Alnashri Yahya, Andreyeva Elena, Giannouchos Theodoros V
Department of Family & Community Medicine, College of Medicine, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia; Department of Health Policy & Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, USA.
Department of Health Policy & Management, Texas A&M University, College Station, TX, USA.
Am J Emerg Med. 2025 Apr;90:47-54. doi: 10.1016/j.ajem.2024.12.081. Epub 2024 Dec 31.
Leaving before medically advised (BMA) is a significant issue in the US healthcare system, leading to adverse health outcomes and increased costs. Despite previous research, multi-year studies using up-to-date nationwide emergency department (ED) data, are limited. This study examines factors associated with leaving BMA from EDs and trends over time, before and during the COVID-19 pandemic.
We conducted a pooled, cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2021. Multivariable logistic regression and interrupted time series (ITS) analyses were used to identify factors associated with leaving BMA and to examine trends over time, respectively.
Out of 721.0 million ED visits, 5.9 million (0.8 %) resulted in leaving BMA. Factors associated with higher odds of leaving BMA included public or no insurance coverage (Medicare: AOR = 1.74, 95 % CI = 1.12-2.70; Medicaid/CHIP/State-based: AOR = 1.86, 95 % CI = 1.40-2.45; Uninsured/Self-pay: AOR = 1.51, 95 % CI = 0.99-2.29), alcohol or substance use disorders (AOR = 2.19, 95 % CI = 1.77-2.70), arrival by ambulance (AOR = 1.68, 95 % CI = 1.31-2.15), and being male (AOR = 1.32, 95 % CI = 1.09-1.62). Conversely, hospital admissions (AOR = 0.11, 95 % CI = 0.05-0.21) and trauma or overdose related visits (AOR = 0.54, 95 % CI = 0.44-0.67) were associated with lower odds of leaving BMA. The COVID-19 pandemic significantly increased the odds of leaving BMA (AOR = 1.44, 95 % CI = 1.06-1.95), with an overall increase of 53.6 % in BMA-related ED visits observed post-March 2020 relatively to the previous years, particularly in the fourth quarters of 2020 and 2021 and second and third quarters of 2020.
In this study, several demographics, socio-economic, and clinical characteristics were associated with higher incidences of leaving ED BMA. The COVID-19 pandemic also exacerbated BMA rates. These findings highlight the need for targeted interventions to improve patient-provider communication and ED triage efficiency, especially in resource-constrained facilities serving lower-income individuals.
在未得到医学建议的情况下离开（BMA）是美国医疗保健系统中的一个重要问题，会导致不良健康后果并增加成本。尽管之前有相关研究，但使用最新全国急诊科（ED）数据的多年研究有限。本研究调查了与在急诊科BMA离开相关的因素以及在2019冠状病毒病（COVID-19）大流行之前和期间随时间的趋势。
我们使用了2016年至2021年国家医院门诊医疗调查（NHAMCS）的数据进行了一项汇总横断面研究。多变量逻辑回归和中断时间序列（ITS）分析分别用于确定与BMA离开相关的因素并研究随时间的趋势。
在7.21亿次急诊科就诊中，有590万次（0.8%）导致了BMA离开。与BMA离开几率较高相关的因素包括公共保险或无保险覆盖（医疗保险：调整后比值比[AOR]=1.74，95%置信区间[CI]=1.12 - 2.70；医疗补助/儿童健康保险计划/基于州的保险：AOR = 1.86，95% CI = 1.40 - 2.45；无保险/自费：AOR = 1.51，95% CI = 0.99 - 2.29）、酒精或物质使用障碍（AOR = 2.19，95% CI = 1.77 - 2.70）、乘救护车到达（AOR = 1.68，95% CI = 1.31 - 2.15）以及男性（AOR = 1.32，95% CI = 1.09 - 1.62）。相反，住院治疗（AOR = 0.11，95% CI = 0.05 - 0.21）以及与创伤或药物过量相关的就诊（AOR = 0.54，95% CI = 0.44 - 0.67）与BMA离开几率较低相关。COVID-19大流行显著增加了BMA离开的几率（AOR = 1.44，95% CI = 1.06 - 1.95），与前几年相比，2020年3月之后观察到与BMA相关的急诊科就诊总体增加了53.6%，特别是在2020年和2021年的第四季度以及2020年的第二和第三季度。
在本研究中，一些人口统计学、社会经济和临床特征与急诊科BMA离开的较高发生率相关。COVID-19大流行也加剧了BMA发生率。这些发现凸显了需要有针对性的干预措施来改善医患沟通和急诊科分诊效率，特别是在为低收入人群服务的资源有限的医疗机构中。
