Discharge against medical advice (DAMA): Causes and predictors

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

BACKGROUND

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.

AIM

To determine the prevalence and reasons for DAMA in orthopedic departments of eight tertiary hospitals in Nigeria.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Analysis of factors affecting discharge with the personal consent of hospitalized patients: A cross-sectional study

Background and Aims

Discharge by personal satisfaction is a condition in which the patient leaves the hospital before completing the care period against medical advice. Thus, this study aims to identify and analyze the reasons for discharge with the personal satisfaction of hospitalized patients.

Methods

The study was descriptive-analytical being performed in 2021. The study population was 2869 discharged inpatients with personal satisfaction. Sampling was done by random and census. The data were collected using a checklist and a researcher-made questionnaire whose validity and reliability were confirmed. The data were analyzed using SPSS24 by K-Score test for qualitative and variance for quantitative variables.

Results

The discharge rate by personal satisfaction was 7.01%, the average age was 42 years, and the average length of stay was 4 days. Further, 57.1% of patients were female, 63.7% were married, and 21% were babies. A total of 22.77% of the patients were discharged with the father's consent, of which 13.2% were re-admitted. The most common reasons for the discharge were feeling of recovery (47.2%), the hospital being educational (30%), and dissatisfaction with the services of doctors (51.6%). Discharge with personal satisfaction had a significant relationship with the length of hospitalization (p < 0.001) and type of hospital (p = 0.04).

Conclusion

The feeling of recovery, the educational nature of the hospital, and dissatisfaction with the services of doctors were the most common reasons for discharge with personal satisfaction. Therefore, monitoring the provision of services, establishing proper patient-doctor communication, and increasing the awareness of patients and parents could reduce this type of discharge and its consequences.

Exploring the inner roots of discharge against medical advice (DAMA) in an academic psychiatric hospital: a qualitative study

Background

To explore the roots of DAMA in the Roozbeh Hospital, an academic mental hospital located in Tehran, Iran, the authors conducted a simple qualitative study. Twenty-four in-depth semi-structured interviews with families and eight with patients who were discharged against medical advice were done about the inner motivation and roots of DAMA. The sampling was convenient in trying to reach the maximum variation. The transcribed verbatim of the interviews was coded and categorized inductively by discussion. Ethical consideration was approved by the TUMS ethical committee.

Results

Findings were classified into six categories: The patient’s insistence, miss the beloved one, sense of improvement, outside hospital concerns, dissatisfaction with the quality of medical care, and worries about the hospitalization consequences.

Conclusions

Addressing the inner roots of DAMA can be an opportunity to understand better patients and their families’/relatives’ experiences and feelings. This will give a deep perspective and insight into the subject.

Incidence of patients leaving against medical advice in government-subsidized hospitals: a descriptive retrospective study

Introduction

this study aimed to determine the prevalence of leaving against medical advice (LAMA) in the local context and the associated predictors to help develop effective strategies to reduce its likelihood.

Methods

this study employed a retrospective approach using medical records of the 16233 patients between 2016 and 2020 at various government-subsidized hospitals in the Hail region of Saudi Arabia.

Results

the prevalence of LAMA was the highest in 2019 (91.9%) and 2017 (21.45%) among insured and non-insured patients, respectively. Furthermore, it was the highest among patients aged 20-25 years and the lowest among patients aged 46 years and above. The incidence of LAMA was the highest (15.48% for males and 29.53% for females) in 2016. In 2016-2019, the most common reason for LAMA was "wanted medication only," while in 2020, the "fear of infection with COVID-19" was the main reason. High blood sugar was the most common diagnosis among the patients under consideration during the study period. Significant association was found between LAMA and patient's insurance status (t = 4.3123; p < 0.002); however, no association was found between LAMA and age (t = -0.8748; p > 0.658) and gender of patients (t = 1.9008; p > 0.302).

Conclusion

strategies such as developing a suitable environment for patients and taking due care of their needs, providing individual consulting services, enhancing staff relations, and providing support to patients in need are vital. The likelihood of LAMA can be minimized by informing hospitalized patients and their relatives about the adverse effects of LAMA.

Role of Sildenafil in Management of Pediatric Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) has high mortality and multiple therapeutic strategies have been used to improve the outcome. Inhaled nitric oxide (INO), a pulmonary vasodilator, is used to improve oxygenation. This study was conducted to determine the role of sildenafil, an oral vasodilator, to improve oxygenation and mortality in pediatric ARDS (PARDS). The prevalence of pulmonary hypertension in PARDS was studied as well. Inclusion criteria included children (1–18 years) with ARDS requiring invasive ventilation admitted to the pediatric intensive care unit of a teaching hospital in Northern India over a 1-year period of time. Thirty-five patients met the inclusion criteria. Cardiologist performed a detailed echocardiogram to determine pulmonary arterial pressure (PAP). Patients with persistent hypoxemia were started on oral sildenafil. The majority (77%) patients had a primary pulmonary etiology of PARDS. Elevated PAP (>25 mm Hg) was detected in 54.3% patients at admission. Sildenafil was given to 20 patients who had severe and persistent hypoxemia. Oxygenation improved in most patients after the first dose with statistically significant improvement in PaO2/FiO2 ratios at both 12 and 24 hours following initiation of therapeutic dosing of sildenafil. Improvement in oxygenation occurred irrespective of initial PAP. Outcomes included a total of 57.1% patients discharged, 28.6% discharged against medical advice (DAMA), and a 14.3% mortality rate. Mortality was related to the severity of PARDS and not the use of sildenafil. This is the first study to determine the effect of sildenafil in PARDS. Sildenafil led to improvement in oxygenation in nearly all the cases without affecting mortality. Due to unavailability of INO in most centers of developing countries, sildenafil may be considered as an inexpensive alternative in cases of persistent hypoxemia in PARDS. We recommend additional randomized controlled trials to confirm the effect of sildenafil in PARDS as determined in this study.

Discharge against medical advice from the emergency department in a university hospital

Background

Patients discharged against medical advice (DAMA) act as a high-risk population for the Emergency Department (ED), regardless of their presentations, and can pose a serious burden for the hospital. This study examines the prevalence, demographic and clinical characteristics, reasons, and clinical outcomes of a small sample of DAMA patients in a teaching university hospital, including readmission, morbidity, and mortality.

Methods

A prospective, descriptive cross-sectional study was conducted in the ED of King Hamad University Hospital (KHUH) with 98,992 patient visits during a 1-year period from June 2018 to June 2019. Consenting DAMA patients were asked to complete a data collection form.

Results

Patients (n = 413) had a mean age of 44.1 years with a female majority (57.1%). The majority were categorized as triage level-3 (87.7%). The main reasons for DAMA included refusal of the procedure/operation (23.2%), long ED waiting time (22.2%), subjective improvement with treatment (17.7%), and children at home (14.8%), whereas the least selected reason was dissatisfaction with medical care (1.2%). Follow-up of DAMA patients revealed that 86 cases (20.8%) were readmitted to the ED within 72 h of which 41 (47.7%) cases were morbidity and 2 (2.3%) were mortality. Marital status was a predictor of DAMA patients who revisit the ED within 72 h.

Conclusion

The results act as a pilot study to examine a small sample of DAMA patients’ characteristics, diagnosis, and ED revisits. Hospitals should investigate further the DAMA population on a larger scale, reasons for refusing procedures, and utilize this knowledge to improve the healthcare process.

Risk Factors and Reasons for Treatment Abandonment for Patients With Esophageal Atresia: A Study From a Tertiary Care Hospital in Beijing, China

Background: This study aims to identify the risk factors and reasons for treatment abandonment for patients with esophageal atresia (EA) in a tertiary care hospital in China. Methods: A retrospective study was conducted on 360 patients with EA admitted to Beijing Children's Hospital between January 1, 2007 and June 1, 2020. Medical records for treatment abandonment and non-treatment abandonment patients were compared. Univariate and multivariate logistic regression analyses were conducted to identify potential risk factors for treatment abandonment. Results: After the diagnosis of EA, parents of 107 patients refused surgical repair and discharged against medical advice, and 253 patients underwent surgical repair. Among these 253 patients, parents of 59 patients abandoned treatment after surgery; 52 patients were discharged in an unstable condition, and parents of seven patients abandoned resuscitation leading to death in the hospital. By comparing clinical characteristics between treatment abandonment before surgery (n = 107) and non-treatment abandonment (n = 253) groups, we found that mother's parity >1, unplanned admission to intensive care unit before surgery, associated anomalies, and Gross type A/B were significant independent risk factors for treatment abandonment before surgery. Furthermore, birth weight <2,545 g, being discharged from neonatal center/intensive care unit and other departments, unplanned admission to intensive care unit after surgery, operative time >133 min, admission before 2016, pneumothorax, and anastomotic leakage were significant independent risk factors for treatment abandonment after surgery. The reasons for treatment abandonment included financial difficulties, multiple malformations with poor prognosis, belief of incurability and concerns about the prognosis of the diseases, postoperative complications, and extensive length of intensive care unit stay. Conclusions: Treatment abandonment of children with EA/TEF is still a common and serious problem in China. This study showed that EA/TEF patients in critical conditions, with associated anomalies, Gross type A/B, and who had occurrence of complications had high-risk for treatment abandonment.

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.

A STUDY OF THE SOCIODEMOGRAPHIC AND CLINICAL PROFILES OF PSYCHIATRIC PATIENTS LEAVING AGAINST MEDICAL ADVICE

AIM OF THE STUDY

We aim to assess the prevalence of psychiatric patients leaving against medical advice (LAMA), the sociodemographic and clinical profiles of the LAMA psychiatric patients, and reasons for LAMA.

MATERIAL AND METHODS

An observational cross-sectional study was undertaken for six months extending from April 2019 to September 2019 in the Department of Psychiatry, Gauhati Medical College Hospital, Guwahati, Assam, India. The study used a semi-structured proforma to collect the sociodemographic variables and clinical characteristics according to ICD-10. The data were analysed by descriptive statistics.

RESULTS

Out of the 523 admitted patients during the study period, 60 chose for LAMA. LAMA was more in young adults, men, those from urban region, less educated, admissions through outpatient department (OPD), diagnosis of mental and behavioural disorders due to psychoactive substance use. Majority of LAMA patients left after one day of hospital stay. Dissatisfied with treatment was the commonest reason for LAMA.

CONCLUSION

In a country with more faith on quacks than modern medicine and a rising expectation of immediate sense of well-being, it was deemed a necessary study to probe more into the issues in order to avoid a revolving door phenomenon. To tackle this problem, prior information constitutes the cornerstone of dealing with this problem.

Pediatric discharge against medical advice

PURPOSE

The purpose of this paper is to identify the reasons for discharges against medical advice (DAMA) and the possible outcomes among pediatric patients.

DESIGN/METHODOLOGY/APPROACH

A retrospective cohort study was conducted on all children admitted and then discharged against medical advice in two maternity and children's hospitals in Jeddah, 2014. Phone interviews were conducted, and medical records were reviewed for DAMA and control groups; a semi-structured questionnaire was used to collect this information.

FINDINGS

The top three reasons identified for DAMA were parent's false assumption that their child's condition had improved (43.8 percent), dissatisfaction with treating/managing team (16.2 percent) and difficulties arranging care for patient's siblings at home (7.7 percent). The readmission rate was significantly higher among DAMA pediatric patients compared to the control group (28.5 percent vs 11.5 percent) at 30-day follow-up, which highlights the importance for developing interventions aimed at reducing DAMA.

ORIGINALITY/VALUE

This study helps us to better understand DAMA reasons and outcomes. Understanding these factors can encourage appropriate interventions and policies for reducing DAMA rates. In this way, pediatric patients can be protected from inappropriate discharge consequences.

Discharge against Medical Advice (DAMA) from an Emergency Department of a Tertiary Care Hospital in Saudi Arabia

Background

The discharge against medical advice (DAMA) in the Emergency Department (ED) is an issue of great concern because it may result in adverse consequences at a later stage. The reported worldwide prevalence of DAMA ranges from 0.07 to 20% for emergency admissions. The outcomes of DAMA can have significantly damaging effects, causing possible relapses of disease, readmission, and increases in medical costs for the patient. Therefore, it is imperative to identify the predictors of DAMA in ED.

Methods

It was a cross-sectional study. The medical records used were those of all the patients (n = 11513) admitted to the Emergency Department (ED) of King Abdullah Bin Abdulaziz University Hospital (KAAUH) in Riyadh, Saudi Arabia, between 2017 and 2018. A thorough analysis was performed using IBM SPSS Statistics version 22. Descriptive statistics were reported for quantitative and categorical variables and assessed by independent t-test/chi-square/ANOVA (analysis of variance), where appropriate. Unadjusted and adjusted odds ratios with their 95% CI (confidence interval) were reported by performing logistic regression. A p value of ≤0.05 was considered statistically significant throughout the study.

Results

The prevalence of DAMA in our study was 1%. In a multivariable analysis, after adjusting for the other covariates, we observed a significant interaction between age and gender. It was observed that the odds of DAMA for ≤40-year-old males were 3.12 times higher than those of a ≤40-year-old female (p value < 0.1). To further investigate this interaction, men and women were modeled separately in multivariable models using the same covariates. We found that, for men, the effect of age (≤40 years) was significant (OR = 3.94, 95% CI 1.31-11.80, p=0.014), while, for women, the effect of age (≤40 years) was not as pronounced (OR = 1.27, 95% CI = 0.66-2.42, p=0.27).

Conclusions

Our study concluded that DAMA was more likely among younger male patients (≤40 years of age). Most of the patients with DAMA were presented to the urgent care of the Emergency Department. We recommend that patients be given some financial support to bear the expenses of the hospital stay from the healthcare facility or from the state. Future studies should assess the socioeconomic status of the patients and estimate the cost that is incurred by the patients.

Uncompleted emergency department care and discharge against medical advice in patients with neurological complaints: a chart review

Background

Uncompleted emergency department care and against-medical-advice discharge represent relevant medical problems with impact on patient safety and potential medicolegal and socioeconomic consequences. They may also indicate structural or procedural problems in the emergency department (ED) relating to patient management and flow. While patients with neurological complaints frequently leave the ED against medical advice or without being seen, no dedicated analysis of this group of patients aiming at the identification of characteristics associated with irregular ED discharge has been performed so far.

Methods

A chart review was performed of all patients with neurological complaints presenting to a German interdisciplinary emergency department between January and December 2017 for neurological evaluation. Demographics, mode of presentation, process times, presenting symptoms and diagnosis were recorded. Patients leaving against medical advice after an informed consent discussion and signing of documentation (DAMA) or leaving prematurely without notifying ED staff (PL) were compared to the total of patients who were admitted or discharged (non-DAMA/PL).

Results

Of all patients presenting with neurological symptoms or complaints, 3% left against medical advice and 2.2% left prematurely. DAMA/PL patients were younger (p < .001), and they were more frequently self-presenting (p < 0.001). Headaches, seizures and sensory deficits were the most frequent presenting symptoms in DAMA/PL patients, and 56.1% of those presenting with a seizure had a history of epilepsy. The most common documented reason for leaving was the duration of door-to-doctor time.

Conclusions

Younger age, self-presenting mode of presentation and presentation with headache, seizures or sensory deficits are associated with premature leave or against-medical-advice discharge of patients with neurological complaints from the ED, and long waiting times were given as the major reason for leaving the ED. Increasing ED staff’s awareness of these factors and the optimization of pre-hospital assessment and demand management, thereby positively impacting on patient flow and ED process times, may help to prevent irregular discharges from the ED.

Effects of Iranian healthcare transformation plan on discharge against medical advice rate and related factors in 2012 and 2016

OBJECTIVE

Discharge against medical advice (DAMA) is a critical problem in hospitals and has several consequences for healthcare systems. The aim of this study was to determine and compare the rate of DAMA and its related factors before and after executing the healthcare transformation plan (HTP) in Iran.

METHODS

In a two-phase, cross-sectional study, the DAMA information of 200 patients in 2016 (after HTP) and the patients of a previous study in 2012 (before HTP) was compared. Samples were randomly selected from the main referral centre in the north-west of Iran. Data were collected using a validated and reliable questionnaire and analysed using the SPSS V.16 software.

RESULTS

In the post-HTP plan period, the rate of DAMA was 3.9%, while this rate was 5.49% in 2012 (p=0.029). A total of 15% (108 out of 721) of patients in the postreform group and 13.5% (101 out of 747) in the prereform group were rehospitalised (p=0.411). The three main categories of reasons for DAMA in 2012 and 2016 were as follows: patient-related factors, 27% vs 45%; staff-related factors, 33% vs 30%; and hospital-related factors (basic amenities), 40% vs 25%. In both periods, the average scores of patient satisfaction were almost the same; however, satisfaction regarding environmental and human factors in hospitals had changed significantly after HTP (p<0.05).

CONCLUSIONS

There was a decrease in the rate of DAMA after HTP in Iran. Considering DAMA as a multifactorial phenomenon, this might be due to the higher relative satisfaction after HTP, indicating an increase in public confidence in general hospitals.

Leaving Against Medical Advice From In-patients Departments Rate, Reasons and Predicting Risk Factors for Re-visiting Hospital Retrospective Cohort From a Tertiary Care Hospital

Background: Approximately 1% to 2% of hospitalized patients get discharged or leave from the hospital against medical advice and up to 26% in some centers. They have higher readmission rate and risk of complications than patients who receive complete care. In this study we aimed to determine the rate of leave against medical advice (LAMA) and reasons for the same across different in-patient departments of a tertiary care hospital.

Methods: Retrospective cohort study on patients admitted in all departments at our institute over a 1-year period. All patients who were admitted to an in-patient ward at the hospital and who left against medical advice by submitting a duly filled LAMA form were included. Univariate and multivariate logistic regression models with forward selection methods were employed. Revisit to hospital within 30 days; to clinic or emergency department was outcome variable for regression.

Results: From June 2015 to May 2016 there were 429 LAMA patients, accounting for 0.7% of total admissions. Females were 223 (52%) compared to males 206 (48%). Finances were quoted as the most common reason for LAMA by 174 (41%) patients followed by domestic problems 78 (18%). Internal medicine was the service with the highest number of LAMA patients ie, 153 (36%) followed by Pediatric medicine with 73 (17%). Of the 429 patients, 147 (34%) patients revisited the hospital within 30 days. Sixty-one percent of these ‘bounced-back’ LAMA patients had worsening or persistence of same problem, or new problem/s had developed. In unadjusted bivariate logistic model, patients who were advised for follow-up during discharge against medical advice were four times more likely to revisit the hospital. Patients who were married had an increased odd of revisiting the hospital.

Conclusion: Financial reasons are the most common stated reasons to LAMA. Patients who LAMA are at a high risk of clinical worsening and ‘bouncing back.’ This is the first study from our region on in-patient LAMA rates, to our knowledge. The results can be used for planning measures to reduce LAMA rates and its consequences.

Treatment Delays for Patients With Acute Ischemic Stroke in an Iranian Emergency Department: A Retrospective Chart Review

STUDY OBJECTIVE

We evaluate the extent and nature of treatment delays and the contributing factors influencing them for patients with acute ischemic stroke, as well as main barriers to stroke care in an Iranian emergency department (ED).

METHODS

A retrospective chart review was conducted on 394 patients with acute ischemic stroke who were referred to the ED of a tertiary academic medical center in northwest Iran from March 21 to June 21, 2017. The steps of this review process included instrument development, medical records retrieval, data extraction, and data verification. Primary outcomes were identified treatment delays and causes of loss of eligibility for intravenous recombinant tissue plasminogen activator (r-tPA).

RESULTS

Of patients with acute ischemic stroke, 80.2% did not meet intravenous r-tPA eligibility; the most common cause was delayed (>4.5 hours) ED arrival after symptom onset (71.82%; n=283). Of 19.8% of subjects for whom the stroke code was activated, intravenous r-tPA was administered in only 5.3%. The average time from patients' arrival to first emergency medicine resident visit, notification of acute stroke team, presence of neurology resident, and computed tomography scan interpretation was lower for patients who met criteria of intravenous r-tPA than for those who lost eligibility for fibrinolytic therapy. The average door-to-needle time was 69 minutes (interquartile range 46 to 91 minutes).

CONCLUSION

Our ED and acute stroke team had a favorable clinical performance meeting established critical time goals of inhospital care for potentially eligible patients, but a poor clinical performance for the majority of patients who were not candidates for fibrinolytic therapy.

Pattern and outcomes of paediatric medical admissions at the Living Word Mission Hospital, Aba, South East Nigeria

INTRODUCTION

There is a decline in child mortality rate globally, courtesy of the erstwhile Millennium Development Goals. However, under-five mortality is still high in the African sub-regions. The need to review the morbidity and mortality pattern among children admitted into private health settings, where 60% of the medical conditions of the masses are being attended to in the sub-regions, cannot be overemphasized. This study aimed at documenting the morbidity pattern and outcomes of admissions among children admitted into the Living Word Mission Hospital (LWMH), Aba, Nigeria.

METHODS

This was a retrospective descriptive study over a 3 year period. The study population comprised of all children aged 1 month to 15 years that were admitted into the pediatric wards of the Living Word Mission Hospital, Aba, Nigeria. The age, gender, diagnoses and disease outcome of these patients, were all retrieved from the pediatric ward registers and hospital medical records. The data were analyzed using SPSS, version 20.0.

RESULTS

There were 2278 pediatric medical cases admitted over the study period. Males were 1364 and females were 914, giving a male: female ratio of 1.5:1. More than 90% of these patients were aged < less than 5 years. Severe malaria (31.1%), septicaemia (16.6%), bronchopneumonia (15.4%), uncomplicated malaria (11.9%), acute watery diarrhea (10.5%) and meningitis (3.7%) were the leading causes of admission. Mortality rate was 5.7%, with 87.5% of these deaths occurring in under-fives. Septicaemia (34.6%) and Severe malaria (23.2%) were the leading causes of death.

CONCLUSION

There is a high rate of paediatric admissions at Living Word Hospital, Aba. The under-five population remains a vulnerable group to both childhood morbidity and mortality. Septicaemia, malaria, bronchopnuemonia and acute watery diarrhoea were the leading causes of morbidity and mortality. Childhood mortality at LWMH is lower than observed in most government hospitals in Nigeria.