|Year : 2013 | Volume
| Issue : 2 | Page : 60-65
Discharge against medical advice: Experience from a rural Nigerian hospital
Joseph O Fadare1, Oluwole A Babatunde2, Timothy Olanrewaju3, Olusegun Busari4
1 Department of Medical Pharmacology and Therapeutics, Obafemi Awolowo University, Ile-Ife, Nigeria
2 Department of Community Medicine, Federal Medical Centre, Ido-Ekiti, Nigeria
3 Department of Medicine, University of Ilorin, Ilorin, Nigeria
4 Department of Internal Medicine, Federal Medical Centre, Ido-Ekiti, Nigeria
|Date of Web Publication||23-May-2014|
Joseph O Fadare
Department of Medical Pharmacology and Therapeutics, Obafemi Awolowo University, Ile-Ife
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Discharge against medical advice (DAMA) is a worldwide problem with negative health and socioeconomic effects. Factors that have been implicated as causes or contributing to DAMA include financial constraints, lack of health insurance, deteriorating clinical condition of the patient, and problematic doctor-patient relationships.
Aims: determine the incidence and profiles ofDAMA on the medical wards, so as to allows for evidence-based interventions to reduce this problem to a minimum.
Materials and Methods: This was a case-control study carried out on the medical wards of Federal Medical Center, Ido-Ekiti, South-West Nigeria. The medical records of all patients admitted to the male and female medical wards between January 2008 and April 2011 were reviewed. After being identified through the admission/discharge log, patients who were DAMA and a similar number of patients with regular discharge had their case notes retrieved. Information extracted included bio-data, diagnosis, duration of hospital stay, and reason for discharge.
Results: One hundred and thirty-eight patients representing 7.2% were DAMA during the study period. Ninety five cases had complete medical records, and full analysis was carried out on these and 94 other cases with regular discharge as control. The mean age of the DAMA cases was 50.8 ± 18.3 years, with 58 (61.1%) of these patients being male; while the mean age of the control group was 54.1 ± 16.5, of which 54 (57.4%) were male. The mean duration of admission for patients with DAMA was 10.4 ± 9.2 days as against 11.9 ± 10 in the control group, a difference that is not statistically significant. The associations between type of discharge, sex, and duration of admission are shown through odds ratios of 0.883 and 0.833 respectively. Financial problems (48%), lack of clinical improvement (28.8%) and leaving to seek alternative/complimentary medical care (23.1%) were the factors found to be responsible for DAMA in the study.
Conclusion: The incidence of discharge against medicine is high in this study. There is a need for all stakeholders to evaluate factors responsible for DAMA, with the aim of reducing this trend.
Keywords: Discharge against medical advice, ethical issues, incidence, patient outcomes
|How to cite this article:|
Fadare JO, Babatunde OA, Olanrewaju T, Busari O. Discharge against medical advice: Experience from a rural Nigerian hospital. Ann Nigerian Med 2013;7:60-5
|How to cite this URL:|
Fadare JO, Babatunde OA, Olanrewaju T, Busari O. Discharge against medical advice: Experience from a rural Nigerian hospital. Ann Nigerian Med [serial online] 2013 [cited 2021 May 6];7:60-5. Available from: https://www.anmjournal.com/text.asp?2013/7/2/60/133098
| Introduction|| |
Discharge against medical advice (DAMA) is a common problem worldwide with attendant negative health and economic consequences. , DAMA can be defined as a situation in which a patient chooses to leave the hospital before the managing physician recommends discharge.  Studies from the United States of America (USA) have shown a prevalence rate of between 1% and 2% while data from a rural community hospital in Canada indicated prevalence of 0.53%. ,,, The rate of DAMA in a study carried out among children in Congo Brazaville was 7.7%.  DAMA rates in many developed countries have been found to be higher among psychiatric patients and those with HIV infection. ,,
Data from different parts of Nigeria have shown the prevalence of DAMA to range from 0.002% to 5.7% among various strata of patients. A retrospective hospital-based study from Enugu, south-eastern Nigeria involving the adult and pediatric populations gave prevalence of 0.002% while the prevalence rate of DAMA among pediatric patients in Abakalilki, Benin and Lagos were 1.5%, 5.7%, and 1.2%, respectively. ,,, Another study carried out in the Accident and Emergency Department of a Teaching Hospital in Calabar, South-South Nigeria gave a rate of 2.6% while a rate of 2.8% was found in a study from Sagamu, South-West Nigeria. ,
Several factors have been implicated as causes or contributing to DAMA, some of which are financial constraints, lack of health insurance, deteriorating clinical condition of patient, problematic doctor-patient relationship and substance abuse. ,, Other factors that may influence the decision to self-discharge include race, severity of disease condition (diagnosis), quality of hospital and lack of the attending physician. ,, Knowing the profiles of DAMA on the medical wards is very important as it allows for evidence-based interventions to reduce to a minimum this problem. To the knowledge of the authors, there is no study on DAMA specifically among medical inpatients in West Africa.
The rationale for our study was based on the above premise. The objective of this study was to determine the incidence and factors contributing to DAMA and compare the findings with those with regular hospital discharge.
| Materials and Methods|| |
This was a case-control study carried out in the Department of Internal Medicine, Federal Medical Center, Ido-Ekiti, South-West Nigeria. It is a health care facility rendering both secondary and tertiary care for a population of about 4 million people from Ekiti State and other neighboring states in Nigeria. The hospital also is accredited for postgraduate residency training in internal medicine, surgery, pediatrics, obstetrics and gynecology and community medicine. There are two medical wards (male and female) made up of 20 beds each.
The study was retrospective in nature and included the medical records of all patients admitted to the medical wards of Federal Medical Center, Ido-Ekiti from January 2008 to April 2011. The admission/discharge log book on the two medical wards was reviewed for the total number of admissions during the period under review, and all DAMA were identified. Cases of DAMA were defined as patients who left the hospital against the opinion of the managing physicians and who had some form of documentation regarding this in their case files. The case notes of these patients were retrieved from the medical records department and reviewed in detail. In the case of the control group, 94 folders of patients who were discharged normally were selected out of 1773 that were discharged normally using systematic random sampling for the folders. The sample size was 94 (equivalent of all the patients that were DAMA). Sample frame was 1773 folders, sample size 94; hence the sampling interval was 18. Every 18 th folder of the patient that was normally discharged was selected and recruited as the control group. Their case notes were also retrieved, entered into a proforma and analyzed. The demographic details, working diagnosis, and duration of admission of the patients were retrieved. The patient's medical history was also scrutinized for history of substance abuse or psychiatric disorder. In addition, the files were inspected to see if there was any form of documentation for DAMA either as a signed document or signed entry in the case notes. The identity of the signatory whether patient, relatives or other third parties was also documented. We also checked the medical history for episodes of re-admission directly related to the disease condition the patient was managed for before DAMA.
The information obtained from the questionnaire was coded, entered, and analyzed using IBM SPSS version 19 (IBM Corporation, Armonk, NY, USA). Descriptive statistics were used to examine the general characteristics of the patients. Demographic variables, which were normally distributed, were described as mean and standard deviation with comparison between groups made with the Student independent t-test. Categorical variables are reported as frequency distribution and proportions with 95% confidence intervals and were compared using the Chi-square test or Fisher's exact test. The odds ratios (OR) for factors associated with DAMA were calculated. P < 0.05 was considered as statistically significant.
Ethical approval was obtained from the Research Ethics Committee of the hospital before the commencement of the study.
| Results|| |
A total of 1911 patients comprising of 1125 males (58.9%) and 786 females (41.1%) were admitted to the medical wards during the study period. Out of these, 138 patients representing 7.2% were DAMA with 89 (64.5%) of them of the male sex. The retrieval of complete medical records was possible in only 95 patients with DAMA. The case notes of 94 patients with regular hospital discharge were also retrieved and further analysis was carried out on them.
The mean age of the DAMA cases was 50.8 ± 18.3 years, with 58 (61.1%) of these patient being male; while the mean age of the control group was 54.1 ± 16.5, of which 54 (57.4%) were male [Table 1].
Among the age groups, DAMA was more common among the elderly patients (above 60 years)-38.9%, followed by young patients (16-39 years)-31.6% and those aged between 40 and 59 years (29.5%). Among the patients, cerebrovascular disease (CVD) was the most common condition (14.7%) followed by diabetes mellitus (DM) and complications (13.7%) and HIV-related conditions (11.6%). The diagnoses of the remaining patients with DAMA and those with regular discharges are shown in [Table 2].
The mean duration of admission for patients with DAMA was 10.4 ± 9.2 days with a range of 1-60 days. Patients that were discharged normally had average duration of admission of 11.9 ± 10 days. This difference in the average duration of hospital stay in both groups was not statistically significant. The breakdown of mean admission duration among DAMA patients according to the diagnosis shows patients with DM having the longest duration of 17.2 days followed by those with congestive cardiac failure (CCF) with 13.1 days, while CVD patients were on admission for an average of 10.8 days. For patients with regular discharge, the average hospital stay was 15.6, 14.4, 11.3, and 11.7 days for CVD, DM, CCF and HIV respectively. The association between the variables age of the patients, sex, and duration of admission and patients' outcome (regular discharge or DAMA) was explored using OR [Table 3].
|Table 3: Association between sex, age, duration of admission; and type of discharge|
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In 75 (78.9%) patients, there was evidence of signed documentation either in the form of a discharge document (DAMA form) or signed entry in the case files. The signatories of the DAMA document are shown in [Figure 1].
|Figure 1: Pie-chart showing the signatories of discharge against medical advice forms|
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Only 54% of all patients DAMA had their complete medical records retrievable. The records were either incomplete or could not be found in the remaining patients [Figure 2].
Out of those that gave reasons for their discharge, financial problems (48%), lack of clinical improvement (28.8%) and leaving to seek alternative/complimentary medical care (23.1%) were stated. Only one patient presented again and was re-admitted for the same condition. No patient among the group had any history of substance abuse.
| Discussion|| |
The preponderance of men among patients with DAMA (male:female ratio - 1.56:1) found in this study follows the trend of similar studies. , This is likely due to the overall majority of male patients. The mean age of patients of 50.8 ± 18.3 years is higher than that found in other studies. , This is likely due to the fact that these other studies included the pediatric age group while ours concentrated mainly on adults. Another plausible reason is that the largest age sub-group among our sample was that of patients above 60 years. The rate of DAMA of 7.2% found over the study period is higher than those reported from other research works cited earlier. ,,,,,,, The patients included in these studies are of different background; some included all adult medical patients (psychiatry inclusive) while others dealt with pediatric cases only. It is possible that the rural setting, which the study was carried out contributed to this outcome. The economy of the region depends heavily on agriculture and financial constraints may have played a major role. The rural setting in itself cannot be an excuse since studies carried out in a similar environment had prevalence of 0.57%.  The economic factor, which includes the availability or otherwise of health insurance, may play a role in this difference.
Majority of patients who were DAMA in our study had noncommunicable conditions like CVD (14.7%) and DM (13.7%). More than half of patients with DM were admitted with diabetic foot ulcer, a fact in keeping with the work of Ogbera et al. who confirmed DM foot ulcer as a major cause of morbidity and mortality in diabetics.  This finding confirms the trend of change in the pattern of diseases in developing countries of the world. In a study by Eze et al. they found prevalence of 8.8% and 3.5% for DM and CVD respectively in 9 year study among all categories of hospital patients.  The relatively low prevalence rates found in that study may be due to the fact that patients from different medical specialties were included. HIV infection was also common among this group of patients, a finding in agreement with the work of Anis et al. who found a DAMA rate of 13% among patients admitted with HIV/AIDS.  In the setting of developing countries like Nigeria, stigmatization of patients with HIV/AIDS is ever present, and HIV may have contributed substantially to the prevalence of DAMA. Another factor that may contribute to the high rate of DAMA in patients with HIV/AIDS is the possibility of psychiatric co-morbidity. It is a well-known fact that HIV infection may be associated with various types of neuro-psychiatric manifestations and these might have contributed to the etiology of DAMA. CCF was found in 10.5% of patients with DAMA. It is also important to note some patients with DAMA had malignant conditions such as PLCC and CLL, while others with working diagnosis of splenomegaly, intra-abdominal malignancy and intra-cranial lesion were still being investigated at the time of discharge. This delay could have led to dissatisfaction on the part of the patients or relatives and generated a sense of distrust especially in the absence of proper communication between them and the managing team. From the above, it is possible that prolonged patient workup and delayed diagnosis may affect the decision of patients to DAMA in the context of developing countries like Nigeria.
The mean duration of hospital stay for patients that were DAMA was 10.4 days. This finding was more than the 5.6 days and 2.3 days recorded in similar Canadian and Nigerian studies respectively. , The absence of neuro-rehabilitation centers or community nursing/homecare scheme in the Nigerian setting makes patients with chronic diseases to stay longer than necessary in the hospital. Furthermore, since most patients or their relatives pay their healthcare bills out of pocket, the physicians are not under any pressure from insurance companies to discharge within a certain time frame so as to save costs; this will certainly affect the duration of stay of the patients. On the other hand, with out of pocket expenditure, patient and their relatives may run out of funds leading to request for premature discharge or DAMA. Another factor that might have contributed to this relatively long hospital stay is the absence or near collapse of primary/community healthcare services. Many of these patients would have benefitted from early discharge with regular follow-up home visits by the primary care physicians or community nurses. The importance of community nursing in the care of chronically ill patients has been shown in studies from Thailand, Australia and China. ,, The Odds ratios when interpreted against the corresponding 95% confidence intervals and P values as shown in [Table 3], reveal that the variables age, sex, and duration of admission were not significantly associated with the type of discharge. This finding suggests that DAMA in the study setting may be influenced by other factors such as socio-cultural, beliefs and attitudes towards orthodox medicine. Further research about how the above mentioned factors may affect the type of discharge needs to be carried out in Nigeria.
Signed documentation for DAMA was available in 75 (78.9%) of the retrieved case files, which is similar to 81.6% found in the Canadian study.  In our study, only 21.6% of the patients personally signed the DAMA form while family members were responsible in 78.4%. It is alarming that in about 22% of patients DAMA, there was no evidence of anyone signing this very important medico-legal document. This is lower than the finding from another Nigerian study where 40.7% of the DAMA documents were signed by the patients.  In the two scenarios, the family still had a greater influence; which can be attributed to financial constraints on the part of the patient at that time of ill health. This shows the strong influence of the family or community on decision making in health matters in our society.
Complete documentation was found in only 54% of all patients that were DAMA. Incomplete documentation, which has also been found in another Nigerian study,  constitutes a major challenge to conduct of good research. There is a need for concerted efforts from all stakeholders in the healthcare sector to work towards overcoming this surmountable challenge.
Financial constraints, progression of the disease condition and opting out for alternative/complimentary medical care were the major reasons for DAMA. This is in keeping with findings from other studies in Africa and differs slightly from studies from the USA where substance abuse, race (may be related to economic power) and lack of health insurance play a major role. ,,,, An Italian study gave personal and family problems and refusal of treatment as reasons for DAMA. 
| Conclusion|| |
The incidence of discharge against medicine is high in this study. The main reasons for DAMA are financial constraints and lack of improvement in medical condition. There is a need for medical doctors to assess properly patients on presentation to determine if admission is necessary. The government should also be encouraged to develop a community-based healthcare scheme to cater for chronic medical conditions. There is also a need to manage and discharge patients as quickly as possible to reduce the financial burden on the patient or relatives.
The main limitation is the retrospective nature of the study with total reliance on old information from case files, which cannot be verified. The sizeable percentage of poorly documented patient records may also have some influence on the findings and consequently the conclusions drawn from the study. The study was carried out in only one center and as such cannot be generalized. However, it gives a clear picture of the incidence of DAMA in patients admitted to the medical wards of a rural specialized hospital in Nigeria.
| Acknowledgments|| |
The authors are grateful to Drs. Olalekan, Ajayi and Opeke for their help in extracting information from the case notes.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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