Faculty Bibliography

Hospital discharges against medical advice (AMA) are common, costly, stigmatizing to patients, and are associated with excess morbidity and mortality. Achieving better quality care for patients discharged AMA has been limited both by the sparse research illuminating how best to care for this challenging patient population, as well as a lack of standards regarding this clinical practice. This paper will review elements of the AMA literature and highlight the gaps, including the predictors of AMA discharge, challenges to high quality informed consent in AMA discharges, problematic aspects of AMA discharge forms, and the stigma associated with patients discharged AMA. These gaps in the evidence base collectively limit the ability to adequately and completely address AMA discharges and improve health care quality. This paper will recommend future directions to answer remaining questions for the field, and offer guidance for providing ethically sound and high quality care for the affected population. Applying the widely accepted principles of patient-centered care and shared decision making to AMA discharges offers the opportunity to improve quality of care and promote ethical health care practice.

BACKGROUND: The discipline of health care ethics consultation (EC) has been limited by the lack of both high quality data and quality standards. To promote high quality ethics consultation practices, staff at the National Center for Ethics in Health Care within the Veterans Health Administration (VHA) developed 2 specific EC tools, ECWeb and the EC Feedback Tool. ECWeb is a web-based database tool that promotes process standards consistent with "CASES," VA's systematic approach to ethics consultation. The EC Feedback Tool, which links to ECWeb records, enables consultation participants to rate their experience on various aspects of EC. This paper describes the ethics consultation requests, processes, and evaluations from all facilities in our system. METHODS: We analyzed data from completed ethics consultations from ECWeb records initiated between October 2008 and September 2011. For each consultation record, users documented in ECWeb the data related to utilization of the EC service (e.g., type of consultation request, requester role (i.e., physician, nurse, patient). Additionally, ECWeb users documented, as applicable, various processes performed during the ethics consultation (e.g., capacity assessment (y/n), a face-to-face patient visit (y/n), and if the consult was identified as being symptomatic of underlying issues that are best addressed at the systems level). The EC Feedback Tool asked respondents to rate the ethics consultant(s) on 12 specific ethics knowledge and skill areas as well as their overall experience with ethics consultation, both on a 5 point Likert scale. RESULTS: We analyzed ECWeb data for 4628 completed consults from 140 facilities across theVHAhealth system .Median consultation volume per facility was 7 in 2009 (mean=9.6, range=0-60), 8 in 2010 (mean=12.4, range=0-106), and 8 in 2011 (mean =12.1, range=0-119). The majority of consultations were classified by the consultants as related to shared decision making (73%). Most consultations (63%) related to patients in the !

Hepatitis C virus (HCV) remains widely prevalent in the U.S. Treatment has improved, but rates of treatment initiation remain low. We sought to identify clinical and sociodemographic characteristics of patients that are associated with failure to initiate treatment of HCV infection. We conducted a retrospective cohort study in our primary care hepatitis C treatment clinic, affiliated with an urban academic hospital. Our population was multi-ethnic, HIV-, HCV+, treatment naive patients. We measured rates of HCV treatment initiation and sociodemographic, viral, and patient-related variables associated with non-initiation of treatment. The total number of treatment-eligible patients was 168, of whom 41 began treatment and 127 did not. In multivariate analysis, individuals with HCV genotypes 1 and 4 were less likely than others to initiate treatment, as were patients with more medical comorbidities. Further research is needed to understand how factors around initiation interact and how interventions can overcome them