Discharges against medical advice: time to take another look. A retrospective review of discharges against medical advice focused on prevention.

BACKGROUND: Discharges against medical advice (DAMA) increase the risk of death. METHODS: We retrieved DAMA from five hospitals within a large health system and reviewed 10% of DAMA from the academic site between 2016 and 2021. RESULTS: DAMA increased at the onset of the pandemic. Patients who discharged AMA multiple times accounted for a third of all DAMA. Detailed review was completed for 278 patients who discharged AMA from the academic site. In this sample, women comprised 52% of those who discharged AMA multiple times. Relative to the proportion of all discharges from the academic site during the study period, Black patients were overrepresented among DAMA (21% vs. 34%, p < .05). Patients with multiple AMA discharges were younger, more likely to be unmarried, or have substance use disorders (SUD) than those who discharged AMA once. The most common reason for requesting premature discharge noted in n = 77, 28% of instances was related to patient obligations outside the hospital. Hospital policies and procedures contributed in n = 29, 10% of instances. Reasons for requesting premature discharge and documentation of key safety processes were similar by gender and race however the sample may be underpowered to detect differences. Capacity was evaluated in 109 (39%). Among those who consumed alcohol (n = 81 (29%)) or had SUDs (n = 112 (40%)), information on the amount or timing of last use was missing in n = 39 (48%) and n = 74 (66%), respectively. Critical tools to manage illness were provided in 45 (16%) of DAMA reviewed. CONCLUSIONS: Drivers of AMA discharge may differ by AMA discharge frequency. Recognition of the common reasons for requesting premature discharge may help destigmatize AMA discharges and also identifies early assessments by social work colleagues as an important prevention strategy. Opportunities also exist in anticipating and preventing withdrawal symptoms and in revising hospital practices that contribute to DAMA.

Epidemics, pandemics, and social conflict: Lessons from the past and possible scenarios for COVID-19.

Since COVID-19 broke out, there has been renewed interest in understanding the economic and social dynamics of historical and more recent epidemics and pandemics, from the plagues of Antiquity to modern-day outbreaks like Ebola. These events can have significant impacts on the interplay between poverty and social cohesion, i.e. how different groups in society interact and cooperate to survive and prosper. To that effect, this paper provides a theory-driven overview of how social responses to past epidemics and pandemics were determined by the epidemiological and non-epidemiological characteristics of these outbreaks, with a particular focus on the conditions giving rise to scapegoating and persecution of minority groups, including migrants. We discuss existing theories as well as historical and quantitative studies, and highlight the cases where epidemics and pandemics may lead to milder or more severe forms of scapegoating. Finally, we conclude with a summary of priorities for future research on epidemics, pandemics and social conflict and discuss the possible effects and policy implications of COVID-19.

Rainfall anomalies are a significant driver of cropland expansion.

Rainfall anomalies have long occupied center stage in policy discussions, and understanding their impacts on agricultural production has become more important as climate change intensifies. However, the global scale of rainfall-induced productivity shocks on changes in cropland is yet to be quantified. Here we identify how rainfall anomalies impact observed patterns of cropped areas at a global scale by leveraging locally determined unexpected variations in rainfall. Employing disaggregated panel data at the grid level, we find that repeated dry anomalies lead to an increase in cropland expansion in developing countries. No discernible effects are detected from repeated wet events. That these effects are confined to developing countries, which are often dominated by small-holder farmers, implies that they may be in response to reduced yields. The estimates suggest that overall, in developing countries, dry anomalies account for ∼9% of the rate of cropland expansion over the past two decades. We perform several tests to check for consistency and robustness of this relationship. First, using forest cover as an alternative measure, we find comparable reductions in forest cover in the same regions where cropland expands due to repeated dry anomalies. Second, we test the relationship in regions where yields are buffered from rainfall anomalies by irrigation infrastructure and find that the impact on cropland expansion is mitigated, providing further support for our results. Since cropland expansion is a significant driver of deforestation, these results have important implications for forest loss and environmental services.