Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study
- Department of Surgery, Federal Medical Center Owo, Owo, Ondo state, Nigeria,
- Department of Neurological Surgery, University College Hospital, University of Ibadan, Ibadan, Oyo state, Nigeria.
Toyin Ayofe Oyemolade
Department of Surgery, Federal Medical Center Owo, Owo, Ondo state, Nigeria,
DOI:10.25259/SNI_559_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Toyin Ayofe Oyemolade1, Amos Olufemi Adeleye2, Oluwakemi C. Ogunyileka1, Folawemimo M. Arogundade1, Ayodele J. Olusola1, Oluwadamilola O. Aribisala1. Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study. 12-Sep-2020;11:290
How to cite this URL: Toyin Ayofe Oyemolade1, Amos Olufemi Adeleye2, Oluwakemi C. Ogunyileka1, Folawemimo M. Arogundade1, Ayodele J. Olusola1, Oluwadamilola O. Aribisala1. Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study. 12-Sep-2020;11:290. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=10250
Background: In low-resource regions of the world, discharge against medical advice (DAMA) is one empiric contributory factor to poor in-hospital outcome that is not often mentioned. This study aims to investigate the determinants of DAMA from a rural neurosurgical service in a developing country.
Methods: This was a prospective observational study of all patients who discharged against medical advice in our service between November 2018 and October 2019.
Results: There were 88 patients, 67 (76.1%) males, in the study, (M:F = 3.2:1), representing 17.4% of our patient population in the study period. The peak incidence was in the 20–29 years age group which accounted for 37.5% of the cases. About 55% of the patients presented directly to our center; 31.8% were referred from other hospitals, while 3.4% came from traditional caregivers and 1.1% from religious homes. Head injury was the most common indication for presentation (76.1% of the cases). The duration of hospital stay ranged from 2 h to 14 days. Majority of the patients (87.5%) left the hospital within 8 h of presentation. The reason for DAMA was financial constraints in 50% of cases, inadequate health literacy in 20.5%, financial constraints and poor health literacy together in 12.5%, religious misgivings in 4.5%, and traditional belief in 2.3%. Neurotrauma was predictive of early DAMA (P = 0.001).
Conclusion: The rate of DAMA was high in our study. Financial constraints with other socioeconomic limitations were the most common causes of DAMA in our environment.
Keywords: Determinants, Developing country, Discharge against medical advice, Rural neurosurgery
Discharge against medical advice (DAMA) is an issue generating some significant concerns in health systems globally.[
Several causes of DAMA have been reported, including financial difficulties/lack of health insurance; dissatisfaction with the care received, and/or, the hospital environment; lack of access to skilled and qualified physicians, lack of advanced medical services; and presumed unsatisfactory results from treatment, and presumed unduly prolonged in-hospital stay of patients.[
The previous studies on DAMA in our country as well as most studies from other parts of the world were in mixed patients’ populations in the medical, psychiatric, or surgical/ orthopedic wards.[
This was a cross-sectional study of all prospective patients who discharged against medical advice in our neurosurgical service over a 12-month period from November 2018 to October 2019. Our neurosurgical practice is a newly inaugurated one in a tertiary level hospital in a rural part of Nigeria, a large country in sub-Saharan Africa. We collected data on the demographic characteristics of the patients, the diagnosis, duration of symptoms, duration of stay in our service before the DAMA, reasons for the DAMA, plus representation in the hospital after the DAMA, as well as the reasons for the representation and the interval between the DAMA and the repeat presentation. Early DAMA (DAMAe) was defined as DAMA within 8 h of admission and late DAMA (DAMAd) as DAMA after 8 h.[
There were 88 patients in the study, 67 (76.1%) males and 21 females (M:F = 3.2:1), representing 17.4% of the 506 cases seen in our neurosurgical practice during the study period [
The median duration of hospital stay in this cohort of patients that discharged AMA was 6.5 h (range = 2 h–14 days). The DAMA was early, within 8 h of admission (DAMAe) in 87.5%, and late, after 8 h (DAMAd) in 12.5%. The reason for DAMA was low income in 50% of cases, low health literacy in 20.5%, low income and health literacy together in 12.5%, long distance in 8.0%, and conflicting religious and traditional beliefs in 4.5% and 2.3%, respectively [
DAMA is a well-recognized concern in in-patient health care globally with significant attendant negative economic and health consequences.[
The predominance of male gender in this study is in agreement with trends in other studies locally and abroad.[
Other reasons for DAMA identified in this study were poor medical insight and the need for proximity to relatives/ caregivers in some of the patients. About 33% of the patients discharged against medical advice because they felt that they were well while 8% left because of their felt need for proximity to relatives/caregivers despite no access to neurosurgical service at these destinations. These factors have all been documented in the literature.[
Notably in this study, none of the patients discharged against medical advice because of dissatisfaction with the care received, or the medical staff, or the hospital environment. This finding is contrary to those of other reports which found a proportion of their patients leaving the hospital against medical advice because of dissatisfaction with the medical staff or the hospital environment.[
DAMA because of religious and traditional beliefs was a rather interesting finding in this study. Although the percentage was low in this study (6.8%) despite the prevalence of these two factors in our environment, this finding highlights the challenge these beliefs pose to health care in poor societies with high level of poor health literacy, particularly in the developing world.
More than four-fifth of our patients (87.5%) in this study were of the early DAMA status, leaving the hospital within 8 h of presentation. This figure is significantly higher than the 25.7% reported by Lakhotia et al.[
DAMA is one of the leading causes of hospital readmission.[
The negative impact of the privately funded model of payment for health care on the outcome of that care, especially as obtains in the low resource settings of many sub-Saharan Africa has been documented. The absence of health insurance covers in all our patients, and the finding of financial constraints as the most common reason for DAMA lends credence to the need to do away with this model of health-care financing. We advocate alternative health-care financing models particularly a functional and sustainable health insurance scheme in other to maximize the health resources available in these settings.[
The rate of DAMA was high in our study possibly due to the expensive nature of neurosurgical in-hospital evaluation and treatment in a resource-constrained developing country milieu of privately funded health-care financing. Low income and level of health literacy were the most common causes of DAMA in this neurosurgical patient population. A diagnosis of neurotrauma significantly predicts early DAMA in this study. Functional health insurance scheme with a wide coverage will go a long way in reducing the incidence of DAMA and improving overall health indices in developing countries like ours.
The authors certify that they have obtained all appropriate patient consent.
Publication of this article was made possible by the James I. and Carolyn R. Ausman Educational Foundation.
There are no conflicts of interest.
This is a simple but elegant study. The authors show convincing evidence that financial constraints is the most important factor in refusal of continuation of treatment for DAMA in the developing nation under study, and that this can result in increased morbidity and mortality. But if one were to consider that ability to pay (financial constraints) was the most important factor, as indeed this paper attempts to prove and argue, then one would expect a more equal proportion of males and females, even taking into account that head injuries occur more frequently in men than in women. In fact, head injuries are more common in men than women because of men’s aggressiveness and more frequent belligerence. So I tend to believe that aggressiveness of males, especially in head injured patients, could still be an important fact to rival, or even surpass, financial reasons in these cases of DAMA. The author(s) did not find this to be the case.
Another interesting fact is that most of us in the US tend to believe that financial constraint is a problem that one only finds in America — and not the rest of the world — because most of the world, we are told, already has socialized medicine and wonderful “free” health care. In fact, in the US everyone that goes to an emergency facility (virtually every hospital) must be treated, regardless of ability to pay. Moreover, the poor have Medicaid; and those 65 or older (the elderly) have Medicare. No one goes without treatment. Hardest hit with catastrophic hospital bills are those of the middle class who have to buy their own medical insurance or chose not to have it because health insurance admittedly is expensive. But virtually no one, despite what one has been led to believe by the American mainstream or globalist media, goes without medical care.
So, I was particularly shocked a couple of years back when a group of our colleagues from China presented a study of patients who were treated with functional neurosurgery for seizure disorders and other maladies. They have had excellent results. Then it was mentioned in passing that it was a shame that the operations could not be performed more widespread because of inability to pay. “How can this be?” I wrote in a comment published in SNI. The authors wrote back in reply that free health care in China today is only for the cadre. Who is this cadre? The communist party intelligentsia, we must presume. The authors would not explain any further and the dialogue abruptly ended.
So, once again I am a bit perplexed that this is happening elsewhere in a developing country, presumably in sub- Saharan Africa because “a global lack of health insurance necessitating out-of-pocket payment for health-care expenses.” The authors do not explain why the DAMA rate in their patients was 17.4% but “previous reports from our country was .0002–5.7%.” Why this discrepancy? What national or regional policy can account for this significant difference? Let me play devil’s advocate for a moment to ask another question worth raising:
Was there any difference in outcome between similar patients who remained in the hospital and continued medical treatment in the hospital versus the DAMA patients in this study? This is a very important question because if there is no significant difference in outcome, informed DAMA patients were correct to exercise their personal autonomy, regardless of reason for leaving, and may have saved themselves and their families considerable out-of-pocket expenses as well as freed themselves from a heavy financial burden. In fact, “Thirty-three percent of the patients discharged against medical advice felt they were well.” It would have been interesting how many of these patients were found among those who later deteriorated because of DAMA.
Indeed, the authors did find several patients who did not do well and had catastrophic results presumably because of their refusing proper care because of DAMA. Nevertheless, a set of patient controls that could have been compared to the DAMA patients would have resulted in a better study, even without randomization, which of course would have been impossible in this study.
Personal autonomy, we as physicians must recognize, is an important aspect of medical care regardless of cause, as important as informed consent. Presumably, availability of social and economic assistance, as can be provided by the community, could help persuade some of these DAMA patients to accept medical in this study, but it would have been interesting if there had been a control group of patients for comparison of outcome among DAMA and non-DAMA patients.
Miguel A. Faria, MD
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