Discharge Against Medical Advice Research Articles

Patient-level and Physician-level Predictors of Discharge Against Medical Advice: A Multilevel Modeling Approach

Background: Discharge Against Medical Advice (DAMA) is a complex and multifaceted issue in healthcare, often challenging the continuity of care and affecting patient outcomes. Objectives: This study aimed to investigate the predictors of Discharge Against Medical Advice (DAMA) by simultaneously examining patient- and physician-level variables within a unified analytical framework. Methods: This cross-sectional study was conducted in 2023 at one of the largest private hospitals in northwest Iran. The study included all 16,071 patients admitted in 2022 and 137 attending physicians. A multilevel analysis model was employed to examine the influence of variables related to patients and physicians in predicting DAMA. Results: The study involved patients with a mean age of 45.28 ± 19.59 years, with 67.7% being women and 14.8% not having health insurance. Among the physicians studied, the mean age was 56.27 ± 12.29 years, with 67.2% being male and 70.1% being hospital shareholders. Patients with DAMA comprised 6.8% (n = 1094). The null model had a log-likelihood value of -3304.90. When patient-level predictors were added, the value increased to -3041.76, a statistically significant improvement (P < 0.001) based on the chi-square test. Subsequently, incorporating physician-level predictors further increased the log-likelihood value to -2996.16, and this increase was also statistically significant compared to the model with only patient-level predictors (P < 0.001). Physician-level factors, including specialization, sex, and experience, were associated with DAMA. Significant patient-level variables included age, type of insurance, and type of disease (P < 0.05). Conclusions: Utilizing multilevel modeling enables the assessment of the significance of both physician-level and patient-level factors. To avoid conflicting results, it is recommended to evaluate hospital performance based on DAMA by considering both levels.

Discharges Against Medical Advice in Pregnant Patients at a Canadian Tertiary Care Center: Does Lack of Access to Childcare Play a Role? [ID 2683591

INTRODUCTION: Discharges against medical advice (AMA) during pregnancy have been associated with poor maternal and fetal outcomes. Moreover, one of the documented reasons why female patients might leave the hospital AMA is lack of access to childcare. In recent years, lack of access to childcare has been identified as a potential risk factor for discharge AMA and maternal mortality at a tertiary care center in Edmonton, Alberta, Canada. The goal of this chart review project is to study the characteristics of pregnant women who leave AMA from this center, and to determine what proportion of these discharges is due to difficulties securing childcare. METHODS: Ethics approval was obtained through the University of Alberta’s Health Research Ethics Board. All patients who were discharged AMA from the triage and antepartum units at the study site between May 28, 2021, and May 27, 2022, were identified. Patients were included in the chart review as long as they remained undelivered at the time of discharge. Reasons for admission and discharge AMA were extracted from each patient’s chart whenever available. Patients' age, gravidity, parity, and gestational age at the time of discharge were also collected. RESULTS: During the study period, approximately 9.3% of recorded discharges from the triage and antepartum units were for patients who left AMA. In total, we included 89 individual patient visits that ended with a discharge AMA. For these patients, the most frequent reason for admission was threatened preterm labor (including short cervix). Although the reason motivating discharges AMA was not documented in the majority of charts reviewed (49/89), lack of access to childcare was the most frequently documented reason provided by patients for leaving AMA (15/40). CONCLUSION: Improving access to childcare for pregnant patients who are admitted to the study site might help to decrease discharges AMA, and therefore help reduce perinatal complications.

Discharge against medical advice (DAMA) in patients with long bone fractures at YEC: Epidemiological, clinical, evolutionary and medico-legal aspects

Discharge against medical advice (DAMA) is a term used in healthcare establishments when a patient leaves a hospital against the advice of their doctor.The aim of this study was to describe the epidemiological, clinical, evolutionary and medico-legal aspects of patients with long bone fractures discharged against medical advice at the Yaoundé Emergency Centre (YEC). This was a retrospective descriptive and analytical study conducted between January 2016 and December 2022 at the YEC. All patients aged 18 years or older with at least one long bone fracture and discharged against medical advice from our study site during the study period were included. Patients were then contacted to collect the reasons for DAMA, the therapeutic itinerary, the type of treatment undertaken, direct costs, and evolutionary data. Statistical analyses were performed using SPSS version 26 software. Six hundred and forty-seven patients were enrolled during the study period, representing a prevalence of DAMA of 45.7%. The mean age of the patients was 35.47 (± 13.86) years, and 475 (73.4%) were men. Socioeconomic status was low in 72.4% of cases. All religions and ethnic groups were represented. Road traffic accidents (RTA) were the cause of trauma in 83% of cases. The main site of injury was the tibia, in 253 (39.1%) cases. Open fractures accounted for 38.8% of cases. The median time to discharge against medical advice was 16 [6-26], , , hours, with 73.4% of DAMA within 24 hours. Lack of financial resources, the choice of traditional treatment and the preference for another hospital were the three main reasons. In our setting, 45.7% of patients with long bone fractures initially admitted to hospital were discharged against medical advice. The type of injury was varied, with 38.8% open fractures, some of which were complex.

Contributors to Hospitalized Infective Endocarditis Outcomes Among Patients With Substance Use.

Background: Patients with substance use (SU) diagnosed with infective endocarditis (IE) have high rates of discharge against medical advice (DAMA) and 30-day readmission. Objective: Evaluate contributors associated with DAMA and 30-day readmission among patients with SU and IE. Methods: This retrospective chart review included patients >18 years, admitted to one hospital in the Northeastern, United States for SU and IE from January 2018 to December 2020. Patient demographic and clinical characteristics and their association with DAMA and 30-day readmission were summarized using descriptive statistics and Logistic Regression. Results: Of the 144 patients, 60.4% used more than one substance, 38.2% experienced DAMA, and 61.1% were readmitted within 30 days. Age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.92-0.98), Length of stay (LOS) (OR, 0.95; 95% CI, 0.93-0.98), Medicaid (OR, 2.98; 95% CI, 1.45-6.16), Medicare (OR, 0.29; 95% CI, 0.10-0.81), opioid usage (OR, 2.29; 95% CI, 1.01-5.16), and stimulant usage (OR, 2.89; 95% CI, 1.43-5.84) were all significantly associated with DAMA but not with 30-day readmission. Conclusions: Additional investigations of factors associated with DAMA and 30-day readmission are needed to help improve practices and reduce negative outcomes. Implications for Nursing: Multiple factors can affect patient adherence to treatment in this high-risk population. Nursing directly impacts the identification and addressing of unique SU IE patient needs to optimize treatment goals.

Factors associated with pediatric trauma patients leaving against medical advice

BackgroundDischarge against medical advice (AMA) leads to worse patient outcomes, increased readmission rates, and higher cost. However, AMA discharge has received limited study, particularly in pediatric trauma patients. Our objective was to explore the risk factors associated with leaving AMA in pediatric trauma patients. MethodsWe performed a retrospective analysis on pediatric trauma patients from 2017 to 2019 using the National Trauma Data Bank. We examined patient characteristics including age (<18 years), race, sex, Glasgow Coma Scale, trauma type, primary payment methods, and Abbreviated Injury Scale. Multiple Logistic Regression models were utilized to determine characteristics associated with leaving AMA. ResultsOf the 224,196 pediatric patients included in the study, 238 left AMA (0.1%). Our study showed black pediatric trauma patients were more likely to leave AMA compared to nonblack patients (OR 1.987, 95% CI 1.501 to 2.631). Patients with self-pay coverage were more likely to leave AMA than those with other insurance coverages (OR 1.759, 95% CI 1.183 to 2.614). Blunt trauma patients were more likely to leave AMA than those with penetrating trauma (OR 1.683, 95% CI 1.216 to 2.330). Every one-year increase in age led to 15% increase in odds of AMA discharge (OR 1.150, 95% CI 1.115 to 1.186). Pediatric patients with severe abdominal injuries were less likely to leave AMA compared to those with mild abdominal injuries (OR 0.271, 95% CI 0.111 to 0.657). Patients with severe lower extremity injury were less likely to leave AMA compared to those with mild lower extremity injuries (OR 0.258, 95% CI 0.127 to 0.522). ConclusionRace, insurance, injury type, and age play a role in AMA discharge of pediatric trauma patients. Black pediatric trauma patients have ∼ double the AMA discharge rate of nonblack patients. AMA discharge remains relevant, and addressing racial and socioeconomic factors provide opportunities for future interventions in pediatric trauma care.Level of Evidence: III, retrospective study.

A111 CHARACTERISTICS OF HOSPITALIZED PATIENTS WITH GASTROINTESTINAL DISEASE WHO LEAVE AGAINST MEDICAL ADVICE

Abstract Background Hospitalized inpatients who leave against medical advice (AMA) may have incomplete care, resulting in readmission and increased healthcare costs. Limited evidence exists in patients diagnosed with a primary gastrointestinal (GI) disease who leave AMA. Identifying patients with GI diagnoses who leave AMA may inform risk stratification to determine which patients are at risk of unplanned discharge. Aims Identify characteristics in patients diagnosed with GI diseases who leave AMA. Methods A retrospective evaluation was conducted using the National Inpatient Sample (NIS) from 2016 to 2020. The NIS provides national-level estimates of cost, quality, and outcomes from hospitalizations in the United States. We used International Classification of Diseases, Tenth Revision diagnostic coding to identify patients admitted with a primary GI problem. The proportion of patients who left AMA for each diagnosis was determined (Figure 1). A multivariable logistic regression was performed to determine factors associated with an AMA discharge, adjusting for age, sex, elective or weekend admission, primary payment method, race, hospital setting, geography, income, Elixhauser comorbidity index, alcohol and/or drug abuse and depression status. Results Between 2016 and 2020, 1.61% of patients with a GI primary problem left the hospital AMA. Characteristics associated with leaving AMA included: older age, female sex, non-white race, rural hospital admission, higher income and having comorbid conditions (Table 1). Patients with a history of alcohol abuse were more likely to leave AMA, while patients with a history of drug abuse were less likely to leave AMA. Conclusions Approximately 1 in 60 patients admitted with a primary GI problem leave hospital AMA and we identify both structural and patient-level factors associated with unplanned discharge. Table 1: Factors Associated With AMA Discharge For GI-related Diagnoses Funding Agencies None

Discharge against medical advice in pediatric wards at tertiary center in Addis Ababa, Ethiopia: A retrospective cross-sectional survey.

Background: Children are at high risk of problems related to discharge against medical advice (DAMA). Because they are not part of the decisions their best interests may be violated. This study is aimed to determine the prevalence, clinical outcomes, and factors associated with discharge against medical advice. &#x0D; Methods: We cross-sectionally described 123 admissions in which caretakers decided to discharge against medical advice. A mixed data collection method from the patient's charts and telephone interviews was employed. A pretested semi-structured questionnaire tool was used. The data was manually cleaned and analyzed using SPSS software version 25, USA. The frequency and percentage of categorical data were calculated, as well as the mean, median, SD, and IQR of the continuous variable. A multivariate regression analysis was performed, with an adjusted odds ratio of 95% CI and a statistical significance of 0.05. &#x0D; Results: Hospital prevalence of DAMA was 1.42%. The median age was 11(±59) months—eighty-one percent of the caretakers signed before leaving the hospital. The median hospitalization was 7 days (IQR=13 days). The majority of the caretakers were discharged during working hours (71%). Discharge was registered in all seasons: winter (31%), spring (28%), summer (23%), and autumn (18 %). Hemato-oncologic conditions, infectious, and neonatal problems were common. Most of the cases were reported from pediatric emergency and neonatology wards. Patients’ poor clinical response and the caretaker's financial constraints were the main reasons for signing DAMA. Death was significant when the DAMA occurred in fast-improving cases and infants; (AOR=6.909, 95% CI-2.191-21.782), and AOR=1.3, 95% CI -0.48-3.3) respectively. &#x0D; Conclusion: DAMA in the Pediatric wards of Tikur-Anbessa Specialized Hospital was similar to the reported data elsewhere. However, death was very high which could be due to insufficient fol-low-up after DAMA.

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.

Race and Ethnicity and Emergency Department Discharge Against Medical Advice

Although discharges against medical advice (DAMA) are associated with greater morbidity and mortality, little is known about current racial and ethnic disparities in DAMA from the emergency department (ED) nationally. To characterize current patterns of racial and ethnic disparities in rates of ED DAMA. This cross-sectional study used data from the Nationwide Emergency Department Sample on all hospital ED visits made between January to December 2019 in the US. The main outcome was odds of ED DAMA for Black and Hispanic patients compared with White patients nationally and in analysis adjusted for sociodemographic factors. Secondary analysis examined hospital-level variation in DAMA rates for Black, Hispanic, and White patients. The study sample included 33 147 251 visits to 989 hospitals, representing the estimated 143 million ED visits in 2019. The median age of patients was 40 years (IQR, 22-61 years). Overall, 1.6% of ED visits resulted in DAMA. DAMA rates were higher for Black patients (2.1%) compared with Hispanic (1.6%) and White (1.4%) patients, males (1.7%) compared with females (1.5%), those with no insurance (2.8%), those with lower income (<$27 999; 1.9%), and those aged 35 to 49 years (2.2%). DAMA visits were highest at metropolitan teaching hospitals (1.8%) and hospitals that served greater proportions of racial and ethnic minoritized patients (serving ≥57.9%; 2.1%). Odds of DAMA were greater for Black patients (odds ratio [OR], 1.45; 95% CI, 1.31-1.57) and Hispanic patients (OR, 1.16; 95% CI, 1.04-1.29) compared with White patients. After adjusting for sociodemographic characteristics (age, sex, income, and insurance status), the adjusted OR (AOR) for DAMA was lower for Black patients compared with the unadjusted OR (AOR, 1.18; 95% CI, 1.09-1.28) and there was no difference in odds for Hispanic patients (AOR, 1.03; 95% CI, 0.92-1.15) compared with White patients. After additional adjustment for hospital random intercepts, DAMA disparities reversed, with Black and Hispanic patients having lower odds of DAMA compared with White patients (Black patients: AOR, 0.94 [95% CI, 0.90-0.98]; Hispanic patients: AOR, 0.68 [95% CI, 0.63-0.72]). The intraclass correlation in this secondary analysis model was 0.118 (95% CI, 0.104-0.133). This national cross-sectional study found that Black and Hispanic patients had greater odds of ED DAMA than White patients in unadjusted analysis. Disparities were reversed after patient-level and hospital-level risk adjustment, and greater between-hospital than within-hospital variation in DAMA was observed, suggesting that Black and Hispanic patients are more likely to receive care in hospitals with higher DAMA rates. Structural racism may contribute to ED DAMA disparities via unequal allocation of health care resources in hospitals that disproportionately treat racial and ethnic minoritized groups. Monitoring variation in DAMA by race and ethnicity and hospital suggests an opportunity to improve equitable access to health care.

Inequities among patient placement in emergency department hallway treatment spaces

BackgroundLimited capacity in the emergency department (ED) secondary to boarding and crowding has resulted in patients receiving care in hallways to provide access to timely evaluation and treatment. However, there are concerns raised by physicians and patients regarding a decrease in patient centered care and quality resulting from hallway care. We sought to explore social risk factors associated with hallway placement and operational outcomes. Study design/methodsObservational study between July 2017 and February 2020. Primary outcome was the adjusted odds ratio (aOR) of patient placement in a hallway treatment space adjusting for patient demographics and ED operational factors. Secondary outcomes included left without being seen (LWBS), discharge against medical advice (AMA), elopement, 72-h ED revisit, 10-day ED revisit and escalation of care during boarding. ResultsAmong 361,377 ED visits, 100,079 (27.7%) visits were assigned to hallway beds. Patient insurance coverage (Medicaid (aOR 1.04, 95% CI 1.01,1.06) and Self-pay/Other (1.08, (1.03, 1.13))) with comparison to private insurance, and patient sex (Male (1.08, (1.06, 1.10))) with comparison to female sex are associated with higher odds of hallway placement but patient age, race, and language were not. These associations are adjusted for ED census, triage assigned severity, ED staffing, boarding level, and time effect, with social factors mutually adjusted. Additionally adjusting for patients' social factors, patients placed in hallways had higher odds of elopement (1.23 (1.07,1.41)), 72-h ED revisit (1.33 (1.08, 1.64)) and 10-day ED revisit (1.23 (1.11, 1.36)) comparing with patients placed in regular ED rooms. We did not find statistically significant associations between hallway placement and LWBS, discharge AMA, or escalation of care. ConclusionWhile hallway usage is ad hoc, we find consistent differences in care delivery with those insured by Medicaid and self-pay or male sex being placed in hallway beds. Further work should examine how new front-end processes such as provider in triage or split flow may be associated with inequities in patient access to emergency and hospital care.

Hospital and emergency department discharge against medical advice in Western Australian Aboriginal children aged 0-4 years from 2002 to 2018: A cohort study.

Discharge against medical advice (DAMA) is a priority issue for the health system. Little is known about the factors associated with DAMA for Aboriginal and/or Torres Strait Islander (Aboriginal) children in Australia. Investigate the associations between DAMA for hospital admissions and emergency department (ED) presentations and: (i) child, family and episode of service characteristics and (ii) 30-day readmission/ re-presentation. We conducted a cohort study of Aboriginal children born in Western Australia (2002-2013) who had ≥1 hospital admissions (n = 16,931) or ED presentations (n = 26,546) within the first 5 years of life. The outcome of interest was hospital and ED DAMA and adjusted odds ratio were derived using multilevel mixed-effects logistic regression. In the Hospital Cohort, there were 43,149 hospitalisations for 16,931 children, with 684 hospitalisations (1.6%) recorded as DAMA. In the ED Cohort, there were 232,082 ED presentations in 26,546 children, with 10,918 ED presentations (4.7%) recorded as DAMA. DAMA occurring in hospitals between 2014 and 2018, the adjusted odds decreased by 75% compared to the period between 2002 and 2005. The adjusted odds of ED DAMA increased by 46% over the same period. Hospital admissions in regional and remote hospitals were almost seven times the adjusted odds of DAMA compared with hospital admissions in Perth metropolitan hospitals. The adjusted odds of ED DAMA decreased by 12% for ED presentations in regional and remote hospitals compared to those in Perth metropolitan hospitals. There was no evidence of hospital DAMA being associated with hospital readmission within 30 days and limited evidence of ED DAMA being associated with re-presenting to an ED within 30 days. The study identified several important determinants of DAMA, including admission status, triage status, location and calendar year. These findings could inform targeted measures to decrease DAMA, particularly in regional and remote communities.

Discharges against medical advice: time to take another look. A retrospective review of discharges against medical advice focused on prevention

ABSTRACT Background Discharges against medical advice (DAMA) increase the risk of death. Methods We retrieved DAMA from five hospitals within a large health system and reviewed 10% of DAMA from the academic site between 2016 and 2021. Results DAMA increased at the onset of the pandemic. Patients who discharged AMA multiple times accounted for a third of all DAMA. Detailed review was completed for 278 patients who discharged AMA from the academic site. In this sample, women comprised 52% of those who discharged AMA multiple times. Relative to the proportion of all discharges from the academic site during the study period, Black patients were overrepresented among DAMA (21% vs. 34%, p < .05). Patients with multiple AMA discharges were younger, more likely to be unmarried, or have substance use disorders (SUD) than those who discharged AMA once. The most common reason for requesting premature discharge noted in n = 77, 28% of instances was related to patient obligations outside the hospital. Hospital policies and procedures contributed in n = 29, 10% of instances. Reasons for requesting premature discharge and documentation of key safety processes were similar by gender and race however the sample may be underpowered to detect differences. Capacity was evaluated in 109 (39%). Among those who consumed alcohol (n = 81 (29%)) or had SUDs (n = 112 (40%)), information on the amount or timing of last use was missing in n = 39 (48%) and n = 74 (66%), respectively. Critical tools to manage illness were provided in 45 (16%) of DAMA reviewed. Conclusions Drivers of AMA discharge may differ by AMA discharge frequency. Recognition of the common reasons for requesting premature discharge may help destigmatize AMA discharges and also identifies early assessments by social work colleagues as an important prevention strategy. Opportunities also exist in anticipating and preventing withdrawal symptoms and in revising hospital practices that contribute to DAMA.

Discharge against medical advice in the neonatal unit of Rivers State University Teaching Hospital, Nigeria: a two-year prospective study

Background: Discharge against medical advice (DAMA) is a silent contributor to neonatal morbidity and mortality in Nigeria. Parents' autonomous decision to discontinue medical care of their babies admitted remains an ethical contention that is frustrating for pediatricians and portends poor neonatal outcomes. DAMA remains a challenge arising from an interplay of parental and hospital-related factors. Hence, epidemiologic data are needed, where none previously exists. Aim of the study was to determine the prevalence, neonate and family sociodemographic characteristics, morbidity pattern and reasons for DAMA among neonates admitted to the Rivers State University Teaching Hospital. Methods: A prospective observational study was conducted among neonates admitted from April 2021 to March 2023. Results: Of 1830 neonatal admissions, 87 were discharged against medical advice giving a DAMA prevalence of 4.8%, of which 48 (55.8%) were females. Most, 66 (75.9%) were born at term, 51 (58.6%) had normal birth weight, 38 (43.7%) admitted at &lt;2 hours of life and (41.4%) were above 2nd birth order. Forty-seven (54%) of mothers, 41 (47.1%) of fathers had tertiary education and 61 (70.1%) were of low/middle socioeconomic class. Neonatal sepsis (61.2%) and neonatal jaundice (31.8%) were the commonest morbidities. Most, 65 (74.7%) of DAMA cases occurred in the 1st week of life and the father 63 (73.3%) was the main requestor of DAMA. The commonest reason for DAMA was financial constraints 50 (57.5%). Conclusions: The prevalence of DAMA was 4.8%. Neonatal sepsis and neonatal jaundice were the commonest morbidity with financial constraints being the main reason for DAMA. The father was the requestor for DAMA in the majority of the cases.

Incidence of Discharge Against Medical Advice in Queensland Hospital Emergency Departments Among Indigenous Patients from 2016 to 2021.

The incidence of discharge against medical advice (DAMA) in emergency departments (EDs) among Indigenous people is a growing concern in Australia. This study aimed to determine the incidence of ED DAMA in public hospitals in Queensland (QLD) from 2016 to 2021 and investigate the disparities in ED DAMA between Indigenous and non-Indigenous patients. The study also assessed the impact of the COVID-19 pandemic on the incidence of ED DAMA. A descriptive epidemiological study was conducted using aggregated data from QLD public hospital EDs. The data was retrieved from Clinical Excellence QLD, Healthcare Improvement Unit, in the QLD Health Open Data Portal for the period 1 January 2016 to 31 December 2021. Incidence rates and unadjusted odds ratios were calculated and compared using the chi-square test to identify differences between Indigenous and non-Indigenous patients. The annual incidence of DAMA in EDs was 7.7% among Indigenous patients, compared to 4.8% among non-Indigenous patients, with the highest rate (8.9%) reported in 2021 among Indigenous patients. The incidence of ED DAMA was higher for Indigenous patients in major cities (20.0%) than in very remote areas (7.4%). Patients in triage categories 4 (10.0%) and 3 (7.3%) accounted for the vast majority of ED DAMA events among Indigenous patients. The acute group A hospitals had the highest incidence of ED DAMA (10.9% for Indigenous patients and 6.5% for non-Indigenous patients). The COVID-19 pandemic had no impact on the incidence of ED DAMA. Indigenous patients experience a disparity in ED DAMA incidence. Addressing this issue requires collaborative efforts from healthcare providers, policymakers, and community organizations.

Gender Specific Difference and Clinical Spectrum of COVID-19 Patients Admitted in Tertiary Care Hospital of Northern India

Objectives: In a tertiary care hospital in Northern India, we examined the demographic, biochemical, and clinical risk factors related to gender differences in COVID-19 patients who were hospitalized. Materials and Methods: The study was carried out in a hospital with tertiary care. In this retrospective comparative observational study the data was collected from march 2020 to end of COVID pandemic. Analyses were done on the n = 1068 individuals who were hospitalized during the study period. Results: There were 1068 individuals evaluated in the trial, with a male-to-female ratio of 2.3:1. Males and females had similar mean ages (55.84 vs. 55.44 years). Difference was found to be statistically significant in asthmatic boys and females (P = 0.01). In our study, a novel severity score (NSS) was utilized to forecast inpatient mortality in COVID-19 patients. NSS scores were higher for men (2.95) than for women (2.65), with P = 006. Under the categories “Expired,” “discharged against medical advice (DAMA),” and “Discharged,” all the criteria that have been previously analyzed were compared. Based on the number of comorbidities, there was a clear, significant difference between patients who were discharged, expired, and under DAMA, with a P = 0.001. Majority of patients with comorbidities that most frequently impacted the cardiovascular and respiratory outcomes. Conclusion: Studies conducted globally found that men experienced a higher rate of mortality. Our study also indicates that when the number of comorbidities rises, the death rate rises. Therefore, individuals with a larger number of comorbidities, such as hypertension, diabetes, coronary artery disease, and peripheral vascular disease, should exercise particular vigilance.

Comparison of PRISM IV and PIM III prognostic scores as mortality indicators among paediatric intensive care unit patients &amp;nbsp;

Introduction: Identifying prognosis of patients admitted in the paediatric intensive care unit (PICU) is of paramount importance to better allocate medical resources, reduce patient-doctor conflict and for overall better patient care. Many scoring systems have been formulated to accomplish this task including paediatric risk of mortality (PRISM) IV and paediatric index of mortality (PIM) III.Objectives: To compare PRISM IV and PIM III as prognostic scoring tools in the PICU of a tertiary healthcare centreMethod: This prospective observational study was conducted in the PICU, Dhiraj hospital, SBKS MI&amp;RC, Gujarat, India, from March 2021 to September 2022. It included all patients from age 1 month to 18 years who were admitted in the PICU for &gt;24 hours and gave consent for this study. They were thoroughly examined and investigations were done within the first hour of admission as per standard guidelines and their PRISM IV and PIM III scores were calculated and data were analysed.Results: A total of 74 patients was enrolled in this study. Whilst 43 (58.1%) patients were discharged, 18 (24.3%)] were discharged against medical advice(DAMA) moribund, 4 were DAMA (non-moribund) and 9 (12.2%) died. Receiver Operating Characteristic (ROC) curves were made for both PRISM IV and PIM III scores. Discriminatory powers of PIM III (AUC 0.725; 95% CI: 0.609 to 0.823) and PRISM IV (AUC 0.8; 95% CI: 0.691 to 0.884) were acceptable. Whilst PRISM IV was the better predictor of mortality at cut off point of &gt;4 with area under curve of 0.8 for correctly predicting mortality, this difference was not statistically significant (p value=0.354). Multivariate logistic regression analysis showed that the duration of stay(days) and PRISM IV value &gt;4 were significant independent risk factors of mortality after adjusting for confounding factors.Conclusions: Both PRISM IV and PIM III were good prognostic scoring tools in the PICU of the tertiary healthcare centre. Multivariate logistic regression analysis showed that the duration of stay(days) and PRISM IV value &gt;4 were significant independent risk factors of mortality after adjusting for confounding factors.

Discharge against medical advice in pediatrics: A review and recommendation of a five-component approach

Patients who are discharge against medical advice (DAMA) present significant challenges on clinical, ethical, financial, and legal levels. Despite its multilevel impact, the factors explaining and predicting DAMA in different regions of the world remain underevaluated, especially in pediatrics. This article aims to provide a scope of review of the phenomenon of DAMA in pediatrics and guide healthcare providers on how to deal with common scenarios of DAMA requests through a five-component approach. A literature search was performed using PubMed with the following keywords: “leave against medical” OR “discharge against medical” AND “pediatrics” OR “child*” without a time limit. This search yielded 30 articles, and two more were added as secondary sources. DAMA is associated with several health adverse outcomes such as a higher prevalence of morbidity, complications, and even mortality. Financial burden associated with medical care seems to be a major factor driving the parental decision as well as difficulties in arranging care for other siblings, the perception that the child’s condition has improved sufficiently to be discharged, parental preferences for traditional or alternative medicine, and dissatisfaction with treatments. Dealing with DAMA requests requires skilled communication paired with a good understanding and the ability to translate the concepts of informed consent and shared-decision making into clinical practice.

Who Left the Hospital Against Medical Advice During the Early COVID-19 Pandemic?

Patients leaving against medical advice (AMA) presents a challenge to hospitals as they try to manage costs and improve patient outcomes in an ever-increasing competitive market. Investigating AMA discharges that occurred during the early COVID-19 pandemic presents a unique opportunity to better understand this phenomenon and be better prepared for the future. This retrospective analysis of 34 379 patients from a nationwide private healthcare system across 20 states analyzed patients during the early stages of the pandemic who chose to leave against medical advice (AMA) after being admitted with COVID-19 infection and identified several patient characteristics associated with subsequent AMA discharge. These patient characteristics included being younger than 50; identifying as male sex; having non-white ethnicity, including both Black and Hispanic; having either Medicaid or no health insurance; and the presence of specific medical comorbidities. The identified medical comorbidities were substance abuse, renal failure, deep vein thrombosis, hypertension with heart failure, hypertension with chronic kidney disease stage 5, rheumatoid arthritis or collagen vascular diseases, alcohol abuse, chronic pulmonary disease, hypertensive encephalopathy, and solid tumor. This study confirms some of the findings in previous studies looking at AMA discharges and has some interesting findings as it relates specifically to the COVID-19-infected patient population. An additional understanding of the factors leading to AMA discharges can help providers and administrators prevent suboptimal discharge outcomes in the future.

Clinical characteristics, in-hospital management, and outcomes of patients with in-hospital vs. community-onset ischaemic stroke: a hospital-based cohort study

Lack of high-quality national-level data on in-hospital ischaemic stroke hinders the development of tailored strategies for this subgroup's identification, treatment, and management. We analyzed and compared clinical characteristics, in-hospital management measures, and outcomes, including death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACEs), disability at discharge, and in-hospital complications between in-hospital and community-onset ischaemic stroke enrolled in the Chinese Stroke Center Association registry from August 2015 to December2022. The cohort comprised 14,948 in-hospital and 1,366,898 community-onset ischaemic stroke patients. In-hospital ischaemic stroke exhibited greater stroke severity, higher prevalence of comorbidities, more pre-admission medications, and had suboptimal management measures, for example, the onset-to-needle time within 4.5h (83.3% vs. 93.1%; difference,-9.8% [-11.4% to-8.3%]), and antithrombotics at discharge (78.6% vs. 90.0%; difference,-11.4% [95% CI,-12.1% to-10.7%]). After adjusting for covariates, in-hospital ischaemic stroke remains associated with higher risks of unfavorable outcomes, including in-hospital death/DAMA (13.9% vs. 8.6%; adjusted risk difference [aRD], 2.2% [95% CI, 1.8%-2.7%]; adjusted odds ratio [aOR], 1.35 [95% CI, 1.25-1.45]), MACE (12.6% vs. 6.5%; aRD, 4.1% [95% CI, 3.5%-4.7%]; aOR, 1.68 [95% CI, 1.52-1.85]), and complications (23.7% vs. 12.1%; aRD, 6.5% [95% CI, 5.1%-7.9%]; aOR, 1.72 [95% CI, 1.64-1.80]), except for disability at discharge (41.1% vs. 33.1%; aRD, 0.4% [95% CI,-1.7% to 2.5%]; aOR, 0.99 [95% CI, 0.88-1.11]). In-hospital ischaemic stroke demonstrated more severe strokes, worse vascular risk profiles, suboptimal management measures, and worse outcomes compared to community-onset ischaemic stroke. This emphasizes the urgent need for improved hospital systems of care and targeted quality improvement initiatives for better outcomes in in-hospital ischaemic stroke. National Key R&D Programme of China and Beijing Hospitals Authority.

Discharge Against Medical Advice After Hospitalization for Sepsis: Predictors, 30-Day Readmissions, and Outcomes

BackgroundSepsis is a leading cause of death worldwide. However, little has been known concerning the status of discharge against medical advice (DAMA) in sepsis patients. ObjectiveTo identify factors associated with DAMA, evaluate the association of DAMA with 30-day unplanned readmission and readmitted outcomes after sepsis hospitalization. MethodsUsing the National Readmission Database, we identified sepsis patients who discharged routinely or DAMA in 2017. Multivariable models were used to identify factors related to DAMA, evaluate the association between DAMA and readmission, and elucidate the relationship between DAMA and outcomes in patients readmitted within 30 days. ResultsAmong 1,012,650 sepsis cases, patients with DAMA accounted for 3.88% (n = 39,308). The unplanned 30-day readmission rates in patients who discharged home and DAMA were 13.08% and 27.21%, respectively. Predictors of DAMA in sepsis included Medicaid, diabetes, smoking, drug abuse, alcohol abuse, and psychoses. DAMA was statistically significantly associated with 30-day (odds ratio [OR] 2.18, 95% confidence interval [CI] 2.09–2.28), 60-day (OR 1.98, 95% CI 1.90–2.06), and 90-day (OR 1.88, 95% CI 1.81–1.96) readmission. DAMA is also associated with higher mortality in patients readmitted within 30 days (OR 1.38, 95% CI 1.17–1.63), whereas there were no statistically significant differences in length of stay and costs between patients who discharged home or DAMA. ConclusionsDAMA occurs in nearly 3.88% of sepsis patients and is linked to higher readmission and mortality. Those at high risk of DAMA should be early identified to motivate intervention to avoid premature discharges and associated adverse outcomes.