Recommended Citation
Fabry S, Hamel D, Simpson D. Reducing Discharge Against Medical Advice (DAMA) Rates in Internal Medicine. Presented at Scientific Day; May 21, 2025; Park Ridge, IL.
Abstract
Background/Significance:
Discharges Against Medical Advice (DAMA) present challenges to patient outcomes and healthcare systems. The Internal Medicine Residency Teaching Service (IMTS) at Aurora Health Care in Milwaukee, Wisconsin, identified a DAMA rate that exceeded the national average by over 5%. Given the risks associated with DAMA (e.g., 12-fold increase in readmission, higher all-cause mortality), a targeted intervention was needed.
Purpose:
To mitigate DAMA rates with a simple tool kit for screening and intervention.
Methods:
The STOP-AMA toolkit is a structured quality improvement initiative for early identification and intervention for patients at DAMA risk. It included a screening tool in the EMR reminding residents of evidence-supported risk factors for DAMA. The STOP-AMA Toolkit prompted residents to consider early social work consultations, withdrawal symptom treatment, ancillary services, and psychiatric consultation. As our hospitalized patients’ health is often affected by numerous social determinants of health, our control group were patients (except Intensive Care Unit and High Dependency) on the hospitalist service. EMR data was utilized to compare results over 11 months.
Results:
Over the first five months post-implementation, DAMA rates increased in both IMTS (5.2% relative increase) and hospitalist control groups (8.7% relative increase). Ongoing monthly trend analyses indicated DAMA rate fluctuations across IMTS and hospitalist services with rates peaking/declining in different months: IMTS rates peaked in November followed by a decline; hospitalist spiked in September before showing variability. Negative externalities resulting from the study were limited but included one case of a patient being declined for a facility due to misinterpretation of the documentation.
Conclusion:
The STOP-AMA toolkit implementation demonstrates the potential for structured interventions to reduce the impact of DAMA. Although DAMA rates increased across both groups, the smaller rise in IMTS rates compared to the control group suggests that the STOP-AMA toolkit may have mitigated what could have been a more significant upward trend. This suggests a promising role for early identification and intervention. Given the complexity of DAMA, future efforts should focus on refining intervention strategies, incorporating additional support, and addressing external factors that may influence patient decisions.
Presentation Notes
Presented at Scientific Day; May 21, 2025; Park Ridge, IL.
Full Text of Presentation
wf_yes
Document Type
Oral/Podium Presentation
Reducing Discharge Against Medical Advice (DAMA) Rates in Internal Medicine
Background/Significance:
Discharges Against Medical Advice (DAMA) present challenges to patient outcomes and healthcare systems. The Internal Medicine Residency Teaching Service (IMTS) at Aurora Health Care in Milwaukee, Wisconsin, identified a DAMA rate that exceeded the national average by over 5%. Given the risks associated with DAMA (e.g., 12-fold increase in readmission, higher all-cause mortality), a targeted intervention was needed.
Purpose:
To mitigate DAMA rates with a simple tool kit for screening and intervention.
Methods:
The STOP-AMA toolkit is a structured quality improvement initiative for early identification and intervention for patients at DAMA risk. It included a screening tool in the EMR reminding residents of evidence-supported risk factors for DAMA. The STOP-AMA Toolkit prompted residents to consider early social work consultations, withdrawal symptom treatment, ancillary services, and psychiatric consultation. As our hospitalized patients’ health is often affected by numerous social determinants of health, our control group were patients (except Intensive Care Unit and High Dependency) on the hospitalist service. EMR data was utilized to compare results over 11 months.
Results:
Over the first five months post-implementation, DAMA rates increased in both IMTS (5.2% relative increase) and hospitalist control groups (8.7% relative increase). Ongoing monthly trend analyses indicated DAMA rate fluctuations across IMTS and hospitalist services with rates peaking/declining in different months: IMTS rates peaked in November followed by a decline; hospitalist spiked in September before showing variability. Negative externalities resulting from the study were limited but included one case of a patient being declined for a facility due to misinterpretation of the documentation.
Conclusion:
The STOP-AMA toolkit implementation demonstrates the potential for structured interventions to reduce the impact of DAMA. Although DAMA rates increased across both groups, the smaller rise in IMTS rates compared to the control group suggests that the STOP-AMA toolkit may have mitigated what could have been a more significant upward trend. This suggests a promising role for early identification and intervention. Given the complexity of DAMA, future efforts should focus on refining intervention strategies, incorporating additional support, and addressing external factors that may influence patient decisions.
Affiliations
Aurora Sinai Medical Center, Aurora UW Medical Group, Aurora St. Luke’s Medical Center