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OBJECTIVE: Leaving Against Medical Advice (LAMA) is a prevalent issue in healthcare settings that may lead to negative patient outcomes. We conducted a systematic review and meta-analysis to assess the impact of LAMA on patient outcomes. MATERIALS AND METHODS: A comprehensive literature search was performed across PubMed, MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, Web of Science, and Scopus. Studies reporting adverse outcomes, including mortality and hospital readmission rates, in patients who underwent LAMA were included. The odds ratios (ORs) with 95% confi- dence intervals (CIs) were pooled using a random- effects model. RESULTS: Eight studies were included in the review, with four contributing to the meta-analysis on 1-year mortality and five to the meta-analysis on hospital readmission rates. LAMA was not significantly associated with higher 1-year mortality [OR = 0.66, 95% CI (0.38, 1.16), p = 0.15] or hospital readmission rates [OR = 0.61, 95% CI (0.30, 1.23), p = 0.16] across the studies. However, there was substantial heterogeneity in the results (I2 = 91% for mortality; I2 = 99% for readmissions). CONCLUSIONS: While individual studies reported varying outcomes, the pooled results did not show a significant association between LAMA and increased 1-year mortality or hospital readmission rates. However, the high degree of heterogeneity suggests the influence of diverse patient populations, healthcare settings, and study methodologies on these outcomes. Further research is needed to better understand the factors contributing to the adverse outcomes associated with LAMA and to develop targeted interventions to mitigate them. [ABSTRACT FROM AUTHOR]

BackgroundAlcohol-related hepatitis is one of the most severe manifestations of alcohol-related liver disease and has been associated with significant morbidity, mortality and financial burden. Patients with alcohol use disorders are at risk of leaving against medical advice (LAMA); however, there is currently a lack of data in the literature to show which patients are at higher risk. In this study, we investigated the specific demographic factors and comorbidities associated with LAMA.MethodsPatients with a primary or secondary discharge diagnosis of alcohol-related hepatitis (ICD10-CM codes K70.4 and K70.1) between January 2016 and December 2019 were included in this study. Demographics, comorbidities, complications and interventions were studied in for patients who LAMA. Multivariate analysis was conducted to elucidate factors contributing to the increased risk of alcohol-related hepatitis.ResultsA total of 538,750 patients were admitted with a diagnosis of alcohol-related hepatitis. Of these, 31,500 (5.84%) patients LAMA. Older age, Hispanic race, private insurance, and higher income status were associated with a lower risk of LAMA, while younger age, African American race, lack of insurance and being in the lowest income quartile were associated with the highest risk.ConclusionsOur findings demonstrated that significant differences exist between patients with alcohol-related hepatitis who LAMA and those who remain hospitalized until discharge. We believe that this study will help healthcare providers identify patients at risk of LAMA, and help promote the targeted education of specific subgroups to improve their understanding of their disease state and decrease adverse events.

Abstract Background Self-discharge is a risk factor for readmission and excess mortality. We assess the rate of self-discharge from the emergency department (ED) among presentations for acute recreational drug toxicity and identify factors associated with self-discharge. Methods From the Euro-DEN Plus database of presentations to the ED with acute recreational drug toxicity, we extracted data from 11 centres in seven European countries from 2014 to 2017. Self-discharge was defined as taking one’s own discharge or escaping from the ED before being medically cleared. We used multiple logistic regression analyses to look for factors associated with self-discharge. Results Among 15,135 included presentations, 1807 (11.9%) self-discharged. Self-discharge rates varied from 1.7 to 17.1% between centres. Synthetic cannabinoids were associated with self-discharge, adjusted odds ratio 1.44 (95% confidence interval 1.10–1.89), as were heroin, 1.44 (1.26–1.64), agitation, 1.27 (1.10–1.46), and naloxone treatment, 1.27 (1.07–1.51), while sedation protected from self-discharge, 0.38 (0.30–0.48). Conclusion One in eight presentations self-discharged. There was a large variation in self-discharge rates across the participating centres, possibly partly reflecting different discharge procedures and practices. Measures to improve the management of agitation and cautious administration of naloxone to avoid opioid withdrawal symptoms may be approaches worth exploring to reduce self-discharge.

Background: Self-discharge is a risk factor for readmission and excess mortality. We assess the rate of self-discharge from the emergency department (ED) among presentations for acute recreational drug toxicity and identify factors associated with self-discharge. Methods: From the Euro-DEN Plus database of presentations to the ED with acute recreational drug toxicity, we extracted data from 11 centres in seven European countries from 2014 to 2017. Self-discharge was defined as taking one's own discharge or escaping from the ED before being medically cleared. We used multiple logistic regression analyses to look for factors associated with self-discharge. Results: Among 15,135 included presentations, 1807 (11.9%) self-discharged. Self-discharge rates varied from 1.7 to 17.1% between centres. Synthetic cannabinoids were associated with self-discharge, adjusted odds ratio 1.44 (95% confidence interval 1.10–1.89), as were heroin, 1.44 (1.26–1.64), agitation, 1.27 (1.10–1.46), and naloxone treatment, 1.27 (1.07–1.51), while sedation protected from self-discharge, 0.38 (0.30–0.48). Conclusion: One in eight presentations self-discharged. There was a large variation in self-discharge rates across the participating centres, possibly partly reflecting different discharge procedures and practices. Measures to improve the management of agitation and cautious administration of naloxone to avoid opioid withdrawal symptoms may be approaches worth exploring to reduce self-discharge. [ABSTRACT FROM AUTHOR]

Background: People with opioid use disorder (OUD) have high rates of hospital admissions and high rates of patient-directed discharge, leading to significant morbidity and mortality. In this study, we aimed to understand hospitalist attitudes toward patients with OUD leaving before treatment completion and their willingness to collaborate with patients in future initiatives focused on improving the experience of hospital-based care for patients with OUD. Methods: We conducted semi-structured interviews with hospitalists at two hospitals in Philadelphia, PA to explore their perspectives on social and structural factors that contribute to patients with OUD leaving the hospital before treatment completion. Interviews were recorded, transcribed, and coded with NVivo using conventional content analysis. Results: Twenty-two hospitalists (64% female, 72.7% White, mean age 37) were interviewed between February and April 2021. Hospitalists listed the following as reasons for patients with OUD leaving before treatment completion: untimely and inadequate pain/withdrawal treatment, limited prescribing options in medications for OUD, restrictive visitor and smoking policies, and patient social and other obligations. Twenty out of 22 hospitalists were willing to engage in collaborative patient-centered care but noted institutional barriers. Conclusion: Hospitalists stated willingness to collaborate with patients on identifying and developing systems-level solutions that would allow for patient-centered care. In-hospital access to addiction consult service, staff with lived experience, and other culturally competent resources are key to reducing self-directed discharge, as is training to address stigma and reframe perceptions of appropriate dosing for pain and withdrawal. Hospitalists note a need for transitions to outpatient care after hospital discharge. [ABSTRACT FROM AUTHOR]

Background: The impact of health literacy on self-efficacy management and quality of life among patients leaving against medical advice is essential to determine so that patients can decide on how they manage their health. Aim: This study examined the impact of health literacy (HL) to quality of life (QOL) and self-efficacy (SE). Methods: A cross-sectional survey was employed with 101 patients who left the hospital against healthcare professionals' medical advice. Convinience sampling was employed as the availabilty and willingness of the participants were considered. With the use of keypersons, willing participants were identified. The researchers used Google Forms for easy distribution of the questionnaire. Data gathering was conducted between May and June 2022. Results: The participants' health literacy (Mean=97.2; SD=13.51) and self-efficacy (Mean= 21.0; SD= 3.68) were moderate. The participants reported that their quality of life was low (Mean= 87.4; SD= 6.61). The length of hospital stay differed significantly from the QOL score. It was found that there were significant relationships among HL, QOL, and SE. Conclusion: The patients who opted for LAMA had moderate health literacy, self-efficacy, and low quality of life. The length of hospital stay was found to differ significantly with QOL. Moreover, it was found that there was a significant impact of HL on QOL and SE. [ABSTRACT FROM AUTHOR]

It is essential to understand why patients choose to leave the hospital in direct opposition to medical advice. This understanding could help to identify individuals who are at risk of adverse outcomes. In realizing this need, this study aimed to explore the factors contributing to the decision of patients to leave the hospital against medical advice. Materials and Methods: This research employed a descriptive-analytical approach. It was conducted in the city of Hail, Kingdom of Saudi Arabia. The participants were 13 patients who had opted to leave against medical advice from the Emergency Department of the government-subsidized hospitals. The researchers employed both purposive and snowball sampling. In snowball sampling, the researchers used referrals from initial participants to generate additional participants. Moreover, purposive sampling was used to find the individual that would best contribute to addressing the research issue. The data gathering was conducted from April to June 2022. Results: Five themes emerged based on the accounts of the 13 participant patients. These included (1) health literacy, (2) self-diagnosing, (3) unclear explanations regarding their condition, (4) prolonged waiting times, and (5) communication issues. Conclusion: The factors contributing to patients leaving against medical advice resulted in the five themes mentioned above. While interactions between patients and healthcare professionals may be challenging, pertinent health information must still be handed down clearly to patients. [ABSTRACT FROM AUTHOR]

Introduction: this study aimed to determine the prevalence of Leaving Against Medical Advice (LAMA) in the local context and the associated predictors to help develop effective strategies to reduce its likelihood. Methods: this study employed a retrospective approach using medical records of the 16233 patients between 2016 and 2020 at various government-subsidized hospitals in the Hail region of Saudi Arabia. Results: the prevalence of LAMA was the highest in 2019 (91.9%) and 2017 (21.45%) among insured and non-insured patients, respectively. Furthermore, it was the highest among patients aged 20-25 years and the lowest among patients aged 46 years and above. The incidence of LAMA was the highest (15.48% for males and 29.53% for females) in 2016. In 2016-2019, the most common reason for LAMA was "wanted medication only," while in 2020, the "fear of infection with COVID-19" was the main reason. High blood sugar was the most common diagnosis among the patients under consideration during the study period. Significant association was found between LAMA and patient's insurance status (t = 4.3123; p < 0.002); however, no association was found between LAMA and age (t = -0.8748; p > 0.658) and gender of patients (t = 1.9008; p > 0.302). Conclusion: strategies such as developing a suitable environment for patients and taking due care of their needs, providing individual consulting services, enhancing staff relations, and providing support to patients in need are vital. The likelihood of LAMA can be minimized by informing hospitalized patients and their relatives about the adverse effects of LAMA. [ABSTRACT FROM AUTHOR]

Leaving against medical advice (AMA) is associated with increased readmission rates, fragmented patient care, and healthcare litigation. Understanding the factors associated with trauma patients leaving AMA from acute care settings will help guide better communication with trauma patients and improve patient satisfaction. This study aims to assess the sociodemographic and in-hospital care characteristics of trauma patients that leave AMA from acute care centers across the U.S. We pooled and analyzed eight years of data (2009–2016) from the National Hospital Ambulatory Medical Care Survey. The outcome variable was whether the patient left AMA or not. The main predictors were the triage class, weekend presentation, health insurance status, the presence of chronic diseases, and the receipt of therapeutic and diagnostic procedures. The sociodemographic characteristics -age, sex, and race/ethnicity, were measured as potential confounders in the developed model. We performed logistic regression and reported the unadjusted and adjusted odds of leaving AMA as well as the 95% confidence intervals. The weighted percent of the trauma patient population that left AMA was 1.8%. The odds of leaving AMA decreased with advancing age, and increased among non-Hispanic Blacks, compared with non-Hispanic Whites. After adjusting for age, race, and gender, the odds of leaving AMA increased among patients that lacked health insurance (AOR: 1.86; 95% CI: 1.51–2.31), and had diagnostic procedures (AOR: 2.79; 95% CI: 2.32–3.36). The odds of leaving AMA reduced among trauma patients who were classified as emergent (AOR: 0.70; 95% CI: 0.50–0.98) and had therapeutic procedures (AOR: 0.39; 95% CI: 0.32–0.47). Predicting trauma patients with increased odds of leaving AMA will inform intentional communication that may reduce leaving AMA rates and improve care. [ABSTRACT FROM AUTHOR]

Abstract Background Though substance use is a known risk factor for self-discharge, patients self-discharging during treatment for acute poisoning have not previously been described. We charted characteristics of patients self-discharging during treatment for acute poisoning by substances of abuse looking for associations between self-discharge, repeated poisoning, and death. Methods All patients 12 years and older treated for acute poisoning by substances of abuse at an emergency outpatient clinic in Oslo, Norway, were included consecutively from October 2011 through September 2012. We collected data on gender, age, main toxic agent, suicidal intention, homelessness, history of severe mental illness, and self-discharge. Information on deaths was retrieved from the National Cause of Death Register. We did a multiple logistic regression analysis to look for associations between self-discharge and repeated poisoning and a Cox regression analysis for associations between self-discharge and death. Results During one year, 1731 patients were treated for 2343 episodes of acute poisoning by substances of abuse. Two-hundred-and-sixty-six (15%) patients self-discharged during at least one poisoning episode. Self-discharging patients were older, median age 39 years vs 32 years (p

Background and Aims: Leaving against medical advice (LAMA) is an unfortunate occurrence in 1–2% of all hospitalized patients and is associated with worse outcomes. While this has been investigated across multiple clinical conditions, studies on patients with chronic pancreatitis (CP) are lacking. We aimed to determine the prevalence and determinants of this event among patients with CP. Methods: The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS), 2007–2014, was used in the study. Patients with LAMA were identified, and the temporal trend of LAMA was estimated and compared among patients with and without CP. We then extracted patients with a discharge diagnosis of CP from the recent years of HCUP-NIS (2012–2014) and described the characteristics of LAMA in these patients. Multivariate logistic regression models were used to evaluate predictors of LAMA. Results: 3.39% of patients with CP discharged against medical advice. LAMA rate in CP patients was higher and increased more steeply at quadruple the rate of those without. More likely to self-discharge were patients who were young, males, non-privately insured, or engaged in alcohol and substance abuse, likewise were those with psychosis and those admitted on a weekend or non-electively. The northeast and for-profit hospitals also had higher odds of LAMA. However, patients transferred from other healthcare facilities have reduced LAMA odds. Among all patients with CP, those with LAMA had shorter length of stay (2.74 [2.62–2.85] days vs. 5.78 [5.71–5.83] days) and lower hospitalization cost $23,271 [$22,171–$24,370] versus $45,472 [$44,381–$46,562] compared to the no-LAMA group. Conclusion: LAMA occurs in approximately 1 in 29 patients with CP and is increasing at almost quadruple the rate of those without. Clinicians need to pay closer attention to the identified at-risk groups for ameliorative targeted interventions. [ABSTRACT FROM AUTHOR]

Background: One of the reasons to leave against medical advice (LAMA) from a hospital is to seek treatment in another hospital. Those patients are at high risk of readmission and mortality compared to patients with planned discharge. The aim of this study was to identify the factors for patients' presentations to an academic tertiary hospital Emergency Department (ED) specifically after LAMA from another hospital and to investigate the outcomes of these presentations. Methods: We conducted a prospective cross-sectional study. We included all patients who presented to Sultan Qaboos University Hospital (SQUH) ED after LAMA from other hospitals in Oman during the six-month study period. We excluded patients who died during hospitalization, those who refused to give consent, and those who were identified only after their ED visits' by reviewing the ED medical records' and were difficult to be contacted. We asked the participants to fill a paper-based questionnaire to investigate the factors of their presentations to SQUH ED. We designed the questionnaire by reviewing the literature on second opinion, patient's satisfaction, and LAMA. The questionnaire underwent a content validation by two experts. We investigated the outcomes of the presentations by reviewing the patients' medical charts. We used descriptive statistics to analyse the data. Results: A total of 112 patients presented to SQUH ED after LAMA from other hospitals. 94 of them participated, while 18 patients were excluded. There was equal male to female distribution among the participants and their mean age was 36.8 years (SD = 26.483). Figure 1 illustrates the previous hospitals where patients LAMA. The majority of patients (66.0%) were LAMA from governorate hospitals. Table 1 presents the factors of presentation to SQUH ED. The most common factor to present to SQUH ED (94.7%) was to get the quality of care delivered in SQUH. Out of 94 patients, 70 (74.5%) were admitted to SQUH. More than one-third of the admitted patients (35.7%) required management in critical care units. Conclusion: This study provides the factors that lead LAMA patients to choose an academic tertiary hospital for their second presentation. Identifying these factors can help the decision makers in the healthcare system in Oman to increase the quality of services in other healthcare facilities. Providing more healthcare facilities with diagnostic modalities like Magnetic Resonance Imaging (MRI) and in some places even Computed Tomography (CT) imaging may help decrease the incidence of LAMA. Also considering the addition of diagnostic and therapeutic units (for example: endoscopic suites and angiography suites) may allow for better health services in these hospitals and therefore minimize the occurrence of LAMA. Furthermore, allowing for and addressing the need for second opinion in some patients and organizing for that formally between different specialties in these hospitals may improve the patient satisfaction and therefore reduce the incidence of LAMA. Ultimately all the previously mentioned interventions can minimize the morbidity and mortality associated with LAMA. The study can also act as a pilot for larger multicentered studies. [ABSTRACT FROM AUTHOR]

In this issue of the Journal of Addiction Medicine , 2 studies fill an important gap in knowledge by examining predictors of leaving against medical advice from inpatient withdrawal management settings. The studies identify important risk factors for leaving against medical advice and highlight important areas for inpatient withdrawal management. These include the use of substance specific standardized protocols and initiation of opioid agonist treatment instead of opioid detoxification given harms associated with opioid withdrawal. Further need for increased training in addiction medicine for primary care physicians, and use of inpatient addiction medicine consult services as part of early intervention for substance withdrawal are also discussed. [ABSTRACT FROM AUTHOR]

Deep tissue infection is a serious sequela that often demands intravenous (IV) antibiotic treatment. With respect to IV drug users (IDU's), research and lived experience demonstrates a trend of failed treatment outcomes, most notably associated with leaving hospital against medical advice (LAMA) prior to treatment completion, increased adverse outcomes and patient hardship. This paper examines an alternative model for delivering and completing IV antibiotic treatment to IDU's in a community care setting. A retrospective study was designed to review client characteristics. A total of 33 in-depth interviews were conducted with clients, clinicians and with staff. The impact of treatment adherence and completion, as well as client satisfaction of care was explored. A total of 165 patients were admitted during the study period. Osteomyelitis was the primary cause for IV antibiotics. Risk of leaving AMA was significantly lower for community model (p value <0.0000). Qualitative narrative analysis is also described with respect to satisfaction, stigma and the need for better models of care. With lower rates of LAMA a community model ought to be considered on a wider scale for provision of comprehensive support for populations with complex underlying health needs. [ABSTRACT FROM AUTHOR]

Abstract: Background: Two recent inpatient studies documented that regular nursing staff rounding increased patient safety and satisfaction. However, the effect of systematic emergency department (ED) staff rounding on patient safety and satisfaction has not been adequately tested. Study Objective: The objective of this study was to test the effectiveness of three different rounding techniques. Methods: An 8-week study using a quasi-experimental, non-equivalent group, time-sampling design was conducted in 28 EDs. The three rounding protocols were: 1) rounds every 30 min; 2) rounds every hour; 3) rounds every hour with an Individualized Patient Care tactic (IPC; patients were asked to name their most important expectation for the ED visit). Baseline data were collected the first 4 weeks; rounding was done the second 4 weeks. Outcome measures compared the baseline to the rounding period data for patients who left without being seen (LWBS), those leaving against medical advice (AMA), patient satisfaction, call light use, and nursing station encounters. Results: The three rounding protocols combined reduced LWBS by 23.4%, leaving AMA by 22.6%, falls by 58.8%, call light use by 34.7%, and approaches to the nursing station by 39.5%. Patient satisfaction ratings for overall care and pain management increased significantly. The protocol using the IPC tactic produced the most significantly improved outcomes. Conclusions: Rounding in the ED reception and treatment areas is effective and improves outcomes. Further research should determine the optimal design for rounding considering the mixed shifts in EDs, seek ways to increase communicating delays to patients, and investigate how to integrate rounding with physician activities. [Copyright &y& Elsevier]

Background: Children are vulnerable and cannot make decisions about their health care. There are many cases of parents leaving against medical advice (LAMA) and this can lead to adverse health problems in the children. Objective: The study was aimed at determining the prevalence of, and factors associated with, leaving against medical advice at the Paediatric Unit of the Aminu Kano Teaching Hospital, Kano. Methods: All patients who left against medical advice were included in the study. The study was a prospective one and information sought were age, sex, duration of hospital stay, socio-economic class of parents and reasons for leaving against medical advice over a five-year period (Jan. 2001 to Dec. 2005). Results: Prevalence rate of LAMA was 2.2%, comprising 68 patients of 3,095 discharges, HIV/Pulmonary tuberculosis 17(23%) were the commonest causes of admission in the group of patients aged (10months-12years). Seventy-five percent of the patients were discharged within two weeks of admission. Sixty patients (88.2%) belonged to the lower soci-economic class. Conclusion: LAMA has multifactorial aetiololgy. Low social economic class, poor financial support and unpreparedness for hospital admission are risk factors

Background: Though substance use is a known risk factor for self-discharge, patients self-discharging during treatment for acute poisoning have not previously been described. We charted characteristics of patients self-discharging during treatment for acute poisoning by substances of abuse looking for associations between self-discharge, repeated poisoning, and death.Methods: All patients 12 years and older treated for acute poisoning by substances of abuse at an emergency outpatient clinic in Oslo, Norway, were included consecutively from October 2011 through September 2012. We collected data on gender, age, main toxic agent, suicidal intention, homelessness, history of severe mental illness, and self-discharge. Information on deaths was retrieved from the National Cause of Death Register. We did a multiple logistic regression analysis to look for associations between self-discharge and repeated poisoning and a Cox regression analysis for associations between self-discharge and death.Results: During one year, 1731 patients were treated for 2343 episodes of acute poisoning by substances of abuse. Two-hundred-and-sixty-six (15%) patients self-discharged during at least one poisoning episode. Self-discharging patients were older, median age 39 years vs 32 years (p <  0.001), more frequently homeless, 20/266 (8%) vs 63/1465 (4%) (p = 0.035), and the main toxic agent more frequently was an opioid, 82/266 (31%) vs 282/1465 (19%) (p <  0.001). Self-discharge was an independent risk factor for repeated poisoning. The adjusted odds ratio for two or more poisoning episodes during one year among self-dischargers was 3.0 (95% CI 2.2-4.1). The association was even stronger for three or more poisoning episodes, adjusted odds ratio 5.0 (3.3-7.5). In total, there were 34 deaths, 9/266 (3.4%) among self-discharging patients and 25/1465 (1.7%) among patients not self-discharging (p = 0.12). The adjusted hazard ratio for death among self-discharging patients was 1.6 (0.75-3.6).Conclusions: Self-discharge was associated with frequent poisonings by substances of abuse. Short-term mortality was doubled among self-discharging patients, though this increase was not statistically significant. Still, the increased risk of repeated poisoning marks self-discharging patients as a vulnerable group who might benefit from targeted post-discharge follow-up measures. [ABSTRACT FROM AUTHOR]