Factors associated with leaving against medical advice among patients hospitalized for dermatologic conditions

To the Editor: Despite substantial burden of skin disease in hospitalized patients and association leaving against medical advice (AMA) with worse outcomes, little is known regarding AMA among for dermatologic conditions.1Glasgow J.M. Vaughn-Sarrazin M. Kaboli P.J. Leaving (AMA): risk 30-day mortality hospital readmission.J Gen Intern Med. 2010; 25: 926-929Crossref PubMed Scopus (120) Google Scholar,2Arnold J.D. Yoon S.J. Kirkorian A.Y. The national inpatient dermatology adults.J Am Acad Dermatol. 2019; 80: 425-432Abstract Full Text PDF (13) Scholar Our objective was to determine factors associated conditions. In this retrospective case-control study National Inpatient Sample (2009-2015), conditions were identified using primary International Classification Diseases, Ninth Revision–Clinical Modification code/clinical classification software. Rao-Scott chi-square test, t analysis variance used unadjusted comparisons by discharge status trends over time. Weighted multivariable logistic regression AMA. Variables significant on univariate initially included model; Akaike information criterion variable inclusion collinear covariates comparing independent models. Analyses performed SAS 9.4 (SAS Institute, Cary, NC) survey procedures/weighting nationally representative estimates. A total 4,523,930 conditions, 66,091 (1.46%) left rate increased from 2009 (1.44%) 2015 (2.22%; P < .001) (Supplemental Table I; available via Mendeley at https://doi.org/10.17632/7wn6m5n5kj.1). Skin/subcutaneous infections most common diagnoses (Table I). analysis, young adult (adjusted odds ratio [aOR], 1.41; 95% confidence interval [CI], 1.33-1.50) men (aOR, 1.56; CI, 1.50-1.63) insurance uninsured 1.91; 1.74-2.09) or Medicaid 1.77; 1.66-1.90) likely leave II). Patients lower income 1.28; 1.16-1.41) those admitted emergently 1.79; 1.59-2.01) had greater undergoing a major procedure 0.38; 0.35-0.40) less urban teaching 1.51; 1.34-1.70) nonteaching 1.70; 1.52-1.91) hospitals more than rural hospitals. Diagnoses, chronic procedures per age group are provided Supplemental II (available https://doi.org/10.17632/7wn6m5n5kj.1).Table ISociodemographic, clinical, characteristics conditionsPatient characteristicsAMA inpatients, % (95% CI) (n = 66,091)Routinely discharged 4,457,839)Sex Male66.03 (65.06-66.99)50.62 (50.35-50.89) Female33.97 (33.01-34.94)49.38 (49.11-49.65)Age Average, y, CI)45.03 (44.60-45.46)56.61 (56.09-57.14) 0-170.76 (0.59-0.92)6.65 (5.88-7.41) 18-3937.45 (36.15-38.75)14.94 (14.61-15.27) 40-5945.58 (44.48-46.68)30.13 (29.66-30.59) 60-7913.49 (12.70-14.28)30.28 (29.88-30.67) ≥802.73 (2.39-3.06)18.01 (17.51-18.51)Race White62.05 (59.04-65.05)69.69 (68.13-71.26) Black19.37 (17.64-21.11)14.74 (13.68-15.79) Hispanic12.88 (11.07-14.70)10.44 (9.36-11.53) Asian/Pacific Islander0.87 (0.62-1.13)1.45 (1.25-1.65) Native American0.83 (0.58-1.08)0.82 (0.61-1.02) Other4.00 (2.73-5.27)2.86 (2.39-3.34)Quartile income, percentile 0-25th39.26 (36.61-41.91)30.97 (29.48-32.45) 26th-50th25.69 (23.66-27.73)25.45 (24.36-26.53) 51st-75th20.86 (19.44-22.29)23.70 (22.73-24.66) 76th-100th14.18 (12.67-15.70)19.89 (18.24-21.55)Primary payer Medicare24.99 (23.93-26.05)46.34 (45.55-47.14) Medicaid32.21 (30.12-34.30)16.41 (15.70-17.12) Private insurance12.42 (11.46-13.39)25.52 (24.84-26.20) Self-pay23.69 (21.93-25.45)7.45 (6.97-7.92) No charge2.02 (1.46-2.57)0.81 (0.61-1.00) Other4.67 (3.96-5.38)3.48 (3.16-3.79)Type admission Emergent94.19 (93.48-94.91)84.15 (83.44-84.86) Elective5.81 (5.09-6.52)15.85 (15.15-16.56)Dermatologic condition Melanoma0.14 (0.07-0.21)0.51 (0.45-0.57) Other nonepithelial cancer0.33 (0.23-0.42)1.18 (1.08-1.29) infection75.90 (74.90-76.90)61.70 (61.06-62.35) Inflammatory condition2.33 (2.07-2.60)3.61 (3.50-3.73) Chronic ulcer17.81 (16.91-18.71)26.87 (26.24-27.49) disorder3.49 (3.14-3.84)6.13 (5.88-6.38)Weekend No74.50 (73.74-75.26)79.68 (79.52-79.85) Yes25.50 (24.74-26.26)20.32 (20.15-20.48)Underwent surgical No91.07 (90.46-91.67)77.09 (76.68-77.50) Yes8.93 (8.33-9.54)22.91 (22.50-23.32)Number 0-120.28 (19.26-21.29)20.35 (19.70-21.00) 2-444.05 (42.99-45.10)30.19 (29.73-30.65) 5 more35.68 (34.47-36.89)49.46 (48.68-50.25)Number 0-12.74 (2.34-3.13)1.78 (1.62-1.95) 2-422.21 (21.14-23.28)17.50 (16.95-18.04) more75.05 (73.79-76.31)80.82 (80.06-81.38)Number 0-182.76 (81.14-84.37)69.57 (68.83-70.31) 2-514.83 (13.60-16.06)24.71 (24.22-25.20) more2.41 (1.91-2.91)5.72 (5.41-6.03)Hospital Bed sizeSmall (1-249 beds)11.01 (9.31-12.70)13.26 (12.42-14.09)Medium (250-424 beds)28.70 (25.62-31.79)25.16 (23.87-26.45)Large (>424 beds)60.29 (56.96-63.62)61.58 (60.05-63.11) Hospital typeRural9.37 (8.27-10.48)13.19 (12.34-14.04)Urban nonteaching44.28 (40.85-47.71)41.66 (39.97-43.35)Urban teaching46.35 (42.75-49.95)45.15 (43.40-46.89)AMA, Against advice; interval. Open table new tab IIMultivariable model demographicsAdjusted CI)P valueSex Male1.56 (1.50-1.63)<.001 FemaleReference—Age, y 0-170.06 (0.04-0.07)<.001 18-391.41 (1.33-1.50)<.001 40-59Reference— 60-790.37 (0.34-0.39)<.001 ≥800.13 (0.11-0.15)<.001Race Non-Hispanic WhiteReference Black0.995 (0.918-1.079).910 Hispanic0.91 (0.81-1.02).089 Islander0.77 (0.60-0.97).029 American1.03 (0.81-1.31).836 Other1.16 (0.99-1.36).066Quartile 0-25th1.28 (1.16-1.41)<.001 26th-50th1.15 (1.03-1.27).0102 51st-75th1.05 (0.97-1.13).211 76th-100thReference—Primary MedicareReference— Medicaid1.77 (1.66-1.90)<.001 insurance0.48 (0.44-0.52)<.001 Self-pay1.91 (1.74-2.09)<.001 charge1.43 (1.20-1.71)<.001 Other0.97 (0.85-1.10).607Admission type Emergent1.79 (1.59-2.01)<.001 ElectiveReference—Dermatologic Melanoma0.73 (0.42-1.26).255 cancer0.74 (0.52-1.04).078 infection1.19 (1.12-1.27)<.001 condition0.81 (0.71-0.93).003 ulcerReference— disorder0.89 (0.79-1.02).086Hospitalization details Underwent procedureNoReference—Yes0.38 (0.35-0.40)<.001 Number conditions0-1Reference—2-41.33 (1.24-1.42)<.0015 more1.04 (0.96-1.13).336 typeRuralReference—Urban nonteaching1.70 (1.52-1.91)<.001Urban teaching1.51 (1.34-1.70)<.001CI, Confidence AMA, similar that all (1.44%).3Ibrahim S.A. Kwoh C.K. Krishnan E. Factors who acute-care advice.Am J Public Health. 2007; 97: 2204-2208Crossref (103) As other either insured AMA.1Glasgow Scholar,3Ibrahim often cite financial reasons AMA; education implications important improving rates safe discharge.4Schaefer G.R. Matus H. Schumann J.H. et al.Financial responsibility advice: legend?.J 2012; 27: 825-830Crossref (25) Fewer diagnoses, adults may increase Possible explanations likelihood include options care, differing patient populations, differences services. Study limitations inability evaluate severity, reliance coding, lack reasons/consequences This broad description disease, disease-specific studies needed identify targeted strategies. have disproportionately taxing readmissions, readmission rates.1Glasgow Scholar,5Zhang Markova A. Harp J. Dusza S. Rosenbach Kaffenberger B.H. Dermatology-specific all-cause calendar-year readmissions costs diseases 2010 2014.J 81: 740-748Abstract (7) Understanding contributors critical developing interventions limit early termination treatment improve health care service use. We would like acknowledge Medicine, Society, Culture program Department Bioethics Case Western Reserve University School Medicine supporting our access database.