Factors affecting leave against medical advice from the emergency department

INTRODUCTION

Efficiency in the delivery of healthcare services through cost reduction and robust operational processes is critical.¹ Quality of medical care provided in the emergency department (ED) can represent the overall quality of medical care provided by a hospital.² Patients’ satisfaction is thought to be an accurate indicator of hospital service quality.³ A patient leaving the hospital against medical advice (LAMA) is considered a ‘missed opportunity’ and is used as an indirect indicator of the quality of ED care.

These are patients who leave the treating facility without completing service after evaluation and initiation of workup or after a physician’s decision to admit them to the hospital.⁴ Patients who choose LAMA are both a challenge and concern for physicians, as these patients are lost to follow-up, and their outcomes remain unknown. Leaving the hospital against the doctor’s advice may put the patient at risk of untreated medical problems, which may necessitate readmission.^5–8 Even though no hospital wants LAMA as it might lead to adverse patient consequences, it is also the patient’s right to choose a healthcare provider.^9,10 Predictors of LAMA can be broadly categorized into patient variables (sociodemographic characteristics, diagnosis, treatment history and attitude towards treatment) and healthcare provider variables (hospital settings, policies, staffing pattern, physician’s clinical style and experience).^11,12

Studies in developing countries have implicated poor financial support and low socioeconomic status as the main reasons for LAMA. Few studies have been done in India; a study done in northern India found that 27.6% of patients chose LAMA due to financial constraints,¹³ whereas a study done in southern India found 50% of patients chose LAMA due to financial constraints.¹⁴ We evaluated the causes of LAMA from the ED in a large, urban, tertiary care, private sector hospital.

METHODS

Our prospective observational study was done in the ED of a tertiary care hospital in urban northern India from October 2021 to March 2022. It included 400 consecutive patients, of either gender who chose LAMA from the ED during the study period. Institutional Ethics Committee approved the study, and informed consent was obtained. Self-administered, closed-ended questionnaires were used to capture the data. The demographic information and clinical history were recorded on admission.

To illustrate the sociodemographic profile of patients, descriptive statistics were used. The chi-square test was used to compare the reasons for LAMA with patients’ characteristics such as their age and sex, income, education, occupation, diagnosis and patient triaging categories. p<0.05 was considered statistically significant. Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) programme for Windows, version 21.0 (SPSS, IBM Corp., Armonk, NY).

RESULTS

During the study period 7598 patients reported to the ED, of which 400 (5.2%) went LAMA. The mean (SD) age of the study participants was 48.3 (17.7) years. The majority of participants were in the 31–40 years age group and males outnumbered females. Most patients were educated up to 12th class, had monthly family income of ₹61 663–123 321 and had no health insurance. Of the 400, 23 (5.75%) returned to the hospital with the same complaints within 72 hours. Of these 23 patients, 6 (26.1%) chose LAMA due to financial constraints, 5 (21.7%) due to non-availability of beds, 4 (17.4%) wanted a second opinion, 3 (13.0%) perceived a risk of infection, while 2 (8.7%) each felt better and had personal reasons. One patient (4.3%) cited conflict with staff. After return to the ED, the length of stay ranged between 0 and 7 days with a mean (SD) duration of 2.9 (1.7) days. For the majority of patients, family members were decision makers for LAMA (Table 1).

All the patients were assigned a triaging category; 187 (46.75%) were categorized as green, 178 (44.5%) as red and 35 (8.75%) as yellow. We found no significant association between triaging categories and reasons for patients going LAMA (Table 2). We did not find the patient’s age or gender to have any bearing on the decision for LAMA.

Among the 400 patients, 103 (25.8%) chose LAMA because they were feeling better after the initial treatment in the ED and did not want to stay for further evaluation and observation; 82 (20.5%) left due to non-availability of the desired category of bed, 69 (17.3%) had financial issues and 59 (14.8%) were concerned about the risk of getting infection (Table 2).

On multiple logistic regression, the presence of health insurance and monthly family income were significant predictors for patients opting for LAMA (Table 3).

DISCUSSION

Patients often leave the ED against medical advice or during treatment, putting their well-being in peril. In private hospitals, patients who lack insurance or are not covered by any medical aid are most likely to choose LAMA while for those who have insurance policies, the decision to go LAMA may be the end of financial support.¹⁵ Limiting LAMA is a challenge in the healthcare field in developing countries such as India where there is minimal health insurance. In our study, of 7598 patients who reported to the ED, 400 (5.2%) were LAMA. Similar findings were reported by Udosen et al. where of 3708 patients seen at the casualty, 97 (2.6%) LAMA.¹⁶ Crilly et al. studied 32 333 patients and found that 470 (1.5%) went LAMA.¹⁷ Gautam et al. reported a 3.3% LAMA rate.¹³ Various other studies have reported a 3%–13% rate of patients who were LAMA.^18–22

In our study, of 400 LAMA patients, 23 (5.8%) returned to the hospital with the same complaint within 3 days. Crilly et al. found that 20 (0.5%) patients returned to the ED within 7 days.¹⁷ Hasan et al. observed that 61% of LAMA patients revisited the hospital with worsening or persistence of the same problem or developed a new problem.²³ Abuzeyad et al. in their study reported a 20.8% readmission rate to the ED within 72 hours of discharge.²⁴ This variability could be due to the relative ease of access to healthcare at government hospitals in Delhi. Financial assistance to patients in other empanelled private hospitals in the form of free diagnostics and free surgery schemes, government-regulated packages for medicines and emergency cashless treatment to victims could have played an important role in the readmission of our patients.

We found that the maximum number of patients belonged to the 31–40-year age group, followed by the 41–50-year age group. Hayat et al.²⁵ and El Metwally et al.²⁰ also found younger age groups to be the most common who went LAMA. This can be attributed to aggressive behaviour, low tolerance levels and higher mobility among this group.

The majority of LAMA patients in our study were males, with the male-to-female ratio being 2:1. Similarly, a high prevalence of males going LAMA was reported by authors of studies done in different geographical regions.^16,20,22,25 However, Al-Badri et al. reported equal male-to-female distribution amongst the LAMA patients.²⁶

In our study, 25.8% took LAMA because they were feeling better and refused further observation in the hospital. Possibly, the availability of home care services and family physician can allow continuity of care under physician supervision. Other reasons were non-availability of the desired category of indoor beds, financial issues, apprehension of getting infection and personal issues such as baby at home and distance from hospital. Dissatisfaction with hospital services due to long waiting time, lack of improvement in the patient’s condition and conflict with the medical staff were other factors for taking LAMA. 10.3% patients did not provide any specific reason. Similar findings were reported by Abuzeyad et al. where refusal of the procedure/operation (23.2%), long ED waiting time (22.2%), subjective improvement with treatment (17.7%) and children at home (14.8%) were the major reasons.²⁴ Shirani et al. found that lack of health insurance was the most frequent reason for LAMA.²⁷ Noohi et al. reported that the main reason for LAMA discharges was patient factors (43.9%), while hospital environment and medical staff were the reasons for 41.2% and 35.2% of cases, respectively.²⁸ Hadadi et al. reported poor communication skills and work overload as the main contributing factors to LAMA.¹⁸ Other studies also found financial constraints as the major reason for LAMA.^14,21,29 This highlights that the healthcare system continues to be expensive, particularly in private hospitals. There is little awareness about health insurance and out-of-pocket expenses limiting appropriate healthcare. Health education may help in better understanding of the disease process and facilitate decision-making. Good clinical care and skilful communication can repose trust in healthcare institutions and doctors.

The distribution of reasons for LAMA was comparable across all age groups and genders in our study. This is in contrast with Bahadori et al. who found significant differences between LAMA rate and patients’ sex and age (p<0.001).³⁰ This study was conducted at a public teaching hospital in Tehran while our study was done at a private hospital and this may have resulted in the difference.

We found that lack of health insurance and low monthly income independently affected the decisions to take LAMA. Similarly, Ding et al. reported that insurance status, male gender and higher acuity level were also associated with a significantly higher emergent hospitalization rate.³¹ Lee et al. also found lack of medical insurance (odds ratio 1.99) as a major risk factor for LAMA across all age groups.¹⁹

The main reason among red (priority 1) category patients leaving the ED was non-availability of intensive care beds. This can be explained by the expedient need for critical care beds. The patients categorized as green, opted for LAMA because majority of them felt better after the initial treatment.

Our study had a few limitations. It was done at a single private tertiary care urban hospital with relatively small sample size. It only focused on the immediate 72 hours return period after LAMA; readmission results after 72 hours were not analyzed. Our study duration overlapped with the Covid-19 pandemic and this could have affected the reasons for LAMA.