Reasons for Discharge against Medical Advice: A Case Study of Emergency Departments in Iran

Document Type : Original Article

Authors

1 Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

2 Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

3 Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran

4 Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Background
Incomplete hospitalization is the cause of disease relapse, readmission, and increase in medical costs. Discharge Against Medical Advice (DAMA) in emergency department (ED) is critical for hospitals. This paper aims to explore the underlying reasons behind DAMA in ED of four teaching hospitals in Kerman, Iran.
 
Methods
This was a cross-sectional study in which the samples were drawn from the patients who chose to leave against medical advice from the ED of teaching hospitals in Kerman from February to March 2011. The sampling was based on census. Data were gathered by a self-constructed questionnaire. The reasons for DAMA were divided into three parts: reasons related to patient, medical staff, and hospital environment. The questionnaire was filled out by a face-to-face interview with patient or a reliable companion.
 
Results
There were 121 cases (5.6%) of DAMA out of the total admissions. The main reason of AMA discharges was related to patient factors in 43.9% of cases, while two other factors (i.e., hospital environment and medical staff) constituded 41.2% and 35.2% of cases, respectively. The majority of patients 65.9% (80 cases) were either uninformed or less informed of the entailing side effects and outcomes of their decision to DAMA. 
 
Conclusion
In comparison to studies conducted in other countries, the rate of DAMA is markedly higher in Iran. The results revealed that patients awareness of the consequences of their decisions is evidently inadequate. The study suggests a number of recommendations. These include, increasing patient awareness of the potential side effects of DAMA and creating the necessary culture for this, improving hospital facilities, and a more careful supervision of medical staff performance.

Keywords

Main Subjects

References

1. Malekmakan L, Haghpanah S, Moravej H, Sharifi M. [The Impact of Intervention on Patient’s Satisfaction In Emergency Departments of the Hospitals Affiliated to Shiraz University of Medical Sciences]. Journal of Jahrom University of Medical Sciences 2010; 7: 51–8.
2. Mackinley RK, Roberts C. Patient satisfaction with out of hours primary medical care. Qual Health Care 2001; 10: 23–8. doi: 10.1136/qhc.10.1.23
3. Carrese JA. Refusal of care: patient’s well-being and physicians ethical obligations; but doctor, I want to go home. JAMA 2006; 296: 691–5. doi: 10.1001/jama.296.6.691
4. Rangraz Jeddi F, Rangraz Jeddi M, Rezaeei Monfared M. [Discharge against medical advice in hospitals of Kashan University of Medical Sciences during 6 month of 2008]. Hakim Journal 2010; 13: 33–9.
5. Kabirzadeh A, Rezazadeh S, Mohseni Saravi B. [Frequency and causes of discharge with personal satisfaction in children of BouAli hospital in Sari 2009]. Journal of North Khorasan University of Medical Sciences 2011; 2: 57–62.
6. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ 2003; 168: 417–20.
7. David J, Alfandre MD. I’m Going Home: Discharges Against Medical Advice. Mayo Clin Proc 2009; 84: 255–60. doi: 10.4065/84.3.255
8. Saitz R, Ghali WA, Moskowitz MA. Characteristics of patients with pneumonia who are discharged from hospital against medical advice. Am J Med 1999; 107: 507–9.doi: 10.4065/84.3.255
9. Dalrymple AJ, Fata M. Cross-validating factors associated with discharges against medical advice. Can J Psychiatry 1993; 38: 285-9.
10. Vander Stoep A, Bohn P, Melville E. A model for predicting discharge against medical advice from adolescent residential treatment. Hosp Community Psychiatry 1991; 42: 725–8.
11. Baptist AP, Warrier I, Arora R, Ager J, Massanari MR. Hospitalized patients with asthma who leave against medical advice: Characteristics, reasons and outcomes. Allergy Clinl Immunol 2007; 119: 924–9. doi: 10.1016/j.jaci.2006.11.695
12. Ibekwe RC, Muoneke VU, Nnebe-Agumadu UH, Amadife MU. Factors influencing discharge against medical advice among pediatric patients in Abakaliki, Southeastern Nigeria. J Trop Pediatr 2009; 55: 39–41. doi: 10.1093/tropej/fmn100
13. Ibrahim SA, Kwoh KC, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health 2007; 97: 2204–7. doi: 10.2105/ajph.2006.100164
14. Fiscella K, Meldrum S, Barnett S. Hospital discharge against advice after myocardial infarction: Death and readmissions. Am J Med 2007; 120: 1047–53. doi: 10.1016/j.amjmed.2007.08.024
15. Taylor C, Lillis C, Lemone P. Fundamental of nursing: The art and science of nursing care. 4th ed. Philadelphia: J.B. Lippincott Co; 2004. doi: 10.1097/00003465-199001000-00006
16. Ashghly Farahani M, Mohammadi I, Ahmadi FA, Maleki M, Hajizadeh E. [Barriers to patient education in the CCU and post CCU: a grounded theory study]. Iran J Nurs 2009; 22: 55–73.
17. Skelton A. Evolution not revolution? The struggle for the recognition and development of patient education in the UK. Patient Education 2001; 44: 23–7. doi: 10.1016/s0738-3991(01)00098-2
18. Hekmatpou D, Anoosheh M, Alhani F. [Pathology of patient education: A qualitative study]. Iran J Nurs 2007; 20: 51–60.
19. Heyrani A, Maleki M, Barati Marnani A, Ravaghi H, Sedaghat M, Jabbari M, et al. Clinical governance implementation in a selected teaching emergency department: A systems approach. Implemen Sci 2012; 7: 84. doi: 10.1186/1748-5908-7-84  
20. Emami Razavi H, Masoumi GR, Jalili M, Siah tir M. [Indicators for hospital emergencies departments]. 2011. Available from: http://balini.tbzmed.ac.ir
21. Manouchehri J, Goodarzynejad H, Khoshgoftar Z, Sheikh Fathollahi M, Aghamohammadi Abyaneh M. Discharge against Medical Advice among Inpatients with Heart Disease in Iran. J Tehran Heart Cent 2012; 7: 72–7.
22. Tavalaiee A, Asarii SA, Habibi M, Khodami HR ,Vahabi SY, Noohi S, et al. [Discharge Against Medical Active from Psychiatric Ward]. Journal of Military Medicine 2006; 8: 24–30.
23. Roodpeyma S, Eshagh Hoseyni S. Discharge of children from hospital against medical advice. World J Pediatr 2010; 6: 353–6. doi: 10.1007/s12519-010-0202-3  
24. Duno R, Pousa E, Sans J, Tolosa C, Ruiz A. Discharge against medical advice at a general hospital in Catalonia. Gen Hosp Psychiatry 2003; 25: 46–50. doi: 10.1016/s0163-8343(02)00253-0
25. Abdulrasheed NA, Babalola MO. Clinical spectrum of discharge against medical advice in a developing country. Indian J Surg 2008; 70: 68–72. doi: 10.1007/s12262-008-0018-8
26. Seaborn MH, Osmun WE. Discharge against medical advice: A community hospitals experience. Can Journal Rural Med 2004; 9: 148–53.
27. Fiscella K, Meldrum S, Franks P. Post partum discharge against medical advice: who leaves and does it matter. Matern Child Health J 2007; 11: 431–6. doi: 10.1007/s10995-007-0194-3
28. Youssef A. Factors associated with discharge against medical advice in a Saudi teaching hospital. Journal of Taibah University Medical Sciences 2012; 7: 13–8. doi: 10.1016/j.jtumed.2012.07.006
29. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med 1998; 13: 568–71. doi: 10.1046/j.1525-1497.1998.00169.x
30. Miro O, Sanchez M, Coll-Vinent B, Milla J. Quality assessment in Emergency Department: behavior respect to attendance demand. Med Clin 2001; 11: 92–7.
31. Shirani F, Jalili M, Asl-E-Soleimani H. Discharge against medical advice from emergency department: results from a tertiary care hospital in Tehran, Iran. Eur J Emerg Med 2010; 17: 318–21. doi: 10.1097/mej.0b013e3283334ef1
32. Monico EP, Schwartz I. Leaving against medical advice: facing the issue in the emergency department. J Healthc Risk Manag 2009; 29: 6–9. doi: 10.1002/jhrm.20009
33. Pages KP, Russo JE, Wingerson DK, Ries RK, Roy-Byrne PP, Cowley DS. Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital. Psychiatr Serv 1998; 49: 1187–92.
34. Planansky K, Johnston R. A survey of patients leaving a mental hospital against medical advice. Hosp Community Psychiatry 1976; 27: 865–8.
35. Greenberg WM, Otero J, Villanueva L. Irregular discharges from a dual diagnosis unit. Am J Drug Alcohol Abuse 1994; 20: 355–71. doi: 10.3109/00952999409106020
36. Ikefuna A , Emodi IJ. An assessment of factors influencing hospital discharges against medical advice of paediatric patients in enugu: a review of 67 cases. Nigerian Journal of Paediatrics 2002; 29: 1–4. doi: 10.4314/njp.v29i1.12033
37. Holden P, Vogtsberger KN, Mohl PC, Fuller DS. Patients who leave the hospital against medical advice: the role of the psychiatric consultant. Psychosomatics 1989; 30: 396–404. doi: 10.1016/s0033-3182(89)72245-3
38. Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnicdisparities in perceptions of physician style and trust. Arch Fam Med 2000; 99: 56-63.
39. Haywood C, Lanzkron S, Ratanawongsa N, Bediako SM, Nelson LL, Beach MC. Hospital self-discharge among adults with sickle-cell disease (SCD): Associations with trust and interpersonal experience with care. J Hosp Med 2010; 5: 289-94. doi: 10.1002/jhm.643
40. Onukwugha E , Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care 2010; 19: 420-4.doi: 10.1136/qshc.2009.036269
41. Mohammad Pour A, Dehgan Naieri N. [The Survey of the Patient Educational Need on Gonabad Health and Treatment Centers]. Ofogh Danesh 2006; 12: 34-9.
42. Kalantari S, Karegar Najafi M, Abbaszadeh A, Sanagoo A, Borhani F. [Nurses’ perceptions of the performance of patient e ducation]. J Jentashayper 2011; 2: 167-74.

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History

  • Receive Date: 20 May 2013
  • Revise Date: 13 June 2013
  • Accept Date: 16 June 2013
  • First Publish Date: 21 June 2013

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