Alarmingly, a follow-up of patients who left treatment midway found that nearly one-third (31.6 percent) did not survive.
Published Sep 08, 2025 | 12:52 PM ⚊ Updated Sep 08, 2025 | 12:52 PM
Synopsis: Nearly half of trauma patients leaving hospitals against medical advice in India do so because they cannot afford treatment, a new study has found. It also found that many patients transferred repeatedly between hospitals seeking affordable care, with a follow-up showing a 35.8 percent mortality rate among those who left mid-treatment.
Nearly half of trauma patients in India who leave hospitals against medical advice do so because they cannot afford to continue treatment, a study by the Christian Medical College (CMC) Vellore, Tamil Nadu, has found.
It highlights a stark reality where financial constraints, rather than medical considerations, determine patient outcomes.
Published in the Indian Journal of Medical Research, the study examined 2,486 trauma patients admitted to CMC’s Level 1 trauma centre between March 2022 and August 2023.
Roughly seven out of every 100 patients left the hospital “Discharge Against Medical Advice” (DAMA). Of these, 42.5 percent cited financial constraints as their primary reason – meaning more than four out of 10 patients abandoned treatment because they could not afford to stay.
“The predominant reason for DAMA was financial, and most were in the lower or upper-lower socioeconomic strata,” the authors noted.
The study showed that 52.8 percent of DAMA patients belonged to the upper-lower socioeconomic class, underlining how families with modest incomes struggle with the cost of extended trauma care.
The second most common reason for leaving treatment was patient preference, accounting for 31.6 percent of cases. This included patients wanting care closer to home or family decisions to transfer treatment elsewhere.
Another 18.3 percent left because doctors determined that recovery chances were slim or long-term rehabilitation would be needed. Hospital-related issues, such as lack of bed availability, were cited in only 7.4 percent of cases.
The study uncovered another troubling aspect of trauma care in India: multiple hospital transfers driven by financial constraints.
“With 87.9 percent of DAMA patients being referred, this would mean that most of these patients received care in at least three hospitals, which is alarming,” said the authors.
This pattern shows that patients often move between healthcare facilities, starting at primary or secondary hospitals before reaching specialised trauma centres, only to leave when costs become prohibitive.
“Many of these patients are investigated repeatedly at each centre, and there is no continuity of care. This is in addition to the cost of each transfer, which usually comes as an out-of-pocket expenditure,” the authors added.
Alarmingly, a follow-up of patients who left treatment midway found that of the 159 DAMA patients who could be tracked, 57 did not survive, representing a mortality rate of 35.8 per cent. “Follow-up of DAMA patients revealed that nearly one-third did not survive,” said the authors.
Among survivors, the pattern of seeking more affordable care became clear. “Of 123 patients (77.4 percent) who continued treatment at another centre, 67 (54.5 percent) did so at a government centre,” said the authors. This migration to government hospitals reflects the desperate search for subsidised care when private healthcare becomes unaffordable.
Perhaps most tellingly, “Under half of the DAMA patients who could be followed up (46.3 percent) required surgical intervention at another centre,” said the authors. This shows that leaving the hospital does not eliminate the need for medical care, it merely delays treatment, often with potentially worse outcomes at government facilities that may be less equipped or overburdened.
Compared to healthcare systems in developed nations, India’s DAMA rates reveal stark inequality.
“The percentage of DAMA patients from our centre was significantly higher than in four similar retrospective studies from trauma centres in a high-income country, where the frequency varied from 0.76 to 1.8 percent,” said the authors.
This shows that India’s DAMA rate is roughly four to nine times higher than in wealthier nations, where insurance coverage and social safety nets help prevent patients from abandoning necessary care due to cost.
The study highlighted the enormous financial burden of trauma care, particularly for complex injuries. “One study from a government trauma centre in India has estimated that the median cost of in-hospital care for patients with a predominant head injury is ₹1,22,666, with 96 percent of this cost being subsidized by the government,” said the authors.
However, this government support is largely unavailable in private hospitals. “Barring a few States, currently, there are no centralized schemes available for trauma patients opting for care in private institutions,” said the authors.
Insurance coverage adds another challenge. “Private healthcare insurance coverage is also poor in India, reaching only 29 percent of households. Even among patients with insurance, many of them do not cover the spectrum of care required for these patients,” said the authors.
The study also noted that certain injuries create particularly severe financial strain. “Patients with TBI and spinal cord injuries usually have an extended hospital course and need long-term rehabilitation, which many patients are unable to afford,” said the authors.
This creates a vicious cycle: the patients who need the most intensive and prolonged care are often those most likely to abandon treatment due to cost. The financial burden goes beyond medical bills. “In addition to the patients themselves, there is a sizeable financial burden secondary to loss of income and catastrophic spending during the treatment period,” said the authors.
The study proposed concrete solutions, including subsidised healthcare.
“We propose that Government subsidization, a public-private partnership economic model, and universal mandatory injury insurance coverage for vehicle owners could be a possible solutions to reduce health inequity and the DAMA rate,” said the authors.
They also emphasised the need for standardisation and quality assurance. “To ensure the standard of care, all trauma centres across the country, both public and private, should adhere to a standardized verification process, and only such centres should be eligible for governmental support and insurance coverage,” said the authors.
The study’s authors acknowledged limitations while calling for broader research and policy action. “DAMA has not been previously studied among trauma patients in our country, and our study could sensitize the need for more extensive data to be collected nationwide to understand the problem better and suggest possible solutions,” said the authors.
They highlighted three key aspects revealed by their research: “Overall, our study findings highlight three important aspects of trauma care. One is that poor patients are often unable to afford comprehensive trauma care at private trauma centres. Secondly, the majority of these patients have TBI or SCI. Third, DAMA patients are understudied and usually excluded from data and clinical audits but appear to have poor outcomes,” said the authors.
The researchers concluded with a direct challenge to policymakers: “Policymakers should focus on achieving health equity to reduce the rate of DAMA and improve overall patient outcomes,” said the authors.
(Edited by Dese Gowda)
