Background
Discharge against medical advice (DAMA) can be defined as the “patient choosing to leave the hospital before the treating physician recommends discharge” [
1]. DAMA is a common problem worldwide, where global prevalence rates range from 0.07 to 20% in the ED [
2,
3]. DAMA can lead to negative clinical outcomes and poor healthcare resource utilization including disease relapse and high healthcare costs; it is also one of the leading causes of readmission rates [
4‐
7]. DAMA patients are considered high-risk patient population as they experience higher mortality rates within 30 days, higher hospital readmission rates, greater length of stay in the hospital following readmission, and higher ED revisit rates of about 24% [
8,
9]. Readmission rates of DAMA patients are 40% higher than patients who complete their treatment period in the hospital [
6]. While treatment related costs for DAMA patients vary around the world, a study in Australia found that the cost of readmitting DAMA patients was $8.6 million per year [
10]. Furthermore, other studies have reported that the hospitalization cost for DAMA patients was 50% higher than if they were fully managed and discharged by physicians during their first visit [
1,
11].
In the ED, patients are categorized as DAMA if they leave before completing their care plan or while waiting to be admitted to the hospital [
3,
4]. Patients who are DAMA are usually males, young, uninsured, of low socioeconomic level, with low triage acuity scale, and a history of substance abuse [
3]. It is estimated that around 99% of DAMA patients have a triage level of 3, 4, or 5 according to the Manchester Triage Scale [
7]. The majority of patients who sign DAMA in the ED are discharged with a diagnosis of chest pain, abdominal pain, or bronco-spastic airway disease [
12].
There are various reasons for patients choosing to be DAMA in the ED, including but not limited to: family commitments, financial implications, conflict with healthcare staff, lack of medical improvement, seeking alternative traditional medicine, and long ED waiting time [
3,
4]. While most studies documented patients’ reasons for DAMA, very few studies explored patient knowledge about the significance of DAMA. One particular study by Taylor and Cameron (2000) reviewed three commonly used types of discharge instruction and found that about 66% of patients were improperly informed about the harmful consequences of their decision to DAMA [
13]. Their recommendations focused on the importance of proper physician-patient communication and the discharge instructions that should be provided by the ED physician to patients who sign DAMA [
14].
In the Gulf Corporation Countries (GCC), only one study was found in Saudi Arabia looking at DAMA in tertiary ED patients [
2]. Due to the identified gaps in the regional literature, Abuzeyad et al. conducted a study (2017) to investigate the prevalence rates and reasons for DAMA in their university hospital for all departments, where the main reasons identified for DAMA in the ED subgroup were subjective improvement (28.8%), children at home (20.4%), long waiting time (17.1%), and not agreeing to the procedure/operation (15%) [
15].
The purpose of this study is to investigate the current demographic and clinical characteristics, reasons, and outcomes of DAMA patients from the ED of a public university hospital in Bahrain over a one-year period including readmission, morbidity, and mortality. Results from the study may help provide evidence on how to develop interventions to reduce DAMA rates and add to the existing literature on DAMA prevalence in the Middle East.
Ethical considerations
The study was ethically approved by the hospital’s Institutional Review Board, which is in compliance with the National Health Regulatory Authority regarding the use of human subjects in research. Information relevant to the research study was presented in the informed consent in appropriate language. Participants were able to withdraw their participation at any stage of the research and notified that their answers would be collected anonymously. There was no financial involvement in the study.
Strict confidentiality was maintained through password protection accessible only by the listed coauthors during the collection, management, and analysis of data. According to the hospital’s Research Department guidelines, data from this study will be retained for 5 years to allow for potential follow up of the study population and will then be destroyed by permanent deletion of all data files.
Discussion
DAMA is one of the most common issues worldwide in healthcare that leads to significant morbidity, mortality, burden on the healthcare system, and high healthcare costs. While much of the research on Emergency Medicine focuses on overcrowding in the EDs worldwide, very little attention is spent on documenting the prevalence of DAMA and its impact on patient outcomes and the healthcare system. This study aimed to determine the prevalence rate, demographic and clinical characteristics, reasons, and clinical outcomes, for DAMA in ED of a university hospital in the Kingdom of Bahrain.
All DAMA patients were categorized as triage levels-2, 3, or 4 (emergent, urgent, and less urgent, respectively), with the majority in triage level-3. Saritemur et al. (2012) found that in a university hospital setting, 99.1% of DAMA patients had triage levels-3, 4, or 5 and less than 1% had triage levels-2, however, their 5-tier triage system followed the Canadian Triage and Acuity Scale (CTAS), versus the Manchester Triage Scale, which was used in this study [
6,
7]. On the other hand, El-Metwally et al. (2019) reported a higher number of DAMA patients in triage level-2 (24.5%) using CTAS, whom are categorized as emergent triage patients [
2].
The most common first-visit discharge diagnosis for DAMA patients (Table
3) were related to gastrointestinal and cardiac complaints, which was consistent with other findings [
3,
4,
12]. The emergency physician evaluated 54.2% patients independently, and further referrals were made to internal medicine, obstetrics & gynecology, and general surgery (17.4, 10.9, and 9.7%, respectively).
Current results reflected that DAMA patients chose similar reasons for DAMA to those from the Abuzeyad et al. (2017) study, as well as new reasons within this study [
15]. Refusal of a procedure/operation accounted for 24%, while other studies reported 16.8% for refusal of an intervention [
7]. It would have been informative to explore which procedures/interventions patients objected to and reasons for refusal, such as cost. These were unfortunately not measured within our study. Consequently, we have looked to literature to explore potential explanations. A study in a trilingual ED in Hong Kong [
18] found that effective communication, including 1- a clear explanation of the processes and procedures including risks of DAMA, 2- a clinician’s engagement with the patient and other clinicians, and 3- contextual factors like time pressure, can influence a patient to participate in a medically advised procedure. Another study highlighted that the quantity and quality of information received by a patient can mitigate any negative emotional factors (e.g., frustration, irritation, stress, and fear), prompting patients to wait longer in the ED to get the needed medical assistance and reduce DAMA [
19].
The second most common reason for DAMA was long ED waiting time (22.2%). As we were unable to measure precise waiting times for this study, we are only able to provide general context that for patients who have already been seen by an ED physician, it can take an average of 4–6 h. This can be attributed to waiting for laboratory reports, imaging reports, beds for admission, specialty consultation, a delay in the admission process, and/or a delay in treatment. In other studies, this reason accounted for 0 to 18.7% [
3,
7,
20]. Our results were in line with previous findings, including those from a retrospective ED study covering a 6-year period, where the prolonged waiting time was the most common cause for DAMA [
21]. The figures for other reasons, including subjective improvement from treatment, children at home, and seeking other opinions, were higher in contrast to another study [
3]. About 5% of the patients chose DAMA due to religious events and holidays, especially in the holy fasting month of Ramadan and other religious holidays. Dissatisfaction with medical care had a low percentage of 1.2%, while in other institutions this can reach up to 10.3% [
7]. Gender and age were the only variables that were found to have a statistically significant difference on reasons for DAMA.
Considering the risks that can accompany DAMA patients after leaving the hospital, we followed up with our patients one-week later to examine those who revisited the ED. Out of 413 patients, 86 (20.8%) had returned to our ED within the first 72-h. Admission involved 41 patients to different specialties, of which 6 were admitted to the intensive and cardiac care units. Another 18 patients decided to sign DAMA for the second time and leave the ED. Individuals whose symptoms subsided were then discharged home, accounting for 15 cases, and 10 patients were discharged with organized follow up with the outpatient clinics or the health care center. Unfortunately, there were 2 patients who presented to the ED with cardiopulmonary arrest and had unsuccessful resuscitation. As observed from the broad range of returning presentations, DAMA patients are exposing themselves to significant multiple morbidities and mortality, and are not protected regardless of the disease type. DAMA patients are among the subgroups who are expected to return back to the ED within 72 h [
22], and in one study, they accounted for up to 49% of patients due to continuing or worsening of the disease process [
23]. The majority of the presenting symptoms were related to the gastrointestinal and cardiovascular systems [
24]. Furthermore, a comparison between DAMA patients who had a revisit within 72 h and those who did not revealed that marital status was a predictor for their return though it was not very statistically significant (
p = 0.054). Divorced patients were more likely to revisit the hospital than single patients. One explanation could be that divorced patients could be dealing with more insecurities related to their health as they might be living alone with no one to take care of them. This would be an interesting research question to further explore in a new study.
ED healthcare performance can be evaluated by several key performance indicators for healthcare quality including ED length of stay, left without being seen, 72-h revisits, morbidity and mortality, and DAMA [
17]. DAMA patients who leave during their clinical management cause a considerable dilemma for ED physicians. In this one-year study, 413 patients were included for the final data analysis, demonstrating that DAMA patients are taking a risky decision due to incomplete or interrupted treatment. We measured a concerning prevalence of morbidity and mortality in our results but due to the small sample size, we could not demonstrate that DAMA patients are at a higher risk of morbidity and mortality. We hope to perform a future cohort study that is case matched because based on literature, DAMA patients will eventually require a higher level of care with an increased cost mainly due to the considerable morbidity and mortality represented by complications and adverse events [
1,
25,
26].
Understanding the risk factors and predictors will eventually improve the ED care process, mitigate complications, and reduce the operational cost. The context of multiple socioeconomic factors of the studied population, the healthcare system, the entitlement for treatment, and the alternative options should be considered when exploring this topic. Furthermore, because of the heterogeneity of the DAMA patient population and their diverse reasons for doing so, it has been suggested that such patients must be offered a high-quality DAMA which includes: justifying the need for admission, the risks of discharge, capacity determination, and providing an alternative follow-up plan [
26]. The literature has emphasized the importance of documenting DAMA patients in detail through their medical charts by the emergency physician. Information documented should include the patient’s capacity, risks related to the discharge, and the DAMA form signed by the patient [
6]. In fact, some have advocated obtaining informed consent, evaluating the decision-making capacity, and assessing the health literacy for any patients who are DAMA with appropriate follow-up if possible [
27]. In particular, we recommend having a patient relation manager or social worker within the ED of our hospital to help communicate with patients wanting to be DAMA.
Limitations
The study had significant limitations related to the small sample size, setting, and method of collecting data. The first limitation was that the study was conducted in one center only, which is not representative and thus cannot be generalized to the rest of the Bahraini ED population. Second, only 20% of DAMA patients participated in our study, which means that there is a high likelihood that study participants were not representative of all DAMA patients at KHUH and differ substantially from the overall ED and DAMA cohorts. Another limitation was related to the inability to follow up with DAMA patients who did not return to our ED, and whose symptoms might have subsided, worsened, presented to another institution.
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