title: Discharge Against Medical Advice From the Emergency Department: Results From a Tertiary Care Hospital in Beirut, Lebanon.
abstract: Patients who leave the emergency department against medical advice are at high risk for complications. Against medical advice (AMA) discharges are also considered high-risk events potentially leading to malpractice litigation.Our aim was to characterize patients who leave AMA in a payment prior to service emergency department (ED) model and to identify predictors for return visits to ED after leaving AMA.We conducted a retrospective review study of charts of ED patients who were discharged AMA between January 1, 2012 and January 1, 2013 at a tertiary care center in Beirut Lebanon. We carried out a descriptive analysis and a bivariate analysis comparing AMA patients without and with return visit within 72 hours. This was followed by a Logistic regression to identify predictors of return visits after leaving AMA.A total of 1213 ED patients were discharged AMA during the study period. Mean age was 46.9 years (±20.9). There were 654 men (53.9%), 737 married (60.8%). The majority (1059 patients (87.3%)) had an emergency severity index of 3 or less (1 or 2). ED average length of stay was 3.8 hours (±6.8). Self payers accounted for 53.9%. Reasons for leaving AMA were: no reason mentioned (44.1%), incomplete workup (30.5%), refusing admission (12.4%), financial reasons (7.9%), long wait times (2.9%), and others (2.2%). Discharge diagnoses were mainly cardiac (23.4%), gastrointestinal (16.4%), infectious (10.1%), and trauma (9.8%).One hundred nineteen returned to ED within 72 hours (9.8%). Predictors of returning to ED after leaving AMA were: older age (OR 1.02 95% CI (1.01-1.03)), private insurance status (OR 4.64 95% (CI 2.89-7.47) within network insurance status (OR 7.20 95% CI (3.86-13.44), longer ED length of stay during the first visit (OR 1.03 95% CI (1.01-1.05).In our setting, the rate of return visit to ED after leaving AMA was 9.8%. Reasons for leaving AMA, high-risk discharge diagnoses and predictors of return visit were identified. Financial status was a strong predictor of return to ED after leaving AMA.
authors.affiliation: From the Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Mazen El
authors.initials: ME
authors.lastname: Sayed
authors.forename: Elsy
authors.initials: E
authors.lastname: Jabbour
authors.forename: Ali
authors.initials: A
authors.lastname: Maatouk
authors.forename: Rana
authors.initials: R
authors.lastname: Bachir
authors.forename: Gilbert Abou
authors.initials: GA
authors.lastname: Dagher
mesh_terms: D003376:Counseling; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007861:Lebanon; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D063128:Tertiary Health Care