dama means a rejection of the permission previously given by the patient to allow health services providers to take care of him ( 3 ) .
dama is accounted for one percent of total discharges in canada and varies from 0.8% to 2.2% in the us ( 5 , 7 ) . besides ,
in studies conducted in iran , various rates of dama have been reported ( 810 ) .
dama is regarded as a risk factor for the recurrence of disease , readmission and higher costs for patient ( 1113 ) .
incurred costs due to dama in five years were estimated to be nearly 3 billion dollars ( 14 ) .
patient dissatisfaction with the medical team , personal or family problems , patient s perception of feeling of wellbeing , dissatisfaction with treatment provided , low economic status , improper equipment , the lack of medical and nursing care can be mentioned as the most significant causes for dama ( 1416 ) . through investigating the rate and causes contributing to dama in hospitals ,
their weaknesses can be identified , and accordingly planning should be done to resolve problems and decrease the rate of dama .
such attempts may play an important role not only in promoting the health of population , but also in reducing additional costs and increasing hospital revenue .
this study , therefore , aimed to estimate the rate of and causes contributing to dama in iranian hospitals through conducting a systematic review and meta - analysis of the results of published studies .
a systematic review and meta - analysis study was conducted in 2014 and a search strategy was developed by an experienced librarian .
required data were collected through searching for key words included :  dama  ,  leaving against medical advice  ,  causes *  ,  hospital  and their persian equivalents using databases including pubmed , ovid , google scholar , embase , scopus , magiran , scientific information database ( sid ) , google search engine , and also gray literature . to increase the confidence in the selection of articles , the reference lists of the articles , certain relevant journals and web sites in this field also were searched .
published articles from january 2000 to december 2014 indicating the rate of dama were included .
the inclusion criteria included : articles in english and persian language ; studies conducted in iranian hospitals , articles reporting the rate of dama .
the following articles were excluded ; letters to editor , presentations in conferences and case reports . to assess the quality of the retrieved articles , two authors evaluated the articles according to the checklist of strengthening the reporting of observational studies in epidemiology ( strobe ) . in the first phase ,
articles non - relevant to the subject of this study were excluded . in the second phase ,
computer software for reference management ( endnote x5 ) was used for organizing and recognizing the duplication articles .
after excluding non - relevant articles and duplicates among different databases as well as matching the exclusion criteria , 17 articles were incorporated into the study ( fig .
the extracted data were summarized in previously designed extraction tables included : author and year , city , sample and sample size , dama prevalence ( % ) , dama - male gender ( % ) , dama cause ( % ) . literature review and retrieval flow diagram to estimate the rate of dama ,
a quantitative meta - analysis method was adopted using computer software ( cma : 2comprehensive meta - analysis ) . in order to report the results , forest plots with 95% confidence interval and
funnel plot were used to report the rate of dama and examine the publication bias , respectively . according to the q statistics indicating heterogeneity of results in different studies , the random effect model was used to perform meta - analyses . to compare the rate of dama between female and male we conducted t - test by using spss version 16 software ( chicago , il , usa ) .
the contributing causes of dama were extracted through the method of manual content - analysis .
this method is used to detect , categorize and report themes from text and is very popular in analyzing qualitative data ( 17 ) .
two researchers coded data by through the following process : data immersion ( getting accustomed to data context ) , identifying and extracting primary codes , themes detection ( assigning the extracted primary codes to the related themes ) , reviewing and completing the detected themes , naming and defining themes , the reliability assurance of extracted codes and themes ( two encoders agreed on removing disputed cases through discussion ) .
a systematic review and meta - analysis study was conducted in 2014 and a search strategy was developed by an experienced librarian .
required data were collected through searching for key words included :  dama  ,  leaving against medical advice  ,  causes *  ,  hospital  and their persian equivalents using databases including pubmed , ovid , google scholar , embase , scopus , magiran , scientific information database ( sid ) , google search engine , and also gray literature . to increase the confidence in the selection of articles , the reference lists of the articles , certain relevant journals and web sites in this field also were searched .
published articles from january 2000 to december 2014 indicating the rate of dama were included .
the inclusion criteria included : articles in english and persian language ; studies conducted in iranian hospitals , articles reporting the rate of dama .
the following articles were excluded ; letters to editor , presentations in conferences and case reports . to assess the quality of the retrieved articles , two authors evaluated the articles according to the checklist of strengthening the reporting of observational studies in epidemiology ( strobe ) . in the first phase ,
articles non - relevant to the subject of this study were excluded . in the second phase ,
computer software for reference management ( endnote x5 ) was used for organizing and recognizing the duplication articles .
after excluding non - relevant articles and duplicates among different databases as well as matching the exclusion criteria , 17 articles were incorporated into the study ( fig .
the extracted data were summarized in previously designed extraction tables included : author and year , city , sample and sample size , dama prevalence ( % ) , dama - male gender ( % ) , dama cause ( % ) . literature review and retrieval flow diagram
a systematic review and meta - analysis study was conducted in 2014 and a search strategy was developed by an experienced librarian .
required data were collected through searching for key words included :  dama  ,  leaving against medical advice  ,  causes *  ,  hospital  and their persian equivalents using databases including pubmed , ovid , google scholar , embase , scopus , magiran , scientific information database ( sid ) , google search engine , and also gray literature . to increase the confidence in the selection of articles , the reference lists of the articles , certain relevant journals and web sites in this field also were searched .
published articles from january 2000 to december 2014 indicating the rate of dama were included .
the inclusion criteria included : articles in english and persian language ; studies conducted in iranian hospitals , articles reporting the rate of dama .
the following articles were excluded ; letters to editor , presentations in conferences and case reports .
to assess the quality of the retrieved articles , two authors evaluated the articles according to the checklist of strengthening the reporting of observational studies in epidemiology ( strobe ) .
in the first phase , articles non - relevant to the subject of this study were excluded . in the second phase ,
computer software for reference management ( endnote x5 ) was used for organizing and recognizing the duplication articles .
after excluding non - relevant articles and duplicates among different databases as well as matching the exclusion criteria , 17 articles were incorporated into the study ( fig .
1 ) . the extracted data were summarized in previously designed extraction tables included : author and year , city , sample and sample size , dama prevalence ( % ) , dama - male gender ( % ) , dama cause ( % ) .
to estimate the rate of dama , a quantitative meta - analysis method was adopted using computer software ( cma : 2comprehensive meta - analysis ) . in order to report the results , forest plots with 95% confidence interval and funnel plot
were used to report the rate of dama and examine the publication bias , respectively . according to the q statistics indicating heterogeneity of results in different studies , the random effect model was used to perform meta - analyses . to compare the rate of dama between female and male we conducted t - test by using spss version 16 software ( chicago , il , usa ) .
the contributing causes of dama were extracted through the method of manual content - analysis .
this method is used to detect , categorize and report themes from text and is very popular in analyzing qualitative data ( 17 ) .
two researchers coded data by through the following process : data immersion ( getting accustomed to data context ) , identifying and extracting primary codes , themes detection ( assigning the extracted primary codes to the related themes ) , reviewing and completing the detected themes , naming and defining themes , the reliability assurance of extracted codes and themes ( two encoders agreed on removing disputed cases through discussion ) .
to estimate the rate of dama , a quantitative meta - analysis method was adopted using computer software ( cma : 2comprehensive meta - analysis ) . in order to report the results , forest plots with 95% confidence interval and funnel plot
were used to report the rate of dama and examine the publication bias , respectively . according to the q statistics indicating heterogeneity of results in different studies , the random effect model was used to perform meta - analyses . to compare the rate of dama between female and male we conducted t - test by using spss version 16 software ( chicago , il , usa ) .
the contributing causes of dama were extracted through the method of manual content - analysis .
this method is used to detect , categorize and report themes from text and is very popular in analyzing qualitative data ( 17 ) .
two researchers coded data by through the following process : data immersion ( getting accustomed to data context ) , identifying and extracting primary codes , themes detection ( assigning the extracted primary codes to the related themes ) , reviewing and completing the detected themes , naming and defining themes , the reliability assurance of extracted codes and themes ( two encoders agreed on removing disputed cases through discussion ) .
out of 913 retrieved articles by the initial search , 17 articles were incorporated into the study ( 8 , 1832).the information from the studied articles has been provided in table 1 . in general , there were 244858 individuals studied in the articles .
the articles were published from 2010 to 2014 . as it is observed in table 1 ,
the studies related to the rate measurement of discharge against medical advice have been conducted only in seven cities of iran especially in tehran with the most frequency .
the lowest rate of discharge against medical advice was reported by a study with the participation of 4835 inpatient children in sari ( 2.2% ) .
the highest rate of discharge against medical advice was belonged to a study conducted on 1171 patient form the department of physiotherapy ( 34.4% ) .
the mean score of discharge against medical advice was higher in men compared with women ( 42.36.5 versus 57.66.5 ) .
the statistical test showed that the difference in the rate of discharge against medical advice between two gender is statistically significant ( p<0.05 ) .
out of the 17 reviewed articles , 3 articles have investigated dama among patients in departments of pediatrics , 2 articles in departments of psychiatry , 4 articles in emergency departments , 7 articles in inpatients wards ( whole hospital ) and 1 article in department of cardiology .
patient- related reasons  and  hospital condition  are two main them of dama cause the rates of dama in terms of these groups are provided in table 2 . while the highest rate of dama is associated with patients in departments of psychiatry ,
discharge against medical advice rate in iranian hospital according to study groups in general , using a random effects model , the rate of dama in iranian hospitals was estimated at 7.9% ( fig .
( dama=7.9% [ 6.3% 9.8% ] , df = 16 i2= 99.5 , q= 3613.9 )
. the rate of discharge against medical advice in iranian hospitals using a random effects model in the current study , a funnel plot was used to examine the publication bias in reviewed studies ( fig .
the results of this figure show that there is the possibility of risk of publication bias .
the funnel plot to examine the possibility of the publication bias using content analysis , causes contributing of dama were categorized into two main categories : causes related to patient and his / her family and hospital - related causes .
the most important causes in each category , in terms of their priority , are presented in fig .
shows , among causes related to patient and his / her family ,  patient s perception of feeling of wellbeing  ( 29% ) ,  financial problems  ( 21% ) and  family problems  ( 16% ) were considered as the most important causes , whereas among hospital related causes .
the most important patient and family related causes contributing to discharge against medical advice the most important hospital related causes contributing to discharge against medical advice as fig . 5 shows , among hospital related causes  lack of attention from physicians and nurses  ( 31% ) ,  inappropriate behavior by hospital team  ( 19% ) and  absences timely physician  ( 14% ) were regarded as the most important causes in dama .
the results of the current study showed that the rate of dama in iranian hospitals is 7.9% .
the most important causes contributing to dama included patient s perception of feeling of wellbeing , financial problems , the lack of attention from physicians and nurses as well as inappropriate behavior by hospital team .
the rate of dama in iranian hospitals is too high in comparison with many studies conducted in developed countries ( 11 , 3337 ) .
one of the possible reasons for this issue can be high quality services in hospitals of developed countries . as the results of the review of studies conducted in iran showed , hospital related causes ( such as the lack of attention from physicians and nurses , inappropriate behavior by hospital team , improper equipment and environment ) are the most important reasons for dama .
so , paying more attention to the improvement of the quality of services provided to patients in iranian hospitals and in particular , special focusing on the hospital related causes mentioned in this study , are necessary . according to the results ,
the rate of dama among patients in departments of psychiatry has been higher than those of other patients and such a higher rate has been also reported in previous studies ( 3842 ) . given the nature of the disease of this group of patients which extends average length of stay in hospital , these patients tend more to dama due to the perception of feeling of wellbeing , boring hospital environment and financial problems . another possible reason may stem from cultural issues , because mental illness is considered as a social stigma and an unpleasant phenomenon from social and family perspectives in iran .
most patients and their families , therefore , tend to early discharge from hospital , so that their relatives and others close to them do not become aware of the hospitalization .
it is , therefore , important to pay more attention to and focus on this group of patients . besides , the rate of dama among children was less than other patients .
the results of some studies also indicated the low rate of dama in departments of pediatrics ( 2 , 4 , 43 ) .
main reasons for this issue may be the lack of decision - making authority of children and parents worries for their children s health .
therefore , they try to solve financial problems anyway and the treatment of their children will be continued until full recovery is made and patient can be discharged based on physicians orders . moreover ,
the rate of dama among children is less because they do not work and are less affected by family problems .
the rate of dama in emergency departments in iranian hospitals was estimated at 11.8% . in comparison with results of most studies conducted in emergency departments ,
one of the main reasons for this issue may be overcrowding in emergency departments in iran , because all 4 studies conducted in emergency departments in iran were done in reference hospitals which are usually overcrowded .
thus increasing the space , facilities and human resources working in these departments can be effective in reducing the rate of dama .
the results showed that dama was in men more than women , and this result had been shown in previous studies ( 4648 ) .
the reason of low rate of discharge in women than men could be because of their more cautious and fear .
it may be due to men job and their responsibility to make a living which forces them to go back home sooner , also ; their early recovery feeling in compared with women due to their physiology and masculine nature . in this study , the main reasons for dama were categorized into two main categories : causes related to patient and his / her family and hospital - related causes . in general , patient s perception of feeling of wellbeing , financial problems , the lack of attention from physicians and nurses as well as inappropriate behavior by hospital team were considered as four main causes contributing to dama . in this regard , results of a study conducted by alibis and rami also pointed to dissatisfaction with treatment trends , financial and family problems , patient s perception of feeling of wellbeing , preferring other hospitals , dissatisfaction with hospital environment , inadequate treatment and being a teaching hospital ( 49 ) . in many studies conducted in other countries , the relationships between causes such as insurance status , socioeconomic status , patient history as well as other similar causes and dama were also investigated ( 5053 ) .
however , unfortunately many of these causes have not been paid enough attention by researchers in iran .
different studies throughout the world have addressed impacts of dama such as costs , readmissions , deaths and morbidities ( 6 , 12 , 5462 ) . such issues regarding patients discharged from iranian hospitals have not been addressed in studies which may be primarily due to the poor information system in iranian hospitals .
given the importance of the issue , the investigation of results and impacts of dama in iranian hospitals is considered as an inevitable necessity .
time is another issue related to studies on dama conducted in iran , so that all studies have conducted from 2010 and in our search results , no study was found which had been published before that time .
the introduction of clinical governance in iran can be considered as a possible reason for this issue , because during the indicated time interval which most studies have been conducted , clinical governance model has been implemented in iranian hospitals ( 63 ) . through implementing this model with special emphasis on dama ,
if this assumption is true , then we can argue that implementing models similar to the clinical governance can be effective in this area . fortunately ,
in recent year , iranian hospitals accreditation standards include great attention to the issue of dama which requires careful attention in order to successfully implement it and achieve excellent results in this field . despite the efforts of authors ,
the lack of access to some theses and hospital reports on dama can be mentioned as a limitation of this study .
the rate of dama in iranian hospitals in comparison with those of other countries is relatively high ; thus effective initiatives in this area are required .
in addition , patient s perception of feeling of wellbeing , financial problems , the lack of attention from physicians and nurses as well as inappropriate behavior by hospital team were mentioned as main reasons for dama .
these causes can be given high priority in plans for quality improvement and reducing dama .
furthermore , given the limited studies conducted in iran and the lack of investigation into some variables contributing to dama and also impacts of dama in iranian hospitals , more research is needed in this area .
all ethical issues including plagiarism , informed consent , misconduct , data fabrication and/or falsification , double publication and/or submission , redundancy , etc . have been completely observed by the author .
 background : discharge against medical advice ( dama ) is a problem for hospitals which may result in increasing readmissions , morbidities , inabilities , deaths and health care costs . 
 this study , aimed to investigate the rate and causes of dama in iranian hospitals.methods:a systematic review and meta - analysis study was conducted in 2014 . 
 required data were collected through searching for key words included :  
 discharge against medical advice  ,  leaving against medical advice  
 ,  causes *  ,  hospital  and their persian equivalents , over databases including pubmed , ovid , google scholar , embase , scopus , magiran , scientific information database ( sid ) . 
 the reference lists of the articles , certain relevant journals and web sites in this field were also searched.results:out of 913 articles initially retrieved , finally 17 articles were incorporated into the study . 
 there were 244858 individuals studied in the articles . using a random effects model , the rate of dama in iranian hospitals 
 was estimated at 7.9% ( 6.3%9.8% ) . 
 while the highest rate of dama was associated with patients in departments of psychiatry ( 12% ) , the lowest rate was related to patients in departments of pediatrics ( 3.7 ) . 
 dama was in men more than women ( p<0.05 ) patient s perception of feeling of wellbeing , financial problems , family problems , the lack of attention from physicians and nurses , inappropriate behavior with patients by hospital team and the lack of timely care were mentioned as main causes for dama.conclusion:the rate of dama in iranian hospitals is relatively high . 
 thus effective initiatives in this area are required . 
Introduction
Methods
None
Search strategy
Including and excluding criteria
Quality Assessment
Data Extraction
Data analysis
Causes
Results
Discussion
Conclusion
Ethical Considerations