Allen Kraut, MD, FRCPC Manitoba College of Family Practice ...

Allen Kraut, MD, FRCPC Manitoba College of Family Practice

Winnipeg, MB April 11, 2014

Relationships with commercial interests:

Grants/Research Support: ◦ Health Sciences Center Research Foundation

◦ Manitoba Health Research Council

◦ WCB of Manitoba

Speakers Bureau/Honoraria/Consulting fees: ◦ None

Other: Medical Director Occupational Health WRHA

PHx – ETOH Abuse, DM II on meds Presents with R leg pain and swelling seven

days after trauma O/E Temp 38.0 BP 135/ 75 BMI 33 R lower leg oozing scab, cellulitis Laboratory evaluation WBC 14,000 Xray - soft tissue swelling no FB Dx – R leg cellulitis

Tx IV Ceftriaxone/ Vancomycin.

◦ 3 days pleasant

leg responds to treatment with decreasing pain and swelling. No signs of withdrawal. Wound swab grows MSSA

◦ Hospital day 4 – Friend comes Takes out IV. Tells nursing staff he is leaving

Leaves ward without signing AMA form.

◦ You are called to the ward Nurse says ” I hope he will be OK because he was confused last

night, but seemed a bit better this morning”.

What do you do? ◦ Nothing

◦ Attempt to reach him to give him oral Antibiotics

◦ Call the police to bring him back

Prognosis? ◦ Short term

◦ Long term

Allan Garland

Clare Ramsey

Kendiss Olafson

Randy Fransoo

Manitoba Centre Health Policy

Marina Yogendran

Dan Chateau

Funding ◦ Health Sciences Center Research Foundation ◦ Manitoba Health Research Council

Ethical approval ◦ U of M Research Ethics Board ◦ HIPC Manitoba Health

Data was collected by MB Health. The results and conclusions are the researchers. No official endorsement of the data by MB Health or the Manitoba Center for Health Policy

Identified all MB residents >18 yrs

Admitted and discharged alive between April 1, 1990 and Feb 28, 2009.

Constructed episodes of care ◦ Account for inter-hospital transfers

Identified AMA discharges from the hospital abstracts ◦ coded by trained personal using uniform

definitions, data collection methods, and data entry software

Kraut et al. BMC Health Services Research 2013, 13:415

1 916 104 hospital episodes – discharged alive

21 417 (1.11%) AMA discharges

610 187 individuals

12 588 (2.06%) AMA 1 time

2 986 (0.49%) AMA ≥ 2 times


0102030405060708090

% people wholeft AMA

% of AMAdischarges

1> 1

Percentage

# of AMA discharges


Males

Younger

Rural in our data Urban in others

Lower SES

Alcohol and Drug problems

Mental Health Issues


00.20.40.60.8

11.21.41.61.8

Hosp. # discharges/10 000

HSC St. BBrandonUrban Com.Rural

AMA percentage discharge

Number of Discharges


Most responsible hospital diagnosis

Total number of episodes

AMA episodes, (% of live discharges)

% of total AMA episodes

Alcohol or drug abuse

24 768 2900 (11.71) 13.54

Poisonings by pharmaceuticals or alcohol

9684 730 (7.54) 3.41

Alcohol-related liver disease

2202 162 (7.36) 0.76

Diabetic ketoacidosis

4728 267 (5.65) 1.25

Tuberculosis 1353 69 (5.10) 0.32


Most responsible hospital diagnosis

Total number of episodes

AMA episodes, (% of live discharges)

% of total AMA episodes

Digestive disorders

217 895 2196 (1.01) 10.25

Circulatory disorders

251 132 1921 (0.76) 8.97

Respiratory disorders

138 875 1445 (1.04) 6.75

Neoplasms 118 692 358 (0.30) 1.67

Complications of pregnancy, childbirth and the puerperium 355 735 2227 (0.63) 10.40


Baptist et al, J Allergy Clin Immunol 2007;119:924-9

Unscheduled Readmission = for any cause, any diagnosis ◦ Age ↑ ◦ Male Sex ◦ Lower SES ◦ Rural residency ◦ Co-morbidities Metastatic cancer, HIV/AIDS, Renal Failure, CHF,

others

◦ AMA 2-3 fold increase

Garland A et al. CMAJ 2013;185:1207-1214

0

1

2

3

4

5

6

7

8

9

0-1 days 2-7 days 8-14 days 16-30days

31-60days

61-90days

91-180days

AMA

nonAMA

% Readmission


Time Interval

Ratio


0

0.5

1

1.5

2

2.5

3

AMA Non-AMA

AOR

AOR


Odds of death at given intervals after hospital discharge associated with leaving hospital against medical advice.


©2013 by Canadian Medical Association

AMA discharges – 1.1% of MB live hospital discharges

AMA discharges associated with increased risk of readmission 60% of which occurs in the first two weeks post discharge

AMA discharges associated with 2- 3 fold increased risk of mortality at all intervals between 7 and 180 days of follow up.

Strategies focused on preventing AMA – may decrease excess rate of readmissions.

Strategies only focused on preventing AMA discharges will have limited ability to reduce the increased risk of death.

To prevent excess mortality this population needs longitudinal interventions that extend beyond hospitalization.

Allen Kraut, MD, FRCPC Manitoba College of Family Practice ...

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