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FACTORS ASSOCIATED WITH A DISCHARGE AGAINST MEDICAL ADVICE FROM AN EMERGENCY DEPARTMENT IN ADULT PATIENTS WITH APPENDICITIS

      Abstract

      Background

      Delays in care can lead to worsened outcomes with acute appendicitis. To get timely treatment, patients must consent.

      Objective

      To determine if there are racial and socioeconomic differences in discharge against medical advice (DAMA) rates from an emergency department after the diagnosis of acute appendicitis.

      Methods

      Patients were identified retrospectively from the 2019 National Emergency Department Sample. The inclusion criteria were patients 18 years of age or older with acute appendicitis. Rates were compared using chi-square or Fisher's exact test. Odds ratios were determined using multiple logistic regression. A p value of 0.05 was used to determine statistical significance.

      Results

      The overall rate of DAMA was low (0.37%). Black patients had the highest rate, and White patients had the lowest (0.72% and 0.28%, respectively, p < 0.001). When controlling for covariates, Black patients also had a higher odds ratio (OR) for DAMA (OR 1.96, 95% confidence interval [CI] 1.29–2.97). Male patients had a higher unadjusted rate (0.47% vs. 0.26% in females, p < 0.001) and were at increased risk (OR 1.78, 95% CI 1.32–2.41). Patients between 30 and 65 years old had an increased risk (OR 1.48, 95% CI 1.10–2.0). Patients with government insurance or no insurance had higher rates than private insurance (0.57% and 0.56% vs. 0.23% respectively, p < 0.001).

      Conclusion

      Race, insurance status, age, and male sex were all associated with increase in DAMA. Risk stratifying patients can help to determine how to best employ mitigations strategies. Reducing DAMA may be the next area for improving reducing disparities in appendicitis care.

      Keywords

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      REFERENCES

        • Totapally A
        • Martinez P
        • Raszynski A
        • Alkhoury F
        • Totapally BR.
        Do racial/ethnic and economic factors affect the rate of complicated appendicitis in children?.
        Surg Res Pract. 2020; 20203268567
        • Michelson KA
        • Reeves SD
        • Grubenhoff JA
        • et al.
        Clinical features and preventability of delayed diagnosis of pediatric appendicitis.
        JAMA Netw Open. 2021; 4e2122248
        • Lee SL
        • Shekherdimian S
        • Chiu VY
        • Sydorak RM.
        Perforated appendicitis in children: equal access to care eliminates racial and socioeconomic disparities.
        J Pediatr Surg. 2010; 45: 1203-1207
        • Lee SL
        • Yaghoubian A
        • Stark R
        • Shekherdimian S.
        Equal access to healthcare does not eliminate disparities in the management of adults with appendicitis.
        J Surg Res. 2011; 170: 209-213
        • Pieracci FM
        • Eachempati SR
        • Barie PS
        • Callahan MA.
        Insurance status, but not race, predicts perforation in adult patients with acute appendicitis.
        J Am Coll Surg. 2007; 205: 445-452
        • Fluke LM
        • McEvoy CS
        • Peruski AH
        • et al.
        Evaluation of disparity in care for perforated appendicitis in a universal healthcare system.
        Pediatr Surg Int. 2020; 36: 219-225
        • Goyal MK
        • Chamberlain JM
        • Webb M
        • et al.
        Pediatric Emergency Care Applied Research Network (PECARN). Racial and ethnic disparities in the delayed diagnosis of appendicitis among children.
        Acad Emerg Med. 2021; 28: 949-956
        • Adeyemi OJ
        • Veri S.
        Characteristics of trauma patients that leave against medical advice: an eight-year survey analysis using the National Hospital Ambulatory Medical Care Survey, 2009–2016.
        J Clin Orthop Trauma. 2021; 17: 18-24
        • Ibrahim SA
        • Kwoh CK
        • Krishnan E.
        Factors associated with patients who leave acute-care hospitals against medical advice.
        Am J Public Health. 2007; 97: 2204-2208
        • Haines K
        • Freeman J
        • Vastaas C
        • et al.
        I'm leaving": factors that impact against medical advice disposition post-trauma.
        J Emerg Med. 2020; 58: 691-697
        • Haines KL
        • Woldanski LM
        • Zens T
        • et al.
        The impact of race and socioeconomic status on treatment and outcomes of blunt splenic injury.
        J Surg Res. 2019; 240: 60-69
        • Menendez ME
        • van Dijk CN
        • Ring D.
        Who leaves the hospital against medical advice in the orthopaedic setting?.
        Clin Orthop Relat Res. 2015; 473: 1140-1149
        • Sheehan OC
        • Dhamoon MS
        • Bettger JP
        • et al.
        Racial differences in persistence to secondary prevention medication regimens after ischemic stroke.
        Ethn Health. 2021; 1: 1-13
        • George M.
        Adherence in asthma and COPD: new strategies for an old problem.
        Respir Care. 2018; 63: 818-831
        • Zogg CK
        • Scott JW
        • Bhulani N
        • et al.
        Impact of Affordable Care Act insurance expansion on pre-hospital access to care: changes in adult perforated appendix admission rates after Medicaid expansion and the Dependent Coverage Provision.
        J Am Coll Surg. 2019; 228 (e1): 29-43
        • Scott JW
        • Rose JA
        • Tsai TC
        • et al.
        Impact of ACA insurance coverage expansion on perforated appendix rates among young adults.
        Med Care. 2016; 54: 818-826
        • Jasperse N
        • Grigorian A
        • Delaplain P
        • et al.
        Predictors of discharge against medical advice in adult trauma patients.
        Surgeon. 2020; 18: 12-18