The relationship between patient characteristics and discharge against medical advice in patients with traumatic brain injury

Discharge against medical advice (DAMA), affecting up to 2% of hospital discharges, is a critical public health concern. Patients with traumatic injuries, particularly traumatic brain injury (TBI), exhibit higher DAMA rates. However, TBI-specific DAMA remains understudied. This study aims to quantify the burden of DAMA in an urban TBI cohort, analyze demographic and injury differences between patients who DAMA and those with standard discharges, and determine potential predictors of DAMA in TBI.

Methods

A retrospective review of TBI patients treated at an urban trauma center between 2017 and 2022 was conducted using data from our institution’s trauma registry, a subset of the National Trauma Registry of the American College of Surgeons (NTRACS). Discharge against medical advice was defined as any discharge against medical recommendations during the index hospital stay following TBI. Discharge against medical advice status was classified based on the recorded registry discharge disposition and dichotomized as DAMA and n-DAMA (non-DAMA discharge included discharge to home, inpatient facility or hospital transfer based on medical recommendation). Descriptive statistics, univariate analyses, and multivariate modeling were used to compare the DAMA and n-DAMA groups.

Results

This study identified 47 (3.7%) patients with DAMA status and 1214 (96.3%) without a premature discharge (n-DAMA). Younger age, male sex, Black race, shorter hospital lengths of stay, alcohol use and intentional injury were associated with DAMA in patients with TBI. Patients with n-DAMA status were more likely to be older and have Medicare insurance. No association was found between discharge against medical advice and TBI severity, GCS score, injury severity score, ventilator usage, intensive care unit days or in-hospital complications. Multivariate analysis found that intentional injury, male sex and alcohol use near the time of injury were predictive of discharge against medical advice.

Conclusion

TBI patients leaving against medical advice were disproportionately younger males, often with injuries linked to alcohol and violence. Given the multiple variables associated with DAMA, targeted prevention programs are crucial for this vulnerable population. Further research is necessary to understand the long-term consequences and re-injury risks after DAMA.