A population-based analysis of leaving the hospital against medical advice: incidence and associated variables

Abstract

BackgroundPrior studies of patients leaving hospital against medical advice (AMA) have been limited by not being population-based or assessing only one type of patient.MethodsWe used administrative data at the Manitoba Centre for Health Policy to evaluate all adult residents of Manitoba, Canada discharged alive from acute care hospitals between April 1, 1990 and February 28, 2009. We identified the rate of leaving AMA, and used multivariable logistic regression to identify socio-demographic and diagnostic variables associated with leaving AMA.ResultsOf 1 916 104 live hospital discharges, 21 417 (1.11%) ended with the patient leaving AMA. The cohort contained 610 187 individuals, of whom 12 588 (2.06%) left AMA once and another 2 986 (0.49%) left AMA more than once. The proportion of AMA discharges did not change over time. Alcohol and drug abuse was the diagnostic group with the highest proportion of AMA discharges, at 11.71%. Having left AMA previously had the strongest association with leaving AMA (odds ratio 170, 95% confidence interval 156–185). Leaving AMA was more common among men, those with lower average household incomes, histories of alcohol or drug abuse or HIV/AIDS. Major surgical procedures were associated with a much lower chance of leaving the hospital AMA.ConclusionsThe rate of leaving hospital AMA did not systematically change over time, but did vary based on patient and illness characteristics. Having left AMA in the past was highly predictive of subsequent AMA events.

Who Leaves the Hospital Against Medical Advice in the Orthopaedic Setting?

“…Most studies suggest that patients leaving against medical advice are either socioeconomically disadvantaged or have psychiatric illness [22,24,32,33,38]. However, we do not know whether patients who leave the hospital before their caregivers recommend discharge after common emergency orthopaedic conditions such as fractures and infections share similar demographic characteristics.…”

Against Medical Advice Discharges

“…[8][9][10] Although there are no conclusive data that AMA discharges are more likely among underrepresented racial minorities, the disproportionate burden of AMA discharges and their worse health outcomes are borne by the homeless, those with substance use disorders, and the uninsured. 3,11 Compared to patients discharged conventionally from an emergency department, 25% of patients discharged AMA reported not wanting to return for follow-up care. 8 This reluctance to return for care is in part mediated by provider-generated stigma and blame 9,12 and may be exacerbated when patients believe that their decision to leave AMA was based upon extenuating circumstance or competing necessity (eg, limited care options for their dependents, poor quality hospital care, etc.…”

“…2 AMA discharges are more likely among patients with substance use disorders, psychiatric illness, and HIV. 3 WHY YOU MIGHT THINK AMA DISCHARGES ARE HELPFUL Although there are little empirical data to inform how and why physicians choose to designate a discharge as AMA when patients decline recommended care, the existing evidence suggests that fears of legal liability are strongly driving the practice. 4 Physicians may believe that they must discharge patients AMA in order to fulfill their legal and ethical responsibilities, or to demonstrate in writing the physician's concern and the significant risk of leaving.…”

Hospitalized Pregnant Women Who Leave Against Medical Advice: Attributes and Reasons

“…In a rather male-dominated society such as Sistan and Blouchestan Province, where men have most of the power and influence, it could be expected that the husband is the person who decides whether his wife stay in hospital or leave, even though it might be against the managing physician's advice. The younger the husband, the higher the chance of pregnant women signing out against medical approval, [2,16,17,20]. An intriguing finding from our study was that health insured patients were more likely to leave a hospital without medical approval.…”

“…1 The distribution (%) of outcomes for pregnant women with DAMA and pregnant women discharged with medical approval Admission factors contributing to an increased risk of DAMA included history of discharge against medical advice in previous hospitalizations, referral from other clinics, emergency admission and admission advice from non-physician individuals. History of DAMA has been found to be strongly associated with discharge against medical advice [20,26]. As compared with emergency admissions, patients who are hospitalized by pre-determined appointment have a lower rate of unplanned discharges [27].…”