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Cheok T, Berman M, Delaney-Bindahneem R, Jennings MP, Bray L, Jaarsma R, Poonnoose PM, Williams K, Jayasekera N. Closing the health gap in Central Australia: reduction in Indigenous Australian inpatient self-discharge rates following routine collaboration with Aboriginal Health Workers. BMC Health Serv Res 2023; 23:874. [PMID: 37592244 PMCID: PMC10436585 DOI: 10.1186/s12913-023-09921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 08/14/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Indigenous Australians experience significant socioeconomic disadvantage and healthcare disparity compared to non-Indigenous Australians. A retrospective cohort study to describe the association between rates of self-discharge in Indigenous orthopaedic patients and the introduction of routine Aboriginal Liaison Officers (ALO) within the Orthopaedic multi-disciplinary team (MDT) was performed. METHODS ALO were introduced within our routine Orthopaedic MDT on the 22nd of February 2021. Two patient cohorts were analysed, Group 1; patients admitted in the 9-months prior to inclusion of ALO, and Group 2; patients admitted within 9-months thereafter. The primary outcome of interest was the rate of self-discharge among Indigenous patients. Secondary outcomes of interest were the stage of treatment when patients self-discharged, recurrent self-discharge, risk factors for self-discharge and association between self-discharge and length of hospital stay. RESULTS Introduction of ALO within routine Orthopaedic MDT was associated with a significant 37% reduced risk of self-discharge among Indigenous patients (p = 0·009), and significantly fewer self-discharges before their definitive surgical and medical treatment (p = 0·0024), or before completion of postoperative intravenous antibiotic treatment (p = 0·030). There was no significant change in the risk of recurrent self-discharge (p = 0·557). Risk factors for self-discharge were younger age; pensioners or unemployed; residents of Alice Springs Town-Camps or of communities within 51 to 100 km of Alice Springs; and those diagnosed with lacerations of the upper limb, but without tendon injury, wound and soft tissue infections or osteomyelitis. In Group 2, the odds of self-discharge decreased with increased length of hospital stay (p = 0·040). CONCLUSIONS Routine inclusion of ALO within the Orthopaedic MDT reduced the risk of self-discharge in Indigenous patients. Those who self-discharged did so only after critical aspects of their care were met.
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Affiliation(s)
- Tim Cheok
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia.
- Department of Orthopaedic Surgery, Palmerston North Hospital, 50, Ruahine Street, Roslyn, Palmerston North, 4414, New Zealand.
| | - Morgan Berman
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Orthopaedic Surgery, Monash Medical Centre, 246, Clayton Road, Clayton, Victoria, 3168, Australia
| | - Richard Delaney-Bindahneem
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
| | - Matthew Phillip Jennings
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Plastics and Reconstructive Surgery, Bendigo Base Hospital, 100 Barnard Street, Bendigo, VIC, 3350, Australia
| | - Linda Bray
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Aboriginal Liaison Services, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
| | - Ruurd Jaarsma
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Orthopaedic Surgery, Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia, 5042, Australia
| | - Pradeep Mathew Poonnoose
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Orthopaedic Surgery, Christian Medical College Hospital, IDA Scudder Road, Vellore, Tamil Nadu, 632004, India
| | - Kanishka Williams
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
| | - Narlaka Jayasekera
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Orthopaedic Surgery, Wairau Hospital, Hospital Road, Blenheim, 7201, New Zealand
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Oyemolade TA, Adeleye AO, Ogunyileka OC, Arogundade FM, Olusola AJ, Aribisala OO. Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study. Surg Neurol Int 2020; 11:290. [PMID: 33033652 PMCID: PMC7538796 DOI: 10.25259/sni_559_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/26/2020] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
| | - Amos Olufemi Adeleye
- Department of Neurological Surgery, University College Hospital, University of Ibadan, Ibadan, Oyo state, Nigeria
| | | | | | - Ayodele J Olusola
- Department of Surgery, Federal Medical Center Owo, Owo, Ondo state, Nigeria
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Predictors of Discharge Against Medical Advice in a Tertiary Paediatric Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16081326. [PMID: 31013860 PMCID: PMC6518110 DOI: 10.3390/ijerph16081326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/01/2019] [Accepted: 04/08/2019] [Indexed: 12/03/2022]
Abstract
Background: Patients who discharge against medical advice (DAMA) from hospital carry a significant risk of readmission and have increased rates of morbidity and mortality. We sought to identify the demographic and clinical characteristics of DAMA patients from a tertiary paediatric hospital. Methods: Data were extracted retrospectively from electronic medical records for all inpatient admissions over a 5-year period. Demographic characteristics (age, sex, Aboriginality, socioeconomic status and remoteness of residence) and clinical characteristics (admitting hospital site, level of urgency on admission, diagnosis and previous DAMA) were extracted and logistic regression models were used to identify predictors of DAMA with 95% confidence intervals. Results: There were 246,359 admissions for 124,757 patients, of which 1871 (0.8%) admissions and 1730 patients (1.4%) DAMA. Predictors of DAMA in a given admission were hospital site (OR 4.8, CI 4.2–5.7, p < 0.01), a mental health/behavioural diagnosis (OR 3.3, CI 2.2–4.8, p < 0.01), Aboriginality (OR 1.6, CI 1.3–2.1, p < 0.01), emergency rather than elective admissions (OR 0.7ha, CI 0.6–0.8, p < 0.01), a gastrointestinal diagnosis (OR 1.5, CI 1.1–2.0, p = 0.04) and a history of previous DAMA (OR 2.0, CI 1.2–3.2, p = 0.05). Conclusions: There are clear predictors of DAMA in this tertiary hospital admission cohort and identification of these provides opportunities for intervention at a practice and policy level in order to prevent adverse outcomes.
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Mahajan RK, Gautam PL, Paul G, Mahajan R. Retrospective Evaluation of Patients Leaving against Medical Advice in aTertiary Care Teaching Hospital. Indian J Crit Care Med 2019; 23:139-142. [PMID: 31097891 PMCID: PMC6487621 DOI: 10.5005/jp-journals-10071-23137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Leaving against medical advice (LAMA) is a worldwide healthcare problem, occurring due to various contributing factors, seen more commonly indeveloping countries like ours. Aim To retrospectively study the prevalence of LAMA along with its affectingfactors. Methods We screened the hospital record of a tertiary care teaching hospital forone year, after obtaining approval from the institutional ethicalcommittee. Patient demography, disease characteristics and status at thetime of LAMA were noted and statistically analysed. Results During the study period, 4.95% patients took LAMA. The mean age was 47.2±21years (range newborn to 103 years) with 2:1 Male: Female ratio. Forty ninepercent of patients resided in rural areas and around 1/3rd were dependenton others for their living. The mean length of stay in hospital was 6.1±9.3days. Around 60% patients required mechanical ventilation and 51% patientshad been explained guarded prognosis. About 53% of patients taking LAMAwere admitted in medical wards, trauma being the most common diagnosis(17.2%). History of alcohol abuse and poisoning with suicidal intent wasseen in 11.47% and 3.9%, respectively. Conclusion The number of patients taking LAMA from our country is quite high. This necessitates formulation and implementation of strategies to reduce the prevalence of LAMA discharges like further investigations to look into the causes contributing to patients taking LAMA, attending to substance abuseissues, recognizing psychological factors and strengthening the socialsystems, encouraging insurance cover, helping patients’ treatment expensesthrough charity care and optimizing healthcare delivery and patient centredpolicies. Key messages LAMA is a global health issue precipitated by unemployment and alcohol abuse, commonly taken due to financial reasons. This necessitates a strong social system and national health insurance schemes to reduce the cost of treatment. How to cite this article Mahajan RK, Gautam PL, et al. Retrospective Evaluation of Patients Leaving against Medical Advice in a Tertiary Care Teaching Hospital. IndianJ Crit Care Med 2019;23(3):139-142.
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Affiliation(s)
- Rubina K Mahajan
- Department of Critical Care Medicine, Dayanand Medical College andHospital, Ludhiana, Punjab, India
| | - Parshotam L Gautam
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Gunchan Paul
- Department of Critical Care Medicine, Dayanand Medical College andHospital, Ludhiana, Punjab, India
| | - Ramit Mahajan
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Paul G, Gautam PL, Mahajan RK, Gautam N, Ragavaiah S. Patients Leaving Against Medical Advice-A National Survey. Indian J Crit Care Med 2019; 23:143-148. [PMID: 31097892 PMCID: PMC6487628 DOI: 10.5005/jp-journals-10071-23138] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Leaving against medical advice (LAMA) is a common health concern seen worldwide. It has variable incidence and reasons depending upon disease, geographical region and type of health care system. Materials and methods We approached anesthesiologists and intensivists for their opinion through ISA and ISCCM contact database using Monkey Survey of 22 questions covering geographical area, type of healthcare system, incidence, reasons, type of disease, expected outcome of LAMA patients etc. Results We received only 1154 responses. Only 584 answered all questions. Out of 1154, only 313 respondents were from government medical colleges or hospitals while remaining responses were from private and corporate sector. Most hospitals had >100 beds. ICUs were semi-closed and supervised by critical-care physicians. LAMA incidence was maximum from ICU (45%) followed by ward (32%) and emergency (25%). Most patients of LAMA had ICU stay for >1 week (60%). Eighty percent of the respondents opined that financial constraints are the most common reason of LAMA. Unsatisfactory care was rarely considered as a factor for LAMA. Approximately 40% patients had advanced malignancy or disease. Nearly 2/3rd strongly believed that insurance cover may reduce the LAMA rate. Conclusion Most patients get LAMA from the ICU after a stay of week. Financial constraints, terminal medical illness, malignancy and sepsis are major causes of LAMA. Remedial methods suggested to decrease the incidence include a good national health policy by the state; improved communication between the patient, caregivers and heathcare team; practice of palliative and end-of-life care support; and lastly, awareness among the people about advance directives. How to cite this article Paul G, Gautam PL et al. Patients Leaving Against Medical Advice-A National Survey. Indian J Crit Care Med 2019;23(3):143-148.
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Affiliation(s)
- Gunchan Paul
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Punjab, India
| | - P L Gautam
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Punjab, India
| | - Rubina Khullar Mahajan
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Punjab, India
| | - Nikhil Gautam
- Department of Psychiatry, Geetanjali Medical College, Rajasthan, India
| | - Suresh Ragavaiah
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Punjab, India
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Ramakrishnan N, Ranganathan L, Abraham BK, Rajagopalan S, Venkataraman R. What Happens to Patients Discharged Against Medical Advice? Indian J Crit Care Med 2018; 22:580-584. [PMID: 30186008 PMCID: PMC6108291 DOI: 10.4103/ijccm.ijccm_101_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Discharge against medical advice (DAMA) when requested by family members of patients in Indian Critical Care Units (CCUs) leads to loss of follow-up and unknown patient outcomes. Exclusion of these patients from research analysis and quality audits confounds these results. We hence explored the proportion of patients leaving DAMA, reasons, and their outcomes at 30 and 90 days. Methods This was a prospective study of CCU patients admitted from July 2013 to February 2014. All patients, who were DAMA during this period, were included in this study. Demographics, APACHE data, and outcomes were collected and compared to patients discharged regularly during the same period. Outcomes of DAMA patients at 30 and 90 days were gathered by telephone follow-up. Results Among the 663 patients admitted to the CCU, 15.1% (100 patients) were DAMA. The baseline APACHE score of the DAMA group was higher than the regular discharge group (29.5 ± 8.6 vs. 26.1 ± 10.3; P = 0.002). During the 30-day follow-up, 23% were alive, 56% dead, and 21% could not be contacted. At 90 days, mortality was 62% and survivors decreased to 14%. Common reasons for DAMA were - wanting to take the patient to another hospital (21%), reluctance for further treatments (12%), financial constraints (9%), and overall poor prognosis (7%). Conclusion A significant proportion of patients in the CCU get DAMA despite high severity of illness. Understanding the outcomes of these patients will help refine CCU quality audit reports and research study results.
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Affiliation(s)
| | - Lakshmi Ranganathan
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Babu K Abraham
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
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Gautam N, Sharma JP, Sharma A, Verma V, Arora P, Gautam PL. Retrospective Evaluation of Patients Who Leave against Medical Advice in a Tertiary Teaching Care Institute. Indian J Crit Care Med 2018; 22:591-596. [PMID: 30186010 PMCID: PMC6108296 DOI: 10.4103/ijccm.ijccm_375_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Context: Discharge against medical advice or leave against medical advice (DAMA or LAMA) is a global phenomenon. The magnitude of LAMA phenomenon has a wide geographical variation. LAMA reasons are an area of concern for all involved in health-care delivery system. Aims and Objectives: The study aimed to evaluate cases of LAMA retrospectively in a tertiary teaching care institute (1) to find the magnitude of LAMA cases (2) to evaluate demographic and patient characteristics of these cases. Subjects and Methods: We screened hospital record of a referral institute over 1 year after approval from IEC and ICMR, New Delhi. Patient demographics and disease characteristics were noted and statistically analyzed after compilation. Results: A total of 47,583 patients were admitted in the year 2015 through emergency and outpatient department. One thousand five hundred and fifty-six (3.3%) patients got DAMA. The mean age of patient excluding infants was 46.64 ± 20.55 years. There were 62.9% of males. Average hospital stay of these cases was 4.09 ± 4.39 days. Most of the patients (70%) belonged to medical specialties and had longer stay as compared to surgical specialties. Most of LAMA patients were suffering from infections, trauma, and malignancies. Most of the patients had LAMA from ward (62%) followed by Intensive Care Unit (ICU) (28.8%) and emergency (9.2%). In 592 (38%) of LAMA patients, the reason for leaving was not clear. The common cited reasons for LAMA were financial (27.6%) and poor prognosis (20.5%). Conclusions: About 3.3% of patients left hospital against medical advice in our retrospective analysis. Most of these cases did so from ward followed by ICU. Financial reasons and expected poor outcome played a significant role.
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Affiliation(s)
- Nikhil Gautam
- Department of Anaesthesia, HIMS, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - J P Sharma
- Department of Anaesthesiology, HIMS, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Anita Sharma
- Department of Medicine, HIMS, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Vivek Verma
- Department of Anaesthesia, HIMS, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Poonam Arora
- Department of Anaesthesiology, HIMS, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Parshotam Lal Gautam
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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