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Leaving Against Medical Advice After Emergency General Surgery: Avoiding a Two-Hit Effect.

Authors
  • Villarreal, Michael Edward1
  • Schubauer, Kathryn2
  • Paredes, Anghela Zarella2
  • Santry, Heena Patel2
  • Tamer, Robert2
  • Strassels, Scott A2
  • Wisler, Jonathan2
  • 1 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio. Electronic address: [email protected]
  • 2 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
Type
Published Article
Journal
Journal of Surgical Research
Publisher
Elsevier
Publication Date
Jan 01, 2021
Volume
257
Pages
278–284
Identifiers
DOI: 10.1016/j.jss.2020.06.058
PMID: 32866668
Source
Medline
Keywords
Language
English
License
Unknown

Abstract

Emergency general surgery has higher adverse outcomes than elective surgery. Patients leaving the hospital against medical advice (AMA) have a greater risk for readmission and complications. We sought to identify clinical and demographic characteristics along with hospital factors associated with leaving AMA after EGS operations. A retrospective review of the Nationwide Inpatient Sample was performed. All patients who underwent an EGS procedure accounting for >80% of the burden of EGS-related inpatient resources were identified. 4:1 propensity score analysis was conducted. Regression analyses determined predictive factors for leaving AMA. 546,856 patients were identified. 1085 (0.2%) patients who underwent EGS left AMA. They were more likely to be men (59% versus 42%), younger (median age 51 y, IQR [37.61] versus 54, IQR [38.69]), qualify for Medicaid (26% versus 13%) or be self-pay (17% versus 9%), and be within the lowest quartile median household income (40% versus 28%) (all P < 0.05). After applying 4:1 propensity score matching, individuals who were self-pay (OR 3.15, 95% CI 2.44-4.06) or insured through Medicare (OR 2.75, 95% CI 2.11-3.57) and Medicaid (OR 3.58, 95% CI 2.83-4.52) had increased odds of leaving AMA compared with privately insured patients. In addition, history of alcohol (OR 2.21, 95% CI 1.65-2.98), drug abuse (OR 4.54, 95% CI 3.23-6.38), and psychosis (OR 2.31, 95% CI 1.65-3.23) were associated with higher likelihood for leaving AMA. Patients undergoing EGS have a high risk of complications, and leaving AMA further increases this risk. Interventions to encourage safe discharge encompassing surgical, psychiatric, and socioeconomic factors are warranted to prevent a two-hit effect and compound postoperative risk. Copyright © 2020 Elsevier Inc. All rights reserved.

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