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Tactics for Reducing AMA Discharges

Posted on Wed, Jul 27, 2016
Tactics for Reducing AMA Discharges

By Adam Corley, MD, FACEP, FAAEM
 
A few weeks ago, I cared for a very nice woman who was suffering from a mild cerebral vascular accident (CVA). Her symptoms of weakness in her arm and leg and mildly slurred speech had been going on for more than a few hours, so I didn’t consider her a TPA candidate.
 
I ordered all of the usual treatment and tests for CVA, including a CT of the brain, which confirmed the diagnosis. I went back in to re-examine her, discuss my findings and recommendations, and to let her know that she would need to be admitted to the hospital for additional testing and to see a neurologist.
 
Her exam was unchanged and she listened patiently as I discussed her test results and my recommendations. She asked several questions to better understand her diagnosis and prognosis and she asked me what would happen if she wasn’t admitted to the hospital. I went over the details of my proposed hospitalization, the tests that we would run and the importance of seeing a neurologist.
 
My patient then told me that she would not be able to stay in the hospital. She was the only caregiver for her sick husband and felt that she could get all of the necessary testing as an outpatient. We discussed the risks, benefits and alternatives to hospitalization and discharge, which she seemed to understand. I made a few phone calls to make sure that she could have easy access to the necessary outpatient testing, treatments and specialists, wrote her prescriptions, and encouraged her to return if her condition worsened or if she changed her mind. She completed the necessary paperwork and then I discharged her home from the ER with a diagnosis of acute ischemic CVA.
 
Patients like this who are discharged against medical advice (AMA) make up 1 to 2 percent of all medical admissions and represent unique ethical, legal, financial and operational challenges in healthcare.
 
A 2007 study published in the Journal of Allergy and Clinical Immunology showed that patients with asthma who leave AMA are four times more likely to return to the ER within 30 days and nearly three times more likely to require readmission to the hospital. A study in the International Journal of Clinical Practice concluded that the average length of stay for a readmission following AMA discharge was 2.4 days longer and cost 56 percent more.
 
Several studies have examined the demographic correlations for patients deciding to leave AMA. Substance abuse, lack of insurance, Medicaid and lower socioeconomic status tend to correlate with higher AMA rates.
 
Recently, I have noticed certain groups and hospital systems considering focusing on reducing AMA discharges as a quality measure. The thinking is that if we can reduce patients leaving AMA, they will receive the care necessary to properly treat their illness and probably save the patient, hospital, insurance company or government payer money at the same time. However, it is critically important to approach this issue in a careful and deliberate manner to preserve patient liberty.
 
Patients who are competent to manage their own healthcare and understand the treatment recommendations presented to them should have the autonomy to make decisions that they feel are in their own best interest. Even the sagest medical advice may not be right for some patients or in certain situations.
 
As we work to improve the quality of healthcare in American and continue to focus on population health, it is critically important to maintain patient autonomy and the sanctity of the doctor-patient relationship. Patients should be free to choose the right treatment course for them or to forgo treatment all together if that is their choice. We must avoid the temptation to apply a one-size-fits-all mentality to the delivery of healthcare.
 
Excellent physician communication, systems that reduce barriers to healthcare delivery, individualized solutions to improve patient experience and a flexible approach to meeting patient needs are all excellent tactics to reduce AMA discharges. However, a heavy-handed approach to pressure patients to comply with recommended treatment would be wrong. We should respect patient autonomy and encourage people to make their own healthcare decisions — even if we disagree with them. 


 
Dr. Adam Corley is a practicing emergency physician with more than 10 years of clinical and leadership experience. Dr. Corley serves as Executive Vice President for EmCare’s West Division. He also serves as the medical director for several EMS services and the Anderson County Texas Sheriff’s Department. Dr. Corley lectures and writes on a variety of topics, including decision science and behavioral economics, management of disruptive behavior in healthcare, conflict resolution and healthcare leadership.
 
 

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Report Offers Guidance on Medical Ethics Education

Posted on Mon, Jun 15, 2015
Report Offers Guidance on Medical Ethics Education

Novel approaches to learning encouraged, such as flipped classroom, use of reflective narratives

WEDNESDAY, June 10, 2015 (HealthDay News) -- An analysis of the current state of medical ethics education in the United States has been published in the June issue ofAcademic Medicine. The article, the Romanell Report, also offers guidance to assist medial ethics educators in meeting expectations.

Joseph A. Carrese, M.D., M.P.H., from the Johns Hopkins University School of Medicine, and colleagues discussed medical ethics in medical education and training, offering guidance on the specific goals of medical ethics education, essential knowledge and skills, best pedagogical methods and processes, and optimal assessment strategies.

The authors propose objectives for medical ethics education, which include understanding the concept of a physician as a fiduciary; recognizing ethical issues that may arise during patient care; using relevant ethical statements to guide judgment and decision making; use of critical and systematic thinking in ethical problems; and articulating ethical reasoning coherently. Teaching approaches should include use of lectures, presentation of clinical cases, and trigger tapes, as well as inviting learners to write reflective narratives. Medical ethics instruction should involve collaboration from different disciplines. Learner-driven teaching strategies should be adopted, as well as use of role-play scenarios and online strategies such as flipped classroom approaches. Learners should be able to manage ethical challenges in a professional manner in areas that range from protection of patient privacy and confidentiality to social media use.

"We believe that the medical ethics curriculum can be improved by focusing it on professional formation as preparation for a lifelong commitment to professionalism in patient care, education, and research," the authors write.

Several authors disclosed ties to the Academy for Professionalism in Health Care.

Full Text



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Patients Want Doctors to Disclose Ties to Industry in MS Trials

Posted on Tue, Mar 17, 2015
Patients Want Doctors to Disclose Ties to Industry in MS Trials

Potential participants in trials of MS therapies want to know about conflicts of interest

TUESDAY, March 10, 2015 (HealthDay News) -- Disclosure of physician-industry relationships is important for potential participants in multiple sclerosis clinical trials and may impact participation in these trials, according to a study published online Feb. 25 in the Multiple Sclerosis Journal.

Andrew J. Solomon, M.D., from the University of Vermont College of Medicine, and colleagues used an anonymous online instrument to examine attitudes of 597 patients with multiple sclerosis concerning disclosure of potential physician-industry conflicts of interest created by clinical trials. The authors further assessed the impact of disclosure of these conflicts of interest on study participation.

The researchers found that detailed disclosure of conflicts of interest was important for potential participants in industry-sponsored trials for multiple sclerosis therapies. The presence of these conflicts might influence patient participation in these trials.

"Findings from this study support a call for uniform guidelines regarding disclosure of physician-industry relationships to prospective research participants for industry-sponsored clinical trials," the authors write.

Several authors disclosed financial ties to the pharmaceutical and biotechnology industries.

Abstract
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Tags: Ethics

Physicians Reminded of Ethical Obligations Regarding Torture

Posted on Mon, Dec 29, 2014
Physicians Reminded of Ethical Obligations Regarding Torture

Should only perform assessments of detainees to determine need for care, provide care

TUESDAY, Dec. 16, 2014 (HealthDay News) -- With the issuing of the new U.S. Senate report on interrogations, the American Medical Association (AMA) is reminding physicians of their ethical obligations relating to torture and interrogation.

As part of the AMA Code of Medical Ethics, physicians must oppose and must not participate in torture, including providing or withholding services, substances, or knowledge to facilitate practice of torture; should only treat individuals when it is in the patient's best interest, and not to verify health so that torture can occur; and should help provide support for victims of torture. Furthermore, during interrogation, physicians should avoid being involved in use of coercion.

Under the Code of Medical Ethics Opinion E-2.0.68, physicians have five ethical obligations: (1) to perform physical and mental assessments of detainees only to determine if there is a need for medical care and provide this care; (2) not to participate in interrogations; (3) not to monitor interrogations; (4) not to participate in developing effective interrogation strategies; and (5) to report their observations to the appropriate authorities.

"We firmly believe that U.S. policies on detainee treatment must comport with the AMA's Code of Medical Ethics and the World Medical Association's Declaration of Tokyo, which forcefully state medicine's opposition to torture or coercive interrogation and prohibit physician participation in such activities," AMA President Robert M. Wah, M.D., said in a statement.

News Release
AMA Statement

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