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Soroudi D, Rosser M, Patel AU, Yin R, McLaughlin M, Hansen SL. Patient-Directed Discharge in Hand Infection Cases: Interactions Between Intravenous Drug Use, Socioeconomic Factors, and Subsequent Readmissions. Ann Plast Surg 2025; 94:437-442. [PMID: 40084988 DOI: 10.1097/sap.0000000000004310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2025]
Abstract
BACKGROUND Patient-directed discharge (PDD) poses a significant challenge in healthcare. Prior studies have shown associations of PDD with factors like race, housing, psychiatric illness, socioeconomic status, and intravenous drug use (IVDU). This study aims to identify factors contributing to PDD in hand infection patients at a public safety-net hospital and to investigate the long-term consequences through readmissions or returns to the emergency department (ED). METHODS A retrospective analysis was conducted on adult patients presenting with hand infections at San Francisco's main public hospital over 1 year. Data collected included demographics, housing status, social support, psychiatric diagnoses, and IVDU. Statistical analysis involved Mann-Whitney U tests, Fisher's exact tests, and logistic regression with odds ratios (ORs). RESULTS A total of 131 patients were included, comprising 95 (73%) conventionally discharged and 36 (27%) PDD patients. Positive correlations were found between PDD and several factors, including unemployment, unstable housing, living alone, lack of a phone number on file, alcohol use, and IVDU. However, in the multivariate analysis, IVDU emerged as the sole statistically significant predictor (OR, 4.22; CI, 1.18-15.05; P = 0.026). Further regression analysis identified unstable housing (OR, 4.39; CI, 1.17-16.44; P = 0.028) and living alone (OR, 4.45; CI, 1.25-15.89; P = 0.021) to be positively correlated with IVDU. PDD had higher ED revisits ( P = 0.025) and readmission rates ( P = 0.014). CONCLUSIONS This study underscores the critical role of socioeconomic factors, particularly IVDU, in influencing PDD among hand infection patients. The findings highlight the need for integrated healthcare strategies addressing medical and social determinants to reduce PDD and improve patient outcomes.
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Affiliation(s)
| | - Micaela Rosser
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Alap U Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
| | | | | | - Scott L Hansen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
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Quick JD, Powell LE, Bien E, Adams NR, Miotke SA, Barta RJ. A 5-year Review of Characteristics and Outcomes of Trauma Surgery Patients Leaving Against Medical Advice. J Patient Saf 2025; 21:159-164. [PMID: 39804227 DOI: 10.1097/pts.0000000000001310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 12/02/2024] [Indexed: 03/25/2025]
Abstract
OBJECTIVES The objective of this study was to characterize the demographic, social, economic, and clinical factors of trauma surgery patients leaving against medical advice (AMA). METHODS Data were retroactively obtained from a level-one trauma center in a medium-sized metropolitan area from January 2017 to December 2021. The sample population consisted of patients admitted or treated by the trauma surgical service. RESULTS In the 5-year study period, 130 surgical patients left AMA and met the inclusion criteria for this study. The average patient was 38.8 years old. The majority were male (77.7%) and White (47.7%). It was found that 74.6% of patients had insurance, 23.6% were experiencing homelessness, and 6.2% required an interpreter. A large percentage of patients had a past medical history significant for depression (31.5%), anxiety disorders (25.4%), and substance use disorder (68.5%). Analysis of the hospital time course of this patient population indicated that patients were most often admitted to trauma surgery (70.0%) and most often required consults by neurosurgery (28.5%). Procedures were performed for 81.5% of patients and social services were consulted for 60.8% of patients. Only 50.8% of patients who left AMA were noted to receive discharge instructions. Nearly half (44.6%) of the patients returned to a hospital to receive additional care within 1 month of their initial AMA discharge date. CONCLUSIONS A concerning number of trauma surgery patients left without discharge instructions, possibly leading to a high rate of 30-day hospital readmission. Future studies are needed to examine and further characterize the relationship between discharge protocol and outcomes of patients leaving AMA.
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Affiliation(s)
- Joseph D Quick
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Lauren E Powell
- Division of Plastic and Reconstructive Surgery, University of Minnesota, Minneapolis, MN
| | - Erica Bien
- Division of Plastic and Reconstructive Surgery, University of Minnesota, Minneapolis, MN
| | - Nellie R Adams
- Regions Hospital, Critical Care Research Center, St. Paul, MN
| | | | - Ruth J Barta
- Department of Craniofacial and Plastic Surgery, Gillette Children's Hospital, St. Paul, MN
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Lorenzo MP, Adams KK, Housman ST. Common Bacterial Infections in Persons Who Inject Drugs. MEDICINES (BASEL, SWITZERLAND) 2025; 12:8. [PMID: 40265354 PMCID: PMC12015887 DOI: 10.3390/medicines12020008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2024] [Revised: 03/17/2025] [Accepted: 03/21/2025] [Indexed: 04/24/2025]
Abstract
Opioid use in the United States has increased dramatically. Bacterial infections are common among persons who inject drugs (PWID), and there is a disparity in the care these individuals receive. As such, outcomes associated with these infections can be poor. Healthcare providers can address these disparities through optimal pharmacotherapy recommendations and assistance with changing approaches to the management of PWID.
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Affiliation(s)
| | - Kathleen K. Adams
- School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA;
| | - Seth T. Housman
- Baystate Medical Center, Springfield, MA 01199, USA;
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA 01119, USA
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Holmes EG, Smith AC, Kara A. Patients Discharged "Against Medical Advice" More than Once: A Cross-Sectional Descriptive Analysis of a Vulnerable Population. J Gen Intern Med 2024:10.1007/s11606-024-09278-5. [PMID: 39707096 DOI: 10.1007/s11606-024-09278-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Accepted: 12/03/2024] [Indexed: 12/23/2024]
Abstract
BACKGROUND Patients who have been discharged "against medical advice" (AMA) are at increased risk of morbidity and mortality, but there is little research about patients who have had more than one AMA discharge. OBJECTIVE We aimed to describe the socio-demographic and clinical characteristics of patients with more than one AMA discharge. DESIGN We conducted a cross-sectional, retrospective chart review of a sample of adult patients who were discharged AMA more than once between 2016 and 2021 and abstracted detailed characteristics of this sample. PATIENTS A total of 81 patients were discharged AMA more than once during the study period. MAIN MEASURES We reviewed demographics, health insurance, substance use and mental health diagnoses, psychiatric consultations, documentation of prior AMA discharges, admitting medical service, length of stay, number of hospitalizations during the study period, and readmission within 30 days of the first AMA discharge. We also noted the presence of relevant psychosocial stressors. KEY RESULTS Among 81 patients reviewed, the average age was 41 years (range 19-76). Most were unmarried (n = 72, 89%) and most had public insurance or were uninsured (n = 74, 91%). More than half (n = 52, 64%) had a readmission within 30 days. The average number of hospitalizations in the study period was 10 (range 2-47). These patients had a high burden of psychosocial stressors including financial stress (56, 69%), housing insecurity (n = 40, 49%), and grief or loss of social support (n = 20, 25%). CONCLUSIONS Patients who have been discharged AMA more than once represent a vulnerable population with significant unmet needs.
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Affiliation(s)
- Emily G Holmes
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA.
- Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.
| | - Alyssa C Smith
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Areeba Kara
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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James H, Morgan J, Nolan S. Characterising individuals with a substance use disorder accessing hospital-based addiction care: Preliminary description of the outcomes for patients accessing addiction care prospective cohort study. Drug Alcohol Rev 2024; 43:1809-1816. [PMID: 38867512 DOI: 10.1111/dar.13888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 05/01/2024] [Accepted: 06/01/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION Individuals with a substance use disorder (SUD) often face barriers to accessing health care, resulting in unmet needs and delayed care. Hospital-based services have the potential to engage individuals with a SUD in ongoing treatment, but there is limited literature characterising this population. METHODS The Outcomes for Patients Accessing Addiction Care study was a prospective hospital-based cohort study conducted at St. Paul's Hospital in Vancouver, Canada. Participants were recruited from January 2018 to March 2020. Data were collected through an interviewer-administered questionnaire, including socio-demographic information, substance use history and mental health screening. RESULTS The cohort included 536 participants, with 31% aged 30-39 years, 63% identifying as White and 74% reporting male sex at birth. Nearly half of the participants were either homeless or living in single room occupancy. Use of substances more than once per week was reported for tobacco/nicotine (86%), marijuana (43%), non-medical use of prescription drugs (29%), illicit stimulants (52%) and illicit opioids (61%). DISCUSSION AND CONCLUSION This preliminary report provides a description of a hospital-based cohort of individuals with a SUD accessing addiction care. The findings highlight demographic characteristics, mental health issues, substance use patterns and barriers to accessing services. Understanding these factors can inform the development of patient-centred interventions and improve engagement and retention in addiction care. Further research is needed to explore interventions and program effectiveness in this population.
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Affiliation(s)
- Hannah James
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Jeffrey Morgan
- British Columbia Centre on Substance Use, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
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Watkeys OJ, O'Hare K, Dean K, Laurens KR, Tzoumakis S, Harris MAClinEpi F, Carr VJ, Green MJ. Patterns of health service use for children with mental disorders in an Australian state population cohort. Aust N Z J Psychiatry 2024; 58:857-874. [PMID: 38912687 PMCID: PMC11440792 DOI: 10.1177/00048674241258599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
OBJECTIVES The rate of mental health services provided to children and young people is increasing worldwide, including in Australia. The aim of this study was to describe patterns of hospital and ambulatory mental health service use among a large population cohort of adolescents followed from birth, with consideration of variation by age, sex and diagnosis. METHODS Characteristics of services provided for children with mental disorder diagnoses between birth and age 17.5 years were ascertained for a population cohort of 85,642 children (52.0% male) born between 2002 and 2005, from 'Admitted Patients', 'Emergency Department' and 'Mental Health Ambulatory' records provided by the New South Wales and Australian Capital Territory Health Departments. RESULTS A total of 11,205 (~13.1%) children received at least one hospital or ambulatory health occasion of service for a mental health condition in the observation period. More than two-fifths of children with mental disorders had diagnoses spanning multiple categories of disorder over time. Ambulatory services were the most heavily used and the most common point of first contact. The rate of mental health service contact increased with age across all services, and for most categories of mental disorder. Girls were more likely to receive services for mental disorders than boys, but boys generally had an earlier age of first service contact. Finally, 3.1% of children presenting to mental health services experienced involuntary psychiatric inpatient admission. CONCLUSIONS The extent of hospital and ambulatory-based mental healthcare service among children emphasises the need for primary prevention and early intervention.
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Affiliation(s)
- Oliver J Watkeys
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Kirstie O'Hare
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Kimberlie Dean
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- Justice Health & Forensic Mental Network, Matraville, NSW, Australia
| | - Kristin R Laurens
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- School of Psychology and Counselling, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Stacy Tzoumakis
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- Griffith Criminology Institute, Griffith University, Southport, QLD, Australia
- School of Criminology and Criminal Justice, Griffith University, Southport, QLD, Australia
| | - Felicity Harris MAClinEpi
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Vaughan J Carr
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- Department of Psychiatry, Monash University, Melbourne, VIC, Australia
| | - Melissa J Green
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
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Liang S, Sun L, Zhang Y, Zhang Q, Jiang N, Zhu H, Chen S, Pan H. Sodium fluctuation as a parameter in predicting mortality in general hospitalized patients. Front Med (Lausanne) 2024; 11:1399638. [PMID: 39081691 PMCID: PMC11286384 DOI: 10.3389/fmed.2024.1399638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/02/2024] [Indexed: 08/02/2024] Open
Abstract
Background Dysnatremia is the most common electrolyte disorder in hospitalized patients. Sodium fluctuation level may be a better parameter in dysnatremia management. We aimed to examine the association between sodium fluctuation level during hospitalization and mortality and to evaluate its value in predicting poor prognosis among general hospitalized patients. Methods Data were collected from patients admitted to Peking Union Medical College Hospital. The generalized estimated equation (GEE) was used to examine the relationship between sodium fluctuation level and mortality. Receiver-operating characteristic (ROC) curve analysis was performed to calculate the optimal cutoff value and the area under the ROC curve (AUC). Results Sodium fluctuation level showed a dose-dependent association with increased mortality in general hospitalized patients. After adjusting age, sex, length of hospital stay, and Charlson comorbidity index, the ORs of group G2 to G6 were 5.92 (95% CI 5.16-6.79), 26.45 (95% CI 22.68-30.86), 50.71 (95% CI 41.78-61.55), 104.38 (95% CI 81.57-133.58), and 157.64 (95% CI 112.83-220.24), respectively, p trend <0.001. Both normonatremia and dysnatremia patients on admission had the dose-dependent associations similar to general hospitalized patients. The AUC of sodium fluctuation level was 0.868 (95% CI 0.859-0.877) in general hospitalized patients, with an optimal cutoff point of 7.5 mmol/L, a sensitivity of 76.5% and a specificity of 84.2%. Conclusion We determined that sodium fluctuation level had a dose-dependent association with increased mortality in general hospitalized patients. Sodium fluctuation level could be used to develop a single parameter system in predicting mortality in general hospitalized patients with acceptable accuracy, sensitivity, and specificity.
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Affiliation(s)
- Siyu Liang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lize Sun
- Eight-year Program of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Zhang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Jiang
- 4+4 Medical Doctor Program, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shi Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Pan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Yu J, Zhang K, Chen T, Lin R, Chen Q, Chen C, Tong M, Chen J, Yu J, Lou Y, Xu P, Zhong C, Chen Q, Sun K, Liu L, Cao L, Zheng C, Wang P, Chen Q, Yang Q, Chen W, Wang X, Yan Z, Zhang X, Cui W, Chen L, Zhang Z, Zhang G. Temporal patterns of organ dysfunction in COVID-19 patients hospitalized in the intensive care unit: A group-based multitrajectory modeling analysis. Int J Infect Dis 2024; 144:107045. [PMID: 38604470 DOI: 10.1016/j.ijid.2024.107045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/19/2024] [Accepted: 04/07/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND The course of organ dysfunction (OD) in Corona Virus Disease 2019 (COVID-19) patients is unknown. Herein, we analyze the temporal patterns of OD in intensive care unit-admitted COVID-19 patients. METHODS Sequential organ failure assessment scores were evaluated daily within 2 weeks of admission to determine the temporal trajectory of OD using group-based multitrajectory modeling (GBMTM). RESULTS A total of 392 patients were enrolled with a 28-day mortality rate of 53.6%. GBMTM identified four distinct trajectories. Group 1 (mild OD, n = 64), with a median APACHE II score of 13 (IQR 9-21), had an early resolution of OD and a low mortality rate. Group 2 (moderate OD, n = 140), with a median APACHE II score of 18 (IQR 13-22), had a 28-day mortality rate of 30.0%. Group 3 (severe OD, n = 117), with a median APACHR II score of 20 (IQR 13-27), had a deterioration trend of respiratory dysfunction and a 28-day mortality rate of 69.2%. Group 4 (extremely severe OD, n = 71), with a median APACHE II score of 20 (IQR 17-27), had a significant and sustained OD affecting all organ systems and a 28-day mortality rate of 97.2%. CONCLUSIONS Four distinct trajectories of OD were identified, and respiratory dysfunction trajectory could predict nonpulmonary OD trajectories and patient prognosis.
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Affiliation(s)
- Jiafei Yu
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Department of Critical Care Medicine, Haiyan People's Hospital, Zhejiang 314300, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Tianqi Chen
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Ronghai Lin
- Department of Critical Care Medicine, Taizhou Municipal Hospital, Zhejiang, 318000, China
| | - Qijiang Chen
- Intensive Care Unit, Ninghai First Hospital, Zhejiang, 315600, China
| | - Chensong Chen
- Intensive Care Unit, Xiangshan First People's Hospital Medical and Health Group, Zhejiang, 315700, China
| | - Minfeng Tong
- Department of Neurosurgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Zhejiang, 321000, China
| | - Jianping Chen
- Department of Emergency Medicine, Dongyang People' Hospital of Wenzhou Medical University, Zhejiang, 322100, China
| | - Jianhua Yu
- Department of Critical Care Medicine, Longquan People's Hospital, Zhejiang, 323700, China
| | - Yuhang Lou
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Panpan Xu
- Department of Critical Care Medicine, Taizhou Municipal Hospital, Zhejiang, 318000, China
| | - Chao Zhong
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Intensive Care Unit, Ninghai First Hospital, Zhejiang, 315600, China
| | - Qianfeng Chen
- Intensive Care Unit, Xiangshan First People's Hospital Medical and Health Group, Zhejiang, 315700, China
| | - Kangwei Sun
- Department of Emergency Medicine, Dongyang People' Hospital of Wenzhou Medical University, Zhejiang, 322100, China
| | - Liyuan Liu
- Department of Critical Care Medicine, Longquan People's Hospital, Zhejiang, 323700, China
| | - Lanxin Cao
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Cheng Zheng
- Department of Critical Care Medicine, Taizhou Municipal Hospital, Zhejiang, 318000, China
| | - Ping Wang
- Intensive Care Unit, Ninghai First Hospital, Zhejiang, 315600, China
| | - Qitao Chen
- Department of Neurosurgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Zhejiang, 321000, China
| | - Qianqian Yang
- Department of Neurosurgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Zhejiang, 321000, China
| | - Weiting Chen
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Department of Emergency and Intensive Care Unit, The First People's Hospital of Linhai, Taizhou, Zhejiang 317000, China
| | - Xiaofang Wang
- Department of Cardiovascular Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zuxi Yan
- Department of Critical Care Medicine, Haiyan People's Hospital, Zhejiang 314300, China
| | - Xuefeng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Jiaxing College School of Medicine, Jiaxing 314031, China
| | - Wei Cui
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Lin Chen
- Department of Neurosurgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Zhejiang, 321000, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Gensheng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; Key Laboratory of Multiple Organ Failure (Zhejiang University), Ministry of Education, Hangzhou 310009, China.
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Yeung HM, Ifrah A, Rockman ME. Quantitative Analysis of Characteristics Associated with Patient-Directed Discharges, Representations, and Readmissions: a Safety-Net Hospital Experience. J Gen Intern Med 2024; 39:1173-1179. [PMID: 38114868 PMCID: PMC11116360 DOI: 10.1007/s11606-023-08563-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND No clinical tools currently exist to stratify patients' risks of patient-directed discharge (PDD). OBJECTIVE This study aims to identify trends and factors associated with PDD, representation, and readmission. DESIGN This was an IRB-approved, single-centered, retrospective study. PARTICIPANTS Patients aged > 18, admitted to medicine service, were included from January 1st through December 31st, 2019. Patients admitted to ICU or surgical services were excluded. MAIN MEASURES Demographics, insurance information, medical history, social history, rates of events occurrences, and discharge disposition were obtained. KEY RESULTS Of the 16,889 encounters, there were 776 (4.6%) PDDs, 4312 (25.5%) representations, and 2924 (17.3%) readmissions. Of those who completed PDDs, 42.1% represented and 26.4% were readmitted. Male sex, age ≤ 45, insurance type, homelessness, and substance use disorders had higher rates of PDD (OR = 2.0; 4.2; 4.5; 6.2; 5.2; p < 0.0001, respectively). Patients with homelessness, substance use disorders, mental health disorders, or prior history of PDD were more likely to represent (OR = 3.6; 2.0; 2.0; 1.5; p < 0.0001, respectively) and be readmitted (OR = 2.2; 1.6; 1.9; 1.5; p < 0.0001, respectively). Patients aged 30-35 had the highest PDD rate at 16%, but this was not associated with representations or readmissions. Between July and September, the PDD rate peaked at 5.5% and similarly representation and readmission rates followed. The rates of subsequent readmissions after PDDs were nearly two-fold compared to non-PDD patients in later half of the year. 51% of all subsequent readmissions occur within 7 days of PDD, compared to 34% in the non-PDD group (OR = 2.0; p < 0.0001). Patients with primary diagnosis of abscess had 16% PDDs. CONCLUSIONS Factors associated with PDD include male, younger age, insurance type, substance use, homelessness, and primary diagnosis of abscess. Factors associated with representation and readmission are homelessness, substance use disorders, mental health disorders, and prior history of PDD. Further research is needed to develop a risk stratification tool to identify at-risk patients.
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Affiliation(s)
- Ho-Man Yeung
- Department of Medicine, Section in Hospital Medicine, Temple University Hospital, Lewis Katz School of Medicine at Temple University, Philadelphia, USA.
| | - Abraham Ifrah
- Department of Medicine, Section in Hospital Medicine, Temple University Hospital, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
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Powell LE, Knutson A, Meyer AJ, McCormick M, Lacey AM. A 15-year review of characteristics and outcomes of patients leaving against medical advice. Burns 2024; 50:616-622. [PMID: 37980269 DOI: 10.1016/j.burns.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/24/2023] [Accepted: 10/06/2023] [Indexed: 11/20/2023]
Abstract
PURPOSE Discharging against medical advice can have significant, detrimental effects on burn patient outcomes as well as higher hospital readmission rates and healthcare expenditures. The goal of this study is to identify characteristics of patients who left against medical advice and suggest solutions to mitigate these factors. Data were collected at our American Burn Association verified Burn Unit over a 15-year period. RESULTS Between 2007 and 2022, 37 patients were identified as having left against medical advice from the burn unit. The average patient age was 37 years old with 64.9% being male, and 70.2% were identified as having a substance abuse history. The majority (51.4%) had Medicaid or State health insurance, 29.7% had no insurance, and 18.9% had private insurance. The mechanism of injury was most commonly frostbite (43.2%). The majority sustained < 1% total body surface area injuries. Most (83.7%) had social work and/or case management involved during their admission, and all (100%) had their involvement if the length of admission was greater than one day. Over half (59.5%) returned to the ED within 2 weeks with complications. CONCLUSIONS This study found that patients discharging against medical advice from the burn unit suffered from smaller injuries, often due to cold related injuries. These patients had comorbid substance abuse or psychiatric histories, and the majority had Medicaid or state health insurance. Recruiting interdisciplinary care members, including social work, psychiatry, and addiction medicine, early may help these patients by encouraging completion of their hospital care and setting up crucial follow-up care.
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Affiliation(s)
- Lauren E Powell
- University of Minnesota, Division of Plastic and Reconstructive Surgery, Minneapolis, MN, USA.
| | - Alexis Knutson
- University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Alyssa J Meyer
- University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Melanie McCormick
- University of Minnesota, Department of Surgery, Minneapolis, MN, USA
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Haber LA, Erickson HP, Lyden JR. Can my incarcerated patient discharge against medical advice? J Hosp Med 2024; 19:227-229. [PMID: 37449866 DOI: 10.1002/jhm.13169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Lawrence A Haber
- Division of Hospital Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Hans P Erickson
- Office of the Federal Public Defender, Albuquerque, New Mexico, USA
| | - Jennifer R Lyden
- Division of Hospital Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Medicine, University of Colorado, Aurora, Colorado, USA
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12
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Martin LJ, Bawor M, Bains S, Burns J, Khoshroo S, Massey M, DeJesus J, Lennox R, Cook-Chaimowitz L, O'Shea T, MacKillop J, Dennis BB. Clinical characteristics and prognostic factors among hospitalized patients with substance use disorders: Findings from a retrospective cohort study of a Canadian inpatient addiction medicine service. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209210. [PMID: 37931685 DOI: 10.1016/j.josat.2023.209210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/19/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Inpatient addiction medicine services (AMS) were developed in response to the growing needs of hospitalized individuals with substance use disorders (SUDs). AMS aim to enable timely initiation of pharmacologic treatment, build hospital capacity to support patients who use substances, and facilitate transition to community services. As an emerging service being adopted in hospitals across North America, the model of care, populations served, substance use trends, and clinical trajectory has not been widely described. This work aims to characterize patients accessing care through the AMS, establishing predictors for clinical trajectories in hospital including patient-initiated discharge (PID) and hospital re-admission. METHODS Using a retrospective cohort design, we describe all patients seen by the AMS between 2018 and 2022 across four hospitals in Hamilton, Ontario. Patients seen by AMS were hospitalized and qualified for a SUD based on DSM-V criteria. The study used descriptive statistics to describe the cohort, where appropriate adjusted time-to-event survival models were constructed to identify predictors for hospital re-admission. RESULTS Patients seen by the AMS (n = 695) frequently lacked access to primary care (47.0 %) and less than half (44.3 %) were receiving community addiction services on admission. The majority met criteria for opioid use disorder (OUD), with injecting being the primary consumption route (54.8 %). Patients exhibited high acuity, with 34.2 % requiring critical care measures. Provision of OAT substantially increased to 77.9 % of patients (29 % on admission). PID occurred in 17.8 % of patients and was significantly associated with an admitting diagnosis of suicidal ideation, infection, heart failure, and distinct substance use profiles including methamphetamine, fentanyl, and heroin use (p < 0.05). PID conferred a 66 % increased risk for re-admission (Hazard-Ratio: 1.66; 95 % CI: 1.08, 2.54; p = 0.02). CONCLUSION Patients served by AMS primarily include individuals with OUD presenting with the associated medical complications and substantial deficits in the social determinants of health (e.g., high housing insecurity, poverty, and disability). PID occurs among 1 in 5 people and is associated with higher rates of re-admission. By identifying individuals at higher risk of adverse outcomes, these results provide an opportunity to improve outcomes in this high-risk, high-vulnerability population.
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Affiliation(s)
- Leslie J Martin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S4L8, Canada.
| | - Monica Bawor
- Department of Medicine, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, UK, W68RF.
| | - Supriya Bains
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Hamilton, ON L8S4L8, Canada.
| | - Jacinda Burns
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton, Hamilton, ON L8S4L8, Canada.
| | - Saba Khoshroo
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton, Hamilton, ON L8S4L8, Canada.
| | - Myra Massey
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton, Hamilton, ON L8S4L8, Canada.
| | - Jane DeJesus
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton, Hamilton, ON L8S4L8, Canada.
| | - Robin Lennox
- Department of Family Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S4L8, Canada.
| | - Lauren Cook-Chaimowitz
- Department of Emergency Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S4L8, Canada.
| | - Tim O'Shea
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S4L8, Canada.
| | - James MacKillop
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton, Hamilton, ON L8S4L8, Canada; Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON L8S4L8, Canada.
| | - Brittany B Dennis
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S4L8, Canada; British Columbia Centre on Substance Use, Vancouver, BC V6Z2A9, Canada.
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13
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Shen C, Thornton JD, Li N, Zhou S, Wang L, Leslie DL, Kawasaki SS. Opioid Overdose Hospitalizations During COVID-19: The Experience of Pennsylvania. SUBSTANCE USE : RESEARCH AND TREATMENT 2024; 18:11782218231222343. [PMID: 38433749 PMCID: PMC10906497 DOI: 10.1177/11782218231222343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/07/2023] [Indexed: 03/05/2024]
Abstract
Objective The COVID-19 pandemic placed extreme burden on hospitals, while opioid overdose is another challenging public health issue. This study aimed to examine the trends and outcomes of opioid overdose hospitalizations in Pennsylvania during 2018 to 2021. Design We identified opioid overdose hospitalizations in the state of Pennsylvania using the state-wide hospital discharge database (PHC4) 2018 to 2021. We examined the number of opioid overdose hospitalizations, the corresponding mortality and discharges against medical advice comparing the pre-COVID period (2018-2019) and the COVID period (2020-2021). We also assessed what patient and hospital characteristics were associated with in-hospital death or leaving against medical advice. Results A total of 13 446 opioid-related hospitalizations were identified in 2018 to 2021. Compared to pre-pandemic, a higher percentage of cases involving synthetics (17.0%vs 10.3%, P < .0001) were observed during COVID. After controlling for covariates, there was no significant difference in opioid overdose in-hospital deaths in the years 2020 to 2021 compared to 2018 to 2019 (OR = 0.846, 95% CI: 0.71-1.01, P = .065). The COVID period was significantly associated with more leaving against medical advice compared to years 2018 to 2019 (OR = 1.265, 95% CI: 1.11-1.44, P = .0003). Compared to commercial insurance, Medicaid insurance was associated with higher odds of both in-hospital death (OR = 1.383, 95% CI: 1.06-1.81, P = .0176) and leaving against medical advice (OR = 1.903, 95% CI: 1.56-2.33, P < .0001). Conclusion There were no substantial changes in the number of overall opioid overdose cases and deaths at hospitals following the outbreak of COVID-19 in Pennsylvania. This observation suggests that an increased number of patients may have succumbed to overdoses outside of hospital settings, possibly due to a higher severity of overdoses. Further, we found that patients were more likely to leave against medical advice during the COVID-19 pandemic.
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Affiliation(s)
- Chan Shen
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, USA
| | - Ning Li
- Department of Economics and Finance, Salisbury University, Salisbury, MD, USA
| | - Shouhao Zhou
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Li Wang
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Douglas L. Leslie
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Sarah S. Kawasaki
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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14
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Owokuhaisa J, Schwartz JI, Wiens MO, Musinguzi P, Rukundo GZ. Planning for Hospital Discharge for Older Adults in Uganda: A Qualitative Study Among Healthcare Providers Using the COM-B Framework. J Multidiscip Healthc 2023; 16:3235-3248. [PMID: 37936911 PMCID: PMC10627173 DOI: 10.2147/jmdh.s430489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/22/2023] [Indexed: 11/09/2023] Open
Abstract
Background Proper discharge planning enhances continuity of patient care, reduces readmissions, and ensures safe and timely transition from health facility to home-based care. The current study aimed at exploring the healthcare providers' perspectives of discharge planning among older adults, with respect to barriers and facilitators within the Ugandan health system. Methods We conducted a qualitative exploratory study that used one-on-one interviews (Additional file 1) to describe individual perspectives of healthcare providers in their routine clinical care setting. The study included medical doctors (including consultants and physicians), nurses and physiotherapists directly involved in providing care to older adults. We conducted 25 in-depth interviews among healthcare providers for older adults with non-communicable diseases. The audio-recorded interviews were transcribed verbatim. Data were manually organized using a framework matrix guided by the COM-B domains (capability, opportunity and motivation) as the broad themes and sub-themes (physical and psychological capability, social and physical opportunity, reflective and automatic motivation) that influence behavior change (discharge planning). Results Discharge planning was facilitated by availability of discharge forms, continuous medical education and working experience. The barriers to discharge planning were understaffing, workload/insufficient time, lack of discharge planning guidelines, lack of multidisciplinary approach and congested inpatient wards. Both barriers and facilitators were at various levels of healthcare service delivery such as patient, caregiver, healthcare provider, health facility and policy levels. Conclusion Barriers to discharge planning spread across all levels of healthcare service delivery, but they can be addressed by enhancing the facilitators. This calls for a multi-level action to ensure adequate and quality patient care during and after hospitalization.
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Affiliation(s)
- Judith Owokuhaisa
- Faculty of Medicine, Department of Physiotherapy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew O Wiens
- Institute for Global Health, British Colombia Children’s Hospital, Vancouver, British Columbia, Canada
- Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pius Musinguzi
- Department of Nursing, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey Zari Rukundo
- Department of Psychiatry, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Coleman R, Coulton S, Phillips T. Factors associated with discharge against medical advice in alcohol withdrawal patients. Alcohol Alcohol 2023; 58:561-564. [PMID: 37449462 DOI: 10.1093/alcalc/agad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/13/2023] [Accepted: 06/25/2023] [Indexed: 07/18/2023] Open
Abstract
This study aimed to examine characteristics associated with discharge against medical advice from the hospital in alcohol withdrawal patients, supporting the work of hospital staff and Alcohol Care Teams and identifying characteristics that may help target patients most likely to discharge against medical advice. We used Hospital Episode Statistics Data to identify demographic and clinical variables and compare these in alcohol withdrawal patients who discharged against medical advice from hospital, compared with those who were discharged by the clinical team. Factors significantly associated with alcohol withdrawal patients discharging against medical advice from hospital were: being admitted as an emergency; discharged on a weekend; living with no fixed abode; being male; being younger and having a shorter length of stay. This study identifies characteristics that can be used to support acute hospitals and Alcohol Care Teams, particularly in the allocation of resources to reduce discharges against medical advice and subsequent readmissions to the hospital. Particular consideration should be given to clinical provision in hospitals in emergency departments and on weekends, and also those patients who are admitted and are of no fixed abode.
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Affiliation(s)
- Rachel Coleman
- Faculty of Health Sciences, Institute for Clinical and Applied Health Research (ICAHR), University of Hull, Cottingham Road, Hull HU6 7RX, UK
| | - Simon Coulton
- Centre for Health Services Research, University of Kent, Canterbury CT2 7NF, UK
| | - Thomas Phillips
- Faculty of Health Sciences, Institute for Clinical and Applied Health Research (ICAHR), University of Hull, Cottingham Road, Hull HU6 7RX, UK
- Alcohol Care Team, Department of Gastroenterology, Hull Royal Infirmary, Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull HU3 2JZ,UK
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16
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Kanemo P, Musa KM, Deenadayalan V, Litvin R, Odeyemi OE, Shaka A, Baskaran N, Shaka H. Readmission rates and outcomes in adults with and without COVID-19 following inpatient chemotherapy admission: A nationwide analysis. World J Clin Oncol 2023; 14:311-323. [PMID: 37700808 PMCID: PMC10494557 DOI: 10.5306/wjco.v14.i8.311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/12/2023] [Accepted: 08/08/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has received considerable attention in the scientific community due to its impact on healthcare systems and various diseases. However, little focus has been given to its effect on cancer treatment. AIM To determine the effect of COVID-19 pandemic on cancer patients' care. METHODS A retrospective review of a Nationwide Readmission Database (NRD) was conducted to analyze hospitalization patterns of patients receiving inpatient chemotherapy (IPCT) during the COVID-19 pandemic in 2020. Two cohorts were defined based on readmission within 30 d and 90 d. Demographic information, readmission rates, hospital-specific variables, length of hospital stay (LOS), and treatment costs were analyzed. Comorbidities were assessed using the Elixhauser comorbidity index. Multivariate Cox regression analysis was performed to identify independent predictors of readmission. Statistical analysis was conducted using Stata® Version 16 software. As the NRD data is anonymous and cannot be used to identify patients, institutional review board approval was not required for this study. RESULTS A total of 87755 hospitalizations for IPCT were identified during the pandemic. Among the 30-day index admission cohort, 55005 patients were included, with 32903 readmissions observed, resulting in a readmission rate of 59.8%. For the 90-day index admission cohort, 33142 patients were included, with 24503 readmissions observed, leading to a readmission rate of 73.93%. The most common causes of readmission included encounters with chemotherapy (66.7%), neutropenia (4.36%), and sepsis (3.3%). Comorbidities were significantly higher among readmitted hospitalizations compared to index hospitalizations in both readmission cohorts. The total cost of readmission for both cohorts amounted to 1193000000.00 dollars. Major predictors of 30-day readmission included peripheral vascular disorders [Hazard ratio (HR) = 1.09, P < 0.05], paralysis (HR = 1.26, P < 0.001), and human immunodeficiency virus/acquired immuno-deficiency syndrome (HR = 1.14, P = 0.03). Predictors of 90-day readmission included lymphoma (HR = 1.14, P < 0.01), paralysis (HR = 1.21, P = 0.02), and peripheral vascular disorders (HR = 1.15, P < 0.01). CONCLUSION The COVID-19 pandemic has significantly impacted the management of patients undergoing IPCT. These findings highlight the urgent need for a more strategic approach to the care of patients receiving IPCT during pandemics.
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Affiliation(s)
- Philip Kanemo
- Department of Internal Medicine, Rapides Regional Medical Center, Alexandria, LA 71301, United States
| | - Keffi Mubarak Musa
- Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria 88445, Kaduna, Nigeria
| | - Vaishali Deenadayalan
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60623, United States
| | - Rafaella Litvin
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60623, United States
| | - Olubunmi Emmanuel Odeyemi
- Department of Internal Medicine, Ladoke Akintola University Teaching Hospital, Ogbomoso 210101, Oyo, Nigeria
| | - Abdultawab Shaka
- Department of Medicine, Windsor University School of Medicine, St. Kitts, Frankfort, IL 60423, United States
| | - Naveen Baskaran
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Hafeez Shaka
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60623, United States
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Cheok T, Berman M, Delaney-Bindahneem R, Jennings MP, Bray L, Jaarsma R, Poonnoose PM, Williams K, Jayasekera N. Closing the health gap in Central Australia: reduction in Indigenous Australian inpatient self-discharge rates following routine collaboration with Aboriginal Health Workers. BMC Health Serv Res 2023; 23:874. [PMID: 37592244 PMCID: PMC10436585 DOI: 10.1186/s12913-023-09921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 08/14/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Indigenous Australians experience significant socioeconomic disadvantage and healthcare disparity compared to non-Indigenous Australians. A retrospective cohort study to describe the association between rates of self-discharge in Indigenous orthopaedic patients and the introduction of routine Aboriginal Liaison Officers (ALO) within the Orthopaedic multi-disciplinary team (MDT) was performed. METHODS ALO were introduced within our routine Orthopaedic MDT on the 22nd of February 2021. Two patient cohorts were analysed, Group 1; patients admitted in the 9-months prior to inclusion of ALO, and Group 2; patients admitted within 9-months thereafter. The primary outcome of interest was the rate of self-discharge among Indigenous patients. Secondary outcomes of interest were the stage of treatment when patients self-discharged, recurrent self-discharge, risk factors for self-discharge and association between self-discharge and length of hospital stay. RESULTS Introduction of ALO within routine Orthopaedic MDT was associated with a significant 37% reduced risk of self-discharge among Indigenous patients (p = 0·009), and significantly fewer self-discharges before their definitive surgical and medical treatment (p = 0·0024), or before completion of postoperative intravenous antibiotic treatment (p = 0·030). There was no significant change in the risk of recurrent self-discharge (p = 0·557). Risk factors for self-discharge were younger age; pensioners or unemployed; residents of Alice Springs Town-Camps or of communities within 51 to 100 km of Alice Springs; and those diagnosed with lacerations of the upper limb, but without tendon injury, wound and soft tissue infections or osteomyelitis. In Group 2, the odds of self-discharge decreased with increased length of hospital stay (p = 0·040). CONCLUSIONS Routine inclusion of ALO within the Orthopaedic MDT reduced the risk of self-discharge in Indigenous patients. Those who self-discharged did so only after critical aspects of their care were met.
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Affiliation(s)
- Tim Cheok
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia.
- Department of Orthopaedic Surgery, Palmerston North Hospital, 50, Ruahine Street, Roslyn, Palmerston North, 4414, New Zealand.
| | - Morgan Berman
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Orthopaedic Surgery, Monash Medical Centre, 246, Clayton Road, Clayton, Victoria, 3168, Australia
| | - Richard Delaney-Bindahneem
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
| | - Matthew Phillip Jennings
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Plastics and Reconstructive Surgery, Bendigo Base Hospital, 100 Barnard Street, Bendigo, VIC, 3350, Australia
| | - Linda Bray
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Aboriginal Liaison Services, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
| | - Ruurd Jaarsma
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Orthopaedic Surgery, Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia, 5042, Australia
| | - Pradeep Mathew Poonnoose
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Orthopaedic Surgery, Christian Medical College Hospital, IDA Scudder Road, Vellore, Tamil Nadu, 632004, India
| | - Kanishka Williams
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
| | - Narlaka Jayasekera
- Department of Trauma and Orthopaedics, Alice Springs Hospital, 6, Gap Road, The Gap, Northern Territory, 0870, Australia
- Department of Orthopaedic Surgery, Wairau Hospital, Hospital Road, Blenheim, 7201, New Zealand
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18
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Foster K, Caswell A, James L, Jessani H, Polanco A, Viggiano M, Jennings C, Yeung HM. The risk factors, consequences, and interventions of discharge against medical advice - A narrative review. Am J Med Sci 2023; 366:16-21. [PMID: 37080431 DOI: 10.1016/j.amjms.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/17/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023]
Abstract
Discharge against medical advice (DAMA) represents an increasingly burdensome public health issue that leads to worse outcomes for patients and high costs to society. While the rate of patients who DAMA is higher within certain institutions and geographic locations, the problem is present across all healthcare systems. DAMAs are often challenging as they occur suddenly and can be unsatisfactory. An opportunity exists to better meet the needs of this patient population; however, many providers are unsure of how they can prevent a DAMA. In this review, we discuss the broader impact, associated factors, the most common reasons, the consequences, and the prevention strategies for DAMA. Further research is needed to create tools for stratifying patients most likely to DAMA. Early identification and appropriate interventions for these patients will allow for safe discharges.
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Affiliation(s)
- Kaleb Foster
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA United States of America
| | - Anne Caswell
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA United States of America
| | - Liz James
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA United States of America
| | - Hussain Jessani
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA United States of America
| | - Angie Polanco
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA United States of America
| | - Matthew Viggiano
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA United States of America
| | - Chase Jennings
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA United States of America
| | - Ho-Man Yeung
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA United States of America.
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19
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Parreco JP, Avila A, Pruett R, Romero DC, Solomon R, Buicko JL, Rosenthal A, Carrillo EH. Financial Toxicity in Emergency General Surgery: Novel Propensity-Matched Outcome Comparison. J Am Coll Surg 2023; 236:775-780. [PMID: 36728000 DOI: 10.1097/xcs.0000000000000571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Financial toxicity describes the harmful effect of individual treatment costs and fiscal burdens that have a compounding negative impact on outcomes in surgery. While this phenomenon has been widely studied in surgical oncology, the purpose of this study was to perform a novel exploration of the impact of financial toxicity in emergency general surgery (EGS) patients throughout the US. STUDY DESIGN The Nationwide Readmissions Database for January and February 2018 was queried for all EGS patients aged 18 to 65 years. One-to-one propensity matching was performed with and without risk for financial toxicity. The primary outcome was mortality, and the secondary outcomes were venous thromboembolism (VTE), prolonged length of stay (LOS), and readmission within 30 days. RESULTS There were 24,154 EGS patients propensity matched. The mortality rate was 0.2% (n = 39), and the rate of VTE was 0.5% (n = 113). With financial toxicity, there was no statistically significant difference for mortality (p = 0.08) or VTE (p = 0.30). The rate of prolonged LOS was 6.2% (n = 824), and the risk was increased with financial toxicity (risk ratio 1.24 [1.12 to 1.37]; p < 0.001). The readmission rate was 7.0% (n = 926), and the risk with financial toxicity was increased (risk ratio 1.21 [1.10 to 1.33]; p < 0.001). The mean count of comorbidities per patient per admission during readmission within 1 year with financial toxicity was 2.1 ± 1.9 versus 1.8 ± 1.7 without (p < 0.001). CONCLUSIONS Despite little difference in the rate of mortality or VTE, EGS patients at risk for financial toxicity have an increased risk of readmission and longer LOS. Fewer comorbidities were identified at index admission than during readmission in patients at risk for financial toxicity. Future studies aimed at reducing this compounding effect of financial toxicity and identifying missed comorbidities have the potential to improve EGS outcomes.
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Affiliation(s)
- Joshua P Parreco
- From the Trauma Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL (Parreco, Solomon, Rosenthal, Carrillo)
| | - Azalia Avila
- the General Surgery Residency, Memorial Healthcare System, Hollywood, FL (Avila, Pruett, Romero)
| | - Rachel Pruett
- the General Surgery Residency, Memorial Healthcare System, Hollywood, FL (Avila, Pruett, Romero)
| | - Dino C Romero
- the General Surgery Residency, Memorial Healthcare System, Hollywood, FL (Avila, Pruett, Romero)
| | - Rachele Solomon
- From the Trauma Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL (Parreco, Solomon, Rosenthal, Carrillo)
| | - Jessica L Buicko
- the Endocrine, Breast, and General Surgery, Florida Atlantic University, Boynton Beach, FL (Buicko)
| | - Andrew Rosenthal
- From the Trauma Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL (Parreco, Solomon, Rosenthal, Carrillo)
| | - Eddy H Carrillo
- From the Trauma Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL (Parreco, Solomon, Rosenthal, Carrillo)
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20
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Levy S, Bassler J, Gagnon K, Prados M, Jeziorski M, McCleskey B, Crockett K, Li L, Bradford D, Cropsey K, Eaton E. Methamphetamines and Serious Injection-Related Infections: Opioid Use Care Continuum and Opportunities to End Alabama's Drug Crisis. Open Forum Infect Dis 2022; 10:ofac708. [PMID: 36726543 PMCID: PMC9879754 DOI: 10.1093/ofid/ofac708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023] Open
Abstract
Background Increasingly, injection opioid use and opioid use disorder (OUD) are complicated by methamphetamine use, but the impact of stimulant use on the care of people who inject drugs (PWID) with serious injection-related infections (SIRIs) is unknown. The objective of this study was to explore hospital outcomes and postdischarge trends for a cohort of hospitalized PWID to identify opportunities for intervention. Methods We queried the electronic medical record for patients hospitalized at the University of Alabama at Birmingham with injection drug use-related infections between 1/11/2016 and 4/24/2021. Patients were categorized as having OUD only (OUD), OUD plus methamphetamine use (OUD/meth), or injection of other substance(s) (other). We utilized statistical analyses to assess group differences across hospital outcomes and postdischarge trends. We determined the OUD continuum of care for those with OUD, with and without methamphetamine use. Results A total of 370 patients met inclusion criteria-many with readmissions (98%) and high mortality (8%). The majority were White, male, and uninsured, with a median age of 38. One in 4 resided outside of a metropolitan area. There were significant differences according to substance use in terms of sociodemographics and hospital outcomes: patients with OUD/meth were more likely to leave via patient-directed discharge, but those with OUD only had the greatest mortality. Comorbid methamphetamine use did not significantly impact the OUD care continuum. Conclusions The current drug crisis in AL will require targeted interventions to engage a young, uninsured population with SIRI in evidence-based addiction and infection services.
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Affiliation(s)
- Sera Levy
- Correspondence: Sera Levy, MS, Department of Psychiatry and Behavioral Neurobiology, Heersink School of Medicine, UAB, The University of Alabama at Birmingham, L107 Volker Hall, 1670 University Blvd, Birmingham, AL 35233 ()
| | - John Bassler
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kelly Gagnon
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myles Prados
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Madison Jeziorski
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brandi McCleskey
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kaylee Crockett
- Department of Family and Community Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Li Li
- Department of Psychiatry, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Davis Bradford
- Department of Internal Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Karen Cropsey
- Department of Psychiatry and Behavioral Neurobiology, Heersink School of Medicine, UAB, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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21
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de Jager E, Gunnarsson R, Ho YH. Self-discharge as a marker of surgical cultural competency and cultural safety for Aboriginal and/or Torres Strait Islander patients. ANZ J Surg 2022; 93:807-809. [PMID: 36582020 DOI: 10.1111/ans.18238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 12/15/2022] [Accepted: 12/18/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Elzerie de Jager
- College of Medicine and Dentistry, The James Cook University, Townsville, Queensland, Australia
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, the Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden.,Research, Education, Development & Innovation, Primary Health Care, Västra Götaland Region, Sweden.,Primary Health Care Center for Homeless People, Närhälsan, Västra Götaland Region, Sweden
| | - Yik-Hong Ho
- College of Medicine and Dentistry, The James Cook University, Townsville, Queensland, Australia.,Townsville Clinical School, The Townsville Hospital, Townsville, Queensland, Australia
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22
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Kwei-Nsoro R, Ojemolon P, Laswi H, Ebhohon E, Shaka A, Mir WA, Siddiqui AH, Philipose J, Shaka H. Rates, Reasons, and Independent Predictors of Readmissions in Portal Venous Thrombosis Hospitalizations in the USA. Gastroenterology Res 2022; 15:253-262. [PMID: 36407807 PMCID: PMC9635786 DOI: 10.14740/gr1561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/09/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT), generally considered rare, is becoming increasingly recognized with advanced imaging. Limited data exist regarding readmissions in PVT and its burden on the overall healthcare cost. This study aimed to outline the burden of PVT readmissions and identify the modifiable predictors of readmissions. METHODS The National Readmission Database (NRD) was used to identify PVT admissions from 2016 to 2019. Using the patient demographic and hospital-specific variables within the NRD, we grouped patient encounters into two cohorts, 30- and 90-day readmission cohorts. We assessed comorbidities using the validated Elixhauser comorbidity index. We obtained inpatient mortality rates, mean length of hospital stay (LOS), total hospital cost (THC), and causes of readmissions in both 30- and 90-day readmission cohorts. Using a multivariate Cox regression analysis, we identified the independent predictors of 30-day readmissions. RESULTS We identified 17,971 unique index hospitalizations, of which 2,971 (16.5%) were readmitted within 30 days. The top five causes of readmissions in both 30-day and 90-day readmission cohorts were PVT, sepsis, hepatocellular cancer, liver failure, and alcoholic liver cirrhosis. The following independent predictors of 30-day readmission were identified: discharge against medical advice (AMA) (adjusted hazard ratio (aHR) 1.86; P = 0.002); renal failure (aHR 1.44, P = 0.014), metastatic cancer (aHR 1.31, P = 0.016), fluid and electrolyte disorders (aHR 1.20, P = 0.004), diabetes mellitus (aHR 1.31, P = 0.001) and alcohol abuse (aHR 1.31, P ≤ 0.001). CONCLUSION The readmission rate identified in this study was higher than the national average and targeted interventions addressing these factors may help reduce the overall health care costs.
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Affiliation(s)
- Robert Kwei-Nsoro
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA,Corresponding Author: Robert Kwei-Nsoro, Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60612, USA.
| | - Pius Ojemolon
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Hisham Laswi
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Ebehiwele Ebhohon
- Department of Internal Medicine, Lincoln Medical Center, Bronx, NY, USA
| | - Abdultawab Shaka
- Department of Medicine, Windsor University School of Medicine, St. Kitts
| | - Wasey Ali Mir
- Department of Pulmonary and Critical Care, St. Elizabeth Medical Center, Brighton, MA, USA
| | | | - Jobin Philipose
- Department of Digestive Health, Mountain View Regional Medical Center, Las Cruces, NM, USA
| | - Hafeez Shaka
- Division of General Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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Kirchberg TN, Costantini TW, Santorelli J, Doucet JJ, Godat LN. Predictors of Readmission Following Treatment for Traumatic Hemothorax. J Surg Res 2022; 277:365-371. [DOI: 10.1016/j.jss.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
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Coombes J, Hunter K, Bennett-Brook K, Porykali B, Ryder C, Banks M, Egana N, Mackean T, Sazali S, Bourke E, Kairuz C. Leave events among Aboriginal and Torres Strait Islander people: a systematic review. BMC Public Health 2022; 22:1488. [PMID: 35927686 PMCID: PMC9354286 DOI: 10.1186/s12889-022-13896-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Leave events are a public health concern resulting in poorer health outcomes. In Australia, leave events disproportionally impact Aboriginal and Torres Strait Islander people. A systematic review was conducted to explore the causes of leave events among Aboriginal and Torres Strait Islander people and strategies to reduce them. METHODS A systematic review was conducted using Medline, Web of Science, Embase and Informit, a database with a strong focus on relevant Australian content. Additionally, we examined the references of the records included, and performed a manual search using Google, Google scholar and the Australia's National Institute for Aboriginal and Torres Strait Islander Health Research. Two independent reviewers screened the records. One author extracted the data and a second author reviewed it. To appraise the quality of the studies the Mixed Methods Appraisal Tool was used as well as the Aboriginal and Torres Strait Islander Quality Appraisal Tool. A narrative synthesis was used to report quantitative findings and an inductive thematic analysis for qualitative studies and reports. RESULTS We located 421 records. Ten records met eligibility criteria and were included in the systematic review. From those, four were quantitative studies, three were qualitative studies and three reports. Five records studied data from the Northern Territory, two from Western Australia, two from New South Whales and one from Queensland. The quantitative studies focused on the characteristics of the patients and found associations between leave events and male gender, age younger than 45 years and town camp residency. Qualitative findings yielded more in depth causes of leave events evidencing that they are associated with health care quality gaps. There were multiple strategies suggested to reduce leave events through adapting health care service delivery. Aboriginal and Torres Strait Islander representation is needed in a variety of roles within health care provision and during decision-making. CONCLUSION This systematic review found that multiple gaps within Australian health care delivery are associated with leave events among Aboriginal and Torres Strait Islander people. The findings suggest that reducing leave events requires better representation of Aboriginal and Torres Strait Islander people within the health workforce. In addition, partnership with Aboriginal and Torres Strait Islander people is needed during the decision-making process in providing health services that meet Aboriginal and Torres Strait Islander cultural needs.
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Affiliation(s)
- J Coombes
- The George Institute for Global Health, Newtown, Australia.
| | - K Hunter
- The George Institute for Global Health, Newtown, Australia
- The University of New South Wales, Sydney, Australia
| | | | - B Porykali
- The George Institute for Global Health, Newtown, Australia
| | - C Ryder
- The George Institute for Global Health, Newtown, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - M Banks
- Australian Commission On Safety and Quality in Health Care, Sydney, Australia
| | - N Egana
- Australian Commission On Safety and Quality in Health Care, Sydney, Australia
| | - T Mackean
- The George Institute for Global Health, Newtown, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - S Sazali
- The George Institute for Global Health, Newtown, Australia
| | - E Bourke
- The George Institute for Global Health, Newtown, Australia
| | - C Kairuz
- The George Institute for Global Health, Newtown, Australia
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Waite MR, Diab S, Adefisoye J. Virtual Behavioral Health Treatment Satisfaction and Outcomes Across Time. J Patient Cent Res Rev 2022; 9:158-165. [PMID: 35935523 PMCID: PMC9302910 DOI: 10.17294/2330-0698.1918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023] Open
Abstract
Purpose The COVID-19 pandemic continues to have major and long-lasting impacts on health care delivery and mental health. As health care shifted to telehealth, legislation was adjusted to expand telehealth allowances, creating a unique opportunity to elucidate outcomes. The aim of this study was to assess long-term patient and clinician satisfaction and outcomes with virtual behavioral health. Methods Data were obtained over 16 months from surveys to patients and clinicians receiving/providing virtual treatment. Outcomes data also were collected from medical records of adults receiving in-person and virtual behavioral health treatment. Data were summarized using descriptive statistics. Groups were compared using various chi-squared tests for categorical variables, Likert response trends over time, and conditional independence, with Wilcoxon rank-sum or Jonckheere trend test used to assess continuous variables. P-values of ≤0.05 were considered statistically significant. Results Patients gave high ratings to virtual treatment and indicated a preference for virtual formats. Both patient and clinician preference for virtual visits increased significantly with time, and many clinicians perceived virtual services to be equally effective to in-person. Virtual programs had higher completion rates, attendance rates, and number of treatment visits, suggesting that virtual behavioral health had equivalent or better outcomes to in-person treatment and that attitudes toward telehealth changed over time. Conclusions If trends found in this study continue, telehealth may emerge as a preferred option long term This is important considering the increase in mental health needs associated with the COVID-19 pandemic and the eventuality that in-person restrictions ease as the pandemic subsides.
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Affiliation(s)
- Mindy R. Waite
- Aurora Behavioral Health Services, Advocate Aurora Health, Wauwatosa, WI
- Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI
| | - Sara Diab
- Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - James Adefisoye
- Aurora University of Wisconsin Medical Group, Advocate Aurora Health, Milwaukee, WI
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Sex Differences in Characteristics of Patients with Infective Endocarditis: A Multicenter Study. J Clin Med 2022; 11:jcm11123514. [PMID: 35743584 PMCID: PMC9224802 DOI: 10.3390/jcm11123514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/11/2022] [Accepted: 06/15/2022] [Indexed: 11/17/2022] Open
Abstract
Infectious diseases like infective endocarditis (IE) may manifest or progress differently between sexes. This study sought to identify the differences in demographic and clinical characteristics among male and female patients with IE. Data were obtained from a newly developed registry comprising all adult patients with first IE admission at the four major tertiary cardiovascular centers in West Virginia, USA during 2014−2018. Patient characteristics were compared between males and females using Chi-square test, Fisher’s exact test, and Wilcoxon rank-sum test. A secondary analysis was restricted to IE patients with drug use only. Among 780 unique patients (390 males, 390 females), significantly more women (a) were younger than males (median age 34.9 vs. 41.4, p < 0.001); (b) reported drug use (77.7% vs. 64.1%, p < 0.001); (c) had tricuspid valve endocarditis (46.4% vs. 30.8%, p < 0.001); and (d) were discharged against medical advice (20% vs. 9.5%, p < 0.001). These differences persisted even within the subgroup of patients with drug use-associated IE. In a state with one of the highest incidences of drug use and overdose deaths, the significantly higher incident IE cases in younger women and higher proportion of women leaving treatment against medical advice are striking. Differential characteristics between male and female patients are important to inform strategies for specialized treatment and care.
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Methadone treatment and patient-directed hospital discharges among patients with opioid use disorder: Observations from general medicine services at an urban, safety-net hospital. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100066. [PMID: 36845982 PMCID: PMC9949313 DOI: 10.1016/j.dadr.2022.100066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/13/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
Introduction People with opioid use disorder (OUD) have high rates of discharge against medical advice from the hospital. Interventions for addressing these patient-directed discharges (PDDs) are lacking. We sought to explore the impact of methadone treatment for OUD on PDD. Methods Using electronic record and billing data from an urban safety-net hospital, we retrospectively examined the first hospitalization on a general medicine service for adults with OUD from January 2016 through June 2018. Associations with PDD compared to planned discharge were examined using multivariable logistic regression. Administration patterns of maintenance therapy versus new in-hospital initiation of methadone were examined using bivariate tests. Results During the study time period, 1,195 patients with OUD were hospitalized. 60.6% of patients received medication for OUD, of which 92.8% was methadone. Patients who received no treatment for OUD had a 19.1% PDD rate while patients initiated on methadone in-hospital had a 20.5% PDD rate and patients on maintenance methadone during the hospitalization had a 8.6% PDD rate. In multivariable logistic regression, methadone maintenance was associated with lower odds of PDD compared to no treatment (aOR 0.53, 95% CI 0.34-0.81), while methadone initiation was not (aOR 0.89, 95% CI 0.56-1.39). About 60% of patients initiated on methadone received 30 mg or less per day. Conclusions In this study sample, maintenance methadone was associated with nearly a 50% reduction in the odds of PDD. More research is needed to assess the impact of higher hospital methadone initiation dosing on PDD and if there is an optimal protective dose.
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Alao MA, Ibrahim OR, Ogunbosi BO, Nna EO, Olapegba PO. Effectiveness of Faith-Based Interventions on the Rate of Discharged Against Medical Advice in Tertiary Newborn Units in Nigeria: A Protocol for an Open Label Randomized Control Trial. Front Public Health 2022; 9:788383. [PMID: 35178371 PMCID: PMC8843870 DOI: 10.3389/fpubh.2021.788383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Discharged against medical advice (DAMA) is a risk factor that often leads to adverse outcomes and hospital readmissions in neonatal units. A few studies have shown that spiritual/faith-based interventions (FBIs) tend to have a lower incidence of DAMA compared with public hospitals. Perhaps, a holistic approach to patient care that addresses the spiritual needs, the soul and the body component of a being in this setting may account for the observed lower incidence of DAMA. Limited randomized control trials (RCTs) exist on FBIs with regard to DAMA in the published literature. This study seeks to compare the effectiveness of FBI, social support, religiosity, and types of FBI on neonatal DAMA against standard of care in tertiary hospitals in Nigeria. METHODS This RCT will be conducted in two public tertiary teaching hospitals in two of the six geopolitical zones in Nigeria. The sociodemographic and clinical details of all patients admitted to the neonatal wards during the study period will be documented. Study participants will be selected through a multistage sampling technique. Subjects will be randomized and allocated to treatment and control arms having the established baseline measure of social support and religiosity. Ethical approval was obtained from the State Research Ethics Review Committee. A written informed consent will be obtained from the parents/caregivers prior to patient enrolment. The study will be conducted in line with the Declaration of Hesinki 2000. Appropriate statistical tools will be used for data collection and analysis. DISCUSSION The outcome of this analysis will give insights into the effectiveness of FBI on DAMA. It will also predict the effect of the mediators of parents/caregivers' religiosity, spirituality, forms of FBI, the religious sect of parents/caregivers, and social support on the rate of DAMA on neonatal admission in tertiary hospitals in Nigeria. This could help Public Health Institutions and Governments make decisions about the determinants of neonatal DAMA and how to mitigate such outcomes. It is hoped that the evidence from this study may guide policy formulation and guidelines on enhancing hospital retention of sick neonates until they are fit for discharge. TRIAL REGISTRATION This study was registered at the Pan Africa Clinical Trial Registry (PACTR202102670906630).
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Affiliation(s)
- Michael Abel Alao
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
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Pergolizzi JV, Magnusson P, Christo PJ, LeQuang JA, Breve F, Mitchell K, Varrassi G. Opioid Therapy in Cancer Patients and Survivors at Risk of Addiction, Misuse or Complex Dependency. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2022; 2:691720. [PMID: 35295520 PMCID: PMC8915703 DOI: 10.3389/fpain.2021.691720] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/13/2021] [Indexed: 12/21/2022]
Abstract
A clinical conundrum can occur when a patient with active opioid use disorder (OUD) or at elevated risk for the condition presents with cancer and related painful symptoms. Despite earlier beliefs that cancer patients were relatively unaffected by opioid misuse, it appears that cancer patients have similar risks as the general population for OUD but are more likely to need and take opioids. Treating such patients requires an individualized approach, informed consent, and a shared decision-making model. Tools exist to help stratify patients for risk of OUD. While improved clinician education in pain control is needed, patients too need to be better informed about the risks and benefits of opioids. Patients may fear pain more than OUD, but opioids are not always the most effective pain reliever for a given patient and some patients do not tolerate or want to take opioids. The association of OUD with mental health disorders (dual diagnosis) can also complicate delivery of care as patients with mental health issues may be less adherent to treatment and may use opioids for “chemical coping” as much as for pain control.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research & Development, Uppsala University, Uppsala, Sweden.,Department of Medicine, Cardiology Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Paul J Christo
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Frank Breve
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, United States
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Dunlop WA, Secombe PJ, Agostino JW, van Haren FMP. Characteristics and outcomes of Aboriginal and Torres Strait Islander patients with dialysis-dependent kidney disease in Australian intensive care units. Intern Med J 2022; 52:458-467. [PMID: 33012108 DOI: 10.1111/imj.15077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/04/2020] [Accepted: 09/27/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND In Australia, 531 people per million population have dialysis-dependent chronic kidney disease (CKD5D). The incidence is four times higher for Aboriginal and Torres Strait Islander (indigenous) people compared with non-Indigenous Australians. CKD5D increases the risk of hospitalisation, admission to the intensive care unit (ICU) and mortality compared with patients without CKD5D. There is limited literature describing short-term outcomes of patients with CKD5D who are admitted to the ICU, comparing indigenous and non-indigenous patients. AIMS This registry-based retrospective cohort analysis compared demographic and clinical data between indigenous and non-indigenous patients with CKD5D and tested whether indigenous status predicted short-term outcomes independently of other contributing factors. Adjusted hospital mortality was the primary outcome measure. METHODS Data were from the Australian and New Zealand Intensive Care Society's Centre for Outcome and Resource Evaluation Adult Patient Database. Australian ICU admissions between 2010 and 2017 were included. Data from 173 ICU (2136 beds) include 1 051 697 ICU admissions, of which 23 793 had a pre-existing diagnosis of CKD5D. RESULTS Indigenous patients comprised 11.9% of CKD5D patients in ICU. CKD5D was prevalent among 4.9% of indigenous and 2.9% of non-indigenous ICU admissions. Indigenous patients were 13.5 years younger, had fewer comorbidities and lower crude mortality despite equivalent calculated mortality risk. After adjusting for age, remoteness and severity of illness, indigenous status did not predict mortality. CONCLUSIONS Socioeconomic disadvantage contributes to earlier development of CKD5D and the overrepresentation in ICU of indigenous people. Mortality is equivalent once correcting for confounders, but addressing inequality requires strengthening preventative care.
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Affiliation(s)
- William A Dunlop
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Paul J Secombe
- Intensive Care Unit, Central Health Service, Alice Springs, Northern Territory, Australia
| | - Jason W Agostino
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Frank M P van Haren
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
- Intensive Care Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
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Brothers TD, Mosseler K, Kirkland S, Melanson P, Barrett L, Webster D. Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis. PLoS One 2022; 17:e0263156. [PMID: 35081174 PMCID: PMC8791472 DOI: 10.1371/journal.pone.0263156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. METHODS Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. RESULTS We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. CONCLUSIONS Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.
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Affiliation(s)
- Thomas D. Brothers
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- UCL Collaborative Centre for Inclusion Heath, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Kimiko Mosseler
- Dalhousie Medicine New Brunswick, Dalhousie University, Saint John, New Brunswick, Canada
| | - Susan Kirkland
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patti Melanson
- Mobile Outreach Street Health (MOSH), Halifax, Nova Scotia, Canada
| | - Lisa Barrett
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Infectious Diseases, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Duncan Webster
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Infectious Diseases, Saint John Regional Hospital and Dalhousie University, Saint John, New Brunswick, Canada
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Appa A, Adamo M, Le S, Davis J, Winston L, Doernberg SB, Chambers H, Martin M, Hills NK, Coffin P, Jain V. Patient-Directed Discharges Among Persons Who Use Drugs Hospitalized with Invasive Staphylococcus aureus Infections: Opportunities for Improvement. Am J Med 2022; 135:91-96. [PMID: 34508704 PMCID: PMC11552656 DOI: 10.1016/j.amjmed.2021.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite the high burden of Staphylococcus aureus infections among persons who use drugs, limited data exist comparing outcomes of patient-directed discharge (known as discharge against medical advice) compared with standard discharge among persons who use drugs hospitalized with S. aureus infection. METHODS We conducted a retrospective study of hospitalizations among adults with S. aureus bacteremia, endocarditis, epidural abscess, or vertebral osteomyelitis at 2 San Francisco hospitals between 2013 and 2018. We compared odds of 1-year readmission for infection persistence or recurrence and 1-year mortality via multivariable logistic regression models adjusting for age, sex, Charlson comorbidity index, and homelessness. RESULTS Overall, 80 of 340 (24%) of hospitalizations for invasive S. aureus infections among persons who use drugs involved patient-directed discharge. More than half of patient-directed discharges 41 of 80 (51%) required readmission for persistent or recurrent S. aureus infection compared with 54 of 260 (21%) patients without patient-directed discharge (adjusted odds ratio 3.8, 95% confidence interval [CI] 2.2-6.7). One-year cumulative mortality was 15% after patient-directed discharge compared with 11% after standard discharge (P = .02); however, this difference was not significant after adjustment for mortality risk factors. More than half of deaths in the patient-directed discharge group (7 of 12, 58%) were due to drug overdose; none was due to S. aureus infection. CONCLUSIONS Among persons who use drugs hospitalized with invasive S. aureus infection, odds of hospital readmission for infection were almost 4-fold higher following patient-directed discharge compared with standard discharge. All-cause 1-year mortality was similarly high in both groups, and drug overdose was a common cause of death in patient-directed discharge group.
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Affiliation(s)
- Ayesha Appa
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco.
| | - Meredith Adamo
- Department of Medicine, University of California San Francisco, San Francisco
| | - Stephenie Le
- Department of Medicine, University of California San Francisco, San Francisco
| | - Jennifer Davis
- Department of Medicine, University of California San Francisco, San Francisco
| | - Lisa Winston
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco
| | - Sarah B Doernberg
- Division of Infectious Diseases, University of California, San Francisco, San Francisco
| | - Henry Chambers
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco
| | - Marlene Martin
- Department of Medicine, University of California San Francisco, San Francisco
| | - Nancy K Hills
- Department of Medicine, University of California San Francisco, San Francisco
| | - Phillip Coffin
- San Francisco Department of Public Health, San Francisco, Calif
| | - Vivek Jain
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco
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Eaton EF. We Thought We Created a Safety Net. We Were Wrong. Clin Infect Dis 2021; 73:e1658-e1660. [PMID: 32881991 DOI: 10.1093/cid/ciaa1291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/01/2020] [Indexed: 01/28/2023] Open
Affiliation(s)
- Ellen F Eaton
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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Bongiovanni T, Hernandez S, Ledesma Y, Menza R, Wick E, Steinman M, Mackersie R, Stein DM, Coffin PO. Surviving traumatic injury, only to die of acute drug poisoning: Should trauma centers be a path for intervention? Surgery 2021; 170:1249-1254. [PMID: 33867166 PMCID: PMC11637652 DOI: 10.1016/j.surg.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/21/2021] [Accepted: 03/01/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although death from drug overdose is a leading cause of injury-related death in the United States, its incidence after traumatic incident is unknown. Moreover, little is known about related risk factors. We sought to determine the incidence and characteristics of and risk factors for trauma patients suffering death by acute drug poisoning ("overdose") after hospitalization for a traumatic incident. METHODS We conducted a retrospective chart review of all admitted trauma patients ≥18 y of age at the only level-1 trauma center in our region from 2012 to 2019, matched with unintentional overdose decedents from the California death registry. We assessed associations between demographic and clinical characteristics with risk of overdose death, using cumulative incidence functions and Fine-Gray subdistribution hazard models. RESULTS Of 9,860 patients residing in San Francisco, CA, USA, at the time of their trauma activation or admission during the study period, 1,418 died (4.3 per 100 person-years), 107 from unintentional overdose (0.3 per 100 person-years). Overdose decedents were 84% male, 50% white, with a mean age of 48 years at the time of presentation; 20% of deaths occurred within 3 months of hospitalization, and 40% were attributed to a prescription opioid. In multivariate analysis, younger age, male sex, white race, and having undergone a urine drug screening were all associated with subsequent death from overdose. CONCLUSION During a mean 3.4-year follow-up, the mortality rate from overdose among adult patients with traumatic incidents was 0.3/100 person-years. Trauma hospitalization may serve as an opportunity to screen and initiate prevention, harm reduction, and treatment interventions.
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Affiliation(s)
- Tasce Bongiovanni
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA; San Francisco General Hospital, Trauma and Acute Care Surgery, San Francisco, CA.
| | - Sophia Hernandez
- University of California San Francisco School of Medicine, San Francisco, CA. https://twitter.com/SEHernandezz
| | - Yeranui Ledesma
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA
| | - Rebecca Menza
- San Francisco General Hospital, Trauma and Acute Care Surgery, San Francisco, CA. https://twitter.com/MenzaNP
| | - Elizabeth Wick
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA
| | - Michael Steinman
- University of California San Francisco School of Medicine, San Francisco, CA; San Francisco VA Medical Center, Division of Geriatrics, San Francisco, CA. https://twitter.com/MikeSteinman
| | - Robert Mackersie
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA; San Francisco General Hospital, Trauma and Acute Care Surgery, San Francisco, CA
| | - Deborah M Stein
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA; San Francisco General Hospital, Trauma and Acute Care Surgery, San Francisco, CA
| | - Phillip O Coffin
- University of California San Francisco School of Medicine, San Francisco, CA; San Francisco Department of Public Health, San Francisco, CA
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Askew DA, Foley W, Kirk C, Williamson D. "I'm outta here!": a qualitative investigation into why Aboriginal and non-Aboriginal people self-discharge from hospital. BMC Health Serv Res 2021; 21:907. [PMID: 34479571 PMCID: PMC8414851 DOI: 10.1186/s12913-021-06880-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Occasions of self-discharge from health services before being seen by a health profession or against medical advice are often used by health systems as an indicator of quality care. People self-discharge because of factors such as dissatisfaction with care, poor communication, long waiting times, and feeling better in addition to external factors such as family and employment responsibilities. These factors, plus a lack of cultural safety, and interpersonal and institutional racism contribute to the disproportionately higher rates of Indigenous people self-discharging from hospital. This qualitative study aimed to increase understanding about the causative and contextual factors that culminate in people self-discharging and identify opportunities to improve the hospital experience for all. METHODS Semi-structured interviews with five Aboriginal and/or Torres Strait Islander (hereafter, respectfully, Indigenous) people and six non-Indigenous people who had self-discharged from a major tertiary hospital in Brisbane, Australia, were audio-recorded, transcribed and thematically analysed. RESULTS Study participants all respected hospitals' vital role of caring for the sick, but the cumulative impact of unmet needs created a tipping point whereby they concluded that remaining in hospital would compromise their health and wellbeing. Five key categories of unmet needs were identified - the need for information; confidence in the quality of care; respectful treatment; basic comforts; and peace of mind. Although Indigenous and non-Indigenous participants had similar unmet needs, for the former, the deleterious impact of unmet needs was compounded by racist and discriminatory behaviours they experienced while in hospital. CONCLUSIONS Respectful, empathetic, person-centred care is likely to result in patients' needs being met, improve the hospital experience and reduce the risk of people self-discharging. For Indigenous people, the ongoing legacy of white colonisation is embodied in everyday lived experiences of interpersonal and institutional racism. Racist and discriminatory behaviours experienced whilst hospitalised are thus rendered both more visible and more traumatic, and exacerbate the deleterious effect of unmet needs. Decreasing self-discharge events requires a shift of thinking away from perceiving this as the behaviour of a deviant individual, but rather as a quality improvement opportunity to ensure that all patients are cared for in a respectful and person-centred manner.
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Affiliation(s)
- Deborah A Askew
- Primary Care Clinical Unit, The University of Queensland, Royal Brisbane & Women's Hospital, Level 8, Health Sciences Building, Qld, 4029, Brisbane, Australia.
- Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care, Metro South Hospital and Health Service, 37 Wirraway Parade, 4077, Inala, Qld, Australia.
| | - Wendy Foley
- Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care, Metro South Hospital and Health Service, 37 Wirraway Parade, 4077, Inala, Qld, Australia
| | - Corey Kirk
- Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care, Metro South Hospital and Health Service, 37 Wirraway Parade, 4077, Inala, Qld, Australia
| | - Daniel Williamson
- Aboriginal and Torres Strait Islander Health Division, Queensland Health, 33 Charlotte Street, Qld, 4001, Brisbane, Australia
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Holmes EG, Cooley BS, Fleisch SB, Rosenstein DL. Against Medical Advice Discharge: A Narrative Review and Recommendations for a Systematic Approach. Am J Med 2021; 134:721-726. [PMID: 33610522 DOI: 10.1016/j.amjmed.2020.12.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 11/26/2022]
Abstract
Approximately 1%-2% of hospitalizations in the United States result in an against medical advice discharge. Still, the practice of discharging patients against medical advice is highly subjective and variable. Discharges against medical advice are associated with physician distress, patient stigma, and adverse outcomes, including increased morbidity and mortality. This review summarizes discharge against medical advice research, proposes a definition for against medical advice discharge, and recommends a standard approach to a patient's request for discharge against medical advice.
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Affiliation(s)
- Emily G Holmes
- Department of Psychiatry, Indiana University, Indianapolis.
| | | | | | - Donald L Rosenstein
- Departments of Psychiatry and Medicine, University of North Carolina, Chapel Hill
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Tong B, Osborne C, Horwood CM, Hakendorf PH, Woodman RJ, Li JY. The prevalence, characteristics, and risk factors of frequently readmitted patients to an internal medicine service. Intern Med J 2021; 52:1561-1568. [PMID: 34031965 DOI: 10.1111/imj.15395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/07/2021] [Accepted: 04/24/2021] [Indexed: 11/28/2022]
Abstract
AIMS To determine the prevalence, characteristics and risk factors associated with frequent readmissions to an internal medicine service at a tertiary public hospital. METHOD A retrospective observational study was conducted at an internal medicine service in a tertiary teaching hospital between 1st January 2010 and the 30th June 2016. Frequent readmission was defined as four or more readmissions within 12 months of discharge from the index admission. Demographic and clinical characteristics, and potential risk factors were evaluated. RESULTS 50 515 patients were included, 1657 (3.3%) had frequent readmissions and were associated with nearly 2.5 times higher in 12-month mortality rates. They were older, had higher rates of Indigenous Australians (3.2%), more disadvantaged status (Index of Relative Socio-Economic Disadvantage decile of 5.3), and more comorbidities (mean Charlson comorbidity index 1.4) in comparison, to infrequent readmission group. The mean length of hospital stay during the index admission was 6 days for frequent readmission group (21.4% staying more than 7 days) with higher incidence of discharge against medical advice (2.0% higher). Intensive care unit admission rate was 6.6% for frequent readmission group compared to 3.9% for infrequent readmission group. Multivariate analysis showed mental disease and disorders, neoplastic, and alcohol/drug use and alcohol/drug induced organic mental disorders are associated with frequent readmission. CONCLUSION The risk factors associated with frequent readmission were older age, indigenous status, being socially disadvantaged, having higher comorbidities, and discharging against medical advice. Conditions that lead to frequent readmissions were mental disorders, alcohol/drug use and alcohol/drug induced organic mental disorders, and neoplastic disorders.
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Affiliation(s)
- Bcy Tong
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia
| | - Cdi Osborne
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia
| | - C M Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, Adelaide, South Australia
| | - P H Hakendorf
- Department of Clinical Epidemiology, Flinders Medical Centre, Adelaide, South Australia
| | - R J Woodman
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia.,Centre for Epidemiology and Biostatistics, College of Medicine & Public Health, Flinders University, Adelaide, South Australia
| | - J Y Li
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia.,Department of Renal Medicine, Flinders Medical Centre, Adelaide, South Australia
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Eaton EF, Vettese T. Management of Opioid Use Disorder and Infectious Disease in the Inpatient Setting. Infect Dis Clin North Am 2021; 34:511-524. [PMID: 32782099 DOI: 10.1016/j.idc.2020.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acute bacterial infections such as endocarditis and skin and soft tissue infections are a common cause of hospitalization among persons with opioid use disorder (OUD). These interactions with acute care physicians provide an opportunity to diagnose OUD and treat patients with medications for OUD, including buprenorphine. When available, Addiction Medicine Consultation can be effective at linking patients to addiction treatment and also engaging patients in care for acute bacterial infections. In health systems without access to addiction medicine experts, infectious diseases providers, hospitalists, and other clinicians serve a valuable role in the diagnosis and treatment of OUD.
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Affiliation(s)
- Ellen F Eaton
- Division of Infectious Disease, University of Alabama at Birmingham, 845 19th Street South, Birmingham, AL 35205, USA.
| | - Theresa Vettese
- Division of General Medicine and Geriatrics, Emory University School of Medicine, 49 Jesse Hill Drive, Atlanta, GA 30303, USA.
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Lin Z, Han H, Wu C, Wei X, Ruan Y, Zhang C, Cao Y, He J. Discharge Against Medical Advice in Acute Ischemic Stroke: the Risk of 30-Day Unplanned Readmission. J Gen Intern Med 2021; 36:1206-1213. [PMID: 33559060 PMCID: PMC8131431 DOI: 10.1007/s11606-020-06366-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Discharge against medical advice may be associated with more readmissions. OBJECTIVE To evaluate DAMA in patients with acute ischemic stroke (AIS) and identify the relationship between DAMA and 30-day unplanned readmissions. DESIGN A retrospective cohort study. PARTICIPANTS The National Readmission Database was used to identify inpatients with a primary diagnosis of AIS who were either discharged home or DAMA between 2010 and 2017 in the USA. MEASURES Demographic features, hospital type, comorbidities, stroke risk factors, severity indices, and treatments were compared between patients discharged routinely and DAMA. Multivariable logistic regression was used to evaluate predictors of DAMA, and a double robust inverse probability of treatment weighting method was used to assess the association between DAMA and 30-day unplanned readmissions. KEY RESULTS Overall, 1,335,484 patients with AIS were included, of whom 2.09% (n = 27,892) were DAMA. The prevalence of DAMA in AIS patients increased from 1.65 in 2010 to 2.57% in 2017. The rates of 30-day unplanned readmissions for DAMA and non-DAMA patients were 16.81% and 7.78%, respectively. Patients with drug abuse, alcohol abuse, smoking, prior stroke, psychoses, and intravenous thrombolysis had greater odds of DAMA. DAMA was associated with all-cause readmissions (OR, 2.04; 95% CI, 2.01-2.07) and remained a strong predictor for transient ischemic attack/stroke-specific and cardiac-specific causes of readmissions. CONCLUSIONS Although the DAMA rate is low in AIS patients, DAMA is a risk factor for all-cause and recurrent stroke-specific readmissions. Future studies are needed to address issues around compliance and engagement with health care to reduce DAMA.
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Affiliation(s)
- Zhen Lin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Hedong Han
- Department of Health Statistics, Second Military Medical University, Shanghai, China
- Department of Respiratory and Critical Care Medicine , Jinling Hospital Nanjing University School of Medicine , 210002, Nanjing, China
| | - Cheng Wu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Xin Wei
- Department of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Yiming Ruan
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Chenxu Zhang
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China.
- Tongji University School of Medicine, Shanghai, China.
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A qualitative assessment of discharge against medical advice among patients hospitalized for injection-related bacterial infections in West Virginia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 94:103206. [PMID: 33765516 DOI: 10.1016/j.drugpo.2021.103206] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The incidence of infective endocarditis (IE) and other systemic bacterial infections is increasing, and people who inject drugs (PWID) have higher rates of discharge against medical advice (AMA) for these infections than patients whose infections are not injection-related. In this study, we characterize factors that contribute to AMA hospital discharge among PWID. METHODS We conducted qualitative interviews with twenty PWID hospitalized with serious injection-related bacterial infections in West Virginia. Participants completed a brief survey and in-depth qualitative interview. Interviews were recorded and transcribed verbatim and analyzed using a codebook developed based on deductive and inductive thematic analysis. We also conducted medical records abstraction and used descriptive statistics to summarize medical and survey data. RESULTS Average age was 34 years, 55% were female, 95% identified as white, and 75% had a primary diagnosis of IE. Drugs injected prior to hospitalization were methamphetamine (60%), prescription opioids (38%), and/or heroin/fentanyl (25%). Participants cited multiple contributors to AMA discharge including negative interactions with hospital staff that they perceived as stigmatizing, including being searched or monitored for illicit drug use; inadequate management of pain and withdrawal; boredom and confinement during lengthy hospitalizations; and isolation from family and other social supports. CONCLUSION We identified multiple factors contributing to AMA discharge that are amenable to intervention. Given the significant morbidity, mortality, and financial costs associated with hospitalizing PWID for serious injection-related bacterial infections, hospitals should be highly motivated to develop and test interventions designed to improve outcomes among these patients.
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Eaton EF, Lee RA, Westfall AO, Mathews RE, McCleskey B, Paddock CS, Lane PS, Cropsey KL. An Integrated Hospital Protocol for Persons With Injection-Related Infections May Increase Medications for Opioid Use Disorder Use but Challenges Remain. J Infect Dis 2021; 222:S499-S505. [PMID: 32877555 DOI: 10.1093/infdis/jiaa005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hospital-based strategies that link persons with infectious complications of opioid use disorder (OUD) to medications for OUD (MOUD) are of great interest. The objective of this study is to determine whether a hospital-based protocol would increase the use of MOUD and to identify barriers to MOUD during admission and at the time of discharge. METHODS This study included participants with a documented or suspected history of injection drug usage receiving care for an infection at the University of Alabama at Birmingham Hospital from 2015 to 2018. The protocol, the intravenous antibiotic and addiction team (IVAT), included Addiction Medicine and Infectious Diseases consultation and a 9-item risk assessment. We quantified MOUD use before and after IVAT and used logistic regression to determine factors associated with MOUD. We explored barriers to MOUD uptake using chart review. RESULTS A total of 37 and 98 patients met criteria in the pre- and post-IVAT periods, respectively. With IVAT, the percentage with OUD receiving MOUD significantly increased (29% pre-IVAT and 37% post-IVAT; P = .026) and MOUD use was higher in "high risk" participants (62%). Clinical and sociodemographic factors were not associated with MOUD receipt. CONCLUSIONS A hospital-based protocol may increase the use of MOUD; however, the uptake of MOUD remains suboptimal (<50%).
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Affiliation(s)
- Ellen F Eaton
- Department of Medicine, Division of Infectious Diseases University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rachael A Lee
- Department of Medicine, Division of Infectious Diseases University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew O Westfall
- Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - R E Mathews
- Department of Medicine, Division of Hospital Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brandi McCleskey
- Department of Pathology, Division of Forensics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cayce S Paddock
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter S Lane
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Karen L Cropsey
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Ben Natan M, Zeevi S, Goldschmid N. Patients Who Leave the Emergency Department Before Treatment Completion: A Retrospective Cohort Study. J Emerg Med 2021; 61:82-88. [PMID: 33648784 DOI: 10.1016/j.jemermed.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/05/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients leaving the emergency department (ED) before treatment completion (LBTC) is a common universal occurrence. We hypothesized that the characteristics of the Israeli health care system, as well as its policy, intended to reduce the burden of nonurgent ED visits, may have an impact on factors associated with LBTC. OBJECTIVES The purpose of this study was to explore factors associated with LBTC in the Israeli context. METHODS This was a retrospective cohort study of patients who visited the ED in a major hospital located in northern-central Israel during 2016-2019. Characteristics of 130 randomly sampled LBTC patients and of 130 non-LBTC patients that constituted the control group, were compared. Odds ratios (OR) are presented. RESULTS A low-acuity triage score (OR 8.18, p < 0.01) and a longer length of stay (OR 1.15, p < 0.01) were found to be risk factors for LBTC, and female gender (OR 0.40, p < 0.01) was found to be a protective factor. In contrast, age and nationality were not found as risk factors. Significant differences were found between the two groups with regard to the main presenting complaint. However, both groups had similar rates of presentations with a psychiatric condition. Approximately half of the LBTC patients presented at times when primary clinics were active. CONCLUSIONS These findings reflect the strengths of the Israeli health care system. Despite the policy intended to reduce the burden of nonurgent ED visits, there are possible shortcomings in the system that should be addressed.
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Affiliation(s)
- Merav Ben Natan
- Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel
| | - Suzy Zeevi
- The Risk Management Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Nimrod Goldschmid
- The Risk Management Unit, Hillel Yaffe Medical Center, Hadera, Israel
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Rouhbakhsh Halvaei S, Sheikh Motahar Vahedi H, Ahmadi A, Mousavi MS, Parsapoor A, Sima AR, Shojaei AA, Shamsi-Gooshki E. Rate and causes of discharge against medical advice from a university hospital emergency department in Iran: an ethical perspective. J Med Ethics Hist Med 2021; 13:15. [PMID: 33532044 PMCID: PMC7816543 DOI: 10.18502/jmehm.v13i15.4391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022] Open
Abstract
Discharge against medical advice (DAMA) is a common problem in the health-care system. It imposes risks to both patients and medical staff and could be the subject of ethical deliberation. This cross-sectional study was conducted in 2017 on 400 patients who were discharged against medical advice from the emergency ward of Shariati Hospital, Tehran, Iran. Patients’ information was collected using clinical records and telephone calls. The collected data were analyzed using STATA software. DAMA rate was 12% in the emergency department of Shariati Hospital. Male gender was found to be a risk factor for DAMA (OR: 1.90; CI (95%): 1.44 - 2.52; P < 0.0001). In addition, younger patients were more likely to leave hospital against medical advice (p-value: 0.04). The more common reasons for DAMA were feeling better, long delay in diagnostic and therapeutic procedures and the hectic ambience of the emergency ward. Patients’ self-discharge is a multi-dimensional phenomenon that is affected by patients’ characteristics, medical conditions and hospital circumstances. It raises some ethical concerns, mainly due to a conflict between patients’ autonomy and beneficence. It is helpful for the medical staff to create an effective relationship with patients who are at higher risk of DAMA, in order to increase their compliance and prevent the consequences of leaving hospital against medical advice.
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Affiliation(s)
| | - Hojat Sheikh Motahar Vahedi
- Associate Professor, Shariati Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ayat Ahmadi
- Assistant Professor, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Sadat Mousavi
- Medical Ethics Supervisor, Medical Ethics and Professionalism Office, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Parsapoor
- Assistant Professor, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Medical Ethics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Reza Sima
- Assistant Professor, Digestive Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Ahmad Shojaei
- Assistant Professor, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Medical Ethics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Shamsi-Gooshki
- Assistant Professor, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Medical Ethics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Akanbi O, Adejumo AC, Soliman M, Kudaravalli P. Chronic Pancreatitis Patients Who Leave Against Medical Advice: Prevalence, Trend, and Predictors. Dig Dis Sci 2021; 66:424-433. [PMID: 32361924 DOI: 10.1007/s10620-020-06279-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 04/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Leaving against medical advice (LAMA) is an unfortunate occurrence in 1-2% of all hospitalized patients and is associated with worse outcomes. While this has been investigated across multiple clinical conditions, studies on patients with chronic pancreatitis (CP) are lacking. We aimed to determine the prevalence and determinants of this event among patients with CP. METHODS The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS), 2007-2014, was used in the study. Patients with LAMA were identified, and the temporal trend of LAMA was estimated and compared among patients with and without CP. We then extracted patients with a discharge diagnosis of CP from the recent years of HCUP-NIS (2012-2014) and described the characteristics of LAMA in these patients. Multivariate logistic regression models were used to evaluate predictors of LAMA. RESULTS 3.39% of patients with CP discharged against medical advice. LAMA rate in CP patients was higher and increased more steeply at quadruple the rate of those without. More likely to self-discharge were patients who were young, males, non-privately insured, or engaged in alcohol and substance abuse, likewise were those with psychosis and those admitted on a weekend or non-electively. The northeast and for-profit hospitals also had higher odds of LAMA. However, patients transferred from other healthcare facilities have reduced LAMA odds. Among all patients with CP, those with LAMA had shorter length of stay (2.74 [2.62-2.85] days vs. 5.78 [5.71-5.83] days) and lower hospitalization cost $23,271 [$22,171-$24,370] versus $45,472 [$44,381-$46,562] compared to the no-LAMA group. CONCLUSION LAMA occurs in approximately 1 in 29 patients with CP and is increasing at almost quadruple the rate of those without. Clinicians need to pay closer attention to the identified at-risk groups for ameliorative targeted interventions.
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Affiliation(s)
- Olalekan Akanbi
- Department of Medicine, Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA.
| | - Adeyinka Charles Adejumo
- Department of Medicine, North Shore Medical Center, Salem, MA, USA
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Mohanad Soliman
- Department of Medicine, Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
| | - Praneeth Kudaravalli
- Department of Medicine, Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
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Albayati A, Douedi S, Alshami A, Hossain MA, Sen S, Buccellato V, Cutroneo A, Beelitz J, Asif A. Why Do Patients Leave against Medical Advice? Reasons, Consequences, Prevention, and Interventions. Healthcare (Basel) 2021; 9:healthcare9020111. [PMID: 33494294 PMCID: PMC7909809 DOI: 10.3390/healthcare9020111] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/09/2021] [Accepted: 01/19/2021] [Indexed: 11/26/2022] Open
Abstract
Background: A patient decides to leave the hospital against medical advice. Is this an erratic eccentric behavior of the patient, or a gap in the quality of care provided by the hospital? With a significant and increasing prevalence of up to 1–2% of all hospital admissions, leaving against medical advice affects both the patient and the healthcare provider. We hereby explore this persistent problem in the healthcare system. We searched Medline and PubMed within the last 10 years, using the keywords “discharge against medical advice,” “DAMA,” “leave against medical advice,” and “AMA.” We retrospectively reviewed 49 articles in our project. Ishikawa fishbone root cause analysis (RCA) was employed to explore reasons for leaving against medical advice (AMA). This report presents the results of the RCA and highlights the consequences of discharge against medical advice (DAMA). In addition, the article explores preventive strategies, as well as interventions to ameliorate leaving AMA.
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Marco CA, Gupta K, Lubov J, Jamison A, Murray BP. Hyperthermia associated with methamphetamine and cocaine use. Am J Emerg Med 2021; 42:20-22. [PMID: 33429187 DOI: 10.1016/j.ajem.2020.12.083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America.
| | - Kunal Gupta
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
| | - Janet Lubov
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
| | - Aisha Jamison
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
| | - Brian Patrick Murray
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
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Lewer D, Jones NR, Hickman M, Larney S, Ezard N, Nielsen S, Degenhardt L. Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: A cohort study and nested crossover-cohort analysis. Drug Alcohol Depend 2020; 217:108343. [PMID: 33122155 PMCID: PMC7736124 DOI: 10.1016/j.drugalcdep.2020.108343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/09/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND People who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice. METHODS We conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission. RESULTS 14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76-0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76-0.93; p < 0.001) times the risk of discharge against medical advice. CONCLUSIONS Among patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk.
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Affiliation(s)
- Dan Lewer
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia; Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 7HB, UK.
| | - Nicola R Jones
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS2 8DZ, UK
| | - Sarah Larney
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia; University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, Quebec H3T 1J4, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Canada
| | - Nadine Ezard
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia; Alcohol and Drug Service, St Vincent's Hospital, Sydney, NSW, Australia; National Centre for Clinical Research in Emerging Drugs, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia
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Gilmartin CE, Milman O, Leung L. Postpartum contraceptive planning of women with substance abuse disorders. Int J Clin Pharm 2020; 43:1006-1014. [PMID: 33236276 DOI: 10.1007/s11096-020-01209-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Women with substance abuse disorders have lower use of contraception. Unplanned pregnancies increase risk of fetal exposure to addictive and teratogenic substances. Postpartum inpatient periods for these women can be challenging times to facilitate contraception planning. OBJECTIVE To explore postnatal contraceptive planning practices, patient preferences for contraception, and supply challenges, and to identify how clinical pharmacists may best provide care in this context. SETTING A tertiary maternity referral hospital in metropolitan Victoria, Australia (January 2015-December 2018). METHOD A retrospective cohort study was conducted on postnatal women with substance abuse disorders. Patients were excluded if they had delivered at another health service, had inadequate documented evidence of a substance abuse disorder, or had incomplete or unavailable medical records. Records were reviewed for demographic data, admission details, and documented contraceptive planning. MAIN OUTCOME MEASURES Documented contraceptive planning, patient contraception preferences and identified supply challenges. RESULTS Ninety-three women were included. Seventy-one (76.3%) had psychiatric disorders or impairments, and 92 (98.9%) had identifiable follow-up challenges (eg. Homelessness). Nine (9.7%) self-discharged/absconded. Eighty-seven (93.5%) had documented postnatal contraception discussions. Sixty-two of 87 (71.3%) considered a medicine/device, three (3.4%) preferred condoms, 10 (11.5%) considered sterilisation, 2 (2.3%) preferred no contraception, and 16 (18.4%) undecided. Etonogestral 68 mg implants were most commonly prescribed (28 of 42; 66.7%). CONCLUSION Inpatient postpartum periods for this cohort were characterised by psycho-social complexities, inconsistent contraceptive planning documentation, and patients seemingly unprepared to consider contraception. This study highlights a need for an earlier decision-making process and pragmatic counselling with antenatal pharmacists.
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Affiliation(s)
- Christine E Gilmartin
- The Royal Women's Hospital Pharmacy Department, The Royal Women's Hospital, Parkville, Victoria, Australia.
| | - Oran Milman
- The Royal Women's Hospital Pharmacy Department, The Royal Women's Hospital, Parkville, Victoria, Australia.,Hawke's Bay Hospital, Hastings, New Zealand
| | - Laura Leung
- The Royal Women's Hospital Pharmacy Department, The Royal Women's Hospital, Parkville, Victoria, Australia
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Leaving Against Medical Advice After Emergency General Surgery: Avoiding a Two-Hit Effect. J Surg Res 2020; 257:278-284. [PMID: 32866668 DOI: 10.1016/j.jss.2020.06.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/04/2020] [Accepted: 06/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Emergency general surgery has higher adverse outcomes than elective surgery. Patients leaving the hospital against medical advice (AMA) have a greater risk for readmission and complications. We sought to identify clinical and demographic characteristics along with hospital factors associated with leaving AMA after EGS operations. METHODS A retrospective review of the Nationwide Inpatient Sample was performed. All patients who underwent an EGS procedure accounting for >80% of the burden of EGS-related inpatient resources were identified. 4:1 propensity score analysis was conducted. Regression analyses determined predictive factors for leaving AMA. RESULTS 546,856 patients were identified. 1085 (0.2%) patients who underwent EGS left AMA. They were more likely to be men (59% versus 42%), younger (median age 51 y, IQR [37.61] versus 54, IQR [38.69]), qualify for Medicaid (26% versus 13%) or be self-pay (17% versus 9%), and be within the lowest quartile median household income (40% versus 28%) (all P < 0.05). After applying 4:1 propensity score matching, individuals who were self-pay (OR 3.15, 95% CI 2.44-4.06) or insured through Medicare (OR 2.75, 95% CI 2.11-3.57) and Medicaid (OR 3.58, 95% CI 2.83-4.52) had increased odds of leaving AMA compared with privately insured patients. In addition, history of alcohol (OR 2.21, 95% CI 1.65-2.98), drug abuse (OR 4.54, 95% CI 3.23-6.38), and psychosis (OR 2.31, 95% CI 1.65-3.23) were associated with higher likelihood for leaving AMA. CONCLUSIONS Patients undergoing EGS have a high risk of complications, and leaving AMA further increases this risk. Interventions to encourage safe discharge encompassing surgical, psychiatric, and socioeconomic factors are warranted to prevent a two-hit effect and compound postoperative risk.
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Raja A, Trivedi PD, Dhamoon MS. Discharge against medical advice among neurological patients: Characteristics and outcomes. Health Serv Res 2020; 55:681-689. [PMID: 32578887 DOI: 10.1111/1475-6773.13306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To study characteristics and outcomes of patients with stroke, traumatic brain injury (TBI), and epilepsy with discharge against medical advice (DAMA). DATA SOURCES/STUDY SETTING Retrospective analysis of the 2013 Nationwide Readmissions Database, a nationally representative inpatient administrative dataset. STUDY DESIGN Associations between predictors and DAMA at index admission were analyzed using adjusted logistic models. We examined 30-day all-cause readmissions. DATA COLLECTION METHODS Patients aged ≥18 years at index admission for International Classification of Diseases-9 diagnosis code of epilepsy, TBI, or stroke were included. PRINCIPAL FINDINGS Discharge against medical advice occurred in 1998/58278 patients (3.43 percent) in the epilepsy group, 1762/211 213 (0.83 percent) in the stroke group, and 1289/74 652 (1.73 percent) in the TBI group. Factors consistently associated with increased likelihood of DAMA included lower age, male sex, non-Medicare and nonprivate insurance, lower socioeconomic status, and behavioral risk factors (smoking history, alcohol history, and drug use). The crude 30-day all-cause readmission rate for those with DAMA from their index admission was 16.4 percent for the stroke cohort, 13.9 percent for epilepsy, and 13.4 percent for TBI. DAMA at index admission was significantly associated with increased risk of 30-day all-cause readmission among all groups (adjusted odds ratio 1.79, 95% CI: 1.65-1.94, P < .0001). CONCLUSIONS Age, sex, insurance status, socioeconomic status, and behavioral factors were associated with DAMA in neurological patients. Further research is needed to develop interventions to reduce DAMA in high-risk groups.
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Affiliation(s)
- Aishwarya Raja
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York
| | - Parth D Trivedi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York
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