Faculty Bibliography

Objectives: 1-2% of all hospital discharges are designated as a discharge against medical advice (DAMA), and patients with DAMA have poorer outcomes. To our knowledge, there is no prior study that decomposes variation at the level of hospital discharges into patient and non-patient-level factors contributing to DAMA, and we seek to do so in our study. Methods: We used the National Inpatient Sample (NIS) 2014, an all-payer healthcare database that provides a stratified sample of 20% of all discharges from US hospitals. We included patients > 18 years, in the general medical group, with known discharge status, and who were not transferred out or did not die in hospital. With our final sample of 2,687,430 discharges, we grouped variables from our 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 (ICC), and evaluated the percentage change in ICC. Results: Our preliminary analysis showed associations with DAMA in line with previous studies: younger age, male gender, African-American race, residence in a large metropolis. Of interest, however, is our finding that of the overall variation in DAMA outcomes, 12.8% is associated with the hospital the discharge occurred from, and 1.2% of the variation with the census division the hospital is located in. This decreased with the addition of variables to the models, and the final, fully-adjusted model has 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions occurring due to the addition of patient demographics. Conclusions: Our study is the first to explore the percentage in variation in DAMA due to patient, hospital and census-division characteristics. We find that even after adjusting for patient-level characteristics, there is a contribution of non-patient-level factors to DAMA outcomes

The Ethics Consultation Quality Assessment Tool (ECQAT) establishes standards by which the quality of ethics consultation records (ECRs) can be assessed. These standards relate to the ethics question, consultation-specific information, ethical analysis, and recommendations and/or conclusions, and result in a score associated with one of four levels of ethics consultation quality. For the ECQAT to be useful in assessing and improving the quality of healthcare ethics consultations, individuals who rate the quality of ECRs need to be able to reliably use the tool. We developed a short course to train ethics consultants in using the ECQAT, and evaluated whether the participants (1) achieved an acceptable level of calibration in matching expert-established quality scores for a set of ethics consultations, and (2) were satisfied with the course. We recruited 28 ethics consultants to participate in a virtual, six-session course. At each session participants and faculty reviewed, rated, and discussed one to two ECRs. The participants' calibration in matching expert-established quality scores improved with repeated exposure at all levels of ethics consultation quality. Participants were generally more accurate when assessing consultation quality at the dichotomous level of "acceptable" (scores of three or four) versus "unacceptable" (scores of one or two) than they were with more a specific score. Participants had higher rates of accuracy with the extreme ratings of "strong" (level four) or "poor" (level one). Although participants were highly satisfied with the course, only a minority of participants achieved the prespecified acceptable level of calibration (that is, 80 percent or greater accuracy between their score and expert-established scores). These results suggest that ECQAT training may require more sessions or need modification in the protocol to achieve higher reliability in scoring. Such trainings are an important next step in ensuring that the ECQAT is a tool that can be used to promote improvement in ethics consultation quality.

Nurses are often first to identify and manage a patient leaving against medical advice (AMA), and so they are critical contributors to the development of strategies to address this problem. We studied AMA discharge in order to help develop useful interventions. We performed a cross-sectional analysis of 55,938 discharges from a single urban hospital for the years 2002-2003 and 2012-2013. AMA discharge rates were higher for HIV-infected patients than for patients with alcohol-related disorders or sickle cell anemia in both time periods, even after adjustment for age, race, sex, insurance status, and household income. For HIV infection, 25% of AMA discharges occurred in patients with multiple AMA discharges and 30-day readmission rates were higher after an AMA discharge: odds ratio 1.57 (95% confidence interval 1.01 to 2.43, p = .046). Team-based and nursing interventions that incorporate the treatment-based values and preferences of HIV-infected patients with prior AMA discharges may improve linkage to care and reduce readmissions.

The phenomenon of leaving the hospital against medical advice (AMA) despite being quite common and associated with significant deleterious health outcomes remains inadequately understood and addressed. Researchers have identified certain patient characteristics as predictors of AMA discharges, but the patients' reasons for these events have not been comprehensively explored. Moreover, because the medical authority model dominates this research area, providers' experiences of AMA discharges remain unstudied. We examined the AMA discharge from a patient-centered perspective by analyzing the content of notes providers generate to record such events. We analyzed providers' notes for all inpatients with a primary HIV diagnosis (N = 33) that, in 2012, left an urban hospital AMA. Applying the Scott and Lyman accounts framework, we identified that the notes constituted records of providers' and patients' excuses and justifications for failing to meet the expectations of a provider offering patient-centered care and a compliant patient receiving care. Alongside the patients' reasons for leaving AMA, the notes also revealed the providers' reasons for honoring or discrediting the patients' accounts. The style of the accounts and the professional status of the notes' authors enabled us to contextualize the production and sharing of AMA notes in the hospital hierarchy. Conceptualizing AMA notes as dyadic accounts elicited specific factors that challenge the patient-provider relationship, and generated insights on how to strengthen it, and thus decrease the rates of AMA discharges and their associated health effects.

The care of "Very Important Patients" is different from other patients because they may receive greater access, attention, and resources from health care staff. Although the term "Very Important Patient" is used regularly in the medical literature and is implicitly understood, in practice it constitutes a wide and heterogeneous group of patients that have a strong effect on health care providers. We define a "Very Important Patient" as a very influential patient whose individual attributes and characteristics (i.e., social status, occupation, position, etc.) coupled with their behavior, have the potential to significantly influence a clinician's judgment or behavior. Physicians, celebrities, the politically powerful, and philanthropists, may all become "Very Important Patients" in the appropriate context. The quality of care may be inferior because health care professionals may deviate from standard practices when caring for them. Understanding the common features among what may otherwise be very different groups of patients can help health care providers manage ethical concerns when they arise. We use a series of vignettes to demonstrate how "Very Important Patient's'" behavior and status can influence a clinician's judgment or actions. Appreciating the ethical principles in these varied circumstances provides health care professionals with the tools to manage ethical conflicts that arise in the care of "Very Important Patients". We conclude each vignette with guidance for how health care providers and administrators can manage the ethical concern.