Acute pancreatitis has been identified as the leading gastrointestinal cause of hospital admissions in the United States, accounting for more than 275,000 admissions per year. Approximately 75% of these patients who present to the emergency department will need to be admitted to the hospital. Alcohol and biliary disease have been documented as the most common causes of acute pancreatitis in the U.S. In recent years, Americans have consumed less alcohol, but gallstone-related causes of pancreatitis have increased, presumably due to a rise in obesity rates and the aging population.

Although relatively rare, some patients who are hospitalized with acute pancreatitis are discharged against medical advice (AMA). “When patients leave AMA, it can result in incomplete treatment,” explains Fahad Chaudhary, MD. “This not only increases the likelihood of readmission but raises risks for long-term adverse consequences for patients.”

Addressing a Need

Historically, the highest rates of AMA discharges have been seen in patients with low socioeconomic status, a history of substance abuse, and mental illness. While AMA discharges have been previously studied in patients with other diseases, research is lacking on AMA in those with pancreatitis. “Given the potential ramifications, research is needed to identify potential risk factors for patients who leave AMA so that we can work on developing and implementing strategies to intervene,” Dr. Chaudhary says.

For a study published in Gastroenterology Research, Dr. Chaudhary and colleagues used data from the Nationwide Inpatient Sample (2003-2016) to examine the prevalence and trends of discharge AMA in patients who were admitted with pancreatitis. The authors also assessed predictors associated with discharge AMA. They compared in-hospital complications and determined predictors of discharge AMA using a multivariate logistic regression. Nearly 200,000 of the more than 7.1 million cases assessed in the study were admissions for pancreatitis in which patients left AMA.

Findings & Implications

Results of the study demonstrated that rate of discharge AMA increased over time, rising from 2.3% in 2003 to 3.2% in 2016. “The rate of patients leaving AMA was nearly double that of patients leaving AMA for all other causes of hospitalization,” says Dr. Chaudhary. “We also found that the most common predictors for patients who left AMA were being younger than 25 years of age, male, black, and from a lower socioeconomic status.” In addition, those with a history of depression, drug abuse, and HIV infection were more likely to be discharged AMA. Of note, the etiology of pancreatitis in these patients was more likely to be the result of alcohol use rather than biliary or other non-alcoholic causes (Table).

“Patients leaving AMA is an incredibly complicated topic to research and cannot be adequately teased out in a single study,” Dr. Chaudhary says. “That said, we know from other studies that common reasons for people leaving AMA include personal obligations, fear of financial obligations, the patient’s own assessment of improvement or lack thereof, and dissatisfaction with care. Some of these factors are out of the clinician’s control, but there are others that we can address. A good place to start is for clinicians to provide patients with frequent updates on their condition and being honest about anticipated length of stay, especially pancreatitis cases in which this can be unclear.”

Future Research

In general, the topic of AMA has not been well studied, and Dr. Chaudhary says more analyses are needed on reasons for patients with pancreatitis leaving AMA. “We need to determine specific interventions that may prevent these patients from leaving AMA to potentially improve outcomes,” he says. “For example, data show that interventions for alcohol abuse in which comprehensive plans are developed with assistance from social workers, psychiatrists, and behavioral therapists can decrease rates of patients leaving AM. Implementing these types of interventions in the hospital may produce similar benefits in our care of patients with pancreatitis. By focusing our efforts to better identify those at high risk for discharge AMA, we may be able to reduce self-discharges, readmissions, hospital costs, and subsequent morbidity resulting from pancreatitis.”

References

Chaudhary F, Albeiruti R, Algahtani F, Alhajii M, Lerfald N, Hutson W. Temporal trends and predictors of pancreatitis patients who leave against medical advice: a nationwide analysis. Gastroenterology Res. 2020;13(2):58–65. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188362/.

Garg SK, Campbell JP, Anugwom C, Wadhwa V, Singh R, Gupta N, Sanaka MR. Incidence and predictors of readmissions in acute pancreatitis: a nationwide analysis. Pancreas. 2018;47(1):46-54.

Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417-420.

Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12):2204-2208.