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Salarikhah E, Farahzadi M H, Moazen H, Masoud M. Factors Associated with Discharge against Medical Advice among Patients Hospitalized in the Psychiatric Hospital of Yazd Province, Iran (2023–2024). EBHPME 2025; 9 (3) :145-151
URL: http://jebhpme.ssu.ac.ir/article-1-551-en.html
URL: http://jebhpme.ssu.ac.ir/article-1-551-en.html
Department of Health Care Management, Tehran South Branch, Islamic Azad University, Tehran, Iran , salarikhah_e@yahoo.com
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Introduction
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| A B S T R A C T
Introduction: Patient satisfaction has increasingly become an important issue in the healthcare system. Discharge against medical advice (DAMA) is considered an important indicator of patient dissatisfaction and may negatively affect treatment outcomes while increasing hospital costs. This issue is particularly significant among psychiatric patients due to the chronic and vulnerable nature of mental disorders. Premature discharge in psychiatric patients can increase the risk of relapse, acute psychiatric crises, suicide, self-harm, or harm to others. From a healthcare system perspective, early discharge is associated with higher readmission rates, additional healthcare costs, and reduced efficiency of the healthcare system. Furthermore, due to the social stigma associated with mental disorders in Iranian society, patients and their families may experience additional pressure to leave the hospital prematurely. Therefore, identifying the factors influencing discharge against medical advice in psychiatric hospitals is essential not only for improving clinical outcomes but also for enhancing patient safety, optimizing healthcare resources, and improving the quality of care.
Materials and Methods: This analytical cross-sectional retrospective study was conducted from April 2023 to September 2024 among patients discharged against medical advice from the psychiatric hospital in Yazd Province, Iran. A list of patients who left the hospital against medical advice during the study period was prepared, and 156 patients were selected using simple random sampling.Data were collected through the Hospital Information System (HIS) and review of patients’ medical records and was analyzed through SPSS. In addition, telephone interviews with patients or their family members were conducted to validate the collected information and obtain additional details regarding the reasons for discharge. Results: Among the 156 patients included in the study, the majority was male (67%). The highest proportion of patients belonged to the 30–39 age group. The most common reasons for discharge were fatigue from the hospital environment (23.1%), occupational and personal problems (20.5%), family dependency (17.3%), and perceived relative recovery (14.1%). Overall, 76.9% of the reasons were related to patient-related factors, while 23.1% were related to hospital-related factors. Conclusion: The findings of this study indicate that most cases of discharge against medical advice in the psychiatric hospital of Yazd are primarily influenced by individual and psychosocial factors. Early discharge in psychiatric patients increases the likelihood of readmission and imposes significant costs on the healthcare system. Therefore, implementing early psychosocial interventions, improving hospital environmental conditions, and reducing social stigma toward mental illness are essential strategies for reducing DAMA rates. Keywords: Discharge, Patient, Discharge against Medical Advice, Psychiatric Hospital |
Introduction
The fundamental mission of healthcare systems is to promote health through the provision of services to patients. Therefore, gaining patient trust and satisfaction with healthcare providers plays a central role in achieving this mission. If patients do not trust healthcare institutions, the healthcare system may fail to fulfill its essential role (1).
DAMA refers to a situation in which a patient voluntarily leaves the hospital before completing the recommended course of treatment, despite the advice of the healthcare team, including physicians and nurses (2). In recent decades, healthcare organizations have increasingly recognized that patient satisfaction is an essential component of healthcare quality (3). The number of patients who leave hospitals against medical advice may reflect dissatisfaction or indicate significant systemic problems within healthcare services (4) .In this type of discharge, the patient voluntarily leaves the hospital before receiving the physician’s approval (5). Discharge against medical advice is considered a major challenge during hospitalization and occurs when a patient leaves the hospital earlier than recommended by the physician (6).
Studies conducted in general hospitals in the United States have reported that approximately one out of every 65 to 120 hospitalized patients leaves the hospital against medical advice (7). Overall, DAMA accounts for approximately 0.8% to 2.2% of all hospital discharges in general hospitals in the United States (8). In Canada, it has been estimated that approximately 20,000 cases of DAMA occur annually (9).
However, DAMA appears to be more common in psychiatric wards compared with medical and surgical wards (10). Studies have reported that the prevalence of DAMA among psychiatric patients ranges from 6% to 35%, with an average of approximately 16% (11). Various studies have identified different factors associated with DAMA. These factors include demographic variables such as age, gender, marital status, and socioeconomic status; mental health-related factors such as substance use history, length of hospitalization, and personality disorders; and environmental factors such as dissatisfaction with hospital facilities and services (12) .In some studies, personal or family problems, perceived improvement in health status, dissatisfaction with treatment, feelings of boredom, fatigue from the hospital environment, and dislike of the hospital setting have also been reported as common reasons for DAMA .Patients who leave the hospital against medical advice often have acute conditions and may still exhibit significant symptoms at the time of discharge. The prognosis of these patients is generally poorer compared with those discharged with medical approval. Furthermore, readmission rates are higher among patients who leave against medical advice (13).
Studies have shown that approximately 21% of patients discharged against medical advice are readmitted within 15 days after discharge, compared with only 3% among patients discharged normally. DAMA is therefore considered one of the strongest predictors of early readmission.In addition to the negative clinical outcomes; DAMA imposes considerable financial burdens on healthcare systems. For example, Barclay et al. estimated that over a five-year period, DAMA resulted in approximately 29.5 million dollars in direct costs and 8.6 million dollars in follow-up costs associated with readmissions (14).
Furthermore, due to the nature of psychiatric disorders, financial difficulties, and cultural issues, patients with psychiatric disorders and their families may prefer early discharge to prevent others from becoming aware of the hospitalization. In Iran, psychiatric disorders are often associated with social stigma, which may contribute to premature discharge (15).
Given the limited number of similar studies conducted in Iran, particularly in psychiatric hospitals, and considering the relatively high rate of DAMA in psychiatric wards compared with general hospitals, the present study aimed to investigate the factors associated with discharge against medical advice in the psychiatric hospital of Yazd Province.
Materials and Methods
This study was a descriptive, cross-sectional, and retrospective study conducted from April 2023 to September 2024 among patients discharged against medical advice from the psychiatric hospital in Yazd Province.Data were collected using a standardized checklist designed based on national hospital accreditation standards to monitor the DAMA indicator. The checklist, approved by the medical records department, included demographic and clinical information such as age, gender, type of insurance, length of hospital stay, final diagnosis, and hospital ward.The checklist also included common reasons for discharge against medical advice, such as perceived improvement, family dependency, fatigue from the hospital environment, and financial problems. In addition, post-discharge outcomes such as readmission or emergency department visits were recorded.
To validate the checklist, it was reviewed by ten experts including psychiatrists, nurses, hospital admission and discharge officers, the nursing director, and the hospital quality improvement manager.Because the checklist was a standardized instrument approved by the University of Medical Sciences, it possessed adequate content validity. To further ensure the accuracy and completeness of the recorded information, telephone follow-ups were conducted with patients or their companions. Data analysis was performed using SPSS version 22. Descriptive statistics including frequency, percentage, mean, and standard deviation were used. Moreover, analytical statistical tests including independent t-test and ANOVA were also applied. The significance level was set at 0.05.
n Z 1- α 2 2 × p (1- p ) d 2 ≅ 156
Results
Among the 156 patients studied, 102 patients (67%) were male and the rest were female. The highest number of patients belonged to the 30–39 age group with 47 individuals (30.1%). In terms of educational level, most patients had secondary school education (Middle school). The majority of patients were covered by Social Security Insurance and Universal Health Insurance (Table 1).
DAMA refers to a situation in which a patient voluntarily leaves the hospital before completing the recommended course of treatment, despite the advice of the healthcare team, including physicians and nurses (2). In recent decades, healthcare organizations have increasingly recognized that patient satisfaction is an essential component of healthcare quality (3). The number of patients who leave hospitals against medical advice may reflect dissatisfaction or indicate significant systemic problems within healthcare services (4) .In this type of discharge, the patient voluntarily leaves the hospital before receiving the physician’s approval (5). Discharge against medical advice is considered a major challenge during hospitalization and occurs when a patient leaves the hospital earlier than recommended by the physician (6).
Studies conducted in general hospitals in the United States have reported that approximately one out of every 65 to 120 hospitalized patients leaves the hospital against medical advice (7). Overall, DAMA accounts for approximately 0.8% to 2.2% of all hospital discharges in general hospitals in the United States (8). In Canada, it has been estimated that approximately 20,000 cases of DAMA occur annually (9).
However, DAMA appears to be more common in psychiatric wards compared with medical and surgical wards (10). Studies have reported that the prevalence of DAMA among psychiatric patients ranges from 6% to 35%, with an average of approximately 16% (11). Various studies have identified different factors associated with DAMA. These factors include demographic variables such as age, gender, marital status, and socioeconomic status; mental health-related factors such as substance use history, length of hospitalization, and personality disorders; and environmental factors such as dissatisfaction with hospital facilities and services (12) .In some studies, personal or family problems, perceived improvement in health status, dissatisfaction with treatment, feelings of boredom, fatigue from the hospital environment, and dislike of the hospital setting have also been reported as common reasons for DAMA .Patients who leave the hospital against medical advice often have acute conditions and may still exhibit significant symptoms at the time of discharge. The prognosis of these patients is generally poorer compared with those discharged with medical approval. Furthermore, readmission rates are higher among patients who leave against medical advice (13).
Studies have shown that approximately 21% of patients discharged against medical advice are readmitted within 15 days after discharge, compared with only 3% among patients discharged normally. DAMA is therefore considered one of the strongest predictors of early readmission.In addition to the negative clinical outcomes; DAMA imposes considerable financial burdens on healthcare systems. For example, Barclay et al. estimated that over a five-year period, DAMA resulted in approximately 29.5 million dollars in direct costs and 8.6 million dollars in follow-up costs associated with readmissions (14).
Furthermore, due to the nature of psychiatric disorders, financial difficulties, and cultural issues, patients with psychiatric disorders and their families may prefer early discharge to prevent others from becoming aware of the hospitalization. In Iran, psychiatric disorders are often associated with social stigma, which may contribute to premature discharge (15).
Given the limited number of similar studies conducted in Iran, particularly in psychiatric hospitals, and considering the relatively high rate of DAMA in psychiatric wards compared with general hospitals, the present study aimed to investigate the factors associated with discharge against medical advice in the psychiatric hospital of Yazd Province.
Materials and Methods
This study was a descriptive, cross-sectional, and retrospective study conducted from April 2023 to September 2024 among patients discharged against medical advice from the psychiatric hospital in Yazd Province.Data were collected using a standardized checklist designed based on national hospital accreditation standards to monitor the DAMA indicator. The checklist, approved by the medical records department, included demographic and clinical information such as age, gender, type of insurance, length of hospital stay, final diagnosis, and hospital ward.The checklist also included common reasons for discharge against medical advice, such as perceived improvement, family dependency, fatigue from the hospital environment, and financial problems. In addition, post-discharge outcomes such as readmission or emergency department visits were recorded.
To validate the checklist, it was reviewed by ten experts including psychiatrists, nurses, hospital admission and discharge officers, the nursing director, and the hospital quality improvement manager.Because the checklist was a standardized instrument approved by the University of Medical Sciences, it possessed adequate content validity. To further ensure the accuracy and completeness of the recorded information, telephone follow-ups were conducted with patients or their companions. Data analysis was performed using SPSS version 22. Descriptive statistics including frequency, percentage, mean, and standard deviation were used. Moreover, analytical statistical tests including independent t-test and ANOVA were also applied. The significance level was set at 0.05.
Results
Among the 156 patients studied, 102 patients (67%) were male and the rest were female. The highest number of patients belonged to the 30–39 age group with 47 individuals (30.1%). In terms of educational level, most patients had secondary school education (Middle school). The majority of patients were covered by Social Security Insurance and Universal Health Insurance (Table 1).
Table 1. Frequency and percentage distribution of patients according to demographic variables
| Variable | Category | Frequency | Percentage |
| Gender | Male | 102 | 67 |
| Female | 54 | 33 | |
| Age group | Under 20 | 15 | 9.6 |
| 20–29 | 33 | 21.2 | |
| 30–39 | 47 | 30.1 | |
| 40–49 | 33 | 21.2 | |
| Above 50 | 28 | 17.9 | |
| Education level | Illiterate | 1 | 0.6 |
| Middle school | 64 | 41 | |
| High school diploma | 50 | 32.1 | |
| Associate degree | 20 | 12.8 | |
| Bachelor’s degree | 21 | 13.5 | |
| Insurance type | Social security insurance | 64 | 41 |
| Medical services insurance | 10 | 6.4 | |
| Uninsured (Self-pay) | 11 | 7.1 | |
| Universal health insurance (Iranian) | 63 | 40.4 | |
| Armed forces insurance | 8 | 5.1 |
The frequency and percentage distribution of several hospitalization-related variables including hospital ward, length of hospital stay, and discharge shift are presented in Table 2.
Among the 156 patients studied, the most frequent primary diagnosis was related to mood disorders (50.6%), followed by psychotic disorders (14.7%) (Table 3).
The most important reasons for discharge against medical advice from the perspective of hospitalized patients were as follows:
Overall, the causes of DAMA were classified into two general categories:
Among the 156 patients studied, the most frequent primary diagnosis was related to mood disorders (50.6%), followed by psychotic disorders (14.7%) (Table 3).
The most important reasons for discharge against medical advice from the perspective of hospitalized patients were as follows:
Overall, the causes of DAMA were classified into two general categories:
- Patient-related factors: 76.9%
- Hospital-related factors: 23.1%
Table 2. Frequency and percentage distribution according to hospitalization related variables
| Variable | Category | Frequency | Percentage |
| Hospital ward | Women’s ward | 41 | 26.3 |
| Men’s ward 1 | 34 | 21.8 | |
| Men’s ward 2 | 1 | 0.6 | |
| Dual ward | 38 | 24.4 | |
| VIP ward | 29 | 18.6 | |
| Relative recovery ward | 13 | 8.3 | |
| Length of stay | Less than 10 days | 118 | 83 |
| More than 10 days | 38 | 18 | |
| Discharge shift | Morning | 133 | 85.3 |
| Evening | 22 | 14.1 | |
| Night | 1 | 0.6 |
Table 3. Frequency and percentage distribution according to primary diagnosis
| Diagnosis | Frequency | Percentage |
| Substance use disorders | 14 | 9 |
| Psychotic disorders | 23 | 14.7 |
| Mood disorders | 79 | 50.6 |
| Obsessive disorders | 7 | 4.5 |
| Personality disorders | 17 | 10.9 |
| Developmental disorders | 2 | 1.3 |
| Discharged before final diagnosis | 14 | 9 |
| Total | 156 | 100 |
Table 4. Main reasons for discharge against medical advice
| Category | Reason | Percentage | Category |
| Patient-related factors | Fatigue from hospital environment | 36 | 23.1 |
| Occupational and personal problems | 32 | 20.5 | |
| Family dependency | 27 | 17.3 | |
| Perceived relative recovery | 22 | 14.1 | |
| Feeling of no improvement | 3 | 1.9 | |
| Hospital-related factors | Inappropriate physical ward environment | 13 | 8.3 |
| Treatment costs | 14 | 9 | |
| Ward overcrowding | 9 | 5.8 | |
| Total | 156 | 100 |
The mean age of patients was 37.17 ± 14.43, with the minimum and maximum ages being 11 and 90, respectively (Table1).
Based on the results of the independent t-test, no significant difference was observed between the mean age of male and female patients (P-value = 0.134). The mean age of male and female patients was 35.91 ± 14.01 and 39.56 ± 15.05 respectively.Although the mean age of female patients was approximately four years higher than that of male patients, this difference was not statistically significant (Table1).
The mean length of hospital stay was 7.03 ± 5.39 days, with the minimum and maximum durations being 1 and 28 days, respectively. Based on the results of ANOVA, there was a significant difference in the mean duration of hospitalization according to the diagnosed disease (P-value = 0.041). The longest mean length of stay was observed among patients with psychotic disorders (9.83 ± 7.29) days.In addition, 2.5% of patients left the emergency department against medical advice, and the most common reason reported was dissatisfaction with the physical environment of the wards (Table2).
Discussion
Discharge against medical advice in psychiatric hospitals is a complex and challenging phenomenon that not only threatens the individual health of patients, but also has considerable consequences for healthcare systems, financial resources, and the quality of healthcare services.The findings of this study showed that the majority of cases of discharge against medical advice in the psychiatric hospital of Yazd were caused by individual factors related to the patient, including perceived relative recovery, family dependency, fatigue from the hospital environment, and occupational or personal problems. These findings indicate the significant role of patients’ perceptions of their health status and environmental conditions in their decision to leave the hospital prematurely.
Although hospital-related factors accounted for a smaller proportion of discharges (approximately 15.2%), their influence should not be overlooked. Factors such as inappropriate ward environment, overcrowding, excessive noise, poor food quality, and treatment costs can make hospitalization unpleasant for patients and increase their motivation to leave the hospital early.These findings indicate that improving hospital facilities, enhancing therapeutic communication, and increasing patient satisfaction with healthcare services may play an important role in reducing the rate of discharge against medical advice.
Another important point is the high rate of discharge against medical advice in psychiatric wards compared with other hospital departments. This issue may be related to the specific nature of psychiatric disorders, the social stigma associated with mental illness in Iranian society, and families’ tendency to conceal the hospitalization of their relatives.
From a healthcare management perspective, discharge against medical advice is associated with increased readmission rates and imposes considerable financial burdens on the healthcare system.
Conclusion
International studies have confirmed that patients who leave the hospital against medical advice have poorer prognoses and higher rates of short-term readmission compared with other patients.
Therefore, identifying high-risk patients and designing preventive interventions such as psychological counseling, patient and family education, and improving communication between healthcare providers and patients may help prevent premature and costly discharge decisions.
Finally, the present study, focusing on the psychiatric hospital of Yazd, provides a clear picture of the causes and consequences of discharge against medical advice and emphasizes the need to revise hospitalization policies, improve the quality of healthcare services, and address cultural and psychological factors.
Reducing such discharges can not only improve community mental health but also increase hospital efficiency, reduce treatment costs, and enhance public trust in the healthcare system.
Ethical consideration
This study was conducted with the necessary permits and code of ethics from the Research
Vice-Chancellor of Shahid Sadoughi University of Medical Sciences (IR.SSU.REC.1403.093).
Acknowledgements
The authors gratefully acknowledge the Psychiatric Hospital of Yazd Province for facilitating access to patients’ data, and the Research Center for Addiction and Behavioral Sciences for their support and approval of the research proposal.
Conflict of interests
The authors report no conflicts of interest (financial or non-financial) related to this study.
Authors' contributions
S.E and M.M Study design and / or data collection; M.H Data analysis; S.E and F,H Writing and editing the article; All authors have read and approved the final version.
Funding
This study received no financial support.
References
1. Rasouli P. Foundations of clinical governance. Hamadan: Hamadan University of Medical Sciences and Health Services; 2011. p. 3-4. [In Persian]
2. Saitz R, Ghali WA, Moskowitz MA. The impact of leaving against medical advice on hospital resource utilization. J Gen Intern Med. 2000;15(2):103-7.
3. Gerbasi JB, Simon RI. Patients' rights and psychiatrists' duties: discharging patients against medical advice. Harv Rev Psychiatry. 2003;11(6):333-43.
4. 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): 2204-8.
5. Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012; 125(6):594-602.
6. Tawk R, Freels S, Mullner R. Associations of mental illness and substance use disorders with leaving against medical advice. J Natl Med Assoc. 2003; 95(5):421-8.
7. Hwang JP, Ahn JS, Lee HJ, Park SH, Lee SS. Discharge against medical advice among inpatients at a tertiary care hospital: prevalence, correlates and outcomes. Psychiatry Investig. 2019;16(1):70-77.
8. Kennedy M, Glickman L, Ibeziako P. Discharge against medical advice in child and adolescent psychiatry: A 10-year retrospective study. J Child Adolesc Psychopharmacol. 2019;29(1):27-33.
9. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003; 168(4):417-20.
10. Alfandre DJ. "I'm going home": discharges against medical advice. Mayo Clin Proc. 2009; 84(3):255-60.
11. Choi M, Kim H, Qian H, Palepu A. Readmission rates of patients discharged against medical advice: A matched cohort study. PLoS One. 2011; 6(9):e24459.
12. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007; 119(4): 924-9.
13. Esmaeili Ranjbar A, Ahmadi S, Khankeh HR, Dalvandi A. Factors associated with discharge against medical advice in emergency department patients: a study protocol. Iran J Emerg Med. 2022; 9(2):45-52. [In Persian]
14. Barclay M, Kipnis P, Lo B, Grosso L, Rennie S, Warton EM, et al. The financial impact of against medical advice discharges in a managed care setting. J Hosp Med. 2013; 8(12):678-83
15. Anis AH, Sun H, Guh DP, Wang X, Farris KB, Schechter MT. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002; 167(6):633-7.
Based on the results of the independent t-test, no significant difference was observed between the mean age of male and female patients (P-value = 0.134). The mean age of male and female patients was 35.91 ± 14.01 and 39.56 ± 15.05 respectively.Although the mean age of female patients was approximately four years higher than that of male patients, this difference was not statistically significant (Table1).
The mean length of hospital stay was 7.03 ± 5.39 days, with the minimum and maximum durations being 1 and 28 days, respectively. Based on the results of ANOVA, there was a significant difference in the mean duration of hospitalization according to the diagnosed disease (P-value = 0.041). The longest mean length of stay was observed among patients with psychotic disorders (9.83 ± 7.29) days.In addition, 2.5% of patients left the emergency department against medical advice, and the most common reason reported was dissatisfaction with the physical environment of the wards (Table2).
Discussion
Discharge against medical advice in psychiatric hospitals is a complex and challenging phenomenon that not only threatens the individual health of patients, but also has considerable consequences for healthcare systems, financial resources, and the quality of healthcare services.The findings of this study showed that the majority of cases of discharge against medical advice in the psychiatric hospital of Yazd were caused by individual factors related to the patient, including perceived relative recovery, family dependency, fatigue from the hospital environment, and occupational or personal problems. These findings indicate the significant role of patients’ perceptions of their health status and environmental conditions in their decision to leave the hospital prematurely.
Although hospital-related factors accounted for a smaller proportion of discharges (approximately 15.2%), their influence should not be overlooked. Factors such as inappropriate ward environment, overcrowding, excessive noise, poor food quality, and treatment costs can make hospitalization unpleasant for patients and increase their motivation to leave the hospital early.These findings indicate that improving hospital facilities, enhancing therapeutic communication, and increasing patient satisfaction with healthcare services may play an important role in reducing the rate of discharge against medical advice.
Another important point is the high rate of discharge against medical advice in psychiatric wards compared with other hospital departments. This issue may be related to the specific nature of psychiatric disorders, the social stigma associated with mental illness in Iranian society, and families’ tendency to conceal the hospitalization of their relatives.
From a healthcare management perspective, discharge against medical advice is associated with increased readmission rates and imposes considerable financial burdens on the healthcare system.
Conclusion
International studies have confirmed that patients who leave the hospital against medical advice have poorer prognoses and higher rates of short-term readmission compared with other patients.
Therefore, identifying high-risk patients and designing preventive interventions such as psychological counseling, patient and family education, and improving communication between healthcare providers and patients may help prevent premature and costly discharge decisions.
Finally, the present study, focusing on the psychiatric hospital of Yazd, provides a clear picture of the causes and consequences of discharge against medical advice and emphasizes the need to revise hospitalization policies, improve the quality of healthcare services, and address cultural and psychological factors.
Reducing such discharges can not only improve community mental health but also increase hospital efficiency, reduce treatment costs, and enhance public trust in the healthcare system.
Ethical consideration
This study was conducted with the necessary permits and code of ethics from the Research
Vice-Chancellor of Shahid Sadoughi University of Medical Sciences (IR.SSU.REC.1403.093).
Acknowledgements
The authors gratefully acknowledge the Psychiatric Hospital of Yazd Province for facilitating access to patients’ data, and the Research Center for Addiction and Behavioral Sciences for their support and approval of the research proposal.
Conflict of interests
The authors report no conflicts of interest (financial or non-financial) related to this study.
Authors' contributions
S.E and M.M Study design and / or data collection; M.H Data analysis; S.E and F,H Writing and editing the article; All authors have read and approved the final version.
Funding
This study received no financial support.
References
1. Rasouli P. Foundations of clinical governance. Hamadan: Hamadan University of Medical Sciences and Health Services; 2011. p. 3-4. [In Persian]
2. Saitz R, Ghali WA, Moskowitz MA. The impact of leaving against medical advice on hospital resource utilization. J Gen Intern Med. 2000;15(2):103-7.
3. Gerbasi JB, Simon RI. Patients' rights and psychiatrists' duties: discharging patients against medical advice. Harv Rev Psychiatry. 2003;11(6):333-43.
4. 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): 2204-8.
5. Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012; 125(6):594-602.
6. Tawk R, Freels S, Mullner R. Associations of mental illness and substance use disorders with leaving against medical advice. J Natl Med Assoc. 2003; 95(5):421-8.
7. Hwang JP, Ahn JS, Lee HJ, Park SH, Lee SS. Discharge against medical advice among inpatients at a tertiary care hospital: prevalence, correlates and outcomes. Psychiatry Investig. 2019;16(1):70-77.
8. Kennedy M, Glickman L, Ibeziako P. Discharge against medical advice in child and adolescent psychiatry: A 10-year retrospective study. J Child Adolesc Psychopharmacol. 2019;29(1):27-33.
9. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003; 168(4):417-20.
10. Alfandre DJ. "I'm going home": discharges against medical advice. Mayo Clin Proc. 2009; 84(3):255-60.
11. Choi M, Kim H, Qian H, Palepu A. Readmission rates of patients discharged against medical advice: A matched cohort study. PLoS One. 2011; 6(9):e24459.
12. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007; 119(4): 924-9.
13. Esmaeili Ranjbar A, Ahmadi S, Khankeh HR, Dalvandi A. Factors associated with discharge against medical advice in emergency department patients: a study protocol. Iran J Emerg Med. 2022; 9(2):45-52. [In Persian]
14. Barclay M, Kipnis P, Lo B, Grosso L, Rennie S, Warton EM, et al. The financial impact of against medical advice discharges in a managed care setting. J Hosp Med. 2013; 8(12):678-83
15. Anis AH, Sun H, Guh DP, Wang X, Farris KB, Schechter MT. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002; 167(6):633-7.
Type of Study: Original article |
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Healt care Management
Received: 2025/10/29 | Accepted: 2026/04/27 | Published: 2026/06/1
Received: 2025/10/29 | Accepted: 2026/04/27 | Published: 2026/06/1
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