Discharge Against Medical Advice in the United States, 2002–2011

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Abstract

Objective:

To describe the national frequency, prevalence, and trends of discharge against medical advice (DAMA) among inpatient hospitalizations in the United States and identify differences across patient- and hospital-level characteristics, overall and in clinically distinct diagnostic subgroups.

Patients and Methods:

We conducted a retrospective, cross-sectional analysis of inpatient hospitalizations (≥18 years), discharged between January 1, 2002, and December 31, 2011, using the Nationwide Inpatient Sample. Descriptive statistics, multivariable logistic, and joinpoint regression were used for statistical analyses.

Results:

Between January 1, 2002, and December 31, 2011, more than 338,000 inpatient hospitalizations were discharged against medical advice each year, with a 1.9% average annual increase in prevalence over the decade (95% CI, 0.8%-3.0%). Temporal trends in DAMA varied by principal diagnosis. Among patients hospitalized for mental health- or substance abuse-related disorders, there was a −2.3% (95% CI, −3.8% to −0.8%) average annual decrease in the rate of DAMA. A statistically significant temporal rate change was not observed among hospitalizations for pregnancy-related disorders. Multivariable regression revealed several patient and hospital characteristics as predictors of DAMA, including lack of health insurance (odds ratio [OR], 3.78; 95% CI, 3.62–3.94), male sex (OR, 2.40; 95% CI, 2.36–2.45), and northeast region (OR, 1.91; 95% CI, 1.72–2.11). Other predictors included age, race/ethnicity, income, primary diagnosis, severity of illness, and hospital location/type and size.

Conclusion:

Rates for DAMA have increased in the United States, and key differences exist across patient and hospital characteristics. Early identification of vulnerable patients and preventive measures such as improved patient-provider communication may reduce DAMA.

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