لخّصلي

When patients decide to leave hospital before their treating physician advises them to do so, this is called a discharge against medical advice (DAMA).The prevalence of DAMA in the USA is in the range of 1%–2% for inpatient hospitalisations and 1%–20% for admissions to emergency departments.
DAMA is a major concern for physicians and healthcare systems, as the disruption to patient care can lead to both disproportionate resource consumption and suboptimal patient health management. DAMA patients face a higher risk of morbidity, such as asthma exacerbations, reinfarctions and adverse pregnancy outcomes for mother and fetus.Moreover, a number of studies have shown that readmission rates at 30 days after DAMA are 40%–100% higher than for patients who complete their treatment and up to four times higher for admissions relating to particular conditions like asthma. As a result, DAMA is associated with an increase in healthcare expenditure. The data indicate a 56% rise in costs in the event of readmissions after DAMA; raw estimates of additional costs for 2014 range from $8.6 million per year in Australia to $822 million in the USA.
By contrast, the association of DAMA with a higher risk of premature death is still debated, as the scientific literature reports small increases in mortality rates or inconclusive results.In two previous studies—one on patients discharged from 129 American Veterans Health Administration hospitals over the years 2004–2008 and another on a subpopulation of patients from an urban hospital in Canada—the authors found statistically significant increases in the risk of death for DAMA patients, with an adjusted HR of 1.11 at 12 months.5 9 Conversely, a recent study conducted by Tan and colleagues in the USA showed a 20% lower risk of in-hospital mortality for DAMA patients than for all other patients.
The authors of the latter research made the point that their finding could be influenced by the study design, which did not capture deaths occurring outside the hospital. Finally, in an older, moderately sized, prospective study conducted by Hwang et al in Canada, the results failed to demonstrate any association between DAMA and mortality. The previous studies, investigating clinical outcomes of DAMA patients, however mainly involved single-centre studies or focussed on a specific patient population (eg, Veterans Health Administration patients) and were generally conducted in countries other than European countries.
In this study, we further investigate the odds of readmission and mortality after DAMA using data extracted from a large, unselected, routinely collected regional archive of emergency department records and hospital discharge records (HDRs) from the Veneto region of Northeast Italy. The goal of this research is to report on the healthrelated outcomes of DAMA patients, in order to provide useful information for the development of strategies to improve management and reduce the adverse outcomes of DAMA.