title: Discharge Against Medical Advice in Traumatic Brain Injury: Follow-Up and Readmission Rate.
abstract: BACKGROUND
  Patients who leave hospital against medical advice (AMA) may be at risk of adverse health outcomes, medical complications, and readmission. In this study, we examined the characteristics of patients who left AMA after traumatic brain injury (TBI), their rates of follow-up visits, and readmission.
  
  
  METHODS
  We retrospectively studied 106 consecutive patients who left the tertiary trauma center AMA (1.8% of all admitted patients with a TBI). Preinjury health and social issues, mechanism of injury, computed tomography findings, and injury markers were collected. They were correlated to compliance with follow-up visits and unplanned emergency room (ER) visits and readmission rates.
  
  
  RESULTS
  The most prevalent premorbid health or social-related issues were alcohol abuse (33%) and assault as a mechanism of trauma (33%). Only 15 (14.2%) subjects came to follow-up visit for their TBI. Sixteen (15.1%) of the 106 subjects had multiple readmissions and/or ER visits related to substance abuse. Seven (6.6%) had multiple readmissions or ER visits with psychiatric reasons. Those patients with multiple readmissions and ER visits showed in higher proportion preexisting neurological condition (p=0.027), homelessness (p=0.012), previous neurosurgery (p=0.014), preexisting encephalomalacia (p=0.011), and had a higher ISS score (p=0.014) than those who were not readmitted multiple times.
  
  
  CONCLUSIONS
  The significantly increased risks of multiple follow-up visits and readmission among TBI patients who leave hospital AMA are related to a premorbid vulnerability and psychosocial issues. Clinicians should target AMA TBI patients with premorbid vulnerability for discharge transition interventions.
authors.affiliation: 1Neurology and Neurosurgery Department,McGill University Centre Department of Neurosurgery, McGill University Health Centre,London,Ontario.
authors.forename: Judith
authors.initials: J
authors.lastname: Marcoux
authors.affiliation: 2Clinical Neurological Sciences,Western University,London,Ontario.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Alkutbi
authors.affiliation: 3Baptist Health South Florida,McGill University Health Centre.
authors.forename: Julie
authors.initials: J
authors.lastname: Lamoureux
authors.affiliation: 4Traumatic Brain Injury Program,McGill University Health Centre.
authors.forename: Mitra
authors.initials: M
authors.lastname: Feyz
authors.affiliation: 1Neurology and Neurosurgery Department,McGill University Centre Department of Neurosurgery, McGill University Health Centre,London,Ontario.
authors.forename: Rajeet S
authors.initials: RS
authors.lastname: Saluja
authors.affiliation: 5Department of Psychology,University of Montreal Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR) Research Institute-McGill University Health Center.
authors.forename: Elaine
authors.initials: E
authors.lastname: de Guise
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000070642:Brain Injuries, Traumatic / Q000175:diagnosis / Q000523:psychology* / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000523:psychology*; D010351:Patient Discharge / Q000639:trends*; D010359:Patient Readmission / Q000639:trends*; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000639:trends; D055815:Young Adult
keywords: Level 1 trauma centre; Traumatic brain injury; discharge against medical advice; doctor-patient relationship; follow-up visits; head trauma; outcome; patient safety; quality of care; readmission