Risk factors for discharge against medical advice in patients with UGI bleeding or abdominal pain: a study of 170 discharges against medical advice among 11,996 emergency department visits.

AIM: The aim of this study was to identify rate of and risk factors for patients leaving against medical advice (AMA) from the emergency department (ED) with abdominal pain or upper gastrointestinal (GI) bleeding. METHODS: The National Hospital Ambulatory Medical Care Survey is a limited access dataset that includes ED visit data. All patients who left AMA between years 2007-2009 who had the diagnosis of upper GI bleeding or abdominal pain were studied. The following demographic factors were analyzed as potential risk factors for discharge AMA: patient age, sex, race/ethnicity, geographic location, annual income, type of insurance, urban versus rural status, prior ED visits, ED waiting time, and diagnosis of psychiatric illness. RESULTS: From 2007-2009, a total of 104,566 ED visits were analyzed, of which 1135 (1.1%) were ED visits of patients leaving AMA. Among those leaving AMA, 170 patients (1.4%) leaving AMA presented with upper GI bleeding or abdominal pain. Of nine analyzed parameters, only two parameters statistically significantly affected the rate of leaving AMA. First, patients aged 19-44 years were significantly more likely to leave AMA (P=0.001, odds ratio (OR)=1.67; 95%-CI: 1.21-2.32) whereas patient aged >65 years were less likely to leave AMA with upper GI bleeding or abdominal pain (P=0.01; OR=0.49; 95%-CI: 0.27-0.87). Second, patients with 1-5 prior ED visits were significantly more likely to leave AMA than other patients (P=0.009; OR=1.85; 95% CI: 1.15-2.97). Patients with psychiatric illness tended to have a greater risk of leaving AMA, with borderline statistical significance (P=0.04) Gender, race/ethnicity, geographic region, type of insurance, urban status, and waiting-time >60 minutes did not significantly affect AMA discharge rates. CONCLUSION: This study identifies risk factors for leaving AMA, including young age (19-44 years old), 1-5 prior ED visits within the prior 2 years, and psychiatric illness. Physicians may use these data to help design targeted strategies, based on the identified risk factors, to reduce AMA discharges.

Crevice corrosion in orthopedic implant metals.

Studies of orthopedic implant alloys in crevice configuration suggest that cobalt-chromium alloys such as Haynes-Stellite 25 are the best choice for multicomponent implants. It is also shown that severe crevice attack may result from use of mixed metals.