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Discharges Against Medical Advice: Prevalence, Predictors, and Populations

  • Madhuram Nagarajan
  • Ada Ibe Offurum
  • Mangla Gulati
  • Eberechukwu Onukwugha
Chapter

Abstract

Discharge against medical advice (DAMA) is when a patient leaves a healthcare institution, typically a hospital where the patient is admitted, before it is deemed medically appropriate. DAMA constitutes approximately 1% of all US hospital discharges; however, the proportion of those leaving against medical advice may be higher in certain populations, and not all DAMA will be avoidable.

We summarize the existing literature and offer a framework to view what is known about DAMA, with the discussion primarily centered on “high-risk” patients and provider liability. While DAMA may seem to be an issue of patient autonomy, the decision-making occurs within a broader interpersonal, community, and social context that is captured using non-patient-level factors.

We argue for investigation of and characterization of the effect of non-patient-level factors that contribute to DAMA, in addition to the better-understood patient-level factors. Building on a richer framework that considers patient and non-patient-level factors, we propose that future research should identify effective multilevel interventions to reduce avoidable DAMA.

Keywords

Discharge against medical advice Against medical advice Leave against medical advice DAMA AMA LAMA 

References

  1. 1.
    Venes D, Taber CW. Taber’s cyclopedic medical dictionary. Philadelphia: F.A. Davis Co.; 2013.; 2013. Available from: http://survey.hshsl.umaryland.edu/?url=http://search.ebscohost.com/login.aspx?direct=true&db=cat01362a&AN=hshs.004293179&site=eds-live.
  2. 2.
    Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010;25(9):926–9.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ 2003 Feb 18 [cited 2017 Jan 5];168(4):417–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12591781.
  4. 4.
    Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health 2007 Dec [cited 2017 Jan 5];97(12):2204–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17971552.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125(6):594–602. Available from:  https://doi.org/10.1016/j.amjmed.2011.12.017 CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Jerrard DA, Chasm RM. Patients leaving against medical advice (AMA) from the emergency department-disease prevalence and willingness to return. J Emerg Med. 2011;41(4):412–7. Available from:  https://doi.org/10.1016/j.jemermed.2009.10.022 CrossRefPubMedGoogle Scholar
  8. 8.
    Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med. 2006;21(9):955–60. Available from:  https://doi.org/10.1007/BF02743144 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Stearns CR, Bakamjian A, Sattar S, Weintraub MR. Discharges against medical advice at a county hospital: provider perceptions and practice. J Hosp Med. 2017;12(1):11–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28125826 CrossRefPubMedGoogle Scholar
  10. 10.
    Kumar B, Deep KS. Discharge against medical advice: approaching a frustratingly common situation. 2015;113. Available from: http://www.kumarmd.org/wp-content/uploads/2015/07/Discharge-Against-Medical-Advice-Approaching-a-Frustratingly-Common-Situation.pdf.
  11. 11.
    Brofenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32(7):513–31.CrossRefGoogle Scholar
  12. 12.
    Golden SD, Earp JA. Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions. Health Educ Behav. 2012;39(3):364–72.CrossRefPubMedGoogle Scholar
  13. 13.
    Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med 1998 [cited 2017 Jan 5];13(8):568–71. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1496999&tool=pmcentrez&rendertype=abstract.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Spooner KK, Salemi JL, Salihu HM, Zoorob RJ. Discharge against medical advice in the United States, 2002–2011. Mayo Clin Proc. 2017;92(4):525–35. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0025619617300733 CrossRefPubMedGoogle Scholar
  15. 15.
    Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Intern Med 1995 Jul [cited 2017 Jan 5];10(7):403–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7472691.
  16. 16.
    Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Loh FE, et al. A qualitative study to identify reasons for discharges against medical advice in the cardiovascular setting. BMJ Open. 2012;2(4). Available from: http://bmjopen.bmj.com/content/2/4/e000902.abstract.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420–4. Available from: http://qualitysafety.bmj.com/content/19/5/420.abstract PubMedPubMedCentralGoogle Scholar
  18. 18.
    Alfandre DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc 2009 Mar [cited 2016 Nov 7];84(3):255–60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19252113.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA. Am J Drug Alcohol Abuse 2004 [cited 2017 May 23];30(2):489–93. Available from: http://www.tandfonline.com/doi/full/10.1081/ADA-120037390.CrossRefPubMedGoogle Scholar
  20. 20.
    Onukwugha E, Shaya FT, Saunders E, Weir MR. Ethnic disparities, hospital quality, and discharges against medical advice among patients with cardiovascular disease. Ethn Dis. 2009;19(2):172–8. Available from: https://www.ethndis.org/edonline/index.php/ethndis/pages/view/priorarchives PubMedGoogle Scholar
  21. 21.
    Brook M, Hilty DM, Liu W, Hu R, Frye MA. Discharge against medical advice from inpatient psychiatric treatment: a literature review. Psychiatr Serv 2006 [cited 2016 Dec 5];57(8):1192–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16870972.CrossRefPubMedGoogle Scholar
  22. 22.
    Tawk R, Freels S, Mullner R. Associations of mental, and medical illnesses with against medical advice discharges: the National Hospital Discharge Survey, 1988–2006. Admin Pol Ment Health Ment Health Serv Res 2013 Mar 6 [cited 2016 Nov 7];40(2):124–32. Available from: http://link.springer.com/10.1007/s10488-011-0382-8.
  23. 23.
    Reinke DA, Walker M, Boslaugh S, Hodge D 3rd. Predictors of pediatric emergency patients discharged against medical advice. Clin Pediatr (Phila). 2009;48(3):263–70.CrossRefGoogle Scholar
  24. 24.
    Macrohon BC, Alfandre D, Sclar D, Robison L, Anis A, Sun H, et al. Pediatrician’s perspectives on discharge against medical advice (DAMA) among pediatric patients: a qualitative study. BMC Pediatr 2012 Dec 18 [cited 2016 Nov 7];12(1):75. Available from: http://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-12-75.
  25. 25.
    Tucker Edmonds B, Ahlberg C, McPherson K, Srinivas S, Lorch S. Predictors and adverse pregnancy outcomes associated with antepartum discharge against medical advice. Matern Child Health J. 2014;18(3):640–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Fiscella K, Meldrum S, Franks P. Postpartum discharge against medical advice: who leaves and does it matter? Matern Child Health J. 2007;11(5):431–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract 2002 Jun [cited 2017 May 23];56(5):325–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12137437.
  28. 28.
    Grossman M. On the concept of health capital and the demand for health. J Political Econ 1972 Mar [cited 2017 May 20];80(2):223–55. Available from: http://www.journals.uchicago.edu/doi/10.1086/259880.
  29. 29.
    Ormel J, Lindenberg S, Steverink N, Vonkorff M. Quality of life and social production functions: a framework for understanding health effects. Soc Sci Med 1997 [cited 2017 May 20];45(7):1051–63. Available from: http://ac.els-cdn.com/S0277953697000324/1-s2.0-S0277953697000324-main.pdf?_tid=d8a3a904-3d96-11e7-9980-00000aab0f27&acdnat=1495310554_7627b547e25e0071a8c8c3f46ba992f0.CrossRefGoogle Scholar
  30. 30.
    Pescosolido BA. Beyond rational choice: the social dynamics of how people seek help. Am J Sociol 1992 Jan [cited 2017 May 20];97(4):1096–138. Available from: http://www.journals.uchicago.edu/doi/10.1086/229863.CrossRefGoogle Scholar
  31. 31.
    Windish DM, Ratanawongsa N. Providers’ perceptions of relationships and professional roles when caring for patients who leave the hospital against medical advice. J Gen Intern Med. 2008;23(10):1698–707.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Yamagishi K. When a 12.86% mortality is more dangerous than 24.14%: implications for risk communication. Appl Cogn Psychol 1997 Dec [cited 2017 May 20];11(6):495–506. Available from: http://doi.wiley.com/10.1002/%28SICI%291099-0720%28199712%2911%3A6%3C495%3A%3AAID-ACP481%3E3.0.CO%3B2-J.CrossRefGoogle Scholar
  33. 33.
    Hendrickx L, Vlek C, Oppewal H. Relative importance of scenario information and frequency information in the judgment of risk. Acta Psychol 1989 [cited 2017 May 20];72(1):41–63. Available from: http://www.sciencedirect.com/science/article/pii/0001691889900504.CrossRefGoogle Scholar
  34. 34.
    Hibbard JH, Peters E. Supporting informed consumer health care decisions: data presentation approaches that facilitate the use of information in choice. Annu Rev Public Health 2003 Jan [cited 2017 May 20];24(1):413–33. Available from: http://www.annualreviews.org/doi/10.1146/annurev.publhealth.24.100901.141005.CrossRefPubMedGoogle Scholar
  35. 35.
    Kaplan RM, Hammel B, Sehimmel LE. Patient information processing and the decision to accept treatment. [cited 2017 May 20]; Available from: http://rmkaplan.bol.ucla.edu/Robert_M._Kaplan/1985_Publications_files/0093.pdf.
  36. 36.
    Jahangir E, Irazola V, Rubinstein A, Wright J, Williams R, Wilkinson J, et al. Need, enabling, predisposing, and behavioral determinants of access to preventative care in Argentina: analysis of the National Survey of Risk Factors. In: Barengo NC, editor. PLoS One [cited 2017 Jan 7];7(9):e45053. Available from: http://dx.plos.org/10.1371/journal.pone.0045053.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Blanchard J, Nayar S, Lurie N. Patient-provider and patient-staff racial concordance and perceptions of mistreatment in the health care setting. J Gen Intern Med 2007 Jul 5 [cited 2017 Jan 5];22(8):1184–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17486386.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Blanchard J, Lurie N. R-E-S-P-E-C-T: patient reports of disrespect in the health care setting and its impact on care. J Fam Pract 2004 Sep [cited 2017 Jan 5];53(9):721–30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15353162.
  39. 39.
    Saitz R. Discharges against medical advice: time to address the causes. CMAJ. 2002;167(6):647–8.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Alfandre D. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med. 2013;28(12):1657–62.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Clark MA, Abbott JT, Adyanthaya T. Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge. Acad Emerg Med. 2014;21(9):1050–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Devitt PJ, Devitt AC, Dewan M. Does identifying a discharge as “Against Medical Advice” confer legal protection? J Fam Pract. 2000;49(3):224–7.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Schaefer GR, Matus H, Schumann JH, Sauter K, Vekhter B, Meltzer DO, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? J Gen Intern Med. 2012;27(7):825–30.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Feng Z, Wright B, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood) 2012 Jun 1 [cited 2017 Aug 10];31(6):1251–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22665837.
  45. 45.
    Public Policy Committee. The observation status problem. J Hosp Med. 2012;7(S2):1–1. Available from: http://doi.wiley.com/10.1002/jhm.1927 CrossRefGoogle Scholar
  46. 46.
    Sheehy AM, Graf B, Gangireddy S, Hoffman R, Ehlenbach M, Heidke C, et al. Hospitalized but not admitted: characteristics of patients with “observation status” at an academic medical center. JAMA Intern Med 2013 Nov 25 [cited 2017 Jun 1];173(21):1991–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23835927.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Horwitz L, Partovian C, Lin Z, Herrin J, Grady J, Conover M, et al. Hospital-wide (all-condition) 30-day risk-standardized readmission measure DRAFT measure methodology report submitted by Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE). [cited 2017 Apr 3]; Available from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/downloads/MMSHospital-WideAll-ConditionReadmissionRate.pdf.
  48. 48.
    Horwitz LI, Partovian C, Lin Z, Grady JN, Herrin J, Conover M, et al. Development and use of an administrative claims measure for profiling hospital-wide performance on 30-day unplanned readmission. Ann Intern Med 2014 Nov 18 [cited 2017 Apr 3];161(10_Supplement):S66–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25402406.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    CMS. Medicare enrollment charts – chronic conditions data warehouse [Internet]. Available from: https://www.ccwdata.org/web/guest/medicare-charts/medicare-enrollment-charts.
  50. 50.
    CMS. Medicaid enrollment charts – chronic conditions data warehouse [Internet]. [cited 2017 Jun 1]. Available from: https://www.ccwdata.org/web/guest/medicaid-charts.
  51. 51.
    van Walraven C, Jennings A, Forster AJ. A meta-analysis of hospital 30-day avoidable readmission rates. J Eval Clin Pract. 2012;18(6):1211–8.CrossRefPubMedGoogle Scholar
  52. 52.
    Vest JR, Gamm LD, Oxford BA, Gonzalez MI, Slawson KM, Jencks S, et al. Determinants of preventable readmissions in the United States: a systematic review. Implement Sci. 2010;5(1):88. Available from: http://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-5-88 CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Thompson MP, Waters TM, Kaplan CM, Cao Y, Bazzoli GJ. Most hospitals received annual penalties for excess readmissions, but some fared better than others. Health Aff (Millwood). 2017;36(5):893–901. Available from: http://content.healthaffairs.org/lookup/doi/10.1377/hlthaff.2016.1204 CrossRefGoogle Scholar
  54. 54.
    Gu Q, Koenig L, Faerberg J, Steinberg CR, Vaz C, Wheatley MP. The medicare hospital readmissions reduction program: potential unintended consequences for hospitals serving vulnerable populations. Health Serv Res. 2014;49(3):818–37.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Lorenz TH, Green JM, Lewis WC, Stone M, Calden G, Thurston JR. Investigation of irregular discharge of tuberculous patients; a special ward procedure for reducing against-medical-advice discharges. Am Rev Tuber U S. 1955;72(5):633–46.Google Scholar
  56. 56.
    Zumla A, Nahid P, Cole ST. Advances in the development of new tuberculosis drugs and treatment regimens. Nat Rev Drug Discov 2013 Apr 30 [cited 2017 May 23];12(5):388–404. Available from: http://www.nature.com/doifinder/10.1038/nrd4001.CrossRefPubMedGoogle Scholar
  57. 57.
    Brush RW, Kaelbling R. Discharge of psychiatric patients against medical advice. J Nerv Ment Dis U S. 1963;136:288–92.CrossRefGoogle Scholar
  58. 58.
    Levine J, Monroe JJ. Discharge of narcotic drug addicts against medical advice. Public Health Rep. 1964;79:13–8.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Lewis JM. Discharge against medical advice. The doctor’s role. Hosp Community Psychiatry. 1966;17(9):266–70.PubMedGoogle Scholar
  60. 60.
    Miles JE, Adlersberg M, Reith G, Cumming J. Discharges against medical advice from voluntary psychiatric units. Hosp Community Psychiatry. 1976;27(12):859–64.PubMedGoogle Scholar
  61. 61.
    Jankowski CB, Drum DE. Diagnostic correlates of discharge against medical advice. Arch Gen Psychiatry. 1977;34(2):153–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/843174 CrossRefPubMedGoogle Scholar
  62. 62.
    Smith DB, Telles JL. Discharges against medical advice at regional acute care hospitals. Am J Public Health 1991 Feb [cited 2017 Jan 25];81(2):212–15. Available from: http://ajph.aphapublications.org/doi/10.2105/AJPH.81.2.212.
  63. 63.
    Moy E, Bartman BA. Race and hospital discharge against medical advice. J Natl Med Assoc. 1996;88(10):658–60.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Madhuram Nagarajan
    • 1
  • Ada Ibe Offurum
    • 2
    • 3
  • Mangla Gulati
    • 2
    • 3
  • Eberechukwu Onukwugha
    • 1
  1. 1.Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreUSA
  2. 2.Department of MedicineUniversity of Maryland School of MedicineBaltimoreUSA
  3. 3.University of Maryland Medical CenterBaltimoreUSA

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