Black and Hispanic patients at the emergency department (ED) were more likely to be discharged against medical advice compared with white patients, according to a national cross-sectional study.
In a sample of over 33 million visits to nearly 1,000 hospitals, unadjusted analyses showed the odds of discharge against medical advice to be 45% higher for Black patients (OR 1.45, 95% CI 1.31-1.57) and 16% higher for Hispanic patients (OR 1.16, 95% CI 1.04-1.29) compared with white patients, reported Jennifer W. Tsai, MD, MEd, of Yale University School of Medicine in New Haven, Connecticut, and co-authors.
After adjustment for sociodemographic characteristics (including age, sex, income, and insurance status), disparities persisted only for Black patients (OR 1.18, 95% CI 1.09-1.28), with no difference for Hispanic patients (OR 1.03, 95% CI 0.92-1.15), the researchers detailed in JAMA Network Open.
Discharge against medical advice rates were higher for Black patients (2.1%) compared with Hispanic (1.6%) and white (1.4%) patients, men (1.7%) compared with women (1.5%), those with no insurance (2.8%), those with lower annual income (<$27,999; 1.9%), and those ages 35 to 49 (2.2%). They were highest at metropolitan teaching hospitals (1.8%) and hospitals that served greater proportions of racial and ethnic minoritized patients (serving ≥57.9%; 2.1%).
“Structural racism may contribute to ED DAMA [discharge against medical advice] disparities via unequal allocation of health care resources in hospitals that disproportionately treat racial and ethnic minoritized groups,” Tsai and team wrote.
“Our findings join a growing body of literature demonstrating how racial and ethnic health inequities are significantly associated with the setting where racial and ethnic minoritized patients are more likely to receive care,” they noted. “That health outcomes are worse in hospitals that care for a disproportionate number of racial and ethnic minoritized patients is inconsistent with the premise of the ‘separate but equal’ doctrine and may represent breach of health justice and civil rights.”
Importantly, disparities in discharge against medical advice were reversed after adjustment for hospital random intercepts, such that compared with white patients, Black and Hispanic patients had lower odds of discharge against medical advice, with ORs of 0.94 (95% CI 0.90-0.98) and 0.68 (95% CI 0.63-0.72), respectively, the study found. In this secondary analysis, the intraclass correlation of 0.118 (95% CI 0.104-0.133) indicated that 11.8% of the overall variance in discharge rates was explained at the hospital level.
That variations in these discharge rates were greater between-hospital than within-hospital suggests that Black and Hispanic patients are more likely to receive care in hospitals with higher rates of discharge against medical advice, Tsai’s group explained.
“For example … we estimate that at a population level, if ED care of Black patients was distributed evenly across hospitals in the U.S. rather than more concentrated in a small number of hospitals with high DAMA rates, there would be 217,544 fewer DAMAs in the Black patient population per year,” they wrote. “Taken together, our analyses show how health disparities are not merely a result of independent biologic or behavioral risk factors at the patient level.”
Tsai and team noted that because discharge against medical advice is associated with fewer interventions, “implications of DAMA for chest pain may include missed detection of myocardial infarction and higher morbidity and mortality.” They also pointed to a 2021 report of a seven-fold higher mortality hazard associated with discharge against medical advice among patients with an opioid overdose-related visit.
This cross-sectional study used data from the Nationwide Emergency Department Sample and included 33,147,251 visits to 989 U.S. hospitals in 2019. Calculations were weighted to be nationally representative. Most visits were made by white patients (55%), followed by Black (20.7%) and Hispanic (15.4%) patients. Median age was 40 years.
Patients with Medicaid (30.4%), female patients (55%), and patients with the lowest-income zip codes (median household annual income less than $47,999; 34.4%) accounted for most of the visits.
Overall, 1.6% of ED visits resulted in discharge against medical advice.
Among the 50 most common Agency for Healthcare Research and Quality Clinical Classifications Software Refined codes in the Nationwide Emergency Department Sample, weighted national rates for discharge against medical advice were highest for abdominal pain, nonspecific chest pain, syncope, headache, and alcohol-related disorders.
Limitations cited by Tsai and team included unknown quality of race and ethnicity data; small sample sizes for Asian, Pacific Islander, and Native American patients; and unavailable criteria for the designation of discharge against medical advice.