Faculty Bibliography

ABSTRACT/UNASSIGNED:There is increasing evidence of the role of non-patient-level factors on discharge against medical advice (DAMA), but limited quantitative information regarding the extent of their impact. This study quantifies the contribution of discharge-level and hospital-level factors to the variation in DAMA. We grouped variables from the 2014 National Inpatient Sample data and ran incremental mixed-effects logit models with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICCs), and evaluated the incremental change in ICC. The final sample included 2,687,430 discharges. 12.8% of the identified variation in the probability of DAMA was associated with the hospital, and 1.2% of the variation was associated with the census division in which the hospital was located. The final, fully-adjusted model had 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions because of the addition of patient demographics. Even after adjusting for measured patient-level characteristics, there was a contribution of non-patient-level factors to DAMA outcomes. The findings identify a role for a multi-level approach to addressing DAMA.

BACKGROUND:A discharge against medical advice (DAMA) is associated with adverse health outcomes. Its association with postdischarge healthcare resource utilization (HcRU) outside an inpatient setting is unknown. This information can help us understand how a DAMA may affect healthcare-seeking behavior following a hospital stay. We evaluated the relationship between a DAMA and 30-day postdischarge HcRU. METHODS:Plus database. We included individuals aged 18 to 64 years with an inpatient admission during 2007-2015 and continuous insurance coverage. We defined comparison groups as DAMA and routine discharge. Both groups were matched on baseline covariates. We quantified the association between a DAMA and 30-day HcRU, as well as 90-day for sensitivity analysis, with use of generalized linear models for binary outcomes (inpatient readmissions, emergency department [ED] visits) and count outcomes (physician office visits, nonphysician outpatient encounters, prescription drug fills). RESULTS:Of the 457,530 individuals in the unmatched sample, 2,245 (0.5%) had a DAMA. In the matched sample, a DAMA was positively associated with an ED visit (adjusted odds ratio, 2.28; 95% confidence interval, 1.90-2.72) but not with an inpatient readmission. There were no differences between groups based on the count outcomes. A DAMA was positively associated with 90-day HcRU (ie, inpatient readmission, ED visit, and prescription drug fills). CONCLUSION/CONCLUSIONS:The relationship between a DAMA and HcRU varied with the HcRU category and postdischarge time interval. This examination of HcRU in the inpatient and outpatient settings provides important information about outcomes following a DAMA.

When patients are admitted to the hospital, they are generally expected to remain in or within close proximity to their assigned rooms in order to promote their safety and appropriate medical care. Although there are circumstances when patients may safely leave their hospital room or floor, guidance within the medical literature for the management of patient movement within the hospital are lacking. Excessive restrictions on patient movement may be seen as overly paternalistic, while lax requirements may interfere with high quality care, patient safety and efficient hospital practice. As a result, guidance in the form of institutional policy is warranted. Such policy development should take into consideration the potential clinical, legal, and ethical concerns in balancing the competing values of patients' preferences and respect for autonomy, while ensuring high quality, safe, and efficacious medical care. This paper will provide a framework for hospitals to create institution-specific patient movement policies that are fair, systematic, and transparent.

Objectives: Discharges against medical advice (AMA) occur when patients leave the hospital prior to a physician-recommended endpoint. It is unknown whether AMA discharges are associated with higher healthcare costs within 30 days of discharge. We examine healthcare costs following a hospital discharge in a commercially insured population.
Method(s): This retrospective cohort study examined individuals aged 18 to 64 with a hospitalization during 2007-2015 from a 10% random sample of enrollees in the IQVIA^TM Adjudicated Health Plan Claims Data. We included individuals with insurance coverage 6 months before and 30 days after their first hospitalization. Individuals with AMA and non-AMA discharges were matched on baseline covariates. Generalized linear models and cost ratios (CR) were used to quantify the association between AMA discharges and 30-day costs. We report CRs overall and by points of service (inpatient, emergency department (ED), physician office, non-physician outpatient encounter (NPOE) and prescription drug fill).
Result(s): Of the 467,746 individuals in the unmatched sample, 2,164 (0.46%) were discharged AMA. Mean (median) costs were 20% (5%) higher in the AMA group compared to the non-AMA group. In the matched sample and relative to those discharged routinely, individuals with an AMA discharge incurred 1.20 times (95% CI: 1.08, 1.34) higher costs. Similarly, individuals with an AMA discharge incurred higher inpatient (CR: 1.71, 95% CI: 1.45, 2.01) and ED (CR: 2.10, 95% CI: 1.84, 2.39) costs within 30 days post-discharge. Conversely, individuals with an AMA discharge incurred lower NPOE (CR: 0.84, 95% CI: 0.74, 0.95) and prescription drug fill (CR: 0.81; 95% CI: 0.73, 0.91) costs. There were no differences in physician office visit costs across the two groups.
Conclusion(s): An AMA discharge is associated with higher 30-day costs compared to those discharged routinely, particularly for acute care services. Future work should determine whether these findings extend to publicly-insured individuals.
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