Haines Krista, Freeman Jennifer, Vastaas Cory, Rust Clay, Cox Christopher, Kasotakis George, Fuller Matthew, Krishnamoorthy Vijay, Siciliano Michelle, Alger Amy, Montgomery Sean, Agarwal Suresh
Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Department of Surgery, Texas Health Harris Methodist Hospital, Fort Worth, Texas.
J Emerg Med. 2020 Apr;58(4):691-697. doi: 10.1016/j.jemermed.2019.12.023. Epub 2020 Mar 12.
Discharge against medical advice (AMA) is an important, yet understudied, aspect of health care-particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs.
The goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment.
We performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status.
Uninsured (odds ratio [OR] 2.72; 95% confidence interval [CI] 2.58-2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37-2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02-1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52-0.75), Asian (OR 0.59; 95% CI 0.49-0.69), and Hispanic (OR 0.80; 95% CI 0.75-0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury.
Insurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.
违反医嘱出院（AMA）是医疗保健中一个重要但研究不足的方面，尤其是在创伤患者群体中。违反医嘱出院会导致死亡率增加、再入院率上升以及医疗保健成本提高。
本分析的目的是确定哪些因素会影响患者在治疗前出院的几率。
我们对国家创伤数据库中2013年至2015年的成年创伤患者（14岁以上）进行了回顾性分析。在1,770,570例已知出院情况的患者中，排除死亡病例后，有24,19１例患者（1.4%）违反医嘱出院。我们确定了患者的特征，包括年龄、性别、种族、民族、保险状况、乙醇使用情况、药物使用情况、地理位置、损伤严重程度评分（ISS）、损伤机制和解剖损伤部位。使用多变量逻辑回归模型来确定哪些患者因素与违反医嘱出院状态相关。
与有私人保险的患者相比，未参保（优势比[OR]2.72；95%置信区间[CI]2.58 - 2.86）或参保医疗补助的创伤患者（OR 2.50；95% CI 2.37 - 2.63）更有可能违反医嘱出院。在控制年龄、性别、ISS和损伤类型后，与白人患者相比，非裔美国患者（OR 1.06；95% CI 1.02 - 1.11）更有可能违反医嘱出院，而美国原住民患者（OR 0.62；95% CI 0.52 - 0.75）、亚洲患者（OR 0.59；95% CI 0.49 - 0.69）和西班牙裔患者（OR 0.80；95% CI 0.75 - 0.８5）违反医嘱出院可能性较小。
保险状况、种族和民族与患者违反医嘱出院的决定相关。未参保和参保医疗补助的患者违反医嘱出院的几率是其他人的两倍多。这些发现表明，种族和社会经济差异是未来降低违反医嘱出院率和改善钝器伤和穿透伤治疗效果努力的重要目标。
