Necrotizing Soft Tissue Infections Patients Who Leave Against Medical Advice: A Nationwide Analysis

Author(s):
Manuel Castillo-Angeles ; Barbara Okafor; Rebecca Wiener; Saba Ilkhani; Christine Wu; Ali Salim; Stephanie Nitzschke; Reza Askari MD

Background:

Discharge against medical advice (AMA) accounts for 1-2% of all hospital discharges and it ultimately leads to worse outcomes, disintegration of patient care, and higher cost of care. While this has been studied across multiple clinical conditions, studies on patients with Necrotizing Soft Tissue Infections (NSTIs) are lacking. The purpose of this study was to determine the prevalence and predictors of leaving AMA within the NSTI population.

Hypothesis:

We hypothesize that the prevalence within this population will be similar and predictors of AMA will be centered on social determinants of health.

Methods:

This was a retrospective analysis of the Nationwide Inpatient Sample (2015-2018). We included patients with a primary diagnosis of NSTIs, which included diagnosis codes for necrotizing fasciitis, gas gangrene and Fournier’s gangrene. We collected demographics and clinical characteristics. We restricted our analysis to patients who were either discharged home or discharged AMA. Multivariable logistic regression was used to identify risk factors associated with leaving AMA.

Results:

A weighted total of 30,935 NSTI admissions were identified. Mean age was 48.55 (SD 14.13), 31% were female and 55% were white. 2,160 (1.8%) were discharged AMA. After adjusted analysis, older age (adjusted odds ratio [aOR]  0.98, 95% Confidence Interval [CI] 0.98 – 0.99) and Hispanic ethnicity (aOR 0.51, 95% CI 0.37 – 0.71) were associated with lower odds of being discharged AMA. However, having public insurance (aOR 4.55, 95% CI 3.14 – 6.58) or being uninsured (aOR 2.30, 95% CI 1.43 – 3.70), lowest median household income quartile for patient’s zip code (aOR 1.49, 95% CI 1.01 – 2.21), and care at an urban non-teaching hospital (aOR 1.68, 95% CI 1.02 – 2.79) were associated with a higher risk of leaving AMA.

Conclusions:

This study shows that race, insurance, and socio-economic status are the most important determinants of being discharged AMA within the NSTI population. Even though the prevalence of leaving AMA for NSTI patients is similar to that reported in other conditions, future efforts should focus on early identification of these vulnerable patients and implementation of strategies to address these disparities and thus, prevent discharge AMA among these patients.