Introduction

The prevalence of discharge against medical advice (DAMA) ranges from 1% to 2% in inpatient admissions and may reach up to 25.9% in some hospitals [1]. These rates vary across different departments and are reported to range from 0.7% to 2.2% in general medical admissions, from 6% to 54% in case of admissions for psychiatric causes, and 0.9% in emergent ones [2-4]. Furthermore, the DAMA rate is highly variable according to the hospital type with reported rates of 0.3% to 2.2% in public hospitals [5-8], 1% in small rural ones [9], and up to 25.9% in other hospitals (teaching, private, and non-profit hospitals) [10-12]. Male gender, lack of health insurance, drug/alcohol addiction, mental health issues, and younger age have all been identified as predictors for higher DAMA rates [3,13-16]. The decision of DAMA was found to be made by patients’ relatives in 58.4% of the cases, while 40.7% of DAMA decisions have been made by the patients themselves [17,18]. This is evidence of the significance of family members’ effect on the DAMA prevalence rate, whether within in-patient or emergency settings [17,18].

Emergency care plays a crucial role in the healthcare process by preserving patients’ lives [19]. DAMA is usually alarming since it usually means the patient is leaving too soon and some expected adverse outcomes may follow with discharge [13]. This is evident by higher readmission rates in DAMA patients, mostly due to the same reason for initial admission or at least a related cause [17,18]. It was found that 32% of DAMA patients will be readmitted within the first month following discharge, compared to only a 12% readmission rate for the patients with regular discharges [20]. Moreover, about 28% of the DAMA patients will be readmitted for the same (or related) cause, compared to only 8% of the regularly discharged ones [21]. These readmission rates differ among countries; a Canadian study has estimated readmission rates at 10% [10], while rates of 0.8%-2.2% have been reported in the United States [5], 6.2% in Australia [22], 20% in Iranian emergency setting [23], 6% in Italy [24], 0.72% in Nigeria [25], and 3.7%-24.4% in other countries [26,27].

In the same context, DAMA would have a negative impact on medical care with higher resource utilization, higher accumulating financial burden, and exhausting the healthcare providers’ method [17,18,28]. A subsequent straining of the healthcare provider-patient relationship may be caused by DAMA in case of readmission [18,29]. An increase in healthcare costs has been reported to be up to 56% in both patients and the medical system [30,31]. In Australia, the total cost of 8.6$ million was estimated as a result of DAMA every year [32]. Therefore, the aim of this study was to investigate the causes and predictors of DAMA in patients referred to the emergency care setting.

Methods

Results

Discussion

DAMA is a serious problem that encounters physicians with varying prevalence among hospital departments [7]. The ethical dilemma between discharging the patient without completing full investigations or treatment is still a major concern among primary care providers [57,59]. Leaving the hospital against medical advice requires a consent signature from the patient, as DAMA is associated with negative consequences, such as the increase in the readmission rates and mortality in severe cases without completing adequate treatment [60]. Patients admitted to emergency departments usually have critical illnesses; therefore, understanding the etiologic origin and the predictive factors are of paramount interest for limiting the phenomenon of DAMA in emergency departments that are associated with worse outcomes in most cases.

Table 2. Study characteristics.

TEDP = total emergency department patients; DAMA = discharged against medical advice; # = range; * = median.

Figure 2. Forest plot of DAMA prevalence rate and associated 95% CI.

Figure 3. Prevalence rates of different DAMA causes and associated 95% CI.

The prevalence of DAMA in the emergency department was 6.3% in our study, which was similar to the retrospective cohort study of Ba et al. [45], where the prevalence of DAMA in the Chinese emergency department was 6.6% [45]. However, the prevalence of DAMA was lower than our study in the two Korean reports conducted by Lee et al. [46] and Jeong et al. [47] estimating a prevalence of 2.78% and 2.8%, respectively. A higher prevalence of DAMA was reported by a retrospective cohort study that recruited Indian geriatric populations revealing a prevalence of 12.8% [49]. Moreover, Jung et al. [48] demonstrated a higher prevalence of DAMA in Korean patients after self-inflicted injury or attempted suicide revealing a prevalence of 22.8%. The difference in the prevalence of DAMA in the included studies can be explained by several hypotheses. The difference in the care systems among different countries plays an important role in the heterogeneity of DAMA prevalence [61]. Moreover, patients with terminal stages of the disease or estimated to have a poor prognosis have a higher prevalence of DAMA compared to their peers of early disease stage [48,49]. Additionally, the difference in the characteristics of patients constitutes an important factor that affects the patients’ choice of leaving against medical advice [50-52].

Figure 4. Prevalence rates of one-time reported DAMA causes and associated 95% CI.

Addressing the causes of DAMA constitutes the key part of it is prevention. Shorter time of hospital stay is favored for limiting the consequences induced by the long hospital stay; therefore, patients prefer to take the risk of DAMA to avoid hazards of long hospital admission [62]. In our study, not being content with the treatment or not agreeing with the diagnosis or treatment, long waiting time, and financial problems were the most common causes driving DAMA. In a retrospective cohort study conducted by Ibekwe et al. [26] on Nigerian children, financial obligations were the most common cause for DAMA request, the decision was obtained from their caregivers as children cannot take their own decision. Abuzeyad et al. [56] indicated that improved health conditions, followed by the long waiting time, was the most common causes of DAMA in Bahrainis patients. No reason mentioned, incomplete workup, and refusing admission were reported by El Sayed et al. [52], as the common reasons for DAMA decision.

Several factors were associated with an increase in the prevalence of DAMA. Moy et al. [63] reported that African American race, young age, male gender, drug, and alcohol-related diagnoses were associated with an elevation in the odds of DAMA. Moreover, certain comorbidities were associated with DAMA rather than controls, such as neurologic disorders, alcoholism, and psychiatric illness [60]. In our study, male gender, younger ages, and local and regional emergency centers were significant predictors for DAMA. Similar observations were reported by the case-control study of Weingart et al. [64]. Those patients preferred to choose DAMA than hospital admission due to many reasons. The predicted long duration of hospital stay plays a substantial role in increasing the rates of DAMA because of the low financial levels in addition to the absence of insurance [53,54]. Moreover, the sense of wellbeing drives DAMA decision in those patients [52,53]. Furthermore, patients who commit DAMA were significantly influenced by familial and work obligations and immediate cure of the disease [55].

In the same context, the process of discharging somebody against medical advice requires a physician-patient discussion of risks, benefits, and alternatives, as well as demonstrating that the patient has capacity to understand the decision. For that, the efficiency of medical staff and hospital environment should be considered in this regard. According to many studies in the literature, physicians and nurses’ quality of medical service had the highest impact on patients’ choice of DAMA [19,65,66]. Although the medical staff expected to provide a comprehensive overview to patients to make the right decision, Noohi et al. [19] found that most of the patients in their study did not have the adequate information about the side effects and outcomes of DAMA decision. Another study showed that most of the patients were discharged with their physician’s order [67]. Additionally, patients’ good relationship with the medical staff was recorded as a main factor helping to reduce the rates of DAMA [68]. Inadequate information among patients about the side effects and outcomes of their decision may be driven by the heavy workload of emergency staff, lack of medical staff knowledge/attention to the problem, and deficient manpower.

Figure 5. OR and associated 95% CI of DAMA predictors. (A) Unadjusted factors and (B) adjusted factors.

Our study should be interpreted with several limitations. Firstly, due to the inclusion of retrospective cohort studies in our study, selection bias could not be avoided. Secondly, significant heterogeneity was observed which stems from the different characteristics of the included populations regarding mean age, sex, occupation, financial levels, educational levels, and the country of the included patients. Finally, including three papers form Korea, out of 14 included ones, may bias the results.

Conclusion

DAMA prevalence in emergency departments is high. More attention should be devoted to those patients in relation to the possible DAMA causes for decreasing negative consequences resulted from committing DAMA.

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.

Funding

None.

Consent for publication

Not applicable.

Ethical approval

Not applicable.

Author details

Theeb Ayedh Alkahtani¹, Asaad Shujaa²

1. Bioethicist, Potion CRO, Integrative Medicine Company, Riyadh, Kingdom of Saudi Arabia
2. Lead of Research at Johns Hopkins Aramco Health Care Centre, Consultant of Emergency Medicine, ICU, Trauma, EMS and Disaster Medicine, Johns Hopkins Aramco Health Care Centre, Saudi Arabia Assistant Professor at Weill Cornell Medical College, USA

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