Discharge against medical advice at a general hospital in Catalonia

1. Introduction 

Doctors of all specialties, during their hospital medical practice, periodically meet a patient who refuses their assistance for different reasons or circumstances and asks permission to leave the hospital against medical advice (AMA). This situation is potentially harmful for both doctor and patient, as the doctor may feel frustrated when unable to carry out his job, while the patient may be threatening his life by leaving the hospital [1]. Although AMA discharge may have potentially serious consequences [2], [3], few studies have approached this issue. Most of these have been conducted in the United States, and have reported an AMA prevalence of 0.7–7% [2], [4], [5]. The literature reports that AMA discharge takes place in all medical departments, and that AMA rates differ according to type of service. In addition, the incidence by department varies greatly depending on the study [1], [3]. However, there seems to be an accentuated concern about the phenomenon among cardiological patients [2], [4]. These studies describe a sociodemographical profile characterized by a young male [1], [5], [6], [7], [8], [9] from a low socio-economic class and living alone [7]. Length of hospitalization for AMA discharge has been described as comparatively short and occurs within the first days of stay [6], [8], [10]. The reasons for AMA discharge are varied, as social and medical aspects are both involved [6]. These may be family issues, conflicts with staff, or a negative attitude towards the prescribed interventions [1], [5], [11]. Drug abuse and psychiatric disturbances are factors that can influence the decision of a patient to leave AMA. The prevalence of psychiatric diagnosis among AMA patients has been described as being between 11–42% [3], [4], [5], [11].

2. Methods 

The study was carried out at the Parc Taulí Hospital, a 550-bed university general hospital in Sabadell (Barcelona, Spain). The hospital is divided into five departments: Internal Medicine, Surgery, Orthopedic Surgery, Obstetrics-gynecology and Rehabilitation.

When a patient asks to leave AMA, hospital policy demands that they fill out a form stating the reasons for AMA discharge and sign it. A multiple-choice list of reasons is provided in the form, which include: 1) Refuses hospital assistance and prefers to stay at home; 2) Prefers to go to another hospital; 3) Is not satisfied with the attitude of professionals towards him; 4) Is not content with the treatment received; 5) Does not agree with the diagnosis or therapeutic procedure offered; 6) Finds level of comfort unacceptable (cleanliness, food, noise); 7) Problems with sharing the room with another patient; 8) Other reasons (specified). Psychiatric evaluation is not required as a routine procedure when a patient asks to leave AMA. However, in every case where the medical doctor considers it appropriate, he asks for a liaison-consultant psychiatrist to assess the case.

Inclusion criterion was AMA discharge during the 1998–99 two-year period. Exclusion criteria were; 1) being under 18 or over 70 years of age; 2) being admitted for alcohol or narcotic detoxification in a specific unit for “drug dependency” situated in the Internal Medicine Department; 3) patients who left AMA to die at home or to be moved to another hospital for geographic reasons.

The study consisted of two parts. First, a retrospective analysis of the epidemiological discharge register was carried out to find out the prevalence, sociodemographic characteristics and medical diagnosis (re-categorized by subspecialties) of AMA discharged patients in each medical department. Then a control group matched by age, sex, ICD medical diagnosis and medical department was selected using the discharge epidemiological register.

Second, a retrospective case-control comparison was undertaken in order to compare length of hospitalization and presence of psychiatric disturbances in both groups. These data, together with the reasons for AMA discharge, were obtained by means of a revision of all the clinical charts. Charts were reviewed by two trained professionals; a consultant psychiatrist and a clinical psychologist, reaching a consensus. The presence of psychiatric disturbances was registered when there was an axis I or axis II DSM-IV diagnosis in the clinical chart. In cases fulfilling more than one diagnosis, only the most severe was considered for analysis. To facilitate statistical analysis, DSM-IV diagnostic subgroups were re-categorized into syndrome diagnoses. Substance abuse/dependence diagnoses were kept in the DSM-IV subgroups, given the higher number of patients found in these categories.

The statistical analysis was carried out using the SPSS statistical package. Student t test was used for the comparison of length of hospitalization between groups while the χ2 test was used to compare the presence of psychiatric disturbances.

3. Results 

A total of 142 patients left the hospital AMA during the two-year period (1998–1999), the global discharge number in the same period being 41,648. The general prevalence of AMA discharge was 0.34%. AMA rates by medical department were 0.44% for the internal medicine department, 0.24% for surgery; 0.26% for orthopedic surgery, 0.32% for Obstetrics-gynecology and 0.93% for rehabilitation (see Table 1). The mean age of AMA patients was 38.6 years, 59.9% of the cases being men and 40.1% women. Average length of hospitalization was 6.9 days. Regarding hospital department, 45.8% had been admitted to the internal medicine department, 17.6% to surgery, 16.2% orthopedic surgery, 14.8% obstetrics-gynecology and 5.6% rehabilitation (see Table 2). When considering medical subspecialties of AMA patients, results showed that within the internal medicine department, a high proportion of patients were from the internal medicine subspecialty. This includes mainly medical diagnoses related to AIDS and chemical poisoning complications. Within the surgical department, a relatively high number of AMA patients were found in the general surgery category, which includes mainly digestive tract hemorrhages, pancreatitis and cancers. (See Table 3). The chart reviews carried out to obtain the psychiatric diagnosis of AMA patients showed that psychiatric diagnosis was present in 48.5% of cases. Despite the fact that patients admitted for detoxification were excluded from the study—only those who were admitted for medical conditions were considered—psychiatric diagnoses among AMA patients were narcotic abuse/dependence in 17.6% of cases, alcohol abuse/dependence in 9.9%, mood disorders in 7.7%, anxiety disorders in 6.3%, personality disorders in 4.2% and psychosis in 2.8% (see Table 2). The reasons for AMA discharge were preference to stay at home (47.2%), other reasons specified as personal or family reasons (14.1%), dissatisfaction with medical care (4.9%), disagreement with diagnosis or therapeutic procedure (4.9%), preference for another hospital (6.3%), and “other reasons” nonspecified (22.6%).

Table 1. AMA rates in each hospital department

	Medical Department	Total	AMA	AMA Rate
	Internal Medicine	14,717	65	0.44%
	Surgery	10,582	25	0.24%
	Orthopaedic Surgery	8,884	23	0.26%
	Obstetrics-Gynaecology	6,603	21	0.32%
	Rehabilitation	862	8	0.93%
	Total	41,648	142

Table 2. Sociodemographic characteristics, length of hospitalisation, admission department and psychiatric diagnosis of AMA and control groups

		AMA Group		Control Group		P-value
	N	142		130
	Sex	N		N
	Men	85	59.9%	81	62.3%
	Women	57	40.1%	49	37.7%
	Age
	Mean	38.6	(SD) 13.6	39.1	(SD) 14.0
	Length of hospitalisation
	Mean	6.9	(SD) 7.3	7.8	(SD) 7.2	NS
	Hospital department
	Internal medicine	65	45.8%	63	48.5%
	Surgery	25	17.6%	18	13.8
	Orthopaedic surgery	23	16.2	27	20.8%
	Obstetrics-gynaecology	21	14.8%	21	16.2%
	Rehabilitation	8	5.6%	1	0.8%
	Psychiatric diagnosis
	None	58	40.8%	67	51.5%	<0.05
	Missing	15	10.6%	18	13.8%
	Psychosis	4	2.8%	2	1.5%
	Mood disorder	11	7.7%	6	4.6%
	Anxiety disorder	9	6.3%	1	0.8%
	Personality disorder	6	4.2%	5	3.8%
	Narcotic dependence	25	17.6%	13	10.0%
	Alcohol dependence	14	9.9%	18	13.8%

Table 3. Medical Subspecialties of AMA patients

	Medical Department	Medical Subspecialty	N	Percentage
	Internal medicine
		Internal medicine	37	.>26.0%
		Cardiovascular	8	5.6%
		Gastrointestinal	1	0.7%
		Endocrine	2	1.4%
		Renal	3	2.1%
		Neurological	6	4.2%
		Oncological	2	1.4%
		Pneumological	6	4.2%
	Surgical
		General surgery	18	12.7%
		Head and neck cancer	2	1.4%
		Opthalomological	0
		Urological	1	0.7%
		Vascular	4	2.8%
	Orthopaedic surgery		23	16.2%
	Obstetrics-Gynaecology		21	14.8%
	Rehabilitation		8	5.6%
	Total		142	100%

When the retrospective case-control comparison study was undertaken, results regarding length of hospitalization did not show a significant difference between the two groups. When comparing psychiatric diagnoses, AMA patients showed a statistically significant higher incidence of psychiatric pathology (48.5%) than the control group (34.5%) (P < .05). In Table 4, the distribution of psychiatric diagnoses of AMA patients among different hospital departments is shown.

Table 4. Psychiatric diagnosis and medical department of AMA patients

	Medical Department	Psychiatric Diagnosis
		None	Not known	Psychotic disorder	Mood disorder	Anxiety disorder	Personality disorder	Narcotic dependence	Alcohol dependence/abuse	Total
	Internal medicine	17	7	3	6	3	2	22	5	65
	Surgery	12	2		3	1	1	1	5	25
	Orthopaedic surgery	14	1	1		2	1		4	23
	Obstetrics-Gynaecology	14	3		2	2				21
	Rehabilitation	1	2			1	2	2		8
	Total	58	15	4	11	9	6	25	14	142

4. Discussion 

The prevalence of AMA discharge at our hospital was low (0.34%) when compared to other studies (mainly USA studies available), which report a prevalence ranging from 0.7% to 7% for general hospitals [2], [3], [4], [5], [8], [9], [12]. With the exception of a recent study conducted at the Clinic Hospital emergency department, which reports an AMA prevalence of 0.19% [12], there is a lack of data regarding prevalence of AMA discharge in other general hospitals in our country. Some American studies report that AMA discharge can change depending on the type of medical insurance coverage or insurance status of the patients. For example, Medicaid patients, and patients identified as self-funding have higher rates of AMA discharge [6], [9]. Taking this into account, the low prevalence of AMA discharge found in our study could be explained by the fact that, in our country, health care is supplied by the Governmental Health Service and is sectored, so that a patient is only admitted to a hospital in their geographical area. Moreover, the population covered by our hospital is, on average, from a medium-low socio-economic level, and would not use private health services.

The sociodemographic profile of AMA patients in our hospital -young adult male- is similar to that reported in the literature, although we did not analyze for marital status or social class.

When reasons for AMA discharge reported by patients were analyzed, social factors (e.g., preference to stay at home, personal or family reasons) rather than medical reasons (e.g., dissatisfaction about medical care, disagreement with diagnostic or therapeutic procedure) were found as the most common reasons to leave AMA. These factors have already been described as characteristic of AMA discharge in the literature [13], [14].

Although AMA discharge was found to affect all medical/surgical specialties, in our study there was a high prevalence of AMA among internal medicine and rehabilitation department patients, corresponding in many cases to patients that had been admitted for either chemical poisoning or medical complications associated with AIDS (see Table 3). This group usually presented an underlying psychiatric pathology consisting mainly of narcotic dependence. It should be taken into consideration that the most frequent means of HIV transmission in Spain is parenteral drug use [15]. AMA discharge in the rest of the services was less frequent and, as can be seen in Table 4, the incidence of psychiatric pathology among them was lower. It could be argued that in these cases, reasons motivating AMA were preference to stay at home or discomfort with the hospital environment rather than psychosocial reasons.

Surprisingly, no significant differences were found between the AMA and control groups average length of hospitalization. This could be explained by the fact that our hospital is mainly an acute care hospital, so that in general the average stay is already short (7.9 days). Furthermore, AMA patients are usually admitted with severe pathology, which prevents them from leaving during the first days of hospitalization.

Despite the low prevalence of AMA patients in our study group, the number of psychiatric disturbances among these patients was high (48.5%) compared with other findings in the literature [3], [4], [5], [7]. Moreover, our results show a statistically significant difference in the incidence of psychiatric pathology between the AMA and control groups. The most common psychiatric subgroups in the AMA group were narcotic dependence and, to a lesser extent, alcohol abuse/dependence, as already reported in previous studies [2], [4], [5]. It is important to emphasize that the basic psychopathological characteristics tend to be the main factors in triggering treatment neglect. In substance abuse patients, for example, the craving for the drug, together with their impulsiveness, aggressiveness, low personal responsibility, low self-control and associated cognitive impairment are all factors that contribute to the premature discharge [14], [16]. Perhaps the desire to create the illusion of control over one’s life provokes this type of behavior and could be found in many different situations if the patient were observed. As control slips away, overt demonstrations of control may become a psychological necessity, which can reveal itself in a variety of situations including hospitalization. It is relevant to point out that this diagnostic group may have decreased the number of personality disorders found among our sample. The reason for this is that personality disorders are quite common among substance abusers and we only considered the main diagnosis for the data analysis, when more than one psychiatric disorder was present. The incidence of other psychiatric diagnoses found in the AMA group such as psychosis or mood and anxiety disorders was lower, although it was the expected among medical hospital populations [17], [18], [19].

A high incidence of psychiatric pathology was also found among patients in the control group (34.5%). A possible reason for this is that controls were matched for medical diagnosis, which very often corresponded to medical complications associated with AIDS, and these in turn are very often related to narcotic dependence. Moreover, the high incidence of alcohol abuse/dependence found among controls is not surprising to us, considering that the prevalence of alcohol related problems in comorbidity with medical disorders at general hospitals in Spain is 15–35% [20]. In relation to the other psychiatric diagnoses, they were slightly more frequent in the AMA group (see Table 4).

One more point to take into account in our study is that no patients with a lack of competence to make decisions left AMA, as a liaison psychiatric intervention is provided for the assessment of the psychopathological state when it is considered appropriate.

Our study had several limitations. First, it is a single institution study and so its results are difficult to generalize. Another drawback was the small sample size and the fact that data were obtained retrospectively through chart reviews. Third, the fact that the control group was matched by medical diagnosis may have biased our results by not allowing a more significant difference to be found between the AMA and control groups regarding incidence of psychiatric disturbances. Finally, in the present study no data were available regarding cases in which psychiatric diagnosis may be secondary to the medical illness.

In conclusion, the prevalence of AMA at our hospital was low in comparison with the rates reported in the literature. The patient at high risk for AMA discharge is a young man with a history of psychiatric pathology, mainly narcotic dependence. The knowledge of the prevalence and patients’ profile of AMA discharge in our setting is relevant as an additional quality marker when assessing hospital assistance.