Makhdoom Ali, Pratt Abimbola, Kuo Yen-Hong, Ahmed Nasim
Hackensack Meridian School of Medicine, Nutley, NJ, USA.
Hackensack Meridian School of Medicine, Nutley, NJ, USA; Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA.
Am J Emerg Med. 2024 May;79:152-156. doi: 10.1016/j.ajem.2024.02.036. Epub 2024 Feb 24.
Discharge against medical advice (AMA) leads to worse patient outcomes, increased readmission rates, and higher cost. However, AMA discharge has received limited study, particularly in pediatric trauma patients. Our objective was to explore the risk factors associated with leaving AMA in pediatric trauma patients.
We performed a retrospective analysis on pediatric trauma patients from 2017 to 2019 using the National Trauma Data Bank. We examined patient characteristics including age (<18 years), race, sex, Glasgow Coma Scale, trauma type, primary payment methods, and Abbreviated Injury Scale. Multiple Logistic Regression models were utilized to determine characteristics associated with leaving AMA.
Of the 224,196 pediatric patients included in the study, 238 left AMA (0.1%). Our study showed black pediatric trauma patients were more likely to leave AMA compared to nonblack patients (OR 1.987, 95% CI 1.501 to 2.631). Patients with self-pay coverage were more likely to leave AMA than those with other insurance coverages (OR 1.759, 95% CI 1.183 to 2.614). Blunt trauma patients were more likely to leave AMA than those with penetrating trauma (OR 1.683, 95% CI 1.216 to 2.330). Every one-year increase in age led to 15% increase in odds of AMA discharge (OR 1.150, 95% CI 1.115 to 1.186). Pediatric patients with severe abdominal injuries were less likely to leave AMA compared to those with mild abdominal injuries (OR 0.271, 95% CI 0.111 to 0.657). Patients with severe lower extremity injury were less likely to leave AMA compared to those with mild lower extremity injuries (OR 0.258, 95% CI 0.127 to 0.522).
Race, insurance, injury type, and age play a role in AMA discharge of pediatric trauma patients. Black pediatric trauma patients have double the AMA discharge rate of nonblack patients. AMA discharge remains relevant, and addressing racial and socioeconomic factors provide opportunities for future interventions in pediatric trauma care.
III, retrospective study.
违反医嘱出院（AMA）会导致患者预后更差、再入院率增加以及费用更高。然而，AMA出院的研究有限，尤其是在儿科创伤患者中。我们的目的是探讨与儿科创伤患者AMA出院相关的风险因素。
我们使用国家创伤数据库对2017年至2019年的儿科创伤患者进行了回顾性分析。我们检查了患者特征，包括年龄（<18岁）、种族、性别、格拉斯哥昏迷量表、创伤类型、主要支付方式和简明损伤量表。采用多元逻辑回归模型来确定与AMA出院相关的特征。
在纳入研究的224,196名儿科患者中，238人AMA出院（0.1%）。我们的研究表明，与非黑人患者相比，黑人儿科创伤患者更有可能AMA出院（比值比1.987，95%置信区间1.501至2.631）。自费保险的患者比其他保险的患者更有可能AMA出院（比值比1.759，95%置信区间1.183至2.614）。钝性创伤患者比穿透性创伤患者更有可能AMA出院（比值比1.683，95%置信区间1.216至2.330）。年龄每增加一岁，AMA出院的几率增加15%（比值比1.150，95%置信区间1.115至1.186）。与轻度腹部损伤的儿科患者相比，重度腹部损伤的患者AMA出院的可能性较小（比值比0.271，95%置信区间0.111至0.657）。与轻度下肢损伤的患者相比，重度下肢损伤的患者AMA出院的可能性较小（比值比0.258，95%置信区间0.127至0.522）。
种族、保险、损伤类型和年龄在儿科创伤患者AMA出院中起作用。黑人儿科创伤患者的AMA出院率是非黑人患者的两倍。AMA出院仍然值得关注，解决种族和社会经济因素为未来儿科创伤护理干预提供了机会。
III级，回顾性研究。
