Discharges Against Medical Advice at a County Hospital: Provider Perceptions and Practice.

BACKGROUND: Patients discharged against medical advice (AMA) have higher rates of readmission and mortality than patients who are conventionally discharged. Bioethicists have proposed best practice approaches for AMA discharges, but studies have revealed that some providers have misconceptions about their roles in these discharges. OBJECTIVE: This study assessed patient characteristics and provider practices for AMA discharges at a county hospital and provider perceptions and knowledge about AMA discharges. DESIGN: This mixed-methods cross-sectional study involved chart abstraction and survey administration. PARTICIPANTS: Charts were reviewed for all AMA discharges (n = 319) at a county hospital in 2014. Surveys were completed by 178 healthcare providers at the hospital. RESULTS: Of 12,036 admissions, 319 (2.7%) ended with an AMA discharge. Compared with conventionally discharged patients, patients who left AMA were more likely to be young, male, and homeless and less likely to be Spanish-speaking. Of the AMA patients, 29.6% had capacity documented, 21.4% had medications prescribed, and 25.7% had follow-up arranged. Of patients readmitted within 6 months after AMA, 23.5% left AMA again at the next visit. Attending physicians and trainee physicians were more likely than nurses to say that AMA patients should receive medications and follow-up (94% and 84% vs 64%; P < 0.05). CONCLUSIONS: Although providers overall felt comfortable determining capacity and discussing AMA discharges, they rarely documented these discussions. Nurses and physicians differed in their thinking regarding whether to arrange follow-up for patients leaving AMA, and in practice arrangements were seldom made. Journal of Hospital Medicine 2017;12:11-17.

No Ifs, Ands, or Buts: Leveraging Population Health to Focus on the Care of Patients Who Smoke.

We developed a multidisciplinary curriculum to improve our residents' proficiency with smoking cessation counseling and prescribing of nicotine replacement therapy (NRT). The curriculum included a didactic portion, informational handouts, and a panel management component during which residents did telephone outreach and clinic in-reach to address high rates of smoking among patients. Residents rated their confidence with smoking cessation counseling and clinical knowledge before and after the intervention. We also tracked the number of patients flagged in the electronic medical record as smokers, the number of patients contacted, and the number of patients who received counseling. Although we did not make statistically significant improvements in perceived confidence with prescribing NRT, we found that there is an urgent need to address smoking cessation in the primary care setting and that working with a clinical pharmacist and psychologist offered a comprehensive approach. Furthermore, by anchoring the intervention with a population health component, almost 200 patients benefited from outreach efforts.