The aim of the current study was to ascertain and analyse the reasons for orthopaedic walkouts at a tertiary care new private hospital.Materials and Methods:This retrospective telephonic structured interview-based study was carried out on all orthopaedic patients taking DAMA during a one-year period from July 2016 to June 2017. They were telephonically interviewed with a structured questionnaire. Hospital and ED records were analysed for demographic as well as temporal characteristics.Results:A total of 68 orthopaedic patients walked out of casualty against medical advice out of a total 775 (8.77%) orthopaedic patients presenting during the period as against 6.4% overall rate of DAMA for all specialties. The main reasons for DAMA were financial unaffordability of treatment (36.7%), preference for another orthopaedic surgeon (22%) and on advice of the patient’s General Practitioner (16.1%).Conclusion:Unaffordability of treatment is a significant cause for walkouts amongst orthopaedic patients. Private hospitals need to recognise and implement processes by which these patients can be treated at affordable costs and with coverage either by medical insurance or robust charity programs. Patient education and awareness are important to encourage them to have insurance coverage.

Rate and causes of discharge against medical advice from a university hospital emergency department in Iran: an ethical perspective.

Discharge against medical advice (DAMA) is a common problem in the health-care system. It imposes risks to both patients and medical staff and could be the subject of ethical deliberation. This cross-sectional study was conducted in 2017 on 400 patients who were discharged against medical advice from the emergency ward of Shariati Hospital, Tehran, Iran. Patients’ information was collected using clinical records and telephone calls. The collected data were analyzed using STATA software. DAMA rate was 12% in the emergency department of Shariati Hospital. Male gender was found to be a risk factor for DAMA (OR: 1.90; CI (95%): 1.44 - 2.52; P < 0.0001). In addition, younger patients were more likely to leave hospital against medical advice (p-value: 0.04). The more common reasons for DAMA were feeling better, long delay in diagnostic and therapeutic procedures and the hectic ambience of the emergency ward.Patients’ self-discharge is a multi-dimensional phenomenon that is affected by patients’ characteristics, medical conditions and hospital circumstances. It raises some ethical concerns, mainly due to a conflict between patients’ autonomy and beneficence. It is helpful for the medical staff to create an effective relationship with patients who are at higher risk of DAMA, in order to increase their compliance and prevent the consequences of leaving hospital against medical advice.

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

Background: In low-resource regions of the world, discharge against medical advice (DAMA) is one empiric contributory factor to poor in-hospital outcome that is not often mentioned. This study aims to investigate the determinants of DAMA from a rural neurosurgical service in a developing country.Methods: This was a prospective observational study of all patients who discharged against medical advice in our service between November 2018 and October 2019.Results: There were 88 patients, 67 (76.1%) males, in the study, (M:F = 3.2:1), representing 17.4% of our patient population in the study period. The peak incidence was in the 20–29 years age group which accounted for 37.5% of the cases. About 55% of the patients presented directly to our center; 31.8% were referred from other hospitals, while 3.4% came from traditional caregivers and 1.1% from religious homes. Head injury was the most common indication for presentation (76.1% of the cases). The duration of hospital stay ranged from 2 h to 14 days. Majority of the patients (87.5%) left the hospital within 8 h of presentation. The reason for DAMA was financial constraints in 50% of cases, inadequate health literacy in 20.5%, financial constraints and poor health literacy together in 12.5%, religious misgivings in 4.5%, and traditional belief in 2.3%. Neurotrauma was predictive of early DAMA (P = 0.001).Conclusion: The rate of DAMA was high in our study. Financial constraints with other socioeconomic limitations were the most common causes of DAMA in our environment.

Discharge against medical advice at the adult accident and emergency department in a tertiary hospital of a developing nation

Introduction. The goals of health care provision include that it be accessible, acceptable, affordable and adequate. Discharge against medical advice (DAMA) is a failure of proper health care provision as there is disagreement arising from dissatisfaction with provided health care. DAMA is common in our sub-region because of many reasons; these includes ignorance, financial constraint of the patient, beliefs in unorthodox care and patients feeling that they are well when their caregivers do not think so. Aim. The objectives of this study are to determine the incidence, method of documentation of DAMA in the case notes and patients reasons for DAMA in our tertiary health institution. The A&amp;E of any hospital in our environment attracts public criticism when there is dissatisfaction with services and DAMA when not handled well can lead to justifiable criticisms and/or litigations. Material and methods. This is a retrospective study. It was carried out at the adult accident and emergency department of Enugu state university of technology teaching hospital Enugu. Duration of the study was from January 2017 to December 2018. Results. A total of 8,152 patients were seen in the accident and emergency during this period. One hundred and seventy one (171) case notes were retrieved and reviewed for the study, DAMA rate of 2.1% was obtained. Fifty one folders (29.8%) did not have reason for the DAMA documented in them. The commonest reason for the DAMA was to seek traditional medical care with frequency of 17.5%. This was closely followed by financial constraint with 15.8%. Documentation for DAMA was done directly in the case notes. Conclusion. The incidence of DAMA from this study is similar to what is obtainable from other local studies, financial constraint on the patients and seeking alternative medical treatment were the commonest reasons for DAMA in our sub-region. Also, the documentation for the DAMA in this study was poorly done.

A Multicenter Case-Historical Control Study on Short-Term Outcomes of Tele-Intensive Care Unit.

Aims: This study aimed to determine the impact of tele-intensive care unit (ICU) on ICU mortality rate (%), and to quantify association of the tele-ICU intervention with ICU length of stay (LOS, days), readmission rates (%), reintubation rates (%), hospital-acquired pressure ulcer (HAPU) rate (%), and discharge against medical advice (DAMA) rate (%) in five hospitals. Methods: A multicenter case-historical control study was conducted on short-term outcomes of tele-ICU program in five private hospitals within Arabian Gulf Region. Critically ill adult patients admitted into ICU without tele-ICU were recorded as control group (pre-tele-ICU), whereas those admitted to tele-ICU were grouped as treatment group (post-tele-ICU). The observed outcomes for each patient were then recorded, namely mortality, reintubation, readmission, HAPU, DAMA, and length of stay (LOS). Results: Chi-square test showed that there are significant differences in mortality rate (χ2 = 6.596, p = 0.010), readmission rate (χ2 = 4.315, p = 0.038), HAPU rate (χ2 = 10.445, p = 0.001), and DAMA rate (χ2 = 4.485, p = 0.034) between pre-tele-ICU and post-tele-ICU, at 0.05 significance difference level. Independent t-test showed that there is significant different in LOS (t = 43.63, p < 0.001) between pre-tele-ICU (mean = 6.72 days) and post-tele-ICU (mean = 5.79 days). Odds ratio showed that critically ill adult patients who admitted to post-tele-ICU have 19% less reduction in mortality rate, 23% less reduction in readmission rate, 43% less reduction in HAPU rate, and 11% less reduction in DAMA rate as compared with those admitted to pre-tele-ICU.Conclusion: Tele-ICU as a step to improve the quality of health care project has shown statistically significant improvement in the adult ICU patients' outcomes, which lead to lesser mortality rate, readmission rate, HAPU rate, DAMA rate, and shorter LOS.

Discharge against medical advice (DAMA): Causes and predictors.

Background and aimDAMA is a result of patient dissatisfaction, which increases the rate of readmission, mortality, and complications. In this study, the causes and predictors of DAMA in Shahid Labbafinejad Hospital of Tehran were determined.MethodsThe descriptive and analytical study was conducted in 2016 from the information of 1,168 hospitalized patients in the period of 2015 and the first half of 2016. Patients’ information was collected using checklists and through clinical records, nursing unit reports, and telephone calls. The collected data were analyzed using SPSS-v18 software and by employing chi-square test and logistic regression modeling.ResultsThe DAMA rate was estimated at 3.27%. Among the causes of DAMA, the high rates were related to personal problems (39.04%) and going to other centers (34.93%), and the lowest level was related to dissatisfaction with the physician (3.08%). Age groups (19–37, OR=2.17), (38–56 years, OR=1.70), and (57–75, OR=1.62), gender (male, OR=1.47), locations (Tehran city, OR=0.61) and (Tehran Province, OR=0.63) were predictors of DAMA (p<0.05).ConclusionsThe importance of DAMA requires practical measures such as creating a suitable environment for patients, providing consulting services for youth, improving staff relations, providing assistance for patients in need, and removing accommodation problems of patients and their companions to reduce the DAMA.

Discharge Against Medical Advice in the United States, 2002-2011

ObjectiveTo describe the national frequency, prevalence, and trends of discharge against medical advice (DAMA) among inpatient hospitalizations in the United States and identify differences across patient- and hospital-level characteristics, overall and in clinically distinct diagnostic subgroups. Patients and MethodsWe conducted a retrospective, cross-sectional analysis of inpatient hospitalizations (≥18 years), discharged between January 1, 2002, and December 31, 2011, using the Nationwide Inpatient Sample. Descriptive statistics, multivariable logistic, and joinpoint regression were used for statistical analyses. ResultsBetween January 1, 2002, and December 31, 2011, more than 338,000 inpatient hospitalizations were discharged against medical advice each year, with a 1.9% average annual increase in prevalence over the decade (95% CI, 0.8%-3.0%). Temporal trends in DAMA varied by principal diagnosis. Among patients hospitalized for mental health- or substance abuse-related disorders, there was a −2.3% (95% CI, −3.8% to −0.8%) average annual decrease in the rate of DAMA. A statistically significant temporal rate change was not observed among hospitalizations for pregnancy-related disorders. Multivariable regression revealed several patient and hospital characteristics as predictors of DAMA, including lack of health insurance (odds ratio [OR], 3.78; 95% CI, 3.62-3.94), male sex (OR, 2.40; 95% CI, 2.36-2.45), and northeast region (OR, 1.91; 95% CI, 1.72-2.11). Other predictors included age, race/ethnicity, income, primary diagnosis, severity of illness, and hospital location/type and size. ConclusionRates for DAMA have increased in the United States, and key differences exist across patient and hospital characteristics. Early identification of vulnerable patients and preventive measures such as improved patient-provider communication may reduce DAMA.