a b s t r a c t

Purposes: A paucity of data exists on the prevalence and predictors of discharging injured patients against medical advice from emergency departments. The aim of this study is to investigate the association between acute alcohol use and being discharged against medical advice.

Methods: We performed a prospective, observational study of injured patients enrolled into the Korean Centers for Disease and Prevention Injury surveillance program in 7 tertiary, academic, and teaching hospitals from June 1, 2008, to November 31, 2011. Injured patients were assigned to 1 of 3 groups: discharged against medical advice, regular discharge, and transferred or admitted. Multivariable logistic regression models were used to analyze the association between acute alcohol use and being discharged against medical advice.

Results: A total of 125,327 patients were enrolled, and 3473 (2.8%) were discharged against medical advice. The proportion of acute alcohol use was significantly higher among the patients who were discharged against med- ical advice (40.1%) than the regular discharged (16.6%) or transferred/admitted (15.5%) patients. In a regression model, acute alcohol use increased the risk of being discharged against medical advice (adjusted odds ratio, 1.86; 95% confidence interval, 1.70-2.03). In addition, we identified the interaction between acute alcohol use and in- tention of injury. Acute alcohol use had a significant association with the discharge against medical advice with the Unintentional injury (adjusted odds ratio, 2.56; 95% confidence interval, 2.30-2.84).

Conclusion: Patients with acute alcohol use before sustaining an injury are at increased risk of being discharged

against medical advice from the emergency departments.

(C) 2015

Introduction

Discharge against medical advice occurs when patients leave the hospital against their physician’s advice [1]. Importantly, patients who have been discharged against medical advice have higher rates of mor- tality and readmission [2-5]. According to a recent population-based study and a 5-year retrospective cohort in 129 Veterans Administration

? Funding acknowledgment: Korea Centers for Disease Control and Prevention support- ed this study financially.The authors have no potential conflicts of interest to disclose.

* Corresponding author at: Department of Emergency Medicine, Seoul National Univer-

sity College of Medicine and Hospital, 101 Daehak-Ro, Jongno-gu, Seoul, Republic of Korea, 110-744. Tel.: +82 2 2072 3257; fax: +82 2 741 7855.

E-mail addresses: [email protected] (J. Jeong), [email protected], [email protected] (K.J. Song), [email protected] (Y.J. Kim), [email protected] (J.S. Cho), [email protected] (J.O. Park), [email protected] (S.C. Lee), [email protected] (Y.S. Ro), [email protected] (J.F. Holmes).

hospitals, 1.1% and 1.7% of patients are discharged against medical advice, respectively [6,7]. However, most of studies evaluating patients discharged against medical advice evaluate admitted patients, as few have been performed in the emergency department (ED) setting [8-11, 13].

In addition, discharge against medical advice from an ED is clinically important, as one ED-based prospective follow up study reported that more than half of those initially discharged against medical advice had significant findings on their return visit [9]. Another retrospective ED- based study reported that discharged against medical advice patients had higher risk of emergent hospitalization compared with patients discharged appropriately [10].

A recent large population-based study reported that the chance of discharge against medical advice varied substantially with the patients’ primary complaints, but patients with injuries and poisonings were at highest risk of discharge against medical advice [6]. Patients with trau- matic injuries account for a substantial amount of the ED volume. These patients generally require rapid assessment and resuscitation

http://dx.doi.org/10.1016/j.ajem.2015.11.065

0735-6757/(C) 2015

[14]. However, a paucity of data exists about the prevalence or predic- tors of discharge against medical advice in injured patients in the ED.

Prior variables increasing patient risk of discharge against medical advice include male sex, younger age, lower social economic status, Medicaid or no insurance, and substance or alcohol abuse [12]. Acute al- cohol use is a risk factor for sustaining a traumatic injury; therefore, al- cohol use may also be a predictive factor for discharge against medical advice in injured patients [15]. Chronic alcohol abuse/alcohol addiction has been examined in several prior studies about discharge against medical advice. However, no previous study has evaluated the associa- tion between acute alcohol use and discharge against medical advice.

The objective of this study is to examine the prevalence of discharge against medical advice and the association between acute alcohol use and discharge against medical advice in injured patients in the ED.

Methods

Study design and patients

We prospectively enrolled patients participating in the injury sur- veillance program of the Korean Centers for Disease and Prevention in 7 tertiary, academic, and teaching hospitals located in urban (n = 5) and suburban areas (n = 2) from June 1, 2008, to November 31, 2011. These EDs provide care for 30,000-80,000 patient visits annually. This study was reviewed and approved by the Institutional Review Board of Seoul National University Hospital.

The study’s inclusion criteria were patients presenting to 1 of 7 EDs following an injury. Patients were excluded for any of the following: age less than 18 years, no data on alcohol use, no data on ED disposition, or dead on arrival to the ED.

Evaluation and outcome measures

We divided patients into 3 groups based on ED disposition: discharge against medical advice, standard discharge, and transfer/admission. We defined discharge against medical advice as any patient discharge against medical advice specified in the medical records or injury registry form. Acute alcohol use was defined as a history of alcohol use within 6 hours be- fore the onset of injury documented by medical record.

The following variables were analyzed: sex, age, year, season, day of the week, ED shift, specific hospital, intentional vs unintentional injury, Mode of transport, patient transfer, and the severity and mechanisms of injury according to the International Classification External Causes of Inju- ries (ICECI) guidelines [15]. Intentional injury group included assault and self-inflicted injury. In addition, we evaluated the severity of injury based on the Excess Mortality Ratio-based Injury Severity Score (EMR-ISS) using the International Classification of Disease, 10 Revision, codes [16].

The primary outcome of this study is to assess the association be- tween ED acute alcohol use and discharge status.

Statistical analysis

Categorical variables were analyzed with ?² tests; and continuous variables, with Student t test (for normally distributed data) and Wilcoxon rank sum test (for nonnormally distributed or ordinal data). In addition, we performed a multinomial logistic regression model to identify the association between acute alcohol use and the type of dis- charge. Results of the regression analysis are presented as the adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Continuous vari- ables were categorized. Patient age was categorized as young adults: 18-39 years, middle-aged adults: 40-59 years, and older adults: 60 years and older. Injury severity score was categorized as mild: EMR- ISS 1-8, moderate: 9-14, or severe: 15-75 [16]. In addition, we tested the interaction between acute alcohol consumption and intentional vs unintentional injury in multivariable logistic models and stratified the

results of the above analysis. Statistical analyses were conducted with the use of SAS software, version 9.3 (SAS Institute, Cary, NC).

Results

Disposition of the study patients

A total of 192,159 patients were entered into the Korean Centers for Disease and Prevention’s injury surveillance program, 126,070 of whom were aged 18 years or older, alive on arrival to the ED, and had discharge disposition documented. Of these, acute alcohol consumption was un- known in 742 patients, and sex was unknown in 1 patient. Therefore, the final data set for analysis consisted of 125,327 patients. Discharge dispositions were as follows: discharge against medical advice (n = 3473, 2.8%), standard discharge (n = 97,989, 78.2%), and transfer/ad- mission (n = 23,865, 19.0%) (Figure).

Baseline characteristics

The baseline characteristics of enrolled patients were described in Table 1. Significantly more patients with acute alcohol consumption were in the discharge against medical advice group (40.1%; 95% CI, 38.4-41.8) than in the standard discharge group (16.6%; 95% CI, 16.3-

16.8) or transfer/admission group (15.5%; 95% CI, 15.1-16.0). There was a significant difference in the injury intention between the 3 groups; the number of the patients with assault and self-injury was greater in the discharge against medical advice group than other groups. The severity of injury was significantly greater in the transfer/admission group than other groups.

The baseline and clinical characteristics depending on the acute alco- hol use are also presented in Table 2.

The association between acute alcohol use and discharge against med- ical advice

As shown in Table 3, in the logistic regression models, there was a significant association between the discharge against medical advice and acute alcohol consumption (OR, 3.42; 95% CI, 3.19-3.67). Further- more, there was a still significant association between the discharge against medical advice and acute alcohol consumption after adjustment for potential confounding variables (aOR, 1.86; 95% CI, 1.70-2.03).

Finally, a significant interaction between acute alcohol use and injury intention was identified. Acute alcohol use had a significant association with the discharge against medical advice with the unintentional injury (aOR, 2.56; 95% CI, 2.30-2.84), but this association was not found with the intentional injury (aOR, 1.13; 95% CI, 0.99-1.28) (Table 4).

Discussion

In this multicenter, observational study of injured patients, the rate of discharge against medical advice in the EDs was low but important. Our results demonstrate that patients with acute alcohol use were more likely to be discharged against medical advice as compared with those without alcohol use. This held true even after adjusting for other factors. In addition, acute alcohol use was associated with unintentional injury patterns. In the interaction analysis, a significant association be- tween acute alcohol consumption and discharge against medical advice in patients with unintentional injury was identified. We did not, howev- er, identify association between acute alcohol use and discharge against medical advice in patients with intentional injuries.

Evidence supports the association between acute alcohol use and in- creased risk of injury, and this study was conducted mainly in EDs [17]. The present multicenter, ED-based study raises the possibility that alco- hol use increases not only the risk of injury but also the risk of leaving the ED before complete evaluation/treatment. Therefore, acute alcohol

Figure. Steps of the enrollment of the study patients.

Table 1

Baseline and clinical characteristics depending on the type of discharge

Total DAMA Regular discharged Transferred/admitted P value

	N = 125,327	%		n = 3473	%		n= 97,989	%		n = 23,865	%
Acute alcohol use												b.001
Yes	21,330	17.0		1393	40.1		16,225	16.6		3712	15.5
95% CI		16.8-17.2			38.4-41.8			16.3-16.8			15.1-16.0
No	103,997	83.0		2080	59.9		81,764	83.4		20,153	84.5
95% CI Sex Male	72,514	82.7-83.2 57.9		2140	58.2-61.5 61.6		55,771	83.2-83.7 56.9		14,603	84.0-84.9 61.2	b.001
Female Age group	52,813	42.1		1333	38.4		42,218	43.1		9262	38.8	b.001
18-39	55,574	44.3		1427	41.1		47,587	48.6		6560	27.5
40-59	44,070	35.2		1424	41.0		34,236	34.9		8410	35.2
>= 60 Injury intention Unintentional	25,683 111,306	20.5 88.8		622 2142	17.9 61.7		16,166 88,022	16.5 89.8		8895 21,142	37.3 88.6	b.001
Intentional	13,088	10.5		1303	37.5		9279	9.5		2506	10.5
Unknown	933	0.7		28	0.8		688	0.7		217	0.9
Injury mechanism Traffic accident	24,865	19.8		284	8.2		18,093	18.5		6488	27.2	b.001
Fall/collision	59,852	47.8		1575	45.3		46,419	47.4		11,858	49.7
Stab wound/gun	17,442	13.9		527	15.2		14,818	15.1		2097	8.8
Burn	2773	2.2		15	0.4		2455	2.5		303	1.2
Intoxication	3871	3.1		736	21.2		1758	1.8		1377	5.8
Asphyxiation, drowning, foreign body, excessive use of body or joint, others, unknown	16,524	13.2		336	9.7		14,446	14.7		1742	7.3
Injury severity (EMR-ISS) 1-8	60,657	48.4		1384	39.9		53,220	54.3		6053	25.4	b.001
9-14	36,770	29.3		810	23.3		31,890	32.5		4070	17.1
15-75	27,598	22.0		1274	36.7		12,618	12.9		13,706	57.4
Missing Transferred from other hospital Yes	302 19,178	0.3 15.3		5 521	0.1 15.0		261 9034	0.3 9.2		36 9623	0.1 40.3	b.001
No	106,149	84.7		2952	85.0		88,955	90.8		14,242	59.7
Use EMS Yes	27,114	21.6		1337	38.5		17,222	17.6		8555	35.9	b.001
No Time of presentation Day	98,213 40,485	78.4 32.3		2136 879	61.5 25.3		80,767 30,143	82.4 30.7		15,310 9463	64.1 39.7	b.001
Evening	55,024	43.9		1309	37.7		43,663	44.6		10,052	42.1
Night Days of the week	29,806	23.8		1284	37.0		24,173	24.7		4349	18.2	b.001
Weekday	79,723	63.6		2360	68.0		60,427	61.7		16,936	71.0
Weekend	45,601	36.4		1113	32.0		37,559	38.3		6929	29.0

Data are missing in 12 patients for time and 3 patients for day of the week. DAMA, discharge against medical advice; EMS, emergency medical services.

Table 2

Baseline and clinical characteristics depending on the acute alcohol consumption

	Total			Alcohol group			Nonalcohol group	P value
	N = 125,327	%		n = 21,330	%		n = 103,997 %
ED disposition DAMA	3473	2.8		1393	6.5		2080 2.0	b.001
95% CI		2.7-2.9			6.2-6.9		1.9-2.1
Regular discharged	97,989	78.2		16,225	76.1		81,764 78.6
95% CI		78.0-78.4			75.5-76.6		78.4-78.9
Transferred/admitted	23,865	19.0		3712	17.4		20,153 19.4
95% CI Sex Male	72,514	18.8-19.3 57.9		16,128	16.9-17.9 75.6		19.1-19.6 56,386 54.2	b.001
Female Age group 18-39	52,813 55,574	42.1 44.3		5202 10,538	24.4 49.4		47,611 45.8 45,036 43.3	b.001
40-59	44,070	35.2		8727	40.9		35,343 34.0
>= 60 Injury intention Unintentional	25,683 111,306	20.5 88.8		2065 13,882	9.7 65.1		23,618 22.7 97,424 93.7	b.001
Intentional	13,088	10.5		7172	33.6		5916 5.7
Unknown Injury mechanism Traffic accident	933 24,865	0.7 19.8		276 2226	1.3 10.4		657 0.6 22,639 21.8	b.001
Fall/collision	59,852	47.8		14,366	67.4		45,486 43.7
Stab wound/gun	17,442	13.9		2259	10.6		15,183 14.6
Burn	2773	2.2		149	0.7		2624 2.5
Intoxication	3871	3.1		1170	5.5		2701 2.6
Asphyxiation, drowning, foreign body, excessive use of	16,524	13.2		1160	5.4		15,364 14.8
body or joint, others, unknown Injury severity (EMR-ISS) 1-9	60,657	48.4		5937	27.8		54,720 52.6	b.001
9-14	36,770	29.4		8375	39.3		28,395 27.3
15-75	27,598	22.0		6969	32.7		20,629 19.8
Missing Transferred from other hospital Yes	302 19,178	0.2 15.3		49 2843	0.2 13.3		253 0.3 16,335 15.7	b.001
No Use EMS Yes	106,149 27,114	84.7 21.6		18,487 7790	86.7 36.5		87,662 84.3 19,324 18.6	b.001
No Time of presentation Day	98,213 40,485	78.4 32.3		13,540 3234	63.5 15.2		84,673 81.4 37,251 35.8	b.001
Evening	55,024	43.9		5777	27.1		49,247 47.4
Night Days of the week Weekdays	29,806 45,601	23.8 36.4		12,318 7709	57.7 36.1		17,488 16.8 37,892 36.4	.414
Weekends	79,723	63.6		13,621	63.9		66,102 63.6

Data are missing in 12 patients for time and 3 patients for day of the week.

use impacts not only primary injury prevention but also efforts of sec- ondary prevention of injury [14].

Prior studies demonstrate that patients with alcohol abuse are at in- creased risk of discharge against medical advice [12,18]. However, few

studies have focused on the association between acute alcohol use and ED discharge. In this study, almost half of the patients who discharged against medical advice drank alcohol before the onset on injury, but in the whole injured patients, the proportion was less than 20%. In

Table 3

multivariate logistic regression models demonstrating association between acute alcohol use, injury intention, and discharge against medical advice^a

Table 4

Interaction analysis between the injury intention and acute alcohol consumption on the discharge against medical advice

Total Outcome:

DAMA

Unadjusted Adjusted^b

Total Outcome:

Adjusted^a

Alcohol Yes No

Injury intention

n n % OR 95% CI OR 95% CI

								n		n	%		OR	95% CI	P value
21,330	1393	6.5	3.42	3.19-3.67	1.86	1.70-2.03	Unintentional
103,997	2080	2.0	1.00		1.00		Alcohol (-)	97,424		1485	1.5		1.00
								13,882		657	4.7		2.56	2.30-2.84	b.001

Alcohol (+)

DAMA

^a A single multivariable logistic regression model showing a correlation between acute alcohol consumption and DAMA between the alcohol or nonalcohol group/unintentional or intentional injury group. “Intentional injury” included assault and self-injury.

^b Adjusted for sex, age, injury severity(EMR-ISS), mechanisms and injury intention, type of hospital, mode of transport, patient transfer, ED shift, and the number of patients seen in the ED during weekdays or day shifts.

Unknown intention

Alcohol (-)	657	6	0.9	1.00
Alcohol (+)	276	22	8.0	8.27	3.27-21.0	b.001

^a Adjusted for sex, age, injury severity(EMR-ISS), mechanisms and injury intention, type of hospital, mode of transport, patient transfer, ED shift, and the number of patients seen in the ED during weekdays or day shifts.

Unintentional	11,1306	2142	1.9	1.00		1.00		Intentional
Intentional	13,088	1303	10.0	5.64	5.25-6.05	2.20	2.00-2.41	Alcohol (-)	5916	589	10.0	1.00
Unknown	933	28	3.0	1.58	1.08-2.30	1.30	0.88-1.92	Alcohol (+)	7172	714	10.0	1.13	0.99-1.28	0.06

addition, the number of patients who discharged against medical advice was about 3 times greater in the alcohol group as compared with the nonalcohol group. We speculate that patients with acute alcohol use are prone to impulse behavior and lack proper self-determination skills. A previous study reported no significant difference in the severity of injury between patients admitted with traumatic brain injury who ulti- mately left the hospital against medical advice and those who underwent regular discharge [19]. In the current study, however, the se- verity of injury (EMR-ISS) was greater in the patients who were discharged against medical advice as compared with those who underwent regular discharge. Moreover, after adjustment of confound- ing variables including injury severity, a significant effect size of acute alcohol consumption in the patients who were discharged against med- ical advice was identified. These differences deserve future study be- cause different studied populations and methods of measuring injury

severity were used.

A significant association between patients discharged against medical advice and intentional injury has been previously demonstrated [19]. Moreover, acute alcohol consumption is believed to increase the risk of self-inflicted injury [20,21]. We identified an association between acute alcohol use and patients with unintentional injury being discharged against medical advice. However, in patients with intentional injury, the overall effect size of acute alcohol consumption was nonsignificant.

As an injury surveillance system, our injury surveillance program collected variables according to ICECI guidelines [15]. We included co- variate variables designated as core in the ICECI guidelines (injury in- tention, injury mechanism) or used in another study which investigated discharged against medical advice after injury (sex, age groups, injury severity) [15,19]. In addition, time variables (shift time, day of the week) and prehospital variables (emergency medical services use, transferred from other hospital) which could have association with injury severity were included as covariates. Almost all these variables could be ascertained in the medical records objectively; some missing values were specified on the results tables.

To date, no study directly examines the differences in patients who

are discharged against medical advice in patients admitted to the hospi- tal and those in the ED. In the United States, a National Hospital Ambu- latory Medical Care Survey reports that 1.2% of ED patients leave against medical advice [22]. A population-based study from Canada reported that 1.1% hospital dischargers were patients leaving the hospital against medical advice [6].

Our results demonstrate 2.8% of ED patients with injuries are discharged against medical advice. Although this rate is higher than these database studies, several possible explanations exist. First, the prevalence of alcohol use is higher in injured patients than ED patients without injuries. Second, patients with acute alcohol use may choose to leave against medical advice because alcohol affects Cognitive skills including judgment.

The results of this study are of significance because they are the first to examine the rate of being discharged against medical advice in in- jured ED patients. In an ED setting, patients with injury and acute alco- hol consumption pose challenging problems for clinicians. These patients are vulnerable to being discharged against medical advice and deserve special attention.

Limitations

To date, ED-based studies have shown that acute alcohol consumption is associated with risky behavior [23]. In the current study, however, we did not examine the association between behavioral characteristics and acute alcohol consumption. This might have introduced a bias in the anal- ysis of alcohol-related behavior. We conducted the current study under the hospital-based observational design. Therefore, our clinical series is

not representative of the entire population. We did not measure serum al- cohol levels. Suspicion of acute alcohol use is subject to both over- and un- derestimation; nevertheless, ICECI guidelines recommended its use, and many previous studies used this method [24]. We did not evaluate ulti- mate outcome in the patients who discharged against medical advice. It is also probable that the patients of this group had a greater severity of in- jury but the injuries were never identified or treated.

Conclusions

Emergency department patients with acute alcohol use before being injured are at risk of being discharged against medical advice. Further follow-up studies are warranted to evaluate outcomes in these patients and to clarify mechanisms underlying being discharged against medical advice in this series.

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