Editor's Choice


Seizure 2021, Vol 84, Editor’s Choice: A nationally representative study on discharge against medical advice among those living with epilepsy

Previous studies suggest that around 3% epilepsy patients leave hospital against medical advice [1]. Seizures are one of the three most common symptoms leading to emergency room presentations which ultimately end in Discharge Against Medical Advice (DAMA) [2]. DAMA gets in the way of proper discharge planning, may lead to medication errors, repeated seizures and other poor health outcomes. It is therefore no surprise that patients who decide to leave hospital prematurely are at strongly increased risk of being re-admitted to hospital within 30 days [1]. Not least because of the high risk of re-admission, DAMA also represents a financial challenge for health and social care systems.

My Editor’s Choice from the current volume of Seizure is an original research paper by Parul Agarwal et al. [3], which seeks to explore the causes and predictors of DAMA. Their study uses the National Inpatient Sample (NIS) for the years 2003 to 2014. The NIS includes all inpatient discharges across 44 states and the District of Columbia, representing more than 96% of the U.S. population. It is a nationally representative database maintained by the Agency for Healthcare Research and Quality. The large case numbers and the availability of data spanning a period 12 years allow detailed exploration and the exploration of temporal trends. For the purpose of their analysis, Agarwal et al. split the available sample of inpatient admissions into those that ended in DAMA vs. those where the final discharge occurred with the clinicians’ approval.

The figures from 2014 provide an impression of the size of the problem: Out of 7,071,762 admissions, 187,850 were coded as related to epilepsy, 3,783 of whom (2.01%) were identified as ending in DAMA. Of the variables which distinguished between the two outcomes in univariate analyses, a number of predictors continued to make a significant contribution to a multivariate model: Blacks had higher odds of DAMA than Whites (AOR = 1.12, 95% CI = 1.02, 1.22, p = 0.02), admissions of patients from poorer households were more likely to end in DAMA (adjusted OR (AOR) = 1.90; 95% CI = 1.65, 2.18; p<0.0001), more Medicaid than Medicare (AOR = 2.14; 95% CI = 1.93, 2.37; p<0.0001) and self-pay admissions (AOR = 3.99; 95% CI = 3.47, 4.59; p<0.0001) admissions were associated with DAMA. Weekend admissions ended in DAMA more commonly than weekday admissions (AOR = 1.17; 95% CI = 1.08, 1.26; p<0.0001). A lower risk of DAMA was associated with older age (AOR = 0.991; 95% CI = 0.989, 0.993; p<0.0001), higher levels of comorbidity (AOR =0.97; 95% CI = 0.96, 0.97; p<0.0001), female sex (AOR = 0.67; 95% CI = 0.62, 0.71; p<0.0001), Hispanic extraction (AOR = 0.74; 95% CI = 0.64, 0.86; p<0.0001), elective admissions (AOR = 0.34; 95% CI= 0.28, 0.42; p<0.0001), and hospital location in the Midwest (AOR = 0.57; 95% CI = 0.49, 0.69; p<0.0001) compared to the Northeast US.

Although epilepsy patients whose admissions ended with DAMA had fewer comorbidities overall, some specific comorbidities (including alcohol and drug abuse disorders as well as mood disorders) were associated with an increased risk of DAMA. Alcohol-related disorders were among the top 5 causes of admission in people with epilepsy who left against medical advice.

The proportion of epilepsy-related admissions ending in DAMA increased substantially between 2003 and 2014 (from 1.13% to 2.01%, p<0.0001).

While the findings of this study can only provide an initial impression of the causes and predictors, the potential of DAMA to fragment care provision, to put patients at risk and waste limited health care resources are so obvious that this study should serve as a wake-up call not only to health but also to social service providers. Especially the near doubling of DAMA since 2003 is deeply troubling. Further research into what actually motivates patients to leave hospital against medical advice is urgently required. The largely social risk factors identified in this study suggest that DAMA is not simply an ending of one particular episode of inpatient care but an expression of a much more profound estrangement between patients with epilepsy and those providing medical care for them.

References:

1) Raja A, Trivedi P D, Dhamoon M S. Discharge against medical advice among neurological patients: Characteristics and outcomes. Health Services Research 2020, 55:681-689.

2) Hoyer C, Stein P, Alonso,A. et al. Uncompleted emergency department care and discharge against medical advice in patients with neurological complaints: a chart review. BMC emergency medicine 2019 (19) 52, doi.org/10.1186/s12873-019-0273-y

3) Agarwal P, Xi H, Jette N, Lin J-Y, Kwon C-S, Dhamoon MS, Mazumdar M. A Nationally Representative Study on Discharge against Medical Advice among those Living with Epilepsy. Seizure 2021 84:84-90.

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