Pediatric Discharge Against Medical Advice in a Tehran Hospital Serving Iranian and Afghan Children: A Mixed-Methods Study
| Author | Shiva Karimzadeh | en |
| Author | Mehdi Jafari | en |
| Author | Hasan Abolghasem Gorji | en |
| Author | Jalal Arabloo | en |
| Orcid | Shiva Karimzadeh [0000-0002-7129-0100] | en |
| Orcid | Mehdi Jafari [0000-0002-2890-9967] | en |
| Orcid | Hasan Abolghasem Gorji [0000-0002-6328-1925] | en |
| Orcid | Jalal Arabloo [0000-0003-1223-4528] | en |
| Issued Date | 2026-11-30 | en |
| Abstract | Background: Pediatric discharge against medical advice (DAMA) may reflect clinical, financial, familial, and service-related pressures, particularly in migrant and uninsured populations. Objectives: To compare DAMA occurrence and documented reasons for DAMA between discharge episodes involving Iranian and Afghan children and to develop expert-informed recommendations. Methods: At a pediatric hospital in Tehran serving Iranian and Afghan children, we conducted a mixed-methods study in 2024 - 2025. The quantitative analysis included all 4,540 discharge episodes, with the discharge episode as the unit of analysis. Child-clustered modified Poisson generalized estimating equation models estimated DAMA occurrence (adjusted for month) and the prevalence of cost/insurance-related reasons among DAMA episodes (adjusted for sex, length of stay, admission reason, and ward). Five Hospital Information System reason categories were hierarchically mutually exclusive; co-recorded reasons were retained separately. A small purposive sample of six DAMA caregivers and seven DAMA care/management staff completed semi-structured interviews, which were analyzed using inductive qualitative content analysis. Eight experts with ≥ 2 years’ DAMA-related experience prioritized domains, and a nine-member panel developed recommendations. Results: Among 4,540 discharge episodes, 1,088 (24.0%) ended in DAMA. DAMA occurred in 61.9% of episodes involving Afghan children and 20.3% of those involving Iranian children (month-adjusted RR = 3.10, 95% CI 2.81 - 3.42). In the mutually exclusive primary classification, perceived recovery was the predominant reason for DAMA among episodes involving Iranian children (74.9%). Cost/insurance-related reasons were recorded in 127/250 (50.8%) DAMA episodes involving Afghan children versus 10/838 (1.2%) involving Iranian children. This marked disparity was estimated imprecisely (adjusted prevalence ratio = 41.63, 95% CI 22.15 - 78.25) because only 10 such episodes involved Iranian children. Eight experts ranked financial/insurance factors as most important. Conclusions: Nationality-defined differences should not be interpreted causally; rather, they should be considered in the context of financial and structural vulnerability. Expert-informed recommendations emphasized communication about clinical readiness, financial assessment and support, and clearer documentation; prospective evaluation is required. | en |
| DOI | https://doi.org/10.5812/healthscope-174240 | en |
| URI | https://brieflands.com/journals/healthscope/articles/174240 | en |
| Keyword | Patient Discharge | en |
| Keyword | Treatment Refusal | en |
| Keyword | Pediatrics | en |
| Keyword | Emigrants and Immigrants | en |
| Keyword | Healthcare Accessibility | en |
| Keyword | Medically Uninsured | en |
| Keyword | Health Equity | en |
| Publisher | Brieflands | en |
| Title | Pediatric Discharge Against Medical Advice in a Tehran Hospital Serving Iranian and Afghan Children: A Mixed-Methods Study | en |
| Type | Research Article | en |
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