title: Patients in a private hospital in India leave the emergency department against medical advice for financial reasons.
abstract: BACKGROUND
  Some reports indicate financial concerns as a factor affecting ED patients leaving the acute care setting against medical advice (AMA). In India, no person is supposed to be denied urgent care because of inability to pay. Since a large proportion of the Indian health care system is financed by out-of-pocket expenses, we investigate the role of financial constraints for ED patients at a private hospital in India in leaving AMA.
  
  
  METHODS
  A prospective ED-based cross-sectional survey of patients leaving AMA was conducted at a private hospital in India from 1 October 2010 to 31 December 2010. Descriptive statistics and the chi-square test were used to identify associations between financial factors and the decision to leave the hospital AMA.
  
  
  RESULTS
  Overall, 55 (3.84%) ED patients left AMA, of which 46 (84%) reported leaving because of financial restrictions. Thirty-nine (71%) respondents indicated the medical bill would represent more that 25% of their annual income. Females (19/19) were more likely to leave AMA for financial reasons compared to males (27/36, p = 0.017). Among females who signed out AMA, the decision was never made by the female herself.
  
  
  CONCLUSIONS
  The number of people leaving the ED AMA in a private Indian hospital is relatively high, with most leaving for financial reasons. In most cases, women did not decide to leave the ED AMA for themselves, whereas males did. This survey suggests that steps are needed to ensure that the inability to pay does not prevent emergent care from being provided.
authors.forename: Sassan
authors.initials: S
authors.lastname: Naderi
authors.affiliation: North Shore-LIJ Health System, 300 Community Drive, Manhasset, NY 11030, USA. jracerra@yahoo.com.
authors.forename: John R
authors.initials: JR
authors.lastname: Acerra
authors.forename: Kathryn
authors.initials: K
authors.lastname: Bailey
authors.forename: Pinaki
authors.initials: P
authors.lastname: Mukherji
authors.forename: Taraknath
authors.initials: T
authors.lastname: Taraphdar
authors.forename: Tirtha
authors.initials: T
authors.lastname: Mukherjee
authors.forename: Abin
authors.initials: A
authors.lastname: Pal
authors.forename: Mary Frances
authors.initials: MF
authors.lastname: Ward
authors.forename: Kathryn
authors.initials: K
authors.lastname: Miele
authors.forename: Maxwell
authors.initials: M
authors.lastname: Mathias
authors.forename: Richard
authors.initials: R
authors.lastname: Tan
authors.forename: Myriam
authors.initials: M
authors.lastname: Kline
authors.forename: Kumar
authors.initials: K
authors.lastname: Alagappan
authors.forename: Robert
authors.initials: R
authors.lastname: Silverman