title: HIV-positive injection drug users who leave the hospital against medical advice: the mitigating role of methadone and social support.
abstract: BACKGROUND
  Leaving the hospital against medical advice has been associated with increased morbidity and readmission. Factors associated with the risk of leaving against medical advice among HIV/AIDS patients or injection drug users have not been examined in detail.
  
  
  OBJECTIVE
  To examine the clinical and social factors associated with leaving against medical advice (AMA) from a specialized HIV/AIDS ward among patients who reported a history of injection drug use.
  
  
  METHODS
  All patients with a history of injection drug use admitted to the HIV/AIDS ward at St. Paul's Hospital, Vancouver, British Columbia (the largest specialized HIV/AIDS hospital ward in Canada) between April 1997 and October 2000 were reviewed retrospectively. A multivariate logistic regression model utilizing a generalized estimating equation algorithm identified factors associated with leaving the hospital AMA.
  
  
  RESULTS
  Of the 1056 hospital admissions to the HIV/AIDS ward by patients with a history of injection drug use, 263 (24.9%) resulted in leaving the hospital AMA. Independent positive predictors of leaving AMA included recent injection drug use (adjusted odds ratio [AOR] = 2.08, 95% confidence interval [CI]: 1.41-3.07) and aboriginal ethnicity (AOR = 1.55, 95% CI: 1.05-2.28). Discharge AMA was also more likely to occur on weekends (AOR = 2.27, 95% CI: 1.49-3.48) and on days when social assistance payments were issued (AOR = 2.95, 95% CI: 1.70-5.10). Factors that independently reduced the odds of hospital discharge AMA included in-hospital methadone use (AOR = 0.49, 95% CI: 0.32-0.76), social support (AOR = 0.33, 95% CI: 0.21-0.51), and older age (per 10-year increment, AOR = 0.56, 95% CI: 0.43-0.73).
  
  
  CONCLUSIONS
  Among HIV-positive patients with a history of injection drug use, the odds of leaving the hospital AMA were reduced for subjects who received inpatient methadone treatment, were of older age, or had social supports. Addiction treatment and interventions that enhance social supports in marginalized populations at risk for hospital discharge AMA should be further explored.
authors.affiliation: Center for Health Evaluation and Outcome Sciences, Division of General Internal Medicine, University of British Columbia, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia, Canada V6Z 1Y6.
authors.forename: Alex C H
authors.initials: AC
authors.lastname: Chan
authors.forename: Anita
authors.initials: A
authors.lastname: Palepu
authors.forename: Daphne P
authors.initials: DP
authors.lastname: Guh
authors.forename: Huiying
authors.initials: H
authors.lastname: Sun
authors.forename: Martin T
authors.initials: MT
authors.lastname: Schechter
authors.forename: Michael V
authors.initials: MV
authors.lastname: O'Shaughnessy
authors.forename: Aslam H
authors.initials: AH
authors.lastname: Anis
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000453:epidemiology; D000328:Adult; D005260:Female; D006679:HIV Seropositivity / Q000453:epidemiology*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008691:Methadone / Q000627:therapeutic use*; D015999:Multivariate Analysis; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D012944:Social Support; D015819:Substance Abuse, Intravenous / Q000453:epidemiology*
chemical_list: D008691:Methadone