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Relationships with commercial interests:
Grants/Research Support: ◦ Health Sciences Center Research Foundation
◦ Manitoba Health Research Council
◦ WCB of Manitoba
Speakers Bureau/Honoraria/Consulting fees: ◦ None
Other: Medical Director Occupational Health WRHA
PHx – ETOH Abuse, DM II on meds Presents with R leg pain and swelling seven
days after trauma O/E Temp 38.0 BP 135/ 75 BMI 33 R lower leg oozing scab, cellulitis Laboratory evaluation WBC 14,000 Xray - soft tissue swelling no FB Dx – R leg cellulitis
Tx IV Ceftriaxone/ Vancomycin.
◦ 3 days pleasant
leg responds to treatment with decreasing pain and swelling. No signs of withdrawal. Wound swab grows MSSA
◦ Hospital day 4 – Friend comes Takes out IV. Tells nursing staff he is leaving
Leaves ward without signing AMA form.
◦ You are called to the ward Nurse says ” I hope he will be OK because he was confused last
night, but seemed a bit better this morning”.
What do you do? ◦ Nothing
◦ Attempt to reach him to give him oral Antibiotics
◦ Call the police to bring him back
Prognosis? ◦ Short term
◦ Long term
Allan Garland
Clare Ramsey
Kendiss Olafson
Randy Fransoo
Manitoba Centre Health Policy
Marina Yogendran
Dan Chateau
Funding ◦ Health Sciences Center Research Foundation ◦ Manitoba Health Research Council
Ethical approval ◦ U of M Research Ethics Board ◦ HIPC Manitoba Health
Data was collected by MB Health. The results and conclusions are the researchers. No official endorsement of the data by MB Health or the Manitoba Center for Health Policy
Identified all MB residents >18 yrs
Admitted and discharged alive between April 1, 1990 and Feb 28, 2009.
Constructed episodes of care ◦ Account for inter-hospital transfers
Identified AMA discharges from the hospital abstracts ◦ coded by trained personal using uniform
definitions, data collection methods, and data entry software
Kraut et al. BMC Health Services Research 2013, 13:415
1 916 104 hospital episodes – discharged alive
21 417 (1.11%) AMA discharges
610 187 individuals
12 588 (2.06%) AMA 1 time
2 986 (0.49%) AMA ≥ 2 times
Kraut et al. BMC Health Services Research 2013, 13:415
0102030405060708090
% people wholeft AMA
% of AMAdischarges
1> 1
Percentage
# of AMA discharges
Kraut et al. BMC Health Services Research 2013, 13:415
Males
Younger
Rural in our data Urban in others
Lower SES
Alcohol and Drug problems
Mental Health Issues
Kraut et al. BMC Health Services Research 2013, 13:415
00.20.40.60.8
11.21.41.61.8
Hosp. # discharges/10 000
HSC St. BBrandonUrban Com.Rural
AMA percentage discharge
Number of Discharges
Kraut et al. BMC Health Services Research 2013, 13:415
Most responsible hospital diagnosis
Total number of episodes
AMA episodes, (% of live discharges)
% of total AMA episodes
Alcohol or drug abuse
24 768 2900 (11.71) 13.54
Poisonings by pharmaceuticals or alcohol
9684 730 (7.54) 3.41
Alcohol-related liver disease
2202 162 (7.36) 0.76
Diabetic ketoacidosis
4728 267 (5.65) 1.25
Tuberculosis 1353 69 (5.10) 0.32
Kraut et al. BMC Health Services Research 2013, 13:415
Most responsible hospital diagnosis
Total number of episodes
AMA episodes, (% of live discharges)
% of total AMA episodes
Digestive disorders
217 895 2196 (1.01) 10.25
Circulatory disorders
251 132 1921 (0.76) 8.97
Respiratory disorders
138 875 1445 (1.04) 6.75
Neoplasms 118 692 358 (0.30) 1.67
Complications of pregnancy, childbirth and the puerperium 355 735 2227 (0.63) 10.40
Kraut et al. BMC Health Services Research 2013, 13:415
Unscheduled Readmission = for any cause, any diagnosis ◦ Age ↑ ◦ Male Sex ◦ Lower SES ◦ Rural residency ◦ Co-morbidities Metastatic cancer, HIV/AIDS, Renal Failure, CHF,
others
◦ AMA 2-3 fold increase
Garland A et al. CMAJ 2013;185:1207-1214
0
1
2
3
4
5
6
7
8
9
0-1 days 2-7 days 8-14 days 16-30days
31-60days
61-90days
91-180days
AMA
nonAMA
% Readmission
Garland A et al. CMAJ 2013;185:1207-1214
Odds of death at given intervals after hospital discharge associated with leaving hospital against medical advice.
Garland A et al. CMAJ 2013;185:1207-1214
©2013 by Canadian Medical Association
AMA discharges – 1.1% of MB live hospital discharges
AMA discharges associated with increased risk of readmission 60% of which occurs in the first two weeks post discharge
AMA discharges associated with 2- 3 fold increased risk of mortality at all intervals between 7 and 180 days of follow up.
Strategies focused on preventing AMA – may decrease excess rate of readmissions.
Strategies only focused on preventing AMA discharges will have limited ability to reduce the increased risk of death.
To prevent excess mortality this population needs longitudinal interventions that extend beyond hospitalization.