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Trends and predictors of leaving before medically advised in US emergency departments from 2016 to 2021
Yahya Alnashri1, Elena Andreyeva2, Theodoros V Giannouchos3
1Department of Family & Community Medicine, College of Medicine, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia; Department of Health Policy & Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, USA.
Insights
Leaving before medically advised (BMA) from emergency departments (EDs) is linked to insurance status, substance use, and male gender. The COVID-19 pandemic significantly increased BMA rates, underscoring the need for improved communication and triage.
Area of Science:
- Healthcare Management
- Public Health
- Emergency Medicine
Background:
- Leaving before medically advised (BMA) from emergency departments (EDs) is a critical issue in the U.S., causing poor health outcomes and escalating costs.
- Limited multi-year studies using recent nationwide ED data exist.
- This study investigates factors and temporal trends of BMA from EDs, including the impact of the COVID-19 pandemic.
Purpose of the Study:
- To identify demographic, socioeconomic, and clinical factors associated with leaving EDs before medical advice.
- To analyze trends in BMA from EDs over a six-year period (2016-2021).
- To assess the influence of the COVID-19 pandemic on BMA rates.
Main Methods:
- A pooled, cross-sectional study utilizing data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2021.
- Multivariable logistic regression was employed to determine factors associated with BMA.
- Interrupted time series (ITS) analyses were used to examine trends in BMA over time.
Main Results:
- Approximately 5.9 million (0.8%) out of 721.0 million ED visits resulted in BMA.
- Higher odds of BMA were associated with public or no insurance, alcohol/substance use disorders, ambulance arrival, and male gender.
- Conversely, hospital admissions and trauma/overdose visits showed lower odds of BMA.
- The COVID-19 pandemic significantly increased BMA rates by 53.6% post-March 2020.
Conclusions:
- Demographic, socioeconomic, and clinical factors significantly influence the incidence of leaving EDs before medical advice.
- The COVID-19 pandemic has demonstrably worsened BMA rates.
- Targeted interventions focusing on patient-provider communication and ED triage efficiency are crucial, particularly for facilities serving vulnerable populations.
Background:
Leaving before medically advised (BMA) is a significant issue in the US healthcare system, leading to adverse health outcomes and increased costs. Despite previous research, multi-year studies using up-to-date nationwide emergency department (ED) data, are limited. This study examines factors associated with leaving BMA from EDs and trends over time, before and during the COVID-19 pandemic.
Methods:
We conducted a pooled, cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2021. Multivariable logistic regression and interrupted time series (ITS) analyses were used to identify factors associated with leaving BMA and to examine trends over time, respectively.
Results:
Out of 721.0 million ED visits, 5.9 million (0.8 %) resulted in leaving BMA. Factors associated with higher odds of leaving BMA included public or no insurance coverage (Medicare: AOR = 1.74, 95 % CI = 1.12-2.70; Medicaid/CHIP/State-based: AOR = 1.86, 95 % CI = 1.40-2.45; Uninsured/Self-pay: AOR = 1.51, 95 % CI = 0.99-2.29), alcohol or substance use disorders (AOR = 2.19, 95 % CI = 1.77-2.70), arrival by ambulance (AOR = 1.68, 95 % CI = 1.31-2.15), and being male (AOR = 1.32, 95 % CI = 1.09-1.62). Conversely, hospital admissions (AOR = 0.11, 95 % CI = 0.05-0.21) and trauma or overdose related visits (AOR = 0.54, 95 % CI = 0.44-0.67) were associated with lower odds of leaving BMA. The COVID-19 pandemic significantly increased the odds of leaving BMA (AOR = 1.44, 95 % CI = 1.06-1.95), with an overall increase of 53.6 % in BMA-related ED visits observed post-March 2020 relatively to the previous years, particularly in the fourth quarters of 2020 and 2021 and second and third quarters of 2020.
Conclusions:
In this study, several demographics, socio-economic, and clinical characteristics were associated with higher incidences of leaving ED BMA. The COVID-19 pandemic also exacerbated BMA rates. These findings highlight the need for targeted interventions to improve patient-provider communication and ED triage efficiency, especially in resource-constrained facilities serving lower-income individuals.
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