Improving Equity at Premature Discharge: Reframing Discharge Against Medical Advice Using the Structural Competency...

Area of Science:

• Medical Sociology
• Health Equity
• Patient-Provider Communication

Background:

• Discharge against medical advice (AMA) presents a complex clinical challenge, often marked by power imbalances, blame, and conflicting priorities between patients and healthcare providers.
• Patients leaving AMA face significant stigma, including negative staff interactions, inadequate symptom management, discriminatory documentation, and substandard discharge care.
• AMA discharge is frequently viewed as individual patient choice, overlooking the influence of broader societal factors, prior experiences, and competing patient priorities.

Discussion:

• Socioeconomic status, insurance, and housing status are key social determinants linked to AMA discharge, exacerbating poor health outcomes and perpetuating stigma.
• Structural competency (SC) offers a framework to understand health and illness as outcomes of societal structures, shifting focus from individual blame.
• Applying SC to AMA discharge can reframe the scenario, mitigating patient blame and fostering more equitable, patient-centered care practices.

Key Insights:

• AMA discharge is a high-risk encounter influenced by systemic inequities and patient-provider dynamics.
• Stigma associated with AMA discharge negatively impacts patient care and health outcomes.
• Structural competency provides a novel approach to address systemic drivers of AMA and promote equitable care.

Outlook:

• Integrating structural competency into medical education can equip providers to better manage AMA discharges.
• Reimagining AMA discharge protocols through a structural lens can lead to improved patient experiences and outcomes.
• Further research is needed to develop and evaluate SC-based interventions for reducing AMA rates and associated stigma.