“I'm Leaving”: Factors That Impact Against Medical Advice Disposition Post-Trauma |
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| Institution: | 1. Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina;2. Department of Surgery, Texas Health Harris Methodist Hospital, Fort Worth, Texas;3. The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina;1. Division of Cardiology, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy;2. Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy;1. Department of Emergency Medicine, Georgetown Public Hospital, Georgetown, Guyana;2. Department of Emergency Medicine, The University of Arizona, Tucson, Arizona;3. Pulmonary Hypertension Program, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada;4. Spirometry Clinic, Georgetown Public Hospital, Georgetown, Guyana;1. Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin;2. Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina;1. Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina;2. The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina;3. Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina;1. Department of Cardiology, Lehigh Valley Hospital Network, Allentown, PA;2. Department of Internal Medicine, Lehigh Valley Hospital Network, Allentown, PA;3. Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN;4. Department of Medicine, SSM Health St Mary’s Hospital, St Louis, MO;5. Department of Internal Medicine, New York Medical College, Valhalla, NY |
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| Abstract: | BackgroundDischarge against medical advice (AMA) is an important, yet understudied, aspect of health care—particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs.ObjectiveThe goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment.MethodsWe performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status.ResultsUninsured (odds ratio OR] 2.72; 95% confidence interval CI] 2.58–2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37–2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02–1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52–0.75), Asian (OR 0.59; 95% CI 0.49–0.69), and Hispanic (OR 0.80; 95% CI 0.75–0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury.ConclusionsInsurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma. |
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| Keywords: | AMA against medical advice trauma outcomes health care disparities medical ethics health policy |
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