Frequency and causes of discharges against medical advice from hospital cardiac care units of East Azerbaijan , Iran

1 PhD Candidate, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 2 Associate Professor, Health Management and Economics Research Center AND Center of Excellence in Health Management and Economics, Iran University of Medical Sciences, Tehran, Iran 3 MSc Student, Department of Health Management, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran 4 MSc Student, Department of Midwifery, Women’s Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 5 PhD Candidate, School of Health Management and Information Sciences , Iran University of Medical Sciences, Tehran, Iran


Introduction
One of the priorities of the modern administration is considering the customer focus and customer satisfaction. 1In the health system, especially in hospitals in recent years, attention to the satisfaction of patients has been considered serious attention. 2When the number of patients that leaves hospitals with personal satisfaction or despite the medical advice, it could be considered as one as indicators of dissatisfaction of patients. 3ischarges against medical advice (DAMA) means the withdrawal of a previously permission has been given to health-care providers to care him.Discharge with suddenly stop treatment, by patient or patient's parents could lead to readmission or death. 4The prevalence of DAMA is about 1% in most studies.6][7][8] Studies determined several factors in DAMA that the most important factors are male sex, young patients, addict patients, alcoholism, and patients with low socioeconomic levels. 9urthermore, feeling better, dissatisfaction of performance and quality of services, and financial problems had been reported major causes of discharge. 102][13] So, it requires effective interventions to reduce it.5][16] However, according to the reviewing results, relatively few studies have been conducted in the field of cardiovascular disease. 17ccording to extension, complications, and importance of service quality in cardiovascular disease, [18][19][20] it seems that it is important to study the rate and effective factors of DAMA in patients with cardiovascular disease and it is needed many studies.The purpose of this study was to study the frequency and effective factors in DAMA in patients with cardiovascular disease admitted to cardiac care unit of hospitals of East Azerbaijan, Iran.This cross-sectional study was performed, in 2013, in Tabriz University of Medical Sciences, Iran.Required data were collected using a form approved by the text review and designed by comments of specialists and included information about file number, contact number, age, sex, type of insurance, history of hospitalization, history of myocardial infarction (MI), comorbid disease and its name, reason of hospitalization, complication and its type, having contraindications, undergoing angioplasty, staying < 48 hours, type of hospital ownership, and hospital location (provincial capital or cities).Validity of forms was confirmed by specialists and experts in the field of cardiovascular disease and for identification of problematic items in the forms; first, some of them were completed as trials and problematic items were corrected.
Required information was extracted from medical records of 2000 patients admitted to 20 cardiac care units (CCU) in 17 hospitals of East Azerbaijan, by two trained interviewers.For selection of samples from the hospitals were used of classified sampling and for selection of patients within the hospital was used of randomized sampling based on file number.Data analysis was performed using descriptive statistics (frequency, mean, percentage, etc.), chi-square test, and linear regression model using the software SPSS software (version 17, SPSS Inc., Chicago, IL., USA).The tests were considered a statistically significant level of 0.05%.
For this study has been achieved ethical approval from Regional Committee for Medical Research Ethics at Tabriz University of Medical Sciences.Furthermore, in publishing the study results, all patients' private information has been remained confidential and was not used from the study results for other purposes.
The most patients were men in the study 1144 (57.2%).The most patients were in the range of 60-79 years old.The average age of patients was 61.75 ± 16.07.Other demographic and descriptive data of samples have been shown in table 1.
From 2000 cases had been studied, results showed that 272 (13.6%) of patients were discharged with personal satisfaction.The frequency of discharge has been shown according to sex and age groups in figure 1.
As shown in figure 1, in all ranges of age, the frequency of DAMA in men is more than women.Furthermore, the highest frequency of discharge is happened in the range of 40-80.The most difference between male and female discharge has been observed in the range of 20-60 years old.Results of studying of variables that affecting the discharge have been shown in table 2.
DAMA was one of the basic problems of health systems in all countries of the world because it leads to reworks and increase costs and adverse effects of the disease and also leads to the worsening of the patient's condition and sometimes deaths. 21It has great importance due to the complexity of the treatment and certain conditions of patients with cardiovascular disease. 22The results showed that the rate of DAMA in patients admitted to the CCU in hospitals of East Azerbaijan is 13.6%.Results of linear regression showed that there was a significant correlation between DAMA and type of insurance, history of MI, comorbid disease, cause of hospitalization, location of hospital, and staying < 48 hours.
As mentioned DAMA in this study was 13.6%.This rate was estimated 4.9% in Manouchehri et al. study in Tehran, Iran.The probable reason for this difference could be due to the patient's type because only hospitalized patients in the coronary care unit (CCU) studied in our study, while in the above study, hospitalized patients in other units also studied.On the other hand, their study was done in a reference hospital, and the most patients were hospitalized from other cities.
This factor could affect in low rate of DAMA.In the study of Fiscella et al., 22 the rate of DAMA has been reported 1.1% in patients with acute MI since the study was performed in California America, high quality of services in that area cans a reason for the low rate of discharge.If this hypothesis is correct, to reduce the rate of DAMA, it requires executing the programs and interventions to improve the quality of services in the hospitals.Estimated rate of DAMA in our study also was higher than many other studies in other patient groups. 8,23,24Moreover, this is worrying and needs to study the reasons and planning to reduce the DAMA.
5][26] Since cardiovascular disease usually occurs at older ages, the higher average age of patients discharged with personal satisfaction in this study than some previous studies is justifiable.Furthermore, the reason of low rate of discharge in older people and teenagers could have two major factors: The first is that this group of people usually are not at age of working age and often supported by others, so they are not worried so much about the costs and prolongation of the treatment process.Second, these people have no choice to make a decision and mostly their family and supervisors decide for them and because of concern about their healthy; their family has no tendency to discharge them with personal satisfaction.Statistical analysis in this study showed that difference in the DAMA is significant in terms of the types of insurance.Since all patients in this study had at least one of the types of insurance, it was not possible to study the effect of having or not the insurance in discharge.
The study of Baptist et al., 8 showed that uninsured people discharged 28.9% with personal satisfaction and 13.7% with physician order 8 also a study of Ibrahim et al. 27 showed that having insurance is a prognostic factor for DAMA. 27Another

Table 1 .
Demographic and descriptive data of hospitalized patients in cardiac care units (CCU) of hospitals in East Azerbaijan MI: Myocardial infarction; ACS: Acute coronary syndrome; CHF: Congestive heart failure Figure 1.The frequency of discharges against medical advice in hospitalized patients in cardiac care units in hospitals of East Azerbaijan province according to sex and age groups

Table 2 .
Variables that affecting the discharges against medical advice (DAMA) in hospitalized patients in cardiac care units (CCU) of hospitals in East Azerbaijan (n = 272)