J Healthc Qual. 2021;43(1):e8-e19. doi: 10.1097/JHQ.0000000000000252.
There is increasing evidence of the role of non-patient-level factors on discharge against medical advice (DAMA), but limited quantitative information regarding the extent of their impact. This study quantifies the contribution of discharge-level and hospital-level factors to the variation in DAMA. We grouped variables from the 2014 National Inpatient Sample data and ran incremental mixed-effects logit models with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICCs), and evaluated the incremental change in ICC. The final sample included 2,687,430 discharges. 12.8% of the identified variation in the probability of DAMA was associated with the hospital, and 1.2% of the variation was associated with the census division in which the hospital was located. The final, fully-adjusted model had 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions because of the addition of patient demographics. Even after adjusting for measured patient-level characteristics, there was a contribution of non-patient-level factors to DAMA outcomes. The findings identify a role for a multi-level approach to addressing DAMA.
越来越多的证据表明，非患者因素在出院医嘱（DAMA）中发挥了作用，但关于其影响程度的定量信息有限。本研究量化了出院水平和医院水平因素对 DAMA 变化的贡献。我们对 2014 年国家住院患者样本数据中的变量进行分组，并在出院、医院和普查区域层面上运行增量混合效应逻辑回归模型。我们获得了组内相关系数（ICC），并评估了 ICC 的增量变化。最终样本包括 2687430 例出院。DAMA 概率的 12.8%的差异与医院相关，1.2%的差异与医院所在的普查分区相关。最终的完全调整模型中，医院水平与 DAMA 相关的变异为 7.3%，由于加入了患者人口统计学特征，减少的百分比最大。即使在调整了测量的患者水平特征后，非患者水平因素对 DAMA 结果仍有一定影响。研究结果表明，需要采取多层次的方法来解决 DAMA 问题。
