Why Patients Sign Out Against Medical Advice (AMA): Factors Motivating Patients to Sign Out AMA

A retrospective review of the against medical advice (AMA) discharges revealed that the majority of the patients left AMA for personal reasons, i.e., sickness or death in the family; reconciliation with spouse, girl friend, or family members; financial problems; and legal issues such as a court date. Strategies to reduce AMA discharges and increase patient retention in treatment are suggested.     

Increased risk of mortality and readmission among patients discharged against medical advice

BackgroundApproximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown.MethodsWe examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (2.4%) were discharged against medical advice, and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities or discharges with home care. Using adjusted and propensity score-matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges.ResultsDischarge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR]_adj 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (OR_matched 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (OR_adj 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (OR_matched 1.65; 95% CI, 1.46-1.87). Finally, discharges against medical advice had shorter lengths of stay than matched planned discharges (3.37 vs 4.16 days, P <.001).ConclusionsDischarge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.     

Albuminuria and associated medical risk factors: A cross-sectional study in 476 type I (insulin-dependent) diabetic patients. Part 1

Albumin concentration in a morning urine sample was analyzed in a cross-sectional study in 476 insulin-dependent diabetic patients. The following groups of patients were defined: A) normal urinary albumin (urine albumin <12.5 mg/L); B) high normal albuminuria (12.5–30 mg/L); C) microalbuminuria, ie, incipient nephropathy (31–299 mg/L); and D) clinical nephropathy (≥300 mg/L). The prevalences of incipient and clinical diabetic nephropathy were 24.8 and 14.4%, respectively. There were no differences in clinical parameters such as age, age at onset or duration of diabetes, blood pressure, serum creatinine, or HbA_1c levels between groups A and B. The frequency of retinopathy in these groups was 55 and 50%, respectively. In group C, there were increases in age, duration of diabetes, blood pressure, serum creatinine, and HbA_1c levels. The frequency of retinopathy was higher (80%), and more patients had severe forms (47%). In group D, there were further increases in all parameters and, in addition, younger age at onset of diabetes. The frequency of retinopathy was 97%, and severe forms of retinopathy were more common (86%). Seventeen percent of the patients were treated for hypertension. These patients were older, had longer duration of diabetes, and had higher levels of blood pressure, serum creatinine, and urinary albumin, as well as a younger age at onset of diabetes than patients not requiring antihypertensive treatment.     

Albuminuria and associated medical risk factors: A cross-sectional study in 451 type II (noninsulin-dependent) diabetic patients. Part 2

The association between urinary albumin concentration (UAC) in a morning urine sample and medical risk factors was evaluated in a cross-sectional study of 451 type II (noninsulin-dependent) diabetic patients. The following four groups of patients were created according to their urinary albumin levels: A) normal (<12.5 mg/L); B) high normal (12.5–30 mg/L); C) microalbuminuria, ie, incipient nephropathy (31–299 mg/L); and D) clinical nephropathy (≥300 mg/L). The patients with high normal levels had higher HbA_1c and systolic blood pressure levels than patients with values within normal limits. The prevalence of incipient and clinical diabetic nephropathy was 20 and 7%, respectively. Incipient nephropathy was associated with higher blood pressures and body weights. Patients with clinical nephropathy had even further increases in these parameters, were older, and had longer duration of diabetes. In both groups of nephropathy, men were preponderant. Thirty six percent of all patients and 73% of patients with clinical nephropathy were treated for hypertension; 55% were treated with insulin. The insulin-treated patients had poorer metabolic control, but there were no differences in blood pressure or serum creatinine levels as compared with those of patients not receiving insulin treatment. The proportion of patients with severe retinopathy increased with the degree of albuminuria, although 22% of the patients with clinical nephropathy continued to be nonretinopathic.     

Exercise for acutely hospitalised older medical patients (2007)

These highlights are produced with permission from the Cochrane Collaboration. To read the full findings and any updates, please visit: http://www.thecochranelibrary.com     

Leaving Against Medical Advice (AMA): Risk of 30-Day Mortality and Hospital Readmission

Background  

With 1–2% of patients leaving the hospital against medical advice (AMA), the potential for these patients to suffer adverse health outcomes is of major concern.     

Prophylaxis against venous thromboembolism in hospitalized medical patients: an evidence-based and practical approach

To discuss the evidence regarding the efficacy and safety of anticoagulant prophylaxis against deep vein thrombosis (DVT) in hospitalized medical patients; to understand barriers to implementation of prophylaxis and how they can be overcome; and to have a practical approach as to which patients should and should not receive anticoagulant prophylaxis. The frequency of DVT in hospitalized medical patients, in the absence of prophylaxis varies from 10-15%. Autopsy studies have shown that pulmonary embolism (PE) is associated with 5-10% of deaths in hospitalized patients. With appropriate use of anticoagulant prophylaxis, there is a 57% reduction in the risk for symptomatic PE (relative risk [RR] 0.43, 95% CI 0.26-0.71), a 62% reduction in the risk for fatal PE (RR 0.38, 95% CI 0.21-0.69), and a 53% reduction in the risk for symptomatic DVT (RR 0.47, 95% CI 0.22-1.00). Anticoagulant prophylaxis is also associated with a non-significant increased risk for major bleeding (RR 1.32, 95% CI 0.73-2.37). Risk factors for DVT and bleeding in medical patients may help to identify patients in whom anticoagulant prophylaxis is indicated or contraindicated but validated risk stratifications schemes are lacking. Among hospitalized medical patients, randomized trials have established an acceptable therapeutic benefit-to-risk ratio of anticoagulant prophylaxis to reduce the incidence of clinically silent and symptomatic venous thromboembolism, including a reduction in the incidence of fatal PE. Additional research is needed to develop a validated risk stratification model for hospitalized medical patients that can help identify patients who would benefit most from anticoagulant prophylaxis.     

Readmissions to medical wards: analysis of demographic and socio-medical factors

BackgroundUnplanned readmissions affect occupancy rates in medical wards and these have been constantly increasing in Israel. We examined the frequency and risk factors affecting the likelihood of 30-day emergency medical readmissions.MethodsWe compared the clinical, epidemiological, and socioeconomic characteristics of readmitted patients during 2009 to a control group matched by age, sex, and primary medical diagnosis.ResultsRate of unplanned readmissions within 30 days was 12.2%. The mean time to readmission was 12.8 days. The mean length of hospital stay at index admission was 4.4 and 3.8 days for the study and control groups, respectively, and 4.99 days in the second admission (study group only). By simple univariate logistic regression, living in a nursing home, chronic kidney disease, ischemic heart disease, previous cerebrovascular accident, number of chronic medications, length of hospital stay at index admission, and hospitalization in the previous year prior to index admission were significantly associated with risk of readmission. In multivariate logistic regression model, only living in a nursing home (OR = 2.94, 95%CI = 1.15–7.48), presence of chronic kidney disease (OR = 1.62, 95%CI = 1.06–2.46), length of index admission ≥ 3 days (OR = 1.53, 95%CI = 1.07–2.2), and hospitalization in the previous year (OR = 3.33, 95%CI = 2.34–4.74) were found to be significantly associated with likelihood of readmission.ConclusionRisk factors affecting 30-days readmission at our medical centre are similar to previous observations, and yet, some are perhaps unique to our region.     

Non-symptom-related factors contributing to delay in seeking medical care by patients with heart failure: a narrative review

Background

Delay in seeking timely medical care by patients with acute coronary syndrome and stroke has been well established in the literature, but less is known about delay in care-seeking behavior by patients with heart failure (HF). The purpose of this narrative review was to synthesize the literature regarding non–symptom-related factors that contribute to delay in seeking medical care for HF symptoms.

Methods and Results

A literature search of Scopus, Medline, and Pubmed was conducted for published articles from database inception to July 2009. Available evidence has shown that non–symptom-related factors, such as HF severity, HF history, age, and ethnocultural background, were related to delay in certain studies; however, null results have also been reported. Other non–symptom-related factors, such as male gender, initial contact with a primary care physician, arriving in the emergency department by means other than ambulance, and patient responses such as self-care, low anxiety, and hopelessness, may play a role in longer delay.

Conclusions

Although this review identified several non–symptom-related factors that may be implicated in care-seeking delay, health care professionals should be vigilant in identifying all high-risk individuals and educating them about warning signs of HF. Moreover, access to outpatient chronic disease management programs that may have potential to reduce care-seeking delay behavior should be explored.