‘LAMA’ i.e. Leave Against Medical Advice is one of the commonly used terms for absconding, which includes those patients who insist upon leaving the hospital against the expressed advice of the treating doctor [1].

When a patient gets absconded from the hospital, other commonly used terms are ‘AWOL’ (Absence Without Leave), ‘elope’, ‘abscond’, ‘escape’, ‘unauthorized absence’, ‘irregular discharge’, ‘DAMA’ and many others. The time period to declare the patient as ‘absconder’ can range between 1-72 hours which can differ according to the admission- discharge policy of each hospital [2].

However, in situations where the patient leaves the hospital without notification from the treating team is called AWOL/ Elopement, which is a form of DAMA. Contrasting from ‘LAMA’, here the essential element of doctor’s expressed advice against leaving is lacking [3].

A LAMA patient becomes a matter of concern and challenge for the health care industry and can be perceived as the inadequate doctor-patient relationship, unsatisfactory communication, failure to adhere to patients’ rights and responsibilities, and burden on morbidity (and mortality), with multifactorial causative factors [4].

Also refusing the treatment advised can be considered as a form of non-compliance from the patient’s part and can lead to unpleasant incidents [5].

This prospective study was conducted to scientifically document LAMA characteristics of the patients selected for comprehensive eye care management from rural eye campsite.

As per the protocol all patients requiring hospital-based care were counseled by a consultant ophthalmologist or resident examining them, the Public Relations Officer (PRO), and health official at the campsite regarding the plan of care. The demographic details and diagnosis was recorded at the point of the first contact.

As LAMA disrupts the care chain of the ophthalmic care system rendered to rural camp patients and reflects its quality, it can be considered as a key indicator for the success of national control of blindness.

Understanding the profile of LAMA patients can be

the patients attending the camp, who were the study population for the research. Sufficient time is given for the patient to understand and discuss with their family member or attendant and clarify any doubt regarding the process. Patients who fail to board the camp vehicle were also considered as LAMA and included in the present study. All the patients selected are brought to the hospital by the camp vehicle, implying the voluntary consent for further service.

The patients were received at Sri Devaraj Urs Medical College and Hospital, registered as inpatients (with demographic data such as age, sex, occupation, address, and marital status) and written consent was taken. Inpatient care included complete evaluation, diagnosis, and treatment. Patients were also evaluated for co-morbid conditions like diabetes and hypertension. Accordingly, they were scheduled for cataract surgery within 24-48 hours after satisfying the standard pre-operative checklist (Category A).

Regular daily ward rounds were done in the morning and evening by ophthalmology consultants and residents, where personal counseling about treatment was made well understood to patients and their attendants. The Ward nurse and intern monitors the inpatients and interact with them whenever necessary.

Patients with severe comorbid conditions that require systemic stabilization were scheduled for surgery only after getting fitness for the same (Category B). However, if the ophthalmic condition requires only medical management it was started promptly. Patients with untreatable conditions like advanced glaucoma, diabetic eye disease, age-related macular degeneration, optic atrophy, etc.

with nil or minimal visual prognosis are counseled and screened for ocular diseases in the other eye (Category C). Patients of Category B and C were required to stay longer than the patients undergoing in category a usual cataract surgery.

Few of them were found demotivated and reluctant for further treatment and are seen leaving against medical advice. Any patient not found in the hospital from 4 or more hours was considered as LAMA and is also included in the present study. LAMA were reported by consultant/ residents/ intern/ nurse. Soon afterward the patients on adjacent beds were interviewed, patient’s records were reviewed and the possible reason for LAMA was analyzed.

Table-2: Profile of LAMA patients and an accompanying person.

42.2% of LAMA patients were seen absconding with one of the family members.

Fig-4: Time of LAMA noted (number of patients, percentage).

Fig-4: Reporting of LAMA by (number of patients, percentage).

Table-3: Probable reason for LAMA.

Fig-5: Reporting of LAMA by medical, non-

may help to understand the profile of such patients [8]. Diversity among the patient population and the nature of treatment may influence LAMA [9].

Leaving against medical advice remains a major healthcare challenge that leads to series of negative health consequences like the risk of complications, irreversible loss of vision (in the current study), increased expenditure, and misuse of resources like time, manpower, and money. Negative publicity, especially in programs associated with the execution of national programs,

can have a far-reaching negative impact. Tracing the LAMA patients places an additional burden on the health care delivery team [10,11].

54 % of the LAMA population were females (46 % were males) in the present study. There are no Ophthalmology studies done in the past for this. Studies done in psychiatric patients of Hayat AA [12] showed male gender (63.5%) to be a predictor of LAMA discharge. The possibility of this because males being the breadwinner in Indian society might be a little reluctant of getting admitted and operated.

The prevalence of LAMA among rural eye camp patients was 3.09%. Comparable studies have showed prevalence rates 17% [13],13.9% [14], and 0.26% [15]. These studies differed in setting, study population, and specialty.

The highest rate (42.3%) of LAMA subjects belonged to the 61-70 years age group, while in subjects above 70 years it was the minimum (11.5%), which was surprisingly the least. All the LAMA subjects above 70 years, were pseudophakic in other eye and hypothetically their previous experience influenced their decision to LAMA. Contrary to our observation, the younger age group was found to be an important predictor of LAMA, especially in the 21-30 years age group among psychiatric in-patient [13].

In this study, LAMA was not influenced by ocular and/ or systemic co-morbidities, although one would expect a delay in the scheduling of the surgery due to systemic or ocular morbidity to influence the decision of the patient to comply with Protocols. A review of the literature showed no similar studies in Ophthalmology in patients. While a few studies were done in psychiatric inpatients showed alcoholic, drug abusers [16,17] and low education [12] as important predictors of LAMA. None of the referred studies showed ophthalmology inpatients, a study

Limitations of the study were as there was no similar literature, making it one of the first among Ophthalmology eye camp patients. Multicentric studies with a broader database can help in better understanding the cause of LAMA. Information such as educational status, socio-economic status, marital status, and psychological assessment may be included in future studies.

LAMA is an indicator of the effectiveness of the community health care delivery system. It is a well-recognized vexing issue world over with regional and specialty differences. It reflects poorly on the utility of the national programs specifically targeted for the underprivileged rural population, more so in the setting of free comprehensive eye care provided at a tertiary care medical college hospital.

It may also add to the incidence of blindness. The reasons are many and the solution is in educating the patients regarding their disease, the adverse effects of refusing treatment in an empathetic manner, respecting their rights as a patient. Better insight into the reason requires understanding their social, economic, cultural, and educational status. Reducing the number of LAMA patients can have a positive impact on the optimal utilization of resources and improve the health status of the community.

The present study can help us understand the profile of LAMA patients and thus improve community health care service since it is a very poorly understood and less studied aspect of the health care delivery system.

Dr. Apurva Shivaji Navale: Data collection, Search for review of literature, Manuscript preparation.

Dr. Sandhya Ramachandra: Study design, Search for review of literature, Manuscript preparation, and correction.

Dr. Rashmi G.: Search for review of literature, manuscript correction.