Abstract
Background
Leaving hospital against medical advice (AMA) is a major source of avoidable morbidity, mortality and healthcare expenditure. The objective of this study was to assess the impact of an innovative HIV/AIDS adult integrated health program on leaving hospital AMA among HIV-positive people who use illicit drugs (PWUD).
Methods
Using generalized estimating equations, we examined the relationship between being a participant of the Dr. Peter Centre (DPC), a specialty HIV/AIDS-focused adult integrated health program, and leaving hospital AMA among a cohort of HIV-positive PWUD patients.
Results
Between July 2005 and July 2011, 181 HIV-positive PWUD who experienced ≥1 hospitalization were recruited into the study. Of the 406 hospital admissions among these individuals, 73 (39.9%) participants left the hospital AMA. In a multivariable model adjusted for confounders, being a participant of the DPC was independently associated with lower odds of leaving hospital AMA (adjusted odds ratio = 0.42; 95% confidence interval: 0.19–0.89).
Conclusions
Our findings suggest that the provision of a broad range of clinical, harm reduction and support services through an innovative HIV/AIDS-focused adult integrated health program operating in proximity to a hospital may curb the rate at which individuals leave hospital prematurely.
Keywords: hospital, discharge against medical advice, HIV, people who use illicit drugs
Background
Leaving hospital against medical advice (AMA) is a growing concern in healthcare settings and is a major source of avoidable morbidity, mortality and healthcare expenditure. For example, studies have suggested that patients who leave hospital AMA experience elevated rates of readmission with worsening of infections or other comorbid conditions.1–4 In addition, population level data indicate the high risk of mortality among individuals who leave hospital AMA.4,5 The healthcare system is also burdened with higher and unnecessary costs associated with readmission,6 as these patients are likely to require longer length of hospital stay at follow-up visits.1
Patients with substance use disorder are particularly vulnerable to leaving hospital AMA. One study showed that approximately one-third of hospitalized HIV-positive people who inject drugs (IDU) admitted to an inner city tertiary care hospital left the hospital AMA.2 Other studies have documented that IDU were 2–4 times more likely to be discharged AMA compared to their non-IDU counterparts.1,2 Furthermore, a retrospective study conducted in Vancouver, Canada revealed that, compared with any other Wednesday in the month, there was approximately a 16% point increase in the likelihood that IDU will decide to leave AMA on the Wednesday when social assistance cheques are issued.7 The same study found that accidental overdose was more likely to occur a few days following cheque day;7 especially troubling finding given high levels of overdose-associated mortality among this population.
Alternative models of care have been implemented in various settings that aim to minimize risks and improve overall health outcomes for people who use illicit drugs (PWUD), including those living with HIV disease.8,9 In Vancouver, Canada, the Dr. Peter Centre (DPC) is an established specialty HIV/AIDS-focused adult integrated health program that provides support to some of the city's most vulnerable citizens who face poverty, homelessness, mental health and addiction issues in addition to HIV/AIDS.10 The DPC is situated in proximity to an acute care hospital and provides three core programs that include a day health program, a 24-h specialized nursing care residence and an enhanced supported housing program. Within these programs, a range of medical and harm reduction programs are provided to adults at the DPC, including counselling, nutrition and a supervised injection program.
Despite the substantial harms and costs associated with the problem of leaving hospital AMA, there is limited empiric research focused on ways to address this problem among PWUD and are living with HIV disease. Given evidence linking HIV to an elevated risk of hospitalization among PWUD,11 and studies showing that severely addicted IDU account for a large proportion of all discharges AMA from an HIV/AIDS ward,2 the objective of this study was to assess the impact of an innovative HIV/AIDS adult integrated health program on leaving hospital AMA among HIV-positive PWUD.
Methods
Study design
Data were collected from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), a prospective cohort study of HIV-positive PWUD in Vancouver, Canada. The specific methods of the ACCESS study have been described in detail elsewhere.12 In brief, beginning in 1996, participants were recruited through self-referral and street-based outreach from Vancouver's Downtown Eastside neighborhood, an area of endemic poverty with an open drug scene and high levels of HIV infection. Individuals were eligible to participate in the ACCESS study if they were aged 18 years or older, were HIV-seropositive, have used illicit drugs other than cannabis in the month prior to enrolment, and provided written informed consent. Participants were compensated $C20 at each study visit.
At baseline and semiannually, participants complete an interviewer-administered questionnaire eliciting demographic data, information on drug use patterns, as well as other characteristics and exposures. At each of these visits, individuals also undergo an examination by a study nurse and provide blood samples for serologic analyses. Information gathered at each interview is augmented by comprehensive information on HIV care and treatment outcomes from the local centralized HIV/AIDS registry. Specifically, through a confidential linkage, a complete clinical profile of all CD4 T-cell counts, plasma HIV-1 RNA viral load (pVL) observations and exposure to specific antiretroviral agents for each participant are obtained. In British Columbia, all provision of antiretroviral therapy (ART) is centralized through a province-wide ART dispensation program. All HIV/AIDS treatment and care, including all medications and clinical monitoring are provided at no cost through the province's public healthcare system. In addition, through a confidential linkage, the interview data is linked to St. Paul's Hospital health records and discharge database, which records all admissions, diagnoses and discharge information for each participant who was hospitalized at St. Paul's Hospital. Written consent was obtained for all data linkages via a Provincial Health Number that is used to uniquely identify individuals. The ACCESS study has been approved by the University of British Columbia/Providence Healthcare Research Ethics Board.
Study participants and variable selection
The present study was restricted to participants who experienced at least one admission to in-patient care at St. Paul's Hospital during the study period. The primary outcome of interest for this analysis was leaving hospital AMA, which was obtained from St. Paul's Hospital administrative discharge database. Participants were defined as leaving hospital AMA if they were reported as either a ‘Code 06: left against medical advice/signed out and were absent without official leave’ or a ‘Code 12: patient did not return from pass’. The primary explanatory variable of interest was being a participant of the DPC, defined as responding ‘yes’ to the following question: ‘Are you a participant at the Dr. Peter Centre?’ Secondary variables believed to be confounders included age (per year increase); gender (male versus female); ancestry (Caucasian versus other); homeless (yes versus no); mental illness diagnosis (yes versus no); illicit drug use (≥daily versus <daily); enrollment in methadone maintenance therapy (yes versus no); difficulty finding equipment (yes versus no); pVL (copies/ml plasma, per log10 increase); CD4 cell count (per 100 cells/ml); and ART initiation ever (yes versus no). All time-varying variables are time-updated and refer to the 6-month period prior to the follow-up interview, unless otherwise stated.
Statistical analyses
As a first step, we compared selected baseline characteristics among participants who left hospital AMA compared to those who did not leave hospital AMA using simple logistic regression. Next, we used generalized estimating equations (GEE) to estimate crude odds ratios (OR) for the effect of being a DPC participant and all other secondary explanatory variables on leaving hospital AMA. We used GEE for the analysis of correlated data since the factors potentially associated with leaving hospital AMA during follow-up were time-dependent measures. We only included individuals with complete data at each given time point.
A multivariable GEE model was constructed to estimate the independent effect of being a DPC participant on leaving hospital AMA, adjusting for various confounders. All confounding variables were entered in the final multivariable model regardless of statistical significance in bivariable analyses as we decided a-priori based on existing literature that these variables should be considered as confounders in this analysis.1,2,13–16 All statistical analyses were performed using R software version 3.1.0 (Foundation for Statistical Computing, Vienna, Austria). All P values are two-sided.
Results
Between July 2005 and July 2011, a total of 181 HIV-positive PWUD had experienced at least one hospitalization and were included in the study: 81 (44.8%) were females and the median age at baseline was 43 years (interquartile range: 38–50 years). Of the 406 hospital admissions among these individuals, 73 (39.9%) participants left the hospital AMA a total of 126 (31.0%) times. In total, 44 (24.3%) individuals were DPC participants. Over the study period, participants contributed a total of 203 person-years of follow-up. The number of times participants were hospitalized ranged between 1 and 10 hospitalizations per participant over the 6-year study period. Table 1 shows the baseline characteristics of the study sample stratified by leaving hospital AMA at baseline.
Table 1.
Characteristics of study participants at baseline (n = 181).
| Left hospital against medical advice | ||||
|---|---|---|---|---|
| Characteristic | Yes n (%) (N = 52) | No n (%) (N = 129) | Odds ratio (95% CI) | P value |
| Dr. Peter Centre participant | ||||
| Yes | 6 (11.5) | 31 (24.0) | 0.41 (0.16–1.06) | 0.06 |
| No | 46 (88.5) | 98 (76.0) | ||
| Age | ||||
| Median | 41 | 44 | 0.96 (0.92–1.00) | 0.05 |
| IQR | (35–48) | (39–51) | ||
| Gender | ||||
| Male | 27 (51.9) | 73 (56.6) | 0.83 (0.43–1.58) | 0.57 |
| Female | 25 (48.1) | 56 (43.4) | ||
| Ancestry | ||||
| Caucasian | 23 (44.2) | 75 (58.1) | 0.57 (0.30–1.09) | 0.09 |
| Other | 29 (55.8) | 54 (41.9) | ||
| Homelessa | ||||
| Yes | 15 (28.8) | 38 (29.5) | 0.97 (0.48–1.97) | 0.94 |
| No | 37 (71.2) | 91 (70.5) | ||
| Mental illness diagnosisa | ||||
| Yes | 24 (46.2) | 69 (53.5) | 0.75 (0.39–1.42) | 0.37 |
| No | 28 (53.8) | 60 (46.5) | ||
| Illicit drug usea | ||||
| ≥Daily | 38 (73.1) | 71 (55.0) | 2.22 (1.10–4.48) | 0.02 |
| <Daily | 14 (26.9) | 58 (45.0) | ||
| Enrollment in MMTa | ||||
| Yes | 22 (42.3) | 61 (47.3) | 0.82 (0.43–1.57) | 0.54 |
| No | 30 (57.7) | 68 (52.7) | ||
| Difficulty finding equipmenta | ||||
| Yes | 13 (25.0) | 31 (24.0) | 1.05 (0.50–2.22) | 0.89 |
| No | 39 (75.0) | 98 (76.0) | ||
| pVLa (per log10 cells/ml) | ||||
| Median | 3.74 | 2.85 | 1.09 (0.87–1.36) | 0.47 |
| IQR | (1.65–4.54) | (1.65–4.66) | ||
| CD4 cell counta (per 100 cells/ml) | ||||
| Median | 3.12 | 2.85 | 1.10 (0.95–1.28) | 0.21 |
| IQR | (2.10–4.61) | (1.50–4.35) | ||
| ART initiation ever | ||||
| Yes | 48 (92.3) | 121 (93.8) | 0.79 (0.23–2.76) | 0.75 |
| No | 4 (7.7) | 8 (6.2) | ||
MMT, methadone maintenance therapy.
aRefers to the 6-month period prior to follow-up.
The crude longitudinal estimates of the odds of leaving hospital AMA are presented in Table 2. DPC participants had significantly lower odds of leaving hospital AMA in unadjusted analysis compared to those who were not DPC participants (OR = 0.43; 95% confidence interval [CI]: 0.20–0.94). Also presented in Table 2, a multivariable model adjusted for various demographic, socioeconomic and clinical confounders showed that being a DPC participant remained independently associated with lower odds of leaving hospital AMA (adjusted OR = 0.42; 95% CI: 0.19–0.89).
Table 2.
Crude and adjusted longitudinal estimates of the odds of leaving hospital against medicaladvice among 181 HIV-positive people who use illicit drugs, 2005–2011.
| Crude | Adjusted | |||
|---|---|---|---|---|
| Characteristic | Odds ratio (95% CI) | P value | Odds ratio (95% CI) | |
| Dr. Peter Centre participant | ||||
| (Yes versus no) | 0.43 (0.20–0.94) | 0.03 | 0.42 (0.19–0.89) | 0.02 |
| Age | ||||
| (Per year older) | 0.95 (0.92–0.98) | < 0.01 | 0.96 (0.92–0.99) | 0.02 |
| Gender | ||||
| (Male versus female) | 0.77 (0.45–1.31) | 0.33 | 1.01 (0.59–1.75) | 0.96 |
| Ancestry | ||||
| (Caucasian versus other) | 0.73 (0.43–1.24) | 0.24 | 0.83 (0.48–1.45) | 0.52 |
| Homelessa | ||||
| (Yes versus no) | 1.04 (0.56–1.93) | 0.90 | 0.83 (0.45–1.54) | 0.55 |
| Mental illness diagnosisa | ||||
| (Yes versus no) | 1.02 (0.59–1.77) | 0.95 | 0.98 (0.58–1.65) | 0.94 |
| Illicit drug usea | ||||
| (≥Daily versus <daily) | 1.43 (0.87–2.37) | 0.16 | 1.21 (0.71–2.06) | 0.49 |
| Enrollment in MMTa | ||||
| (Yes versus no) | 0.81 (0.47–1.38) | 0.43 | 0.76 (0.42–1.35) | 0.34 |
| Difficulty finding equipmenta | ||||
| (Yes versus no) | 1.52 (0.90–2.58) | 0.12 | 1.59 (0.92–2.75) | 0.10 |
| pVLa | ||||
| (Per log10 increase) | 1.16 (0.98–1.38) | 0.08 | 1.08 (0.91–1.29) | 0.39 |
| CD4 cell counta | ||||
| (Per 100 cells) | 1.01 (0.90–1.13) | 0.88 | 1.01 (0.93–1.20) | 0.41 |
| ART initiation ever | ||||
| (Yes versus no) | 0.63 (0.18–2.21) | 0.47 | 0.71 (0.19–2.63) | 0.61 |
MMT: methadone maintenance therapy.
aRefers to the 6-month period prior to follow-up.
Discussion
Main findings of this study
The present study observed that leaving hospital AMA was common among our participants, with approximately 40% leaving hospital AMA at some point during the 6-year study period. After adjusting for a range of relevant factors, we found that being a DPC participant was associated with a significantly reduced odds of leaving AMA compared with non-DPC participants. To our knowledge, this study is the first to demonstrate the role of a comprehensive and integrated HIV/AIDS-focused health program operating in proximity to a hospital on leaving hospital prematurely among HIV-positive PWUD.
What is already known on this topic
Similar to previous research on HIV-positive IDU,2 our findings indicate that a substantial proportion of HIV-positive PWUD in our sample left hospital AMA. This is concerning given the known risks associated with leaving hospital prematurely.4,5,14 Our findings also support a growing body of literature that conceptualizes hospitals as a ‘risk environment’ for drug-using populations17 and acknowledges the presence of various social, structural and environmental forces within hospital environments interact to increase vulnerability to adverse health outcomes among PWUD.18,19 Several reasons for leaving hospital AMA have been described. First, the existence of required structure and rules, including abstinence-only based drug policies, within hospital settings may increase the likelihood that patients with severe drug addiction will leave hospital AMA to maintain their drug-using habits.17 Second, the stigma, discrimination and negative cultural stereotypes that patients may experience within hospital settings may also lead them to leave hospital prematurely.20,21 Lastly, given hesitations over the prescribing pain medication to PWUD patients in acute care settings for fear of exacerbating an existing addiction, or concerns regarding ‘drug-seeking’ behavior,22,23 it may be that PWUD patients are leaving hospital AMA to self-manage their pain.24 Efforts to improve pain management for PWUD, as well as to improve cultural competency and remove negative stereotypes among healthcare workers through education and training programs are needed in this setting.25
What this study adds
Our findings indicate that an HIV/AIDS adult integrated health program, which implements harm reduction strategies, operating in proximity to a hospital may curb the rate of leaving hospital prematurely among PWUD patients. Given that there is paucity of data on novel interventions specific to discharging AMA among this population,26 drawing from the current literature on PWUD in acute care settings more broadly may be useful. A body of literature has demonstrated that stigma, discrimination and drug addiction within acute care settings are tightly related.20,21 As mentioned earlier, abstinence-based policies and lack of harm reduction services within hospital settings may also contribute to PWUD leaving hospital before completing their treatment.17 As such, the DPC's harm reduction programs incorporated into their integrated healthcare program may be responsible for driving the negative association between being a DPC participant and leaving hospital AMA. For instance, it may be that DPC participants who are admitted into hospital are provided with a safe environment in a nearby location where they can access sterile drug paraphernalia and, after a nursing assessment, use their illicit drugs under the supervision of a nurse without increasing their risk of leaving hospital AMA.27 Moreover, the DPC may provide respite from the hospital, particularly around the stigma and abstinence-based policies that may promote AMA.28,29 Other broader integrated health strategies, including education, social support and nutrition, may also be driving the aforementioned association. Given that little is known about this topic, future in-depth qualitative research should seek to explore why participants of an HIV/AIDS adult integrated health program in proximity to a hospital, which has an environment that recognizes the need for harm reduction strategies, are less likely to leave hospital AMA.
Limitations of this study
There are several limitations to this study. First, causation cannot be inferred because of the observational nature of the ACCESS study, and the potential effect of residual and unmeasured confounding must be considered when interpreting the effect of being a DPC participant on leaving hospital AMA. Second, the temporality of this observational study cannot be assessed. Third, our sample was not randomly recruited and therefore may not be representative of all local HIV-positive PWUD. Fourth, the study included some data derived from self-report and thus, may be subject to reporting biases. However, our outcome of interest and clinical measures were observed from comprehensive administrative records and we do not believe individuals differentially reported being a DPC participant based on these measures. Fifth, there may be selection bias due to the fact that participants were not randomly assigned to be a DPC participant. Lastly, this research project included only one hospital. This limitation would have resulted in an underestimation of hospital use, as some participants may have accessed other hospitals during the study period. However, St. Paul's Hospital services the majority of illicit drug users in this setting and operates in proximity to the DPC program that we sought to investigate.30–32
Conclusions
In sum, we found that a substantial proportion of PWUD in this study reported leaving hospital AMA. We also demonstrated that an HIV/AIDS integrated health program in proximity to hospitals may curb the rate of leaving hospital prematurely. Our findings are supportive of the development of similar programs in similar settings, which may minimize high AMA-related human and fiscal costs. Additionally, employing a comprehensive harm reduction program within acute care settings and improving cultural competency among healthcare workers may be valuable for reducing the negative consequences associated with leaving hospital AMA.
Acknowledgements
The authors thank the study participants for their contribution to the research, as well as current and past researchers and staff.
Funding
The ACCESS study was supported by the US National Institutes of Health (R01DA021525). This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supports E.W. L.T. is supported by the Canadian Institutes of Health Research. M.-J.M. is supported, in part, by the National Institutes of Health (R01-DA021525). J.M.'s TasP research has received support from the BC-Ministry of Health, US NIH (NIDA R01DA036307), UNAIDS, ANRS and MAC AIDS Fund. Institutional grants have been provided by Abbvie, BMS, Gilead Sciences, J&J, Merck and ViiV Healthcare. He has served on Advisory Boards for Teva, Gilead Sciences and InnaVirVax.
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