目标:鉴于大多数创伤入院的非选择性,经历创伤的患者在没有医生建议的情况下面临出院的特殊风险。尽管医疗系统存在计划外重新入院和财政负担的风险,住院患者违反医疗建议的出院率继续上升。本研究旨在评估因外伤住院的患者中,出院患者与医疗建议相关的演变趋势和结果。
方法:查询了2016-2020年全国再入院数据库,以确定所有因外伤而住院的患者。患者队列被分层为那些在医疗建议下出院的人和那些没有出院的人。使用非参数测试评估了随时间推移的医疗建议和相关费用的出院时间趋势。建立了多变量回归模型,以评估与医疗建议有关的出院因素。出院与医疗建议与住院时间的联系,住院费用,随后评估了计划外的30天再入院.
结果:在估计的4,969,717名患者中,65,354(1.3%)因外伤住院后因医疗建议而出院。在学习期间,违反医疗建议出院的发生率增加(nptrend<0.001)。风险调整后,年龄较大(调整后的赔率比,0.98/年;95%置信区间,0.97-0.98),女性(调整后的赔率比,0.65;95%置信区间,0.64-0.67),和高容量创伤中心的管理(调整后的赔率比,0.71;95%置信区间,0.69-0.74)与医疗建议的出院几率较低相关。与其他人相比,根据医疗建议出院与住院时间减少1.3天相关(95%置信区间,1.1-1.5天)和指数住院费用为2200美元(5%置信区间,$1,600-2,900),虽然有更大的计划外30天再入院的风险(调整后的赔率比,2.21;95%置信区间,2.06-2.36)。
结论:近年来,违反医疗建议的出院发生率及其相关费用负担有所增加。社区一级的干预措施和机构努力减轻医疗建议的出院可能会提高创伤患者的护理质量和资源分配。
OBJECTIVE: Given the nonelective nature of most trauma admissions, patients who experience trauma are at a particular risk of discharge against medical advice. Despite the risk of unplanned readmission and financial burden on the health care system, discharge against medical advice among hospitalized patients continues to rise. The present study aimed to assess evolving trends and outcomes associated in patients with discharge against medical advice among patients hospitalized for traumatic injury.
METHODS: The 2016-2020 Nationwide Readmissions Database was queried to identify all hospitalizations for traumatic injuries. The patient cohort was stratified into those who had discharge against medical advice and those who did not. Temporal trends of discharge against medical advice and associated costs over time were evaluated using nonparametric tests. Multivariable regression models were developed to assess factors associated with discharge against medical advice. Associations of discharge against medical advice with length of stay, hospitalization costs, and unplanned 30-day readmission were subsequently evaluated.
RESULTS: Of an estimated 4,969,717 patients, 65,354 (1.3%) had discharge against medical advice after hospitalization for traumatic injury. Over the study period, the incidence of discharge against medical advice increased (nptrend <0.001). After risk adjustment, older age (adjusted odds ratio, 0.98/per year; 95% confidence interval, 0.97-0.98), female sex (adjusted odds ratio, 0.65; 95% confidence interval, 0.64-0.67), and management at high-volume trauma center (adjusted odds ratio, 0.71; 95% confidence interval, 0.69-0.74) were associated with lower odds of discharge against medical advice. Compared with others, discharge against medical advice was associated with decrements in length of stay by 1.3 days (95% confidence interval, 1.1-1.5 days) and index hospitalization costs by $2,200 (5% confidence interval, $1,600-2,900), while having a greater risk of unplanned 30-day readmission (adjusted odds ratio, 2.21; 95% confidence interval, 2.06-2.36).
CONCLUSIONS: The incidence of discharge against medical advice and its associated cost burden have increased in recent years. Community-level interventions and institutional efforts to mitigate discharge against medical advice may improve the quality of care and resource allocation for patients with traumatic injuries.