The causes of discharge against medical advice and suggestions for its reduction in Tabriz Sina Medical Center (phenomenological study)

INTRODUCTION

As the most essential health-care institution, the hospital has been heavily influenced by global changes and is acquiring new features every day.^[1] Patient satisfaction is an essential part of the quality of hospital treatment outcomes. One of the problems that result from patient dissatisfaction is discharge against medical advice (DAMA), which, in addition to creating obstacles to the treatment of patients, also poses significant problems for hospitals.^[2,3] DAMA is considered to be a significant problem in hospitalization.^[4,5,6,7] It means that the patient, despite the physician’s recommendation, is earlier leaves the hospital.^[8] Statistics shows that DAMA in advanced countries such as the United States involves 0.8–2.2% of total discharge.^[9]

According to the records of the patients in the medical records unit of Sina Medical Center during 2017, 870 people signed the DAMA form and left the hospital voluntarily. Because of these high statistics, a qualitative study would be beneficial. The purpose of this study was to identify the causes of DAMA by patients admitted to Sina Hospital of Tabriz. Finally, strategies for reducing DAMA are provided. The questions in this study are as follows:

1. Why are you discharged against medical advice?

2. How can we make you satisfied with hospitalization and continuing treatment?

3. What are the strategies for reducing DAMA at Sina Training and Medical Center?

The result of the studies shows that the reasons related to the patient, the hospital environment, and the causes related to the hospital staff are, respectively, the most important reasons for DAMA.^[10] Furthermore, personal or family problems, feelings of recovery, dissatisfaction with treatment, feeling unwell, and tired of the hospital environment are some of the factors that lead to DAMA.^[11] Other causes mentioned are financial concerns, cultural and social issues, hospital environment, patient knowledge and attitude, ability and verbal communication skills, and skills of medical personnel.^[12] The results of the Alebiosu and Raimi survey show that patients leave the hospital for the following reasons: Dissatisfaction with treatment, family and financial problems, recovery, preferring other hospitals, dissatisfaction with the hospital environment, inadequate treatment, and being an educator of the hospital.^[13] About 25% of patients who are discharged against medical advice will require readmission.^[14]

In Iran, dissatisfaction with diagnostic and therapeutic measures (38.2%) is the reason for the DAMA of patients.^[15] In the male gender, ages 35–49 years, mental/personality disorders and drug abuse are also considered as other factors for DAMA.^[16]

Bastani et al. in their study titled “Causes of Discharge against medical advice in Tajrish Martyrs Training Center,” concluded that internal ward with 18%, delivery with 16%, and surgical ward with 15.5% had the highest rate of discharge. The neonatal emergency department had the least DAMA. Furthermore, there was no significant relationship between patients’ gender and type of hospitalization with DAMA.^[17]

Salehi et al. concluded in their study that 48.5% of patients with personal reasons, 26% due to dissatisfaction with services (hospital conditions), and 25.5% due to a combination of causes; they left the hospital with their responsibility. Most of the patients who discharged against medical advice were admitted to the emergency department.^[18]

Askari et al. in a study, entitled “Ranking Causes of DAMA with Fuzzy Hierarchy Process,” concluded that the most important causes of DAMA are as follows: Patient financial problems and cost 36.2, 28.7% recovery feeling, fatigue from the hospital environment, and prolongation of treatment period 18.4%.^[19]

Choi et al. in their study, “Readmission rates of patients discharged against medical advice: a matched cohort study,” concluded that 32.3% of these individuals were homeless. About 25.6% of people rehospitalized within 14 days after discharge. Furthermore, among patients who were discharged against medical advice, the mortality rate during 1 year after discharge was high.^[20]

Glasgow et al. in their study “Learning Against Medical Advice: Risk of 30-Day Mortality and Hospital Readmission,” found that patients who were discharged against medical advice had the highest readmission rates and mortality rates over 30 days. Among 97 patients who were discharged against medical advice in this study, 21% were readmitted. These patients may also have mortality because they delay readmission, so their mortality is 57% higher than others.^[21]

Duñó et al. concluded in their study, “Discharge Against Medical Advice at a General Hospitals Catalonia:” The rate of DAMA was 34% over 2 years. To study the sociodemographic and psychopathological features of patients who leave DAMA, they performed a retrospective case–control comparison study of the length of hospitalization and presence of psychiatric disturbances on patients who left DAMA from the University General Hospital in Catalan Spain over a 2-year period. An analysis of the hospital epidemiological discharge register and retrospective chart review for the presence of psychiatric disturbances was used. There was no significant relationship between the days of hospitalization and DAMA.^[22]

MATERIAL AND METHODS

The approach of this research is qualitative, based on the philosophy of phenomenology. Phenomenology means the study of the phenomena. The phenomenon may be events, situations, experiences, or concepts. The primary purpose of phenomenological studies is to describe experiences from the language of participants who have experienced the phenomenon themselves.^[23]

The study population consisted of all patients who completed the DAMA form in 2017 who had left the study hospital. The hospital under study is a government-funded educational and treatment center with 25 inpatient departments and its primary specialty is skin, burns, and poisoning in the northwest of Iran. The study population included all hospitalized patients whose information was recorded in the hospital medical records.

Interviews were conducted by telephone, in which the interviewee (patient or companion) could freely express his or her views and reasons. This survey uses an open and unstructured questionnaire. The interviews were interrupted when the information (open-ended answers and explanations) saturated.^[24]

The method of analysis is a thematic one. The interviews are read by the researcher several times to immerse the data, then the coding is done, and these codes are categorized into main themes and sub-themes.^[23]

Various methods have been used to confirm the results and the reliability and validity of the study, such as allocating sufficient time to collect data, maintaining excellent communication with the participants, and conducting interviews at times set by the participants to increase data acceptability and trust.^[25,26]

Discussion

After analyzing and interpreting the interviews, the leading causes of DAMA are identified as three main themes: (1) Problems related to the patient, (2) problems related to health-care issues, and (3) problems associated with hospital facilities [Table 1].

Table 1: Coding and categorization.

Rows	Themes	Sub-themes (codes)
1	Problems associated with hospital facilities	Individuals’ preference to continue treatment at other centers due to the poor quality of hospital (9 codes). Being an educational hospital (3 codes). Being a government hospital (3 codes). Failure to attend a physician on time (3 codes). Lack of private rooms (3 codes). The high hospital costs (1 code). Improper hospital nutrition (1 code). Dissatisfaction with the facilities and equipment (1 code). Doctors recommend (1 code)
2	Problems related to health-care issues	Dissatisfaction with medical services (6 codes). Failure to follow patient comfort (3 codes). Dissatisfaction with nursing services (3 codes). Improper treatment of personnel (1 code)
3	Problems related to the patient	Prolongation of hospital stays (12 codes). The plight of the family (6 Codes). Having no one to companion (3 codes). Patient restlessness (3 codes). Previous unpleasant experience (2 codes). Job involvement (2 codes). Long distance from home to the hospital (2 codes). Feeling of recovery (2 codes). Having a young child (1 code). Fear of surgery and admission (1 code)

The following results were obtained in the study of DAMA according to the inpatient ward: According to Chart 1 the rate of DAMA was Highest in the surgical ward among the other wards. The restoration and burn wards of men and women also had a high frequency, respectively. The ICU general also had the least frequency of DAMA.

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Chart 1:

Discharge against medical advice according to the inpatient ward.

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The following results were obtained in the study of DAMA according to the duration of hospitalization: Regarding the duration of hospitalization after interviewing and gathering information, a significant number of individuals considered the duration of hospitalization as a reason for their DAMA. Furthermore, the average length of stay of most people was over 2 days. About 12% of the patients were hospitalized for <1 day. About 17% of the patients were hospitalized for 1 day, 55% for 2–7 days [Chart 2]. About 17% of the patients were hospitalized for more than 7 days. Prolonged hospitalization, according to patients, has caused people to miss, stay away from work, and life, work and family problems, and even patient restlessness.

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Chart 2:

Discharge against medical advice according to the duration of hospitalization.

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After reviewing and interpreting the interviews, the following strategies were categorized using a focus group approach to manage and reduce DAMA. The focus group is a semi-structured group interview session conducted by the group leader in an informal setting to gather information on a particular topic.^[27] In the present study, after the meeting with managers, the following strategies were scored and categorized and presented.

1. Effective communication between physicians and patients

2. To prevent DAMA because the financial situation informs patients and their companions, the costs of hospitalization, and surgical procedures

3. DAMA should be performed with the presence of the treating physician, and the head nurse of the ward and the complications and problems of the DAMA should be reported to the patient and their companions

4. The patient shall state in writing or orally the reason for their DAMA

5. If DAMA is due to financial factors, the hospital accounting department shall, as far as possible, work with the patient, and his/her family in coordination with the hospital management

6. List and try to provide the needed medical equipment, because it is one of the reasons for DAMA

7. Patients with mental disorders will be diagnosed by a physician and reported to their companions

8. In any case, physicians have no right to force a patient to DAMA, and this should be reported to the physician in writing by the hospital manager

9. Ask the patient and their companions to contact the physician if there is a problem after DAMA and to return to the hospital after 2 weeks for follow-up

10. Consideration to the patient’s decision-making capacity by physicians

11. DAMA should be recorded in the hospital’s HIS system and informed to physicians who have more DAMA

12. Conducting training sessions with physicians to justify patients and the consequences of DAMA.

CONCLUSION

The most common reasons for DAMA in Sina educational and medical center were problems related to the patient, which included personal, family problems, prolonged hospital stay, and patient’s restlessness.

High levels of DAMA at Sina Hospital can be a sign of patient dissatisfaction. Therefore, it is imperative to pay attention to new discussions of hospital management sciences such as clinical governance and its components such as risk management and patient safety. Increasing patient-centered quality of service, increased physician-patient communication, patient participation in treatment, and increased patient satisfaction can dramatically reduce DAMA in the studied hospital. Early identification of these patients can also help determine appropriate solutions to prevent early discharge. Furthermore, the need to pay attention to patients’ rights and respect for patients’ privacy can reduce the patient’s DAMA. It is necessary for every disease, and every ward makes specific intervention strategies.

For the future research, the following is suggested:

1. Interventions to reduce DAMA of Sina medical center

2. Comparison of DAMA in different years in Sina medical center

3. Evaluation of DAMA rate in Tabriz’s hospitals

4. Comparison of DAMA in Tabriz’s public and private hospitals

5. A comparative study of the rate and cause of DAMA in different countries.