|Year : 2018 | Volume
| Issue : 1 | Page : 18-21
Leaving against medical advice: Pediatric surgical perspective
Anand Pandey1, Piyush Kumar1, Anurag Srivastava2, Archika Gupta1, Jiledar Rawat1, Ashish Wakhlu1, Shiv Narain Kureel1
1 Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Community Medicine, Teerthanthkar Mahavir Medical College and Research Centre, Moradabad, Uttar Pradesh, India
|Date of Web Publication||18-Jun-2018|
Dr. Anand Pandey
Department of Pediatric Surgery, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: There is a paucity of published literature for patients who leave against medical advice (LAMA). There is no such published study conducted in pediatric surgery in India.
Materials and Methods: We retrospectively analyzed our records of those patients who left against medical service. We evaluated the records on various parameters such as age at presentation, sex, duration of stay, and any procedure performed. Duration of stay was subdivided into early LAMA (<3 days) or delayed (>3 days).
Results: The study period ranged from July 2012 to July 2015. During this period, the total number of admissions was 5604. Of these, 520 (9%) patients left the hospital. Most of the patients were <1 year of age (380, 73%). Male-to-female ratio was 2.9:1. The ratio of emergency to elective admission was 4.4:1. The ratio of patients who left in <3 days to patients who stayed more than 3 days was 3.3:1. Most of the patients had gastrointestinal problems. Four hundred and thirty-nine patients left without any surgical intervention, whereas remaining 81 patients underwent some sort of surgical intervention. The exact cause of LAMA was difficult to ascertain; however, probable causes included cost factor, poor general condition, and dissatisfaction with available resources.
Conclusion: LAMA is higher in neonatal period, emergency admission, and within 72 h. Attention toward education, avoiding gender bias, and raising the standards of living may help in accomplishing our goals. A large database of the causes and demographics is important to formulate the measures to minimize it.
Keywords: Leaving against medical advice, pediatric, risk factors
|How to cite this article:|
Pandey A, Kumar P, Srivastava A, Gupta A, Rawat J, Wakhlu A, Kureel SN. Leaving against medical advice: Pediatric surgical perspective. J Med Soc 2018;32:18-21
|How to cite this URL:|
Pandey A, Kumar P, Srivastava A, Gupta A, Rawat J, Wakhlu A, Kureel SN. Leaving against medical advice: Pediatric surgical perspective. J Med Soc [serial online] 2018 [cited 2019 Jan 19];32:18-21. Available from: http://www.jmedsoc.org/text.asp?2018/32/1/18/213950
| Introduction|| |
Leaving against medical advice (LAMA) is a term used when patients leave hospital before a treating physician advises. It is a global clinical phenomenon contributing significantly to adverse patients' outcome.
It is a matter of serious concern, and it is a challenge for health care providers. Noncompliance of the patient may result in harm to the individual's health. Besides, professional liability is also a concern for physicians caring for these patients.
There have been various studies on LAMA in general or adult population. The statistics are limited in the pediatric population. Besides, there has been no exclusive study on LAMA in pediatric surgery. As the name implies, pediatric surgery deals with specific surgical problems of children. The present study attempted to evaluate the demographics and responsible factor for LAMA in pediatric surgery center.
| Materials and Methods|| |
This was a retrospective study conducted in the Department of Pediatric Surgery of the University Hospital. Hospital records of those patients who left against medical service were analyzed. Our hospital is the only state government hospital having a recognized Pediatric Surgical Department catering to the surgical problems of children. Approximately 2000 admissions are made in a year, of which about 1700 operations, both major and minor, are performed in a year. The department had faculty strength of three till March 2015, which rose to 8 thereafter. The surgeons, including senior resident, are available round the clock for the patients' care.
Since it is a government hospital, most of the drugs are supplied. The stay, apart from private ward, is free of cost. The patients have to bear the cost of surgical consumables, which depends on the type of surgery. Besides, if some drugs are not available in the hospital, they may have to purchase it.
Written statement of LAMA was obtained from all patients. The attendants were, however, not forced in writing to detail the cause of LAMA.
The records were evaluated on various parameters such as age at presentation, sex, duration of stay, and any procedure performed. Various parameters were further subdivided on the basis of duration of stay. Those patients who left in <3 days were kept in Group A and those leaving after 3 three were put in Group B.
All the data were entered into Microsoft Excel sheet. The results were analyzed using IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp. Tables were generated and Chi-square test was applied for statistical analysis. P < 0.05 was taken as significant.
| Results|| |
This study ranged from April 2012 to March 2015. The total number of admitted patients was 5604 (male - 4206, female - 1398; M:F: 3:1). Of these, 520 (9%) patients left the hospital. The patients belonging to the rural area were 92% (479 of 520 patients). Most of the patients were <1 year of age (380, 73%; [Table 1]. The male-to-female ratio was 2.9:1 (male - 388, female - 132). This ratio was same in both groups (P > 0.05). Of the total admitted patients, 9.2% of male and 9.4% of female left against medical advise (P > 0.05). The number of patients who were admitted in emergency was 424 (81.5%) and remaining 96 (18.5%). This ratio of emergency to elective admission was 4.4:1 and this difference was statistically significant (P< 0.05). The ratio was 4.2:1 for Group A and 5:1 for Group B. Thus, intergroup difference was statistically insignificant (P > 0.05). The number of patients in Groups A and B was 400 (77%) and 120 (23%), respectively. Thus, the ratio was 3.3:1. Most of the patients had gastrointestinal problems. It was followed by thoracic cases, urologic, and neurosurgical cases, respectively [Table 2]. Four hundred and thirty-nine patients left without any surgical intervention, whereas remaining 81 patients underwent some sort of surgical intervention. There was no clustering of patients on a month-wise analysis. There was no specific pattern of LAMA in this study.
|Table 1: Age-wise distribution of patients who left the hospital against medical advice|
Click here to view
The causes for LAMA in Group A were mentioned in 209 patients. These included financial constraints (89), poor prognosis explained to the patient's attendants (62), poor general condition of the patient (44), and dissatisfaction with the available resources (14). In Group B, the causes of LAMA were mentioned in 96 patients. These included postoperative complications and low general condition refractory to treatment (51), over than expected expenditure (26), and dissatisfaction with the treatment (19). The exact cause was not ascertained in remaining patients.
| Discussion|| |
LAMA is a serious problem, which may lead to poor health care, increased mortality, adverse consequences in long-term, and disorder in treating process. Hence, in comparison of patients with proper discharge, such patients are at increased risk of mortality and morbidity arising from the disease. In this study, 9% of patients left against medical advise. This is in between the range of 5%–10% of LAMA at other pediatric centers in India but not a Pediatric Surgical center., Overall, this differs in different part of the world ranging from 1% to 25%. We intentionally divided patients into Groups A and B of early and late LAMA as we wished to analyze the estimate of patients who LAMA late in the course of stay despite getting familiar with the hospital settings. Besides, it may have a bearing on the overall expenditure on the patients, both by the attendants and the hospital.
In our setup, there is a trend for more care for the male child. This is evident from the number of consultation taken for the male children as compared to the girl children. Although statistically insignificant, there is a slight dip in the ratio of male and female from those admitted to those who LAMA (from 3:1 to 2.9:1). This suggests that more male children were brought for treatment; however, LAMA was slightly more for female sex. This is common in India; however, this is not universally true even in developing countries., Since most of the patients belonged to the rural background where literacy rate is less, it is probable that low socioeconomic status is associated with LAMA. This has also been noticed in other studies.,
Most of the patients who left the hospital were admitted as emergency cases. This suggests the vulnerability of attendants of such patients. Initially, they get their child admitted; however, during treatment, they change their mind. Early LAMA may not be affecting the burden on the overall resources as treatment is just started, but LAMA after 48 h may result in major resource wastage from the hospital as well as attendants. Since the insurance sector is very deficient in the pediatric surgical setup in India, there are sporadic beneficiaries of the insurance schemes. Besides, insurance sector in India does not include many congenital problems in their list of diseases. This further compounds the problem. Either the attendants are not willing to spend as in Group A, or they have spent beyond their capacities as in Group B. In either case, end result is LAMA.
Most of the patients (439) left without any surgical intervention whereas remaining 81 patients underwent some sort of surgical intervention. We could not ascertain the cause of LAMA in all patients; however, the common causes noted in Group A were financial constraints, poor prognosis explained to the patient's attendants, poor general condition of the patient, and dissatisfaction with the available resources. In Group B, postoperative complications and low general condition refractory to treatment, over than expected expenditure, and dissatisfaction with the treatment were the causes identified for LAMA. Many of these factors have been observed by other authors.,,, Besides these, parental misjudgment of improvement in health, nobody to care for other children at home, living away from home, and frequent blood sampling are other documented causes for LAMA in children.,,
In pediatric surgery, many patients present with congenital problems. These may need more than one surgery. Besides, many patients present late due to the ignorance of the attendants, which may lead to low general condition of the patients. When these matters are informed to the attendants, they show disinterest for the treatment and a tendency for LAMA. Even if the patient is admitted, poor low general condition promotes LAMA later in the course of stay. Many attendants come to the government hospital with a false belief of absolutely free treatment. It is when the expenses are incurred on them, and they face financial constraints. Although not documented, the parents also have a hope of giving birth to a new child rather rearing a child with anomalies. Besides this, other undocumented cause is requirement of blood for the surgery of the little patients, which the attendants try to evade.
| Conclusion|| |
LAMA continues to be a scourge in pediatric surgery setup. We have attempted to provide an in-depth analysis of this vexing entity. A large database of the causes and demographics is important to formulate the measures to minimize it. Attention toward education, avoiding gender bias, and raising the standards of living may help in accomplishing our goals.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Roy MP, Gupta R. leaving against medical advice: Underestimated challenge in children. Indian Pediatr 2016;53:264.
Saia M, Buja A, Mantoan D, Bertoncello C, Baldovin T, Callegaro G, et al.
Frequency and trends of hospital discharges against medical advice (DAMA) in a large administrative database. Ann Ist Super Sanita 2014;50:357-62.
Seaborn Moyse H, Osmun WE. Discharges against medical advice: A community hospital's experience. Can J Rural Med 2004;9:148-53.
Ebrahimipour H, Mergi M, Hooshmand E, Nezamdoust F, Molavi-Taleghani Y, Hoseinzadeh H, et al
. Factors associated with discharge of children from hospital against medical advice (AMA) at Doctor Sheikh Pediatric Hospital (DSPH) in Mashhad: 2011-2013. World J Med Sci 2014;11:196-201.
Awasthi S, Pandey N. Rural background and low parental literacy associated with discharge against medical advice from a tertiary care government hospital in India. Clin Epidemiol Glob Health 2015;3:24-8.
Jimoh BM, Anthonia OC, Chinwe I, Oluwafemi A, Ganiyu A, Haroun A, et al.
Prospective evaluation of cases of discharge against medical advice in Abuja, Nigeria. Scientific World Journal 2015;2015:314817.
Onyiriuka AN. Pediatric discharge against medical advice: Experience from a Nigerian secondary healthcare institution. Med J Islam Repub Iran 2011;25:194-9.
Onyiriuka AN. Discharge of hospitalized under-fives against medical advice in Benin City, Nigeria. Niger J Clin Pract 2007;10:200-4.
Al-Ghafri M, Al-Bulushi A, Al-Qasmi A. Prevalence of and reasons for patients leaving against medical advice from paediatric wards in Oman. Sultan Qaboos Univ Med J 2016;16:e74-7.
Naderi S, Acerra JR, Bailey K, Mukherji P, Taraphdar T, Mukherjee T, et al.
Patients in a private hospital in India leave the emergency department against medical advice for financial reasons. Int J Emerg Med 2014;7:13.
[Table 1], [Table 2]