title: Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systematic Review.
abstract: BACKGROUND
  Leaving the hospital against medical advice is an increasing problem in acute care settings and is associated with an array of negative health consequences that may lead to readmission for a worsened health outcome or mortality. Leaving the hospital against medical advice is particularly common among people who use illicit drugs (PWUD) and has been linked to a number of complex issues; however, few studies have focused specifically on this population beyond identifying them as being at an increased risk of leaving the hospital prematurely. Furthermore, programs and interventions for reducing the rate of leaving the hospital against medical advice among PWUD in acute care settings have not been well studied.
  
  
  OBJECTIVE
  We systematically assessed the literature examining hospital discharge against medical advice from acute care among this population and identified potential methods to minimize the occurrence of this phenomenon.
  
  
  METHODS
  We searched 5 electronic databases (from database inception to August 2014) and article reference lists for articles investigating hospital discharge from acute care against medical advice among PWUD. Search terms consistent across databases included "patient discharge," "hospital discharge," "against medical advice," "drug user," "substance-related disorders," and "intravenous substance abuse."
  
  
  METHODS
  Studies were eligible for inclusion if they were published in a peer-reviewed journal as an original research article in English. We excluded gray literature, case reports, case series, reviews, and editorials. We retained original studies that reported illicit drug use as a predictor of leaving the hospital against medical advice and studies of discharge against medical advice that included PWUD as a population of interest, and we assessed significance through appropriate statistical tests. We excluded studies that reported patients leaving the hospital against medical advice from psychiatric hospitals, drug treatment centers and emergency departments, and studies that discussed misuse of alcohol but not illicit drugs.
  
  
  METHODS
  We created an electronic database that included study abstracts and relevant information matching the keywords and search criteria. We reviewed potentially eligible articles independently by scanning the titles, abstracts, and full texts of articles after removing duplicates. We identified studies for which eligibility was unclear and decided which studies to include after thoroughly reviewing and discussing them.
  
  
  RESULTS
  Of the 1649 studies that matched the search criteria, 17 met our inclusion criteria. Thirteen studies identified substance misuse as a significant predictor of leaving the hospital against medical advice. Three studies assessed the prevalence and predictors of leaving the hospital against medical advice among people who inject drugs and found that this phenomenon was commonly reported (prevalence range = 25%-30%). Factors positively associated with leaving the hospital against medical advice included recent injection drug use, Aboriginal ancestry, leaving on weekends and welfare check day. In-hospital methadone use, social support, older age, and admission to a community-based model of care were negatively associated with the outcome.
  
  
  CONCLUSIONS
  To better understand risk factors associated with leaving the hospital against medical advice among PWUD, future research should consider the effect of individual, social, and structural characteristics on leaving the hospital against medical advice among PWUD. The development and evaluation of novel methods to address interventions to reduce the rate of leaving the hospital prematurely is necessary.
authors.affiliation: Both authors are with the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
authors.forename: Lianping
authors.initials: L
authors.lastname: Ti
authors.affiliation: Both authors are with the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
authors.forename: Lianlian
authors.initials: L
authors.lastname: Ti
mesh_terms: D006760:Hospitalization; D006801:Humans; D012307:Risk Factors; D019966:Substance-Related Disorders / Q000523:psychology*; D016312:Treatment Refusal / Q000523:psychology