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. 2023 Mar 27;13(3):e068801.
doi: 10.1136/bmjopen-2022-068801.

How does discharge against medical advice affect risk of mortality and unplanned readmission? A retrospective cohort study set in a large UK medical admissions unit

Anand Alagappan  1 , Thomas J G Chambers  2   3 , Erik Brown  4 , Sheila M Grecian  3 , Khalida Ann Lockman  1   5
Affiliations

How does discharge against medical advice affect risk of mortality and unplanned readmission? A retrospective cohort study set in a large UK medical admissions unit

Anand Alagappan et al. BMJ Open. .

Abstract

Objectives: To assess the frequency of discharge against medical advice (DAMA) in a large UK teaching hospital, explore factors which increase the risk of DAMA and identify how DAMA impacts patient risk of mortality and readmission.

Design: Retrospective cohort study.

Setting: Large acute teaching hospital in the UK.

Patients: 36 683 patients discharged from the acute medical unit of a large UK teaching hospital between 1 January 2012 and 31 December 2016.

Measurements: Patients were censored on 1 January 2021. Mortality and 30-day unplanned readmission rates were assessed. Deprivation, age and sex were taken as covariates.

Results: 3% of patients discharged against medical advice. These patients were younger (median age (years) (IQR)): planned discharge (PD) 59 (40-77); DAMA 39 (28-51), predominantly of male sex (PD 48%; DAMA 66%) and were of greater social deprivation (in three most deprived quintiles PD 69%; DAMA 84%). DAMA was associated with increased risk of death in patients under the age of 33.3 years (adjusted HR 2.6 (1.2-5.8)) and increased incidence of 30-day readmission (standardised incidence ratio 1.9 (1.5-2.2)).

Limitations: Readmission to acute hospitals outside of the local health board may have been missed. We were unable to include information regarding comorbidity or severity of presentation.

Conclusions: These data highlight the vulnerability of younger patients who DAMA, even in a free-at-the-point-of-delivery healthcare setting.

Keywords: Health economics; INTERNAL MEDICINE; PUBLIC HEALTH.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Flowchart showing the patients excluded from the initial 37 409 discharges included in initial analyses.
Figure 2
Figure 2
Kaplan-Meier survival curves broken down by age group and sex. Red lines show planned discharges and green lines show those against medical advice. DAMA, discharge against medical advice; PD, planned discharge.
Figure 3
Figure 3
Standardised incidence rate of 30-day readmission to hospital in DAMA cohort vs planned discharge cohort adjusting for age, length of stay, sex, SIMD, discharge specialty and month and year of discharge. DAMA, discharge against medical advice; LOS, length of stay; SIMD, Scottish Index of Multiple Deprivation; SIR, standardised incidence rate; SPEC, hospital speciality.
See this image and copyright information in PMC

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