Centre for Improving Health Services for Aboriginal and Torres Strait Islander Children and Families (ISAC), Kurongkurl Katitjin, Edith Cowan University, Perth, Western Australia, Australia.
Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.
Paediatr Perinat Epidemiol. 2023 Nov;37(8):691-703. doi: 10.1111/ppe.13018. Epub 2023 Nov 20.
Discharge against medical advice (DAMA) is a priority issue for the health system. Little is known about the factors associated with DAMA for Aboriginal and/or Torres Strait Islander (Aboriginal) children in Australia.
Investigate the associations between DAMA for hospital admissions and emergency department (ED) presentations and: (i) child, family and episode of service characteristics and (ii) 30-day readmission/ re-presentation.
We conducted a cohort study of Aboriginal children born in Western Australia (2002-2013) who had ≥1 hospital admissions (n = 16,931) or ED presentations (n = 26,546) within the first 5 years of life. The outcome of interest was hospital and ED DAMA and adjusted odds ratio were derived using multilevel mixed-effects logistic regression.
In the Hospital Cohort, there were 43,149 hospitalisations for 16,931 children, with 684 hospitalisations (1.6%) recorded as DAMA. In the ED Cohort, there were 232,082 ED presentations in 26,546 children, with 10,918 ED presentations (4.7%) recorded as DAMA. DAMA occurring in hospitals between 2014 and 2018, the adjusted odds decreased by 75% compared to the period between 2002 and 2005. The adjusted odds of ED DAMA increased by 46% over the same period. Hospital admissions in regional and remote hospitals were almost seven times the adjusted odds of DAMA compared with hospital admissions in Perth metropolitan hospitals. The adjusted odds of ED DAMA decreased by 12% for ED presentations in regional and remote hospitals compared to those in Perth metropolitan hospitals. There was no evidence of hospital DAMA being associated with hospital readmission within 30 days and limited evidence of ED DAMA being associated with re-presenting to an ED within 30 days.
The study identified several important determinants of DAMA, including admission status, triage status, location and calendar year. These findings could inform targeted measures to decrease DAMA, particularly in regional and remote communities.
出院时未经医嘱（DAMA）是医疗系统的一个优先事项。关于澳大利亚原住民和/或托雷斯海峡岛民（Aboriginal）儿童的 DAMA 与哪些因素相关，我们知之甚少。
调查因住院和急诊科（ED）就诊而导致的 DAMA 与以下因素之间的关联：（i）儿童、家庭和服务情节特征，以及（ii）30 天内再入院/再次就诊。
我们对西澳大利亚州（2002-2013 年）出生的原住民儿童进行了一项队列研究，这些儿童在生命的前 5 年内至少有 1 次住院（n=16931）或 ED 就诊（n=26546）。感兴趣的结果是住院和 ED 的 DAMA，使用多级混合效应逻辑回归得出调整后的优势比。
在住院患者队列中，有 43149 次住院，涉及 16931 名儿童，其中有 684 次住院（1.6%）记录为 DAMA。在 ED 队列中，有 232082 次 ED 就诊，涉及 26546 名儿童，其中有 10918 次 ED 就诊（4.7%）记录为 DAMA。与 2002-2005 年期间相比，2014-2018 年期间医院发生的 DAMA 减少了 75%。同一时期 ED 发生 DAMA 的调整后优势增加了 46%。与珀斯大都市医院的住院相比，地区和偏远地区医院的住院治疗 DAMA 的调整后优势几乎高出 7 倍。与珀斯大都市医院相比，地区和偏远地区医院的 ED 就诊 DAMA 的调整后优势下降了 12%。没有证据表明医院 DAMA 与 30 天内的再次住院有关，也没有证据表明 ED DAMA 与 30 天内再次到 ED 就诊有关。
该研究确定了 DAMA 的几个重要决定因素，包括入院状态、分诊状态、位置和日历年份。这些发现可以为减少 DAMA 提供针对性措施提供信息，尤其是在地区和偏远社区。
