title: Who leaves the hospital against medical advice in the orthopaedic setting?
abstract: BACKGROUND
  Patients who leave the hospital against medical advice are at risk for readmission and for a variety of complications and are likely to consume more healthcare resources. However, little is known about which factors, if any, may be associated with self-discharge (discharge against medical advice) among orthopaedic inpatients.
  
  
  OBJECTIVE
  We studied the frequency and factors associated with self-discharge in patients hospitalized for orthopaedic trauma and musculoskeletal infection.
  
  
  METHODS
  Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified approximately 7,067,432 patient hospitalizations for orthopaedic trauma and 5,488,686 for musculoskeletal infection. We calculated the proportions of admissions that ended in self-discharge for both trauma and infection patients; then, we examined patient demographics, diagnoses, and hospital factors. Multivariable logistic regression models were constructed to determine independent predictors of self-discharge.
  
  
  RESULTS
  Approximately one in 333 (0.3%) patients hospitalized for an isolated fracture and one in 47 (2.1%) patients with musculoskeletal infection left against medical advice. Patient characteristics associated with self-discharge included age < 75 years (trauma: odds ratio [OR] 2.7, 95% confidence interval [CI] 2.5-2.8, p < 0.001; infection: OR 3.9, 95% CI 3.8-4.1, p < 0.001), male sex (trauma: OR 1.7, 95% CI 1.7-1.8, p < 0.001; infection: OR 1.4, 95% CI 1.3-1.4, p < 0.001), black race/ethnicity (trauma: OR 1.5, 95% CI 1.4-1.6, p < 0.001; infection: OR 1.1, 95% CI 1.1-1.1, p < 0.001), low household income (trauma: OR 1.5, 95% CI 1.4-1.5, p < 0.001; infection: OR 1.4, 95% CI 1.4-1.4, p < 0.001), nonprivate insurance (Medicare [trauma: OR 1.7, 95% CI 1.6-1.8, p < 0.001; infection: OR 2.5, 95% CI 2.4-2.5, p < 0.001] and Medicaid [trauma: OR 2.6, 95% CI 2.5-2.7, p < 0.001; infection: OR 3.2, 95% CI 3.2-3.3, p < 0.001]), and no insurance coverage (trauma: OR 3.0, 95% CI 2.9-3.1, p < 0.001; infection: OR 3.5, 95% CI 3.4-3.5, p < 0.001), less medical comorbidity (trauma: OR 0.94 per one-unit increase in the number of comorbidities, 95% CI 0.93-0.95, p < 0.001; infection: OR 0.88, 95% CI 0.87-0.88, p < 0.001), alcohol (trauma: OR, 2.3, 95% 2.2-2.4, p < 0.001; infection: OR 1.5, 95% CI 1.5-1.5, p < 0.001), opioid (trauma: OR 2.9, 95% CI 2.7-3.1, p < 0.001; infection: OR 4.4, 95% CI 4.3-4.4, p < 0.001) and nonopioid drug abuse (trauma: OR, 2.0, 95% CI 1.9-2.1, p < 0.001; infection: OR 2.8, 95% CI 2.8-2.9, p < 0.001), psychosis (trauma: OR 1.3, 95%CI 1.2-1.3, p < 0.001; infection: OR 1.3, 95% CI 1.3, 1.4, p < 0.001), and AIDS/HIV infection (trauma: OR 1.5, 95% CI 1.2-1.8, p < 0.001; infection: OR 1.3, 95% CI 1.3-1.4, p < 0.001). Patients with upper extremity fractures (OR 1.9, 95% CI 1.8-1.9, p < 0.001) or fractures of the neck and trunk (OR 2.1, 95% CI 2.0-2.2, p < 0.001) were more likely to leave against medical advice than patients with lower extremity fractures. Among infection hospitalizations, patients with cellulitis had the highest odds of self-discharge compared with carbuncle/furuncle (OR 1.3, 95% CI 1.2-1.5, p < 0.001). Self-discharges were more likely to occur at hospitals of larger size (trauma: OR 1.2, 95% CI 1.1-1.2, p < 0.001; infection: nonsignificant), located in urban settings (trauma: OR 1.3, 95% CI 1.2-1.4, p < 0.001; infection: OR 1.6, 95% CI 1.5-1.6, p < 0.001), and in the Northeast (trauma: OR 1.7, 95% CI 1.6-1.8, p < 0.001; infection: OR 1.6, 95% CI 1.6-1.6, p < 0.001) than at small, rural hospitals in the South.
  
  
  CONCLUSIONS
  Our data can be used to promptly identify orthopaedic inpatients at higher risk of self-discharge on admission and target interventions to optimize treatment adherence. Strategies to enhance physician communication skills among patients with low health literacy, improve cultural sensitivity, and proactively address substance abuse issues early during hospital admission may aid in preventing discharge dilemmas and merit additional study.
  
  
  METHODS
  Level III, prognostic study. See the Instructions for Authors for complete description of levels of evidence.
authors.affiliation: Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA, 02114, USA, marianofurrer@gmail.com.
authors.forename: Mariano E
authors.initials: ME
authors.lastname: Menendez
authors.forename: C Niek
authors.initials: CN
authors.lastname: van Dijk
authors.forename: David
authors.initials: D
authors.lastname: Ring
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D005260:Female; D057220:Health Literacy; D006760:Hospitalization; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D009985:Orthopedics; D010351:Patient Discharge; D010817:Physician-Patient Relations; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States; D055815:Young Adult