• Krista Haines, Jennifer Freeman, Cory Vastaas, Clay Rust, Christopher Cox, George Kasotakis, Matthew Fuller, Vijay Krishnamoorthy, Michelle Siciliano, Amy Alger, Sean Montgomery, and Suresh Agarwal.
• Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
• J Emerg Med. 2020 Apr 1; 58 (4): 691-697.

BackgroundDischarge against medical advice (AMA) is an important, yet understudied, aspect of health care-particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs.ObjectiveThe goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment.MethodsWe performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status.ResultsUninsured (odds ratio [OR] 2.72; 95% confidence interval [CI] 2.58-2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37-2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02-1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52-0.75), Asian (OR 0.59; 95% CI 0.49-0.69), and Hispanic (OR 0.80; 95% CI 0.75-0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury.ConclusionsInsurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.Copyright © 2020 Elsevier Inc. All rights reserved.

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