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Shifts in Demographics and Characteristics Among Patients Leaving Against Medical Advice From Before, During, and
Aaron Shaykevich1, David Yagudayev1, Jamie Romeiser1
1Public Health and Preventative Medicine, State University of New York Upstate Medical University, Syracuse, USA.
Insights
Discharges against medical advice (AMA) increased among socially disadvantaged and minority patients post-COVID-19, with longer hospital stays and more ICU departures. Targeted interventions are needed to improve trust and outcomes.
Area of Science:
- Public Health
- Health Services Research
- Epidemiology
Background:
- Discharges against medical advice (AMA) are linked to adverse patient outcomes, including readmission and mortality.
- The COVID-19 pandemic potentially influenced public trust in healthcare, impacting patient decisions regarding AMA discharges.
- Understanding demographic shifts in AMA discharges is crucial for public health interventions.
Purpose of the Study:
- To analyze changes in the demographic and clinical characteristics of patients discharged against medical advice (AMA) before, during, and after the COVID-19 pandemic.
- To identify temporal associations between the COVID-19 pandemic and the profile of patients with AMA discharges.
- To inform targeted strategies for reducing AMA discharges and improving patient outcomes.
Main Methods:
- Retrospective cohort study of 1,560 adult inpatients discharged AMA.
- Analysis of three distinct time periods: pre-COVID-19, during COVID-19, and post-COVID-19.
- Bivariate and multinomial logistic regression analyses of demographic variables, Social Deprivation Index (SDI), and comorbidities.
Main Results:
- Increased proportion of Black patients among AMA discharges during the COVID-19 period compared to pre-pandemic.
- Extended hospital length of stay prior to AMA discharge observed during and after the pandemic.
- Higher Social Deprivation Index (SDI) scores associated with AMA discharges in the post-COVID-19 period.
- Significant increase in AMA discharges originating from the Intensive Care Unit (ICU) after the pandemic.
Conclusions:
- The COVID-19 pandemic is temporally associated with shifts in the determinants of AMA discharges.
- Patients discharged AMA post-pandemic are more likely to be socially disadvantaged, from minority backgrounds, have longer hospital stays, and leave from the ICU.
- There is a need for targeted interventions to enhance patient trust and support, particularly in vulnerable populations, to mitigate AMA discharges and improve health outcomes.
Introduction:
Discharges against medical advice (AMA) present a significant public health challenge and are associated with increased readmission and mortality rates. The COVID-19 pandemic altered the healthcare landscape regarding public trust in the United States, which may have impacted the demographic and clinical profile of patients with AMA discharges. The aim of this study is to identify potential changes in the demographics of AMA discharges before, during, and after the COVID-19 pandemic at a large academic medical center. Methods: This non-interventional retrospective cohort study included adult inpatients (n = 1,560) discharged AMA during three time periods: pre-COVID-19, during COVID-19, and post COVID-19. Demographic variables, the Social Deprivation Index (SDI), and comorbidities were analyzed via bivariate analysis and subsequently via multinomial logistic regression. Results: During COVID-19, Black patients made up a larger portion of AMA discharges compared to before the pandemic. The length of hospital stay before leaving AMA increased during and after the pandemic (43.1% discharged within two days before COVID-19, compared to 40.7% during the pandemic and 28.3% after the pandemic). In the post-COVID-19 period, AMA discharges were associated with higher SDI scores (M = 72.05 (SD = 28.67)) compared to before and during COVID-19 (M = 68.03 (SD = 29.43) before, 67.71 (SD = 29.87) during). Patients were also more likely to stay longer before leaving AMA than during COVID-19. Additionally, the frequency of AMA discharges originating from the ICU increased significantly following the resolution of the pandemic.
Conclusion:
The determinants of AMA discharges have a temporal association with the COVID-19 pandemic. Findings suggest that patients leaving AMA are now more likely to be socially disadvantaged, from minority backgrounds, to have longer hospital stays, and to be leaving directly from the ICU. Targeted interventions to improve patient trust and support in these populations are needed to reduce AMA discharges and improve outcomes.
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