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The Role of Socioeconomic Status in Individuals that Leave Against Medical Advice
Sharleen Yuan1, Sarah Ashmore1, Kaushal R Chaudhary2
1University of South Dakota Sanford School of Medicine, Vermillion, South Dakota.
Insights
Individuals lacking insurance or with public insurance face higher risks of leaving against medical advice (AMA). Targeted interventions are needed to reduce AMA discharges and improve patient care.
Area of Science:
- Health Services Research
- Health Economics
- Patient Safety
Background:
- Leaving against medical advice (AMA) is associated with increased mortality and healthcare costs.
- Failure to complete treatment due to AMA discharge leads to higher readmission rates and comorbidities.
Purpose of the Study:
- To identify patient characteristics and socioeconomic factors associated with leaving against medical advice (AMA).
- To examine the impact of insurance status, income, and ethnicity on AMA discharge rates.
Main Methods:
- Retrospective analysis of the 2012 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database.
- Examined discharge type (AMA vs. non-AMA) against primary payer, patient, and hospital characteristics.
- Used weighted logistic regression analysis (Proc Surverylogistic) in SAS 9.4, with statistical significance set at p < 0.05.
Main Results:
- Lack of insurance (ORadj = 4.16), Medicare (ORadj = 2.10), and Medicaid (ORadj = 2.94) significantly increased odds of AMA discharge.
- Higher income groups showed a 20-30% decrease in AMA discharge compared to lower income groups.
- Hispanic (ORadj = 0.665) and Asian/Pacific Islander (ORadj = 0.56) groups had decreased odds of AMA discharge, while Black and Native American groups did not show increased risk compared to White individuals.
Conclusions:
- Individuals lacking insurance, with public insurance, or in the lowest income quartile are at higher risk for AMA discharge.
- While ethnicity plays a role, the disparities in AMA discharge rates may be less extreme than previously suggested.
- Healthcare providers need targeted preventative measures to address high-risk populations and improve patient care standards.
Introduction:
Individuals leaving against medical advice (AMA) are at risk for adverse health outcomes including a 40 percent increased mortality rate a year after self-discharge. Additionally, leaving AMA may dramatically increase medical costs due to failure to complete treatment resulting in higher risk of readmission with additional co-morbidities.
Methods:
Retrospective study of inpatients utilizing the Healthcare Cost and Utilization Project (HCUP) 2012 National Inpatient Sample (NIS) database. Primary outcome of interest was discharge type (AMA versus non-AMA) examined against primary payer type, patient and hospital characteristics. Analysis performed on the weighted discharges using Proc Surverylogistic. Statistical significance set at p less than 0.05. All analysis was performed in SAS version 9.4 (SAS Institute).
Results:
After adjustment for possible cofounders and socioeconomic factors, there were increased odds of leaving against medical advice in those that lacked insurance (ORadj = 4.16, p less than 0.001) or had Medicare (ORadj = 2.10, p less than 0.001) or Medicaid (ORadj = 2.94, p less than 0.001). Compared to individuals in the lower income brackets, groups with higher incomes had a 20-30 percent decrease in leaving AMA. However, in comparison to white individuals, black (ORadj = 1.023, p = 0.2688) and Native Americans (ORadj = 0.994, p=0.9322) were not at an increased risk of leaving AMA. Hispanic (ORadj = 0.665, p less than 0.001) and the Asian/Pacific Islander (ORadj = 0.56, p less than 0.001) groups had decreased odds of leaving AMA.
Conclusion:
Groups at risk for leaving AMA were individuals lacking insurance, having public insurance, and those within the 0-25th percentile in income. Although ethnicity does play a factor in leaving against medical advice, our data indicates that the gap is not as extreme as previously stated. Additional work needs to be done to help health care providers set targeted preventative measures to address those at increased risk for leaving AMA in order to provide a higher standard of care for the patient.
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