Increased Risk of Mortality and Readmission among Patients Discharged Against Medical Advice

Abstract

Background Approximately 500,000 patients are discharged from U.S. hospitals against medical advice annually, but the associated risks are unknown. Methods We examined 148,810 discharges from an urban, academic health system between 7/1/2002 and 6/30/2008. Of these, 3,544 (2.4%) were discharged against medical advice and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities, or discharges with home-care. Using adjusted and propensity score matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges. Results Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (ORadj = 2.05, 95% CI: 1.48–2.86), and in propensity-matched analysis (ORmatched = 2.46, 95% CI: 1.29 – 4.68). Discharge against medical advice was also associated with higher 30-day readmission after adjustment (ORadj 1.84; 95% CI 1.69 – 2.01), and in propensity-matched analysis (ORmatched 1.65, 95% CI: 1.46 – 1.87). Finally, discharges against medical advice had shorter lengths-of-stay than matched planned discharges (3.37 vs. 4.16 days, p <0.001). Conclusions Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths-of-stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.

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

“…Patients who leave against medical advice represent a public health and financial concern. They are at increased risk of mortality, morbidity, and readmission and are likely to consume a disproportionate share of increasingly scarce healthcare resources [4,11,13,18,40,44].…”

Prospective Evaluation of Patients Leaving against Medical Advice of a Tertiary Care Hospital: Comparison of Emergency and Intensive Care Units

“…The results of this study were in contrast to the western data where a very low rate of 0.2% has been recorded, but comparable to statistics from developing countries where a rate of 3.5-5% has been documented from the emergency unit. 4,5,6 To the best of our knowledge, there is no data about DAMA from the intensive care unit in literature. The markedly high incidence of DAMA from intensive care unit may be multifactorial.…”

“…1 These patients are often acutely ill at the time of self-discharge and have incompletely treated medical problems, hence remain exposed to high risks of mortality and morbidity. 2,3,4 There is a high incidence of re-admission and complications accounting for higher costs of treatment. Therefore, avoiding the clinical situation of DAMA will not only benefit the patients but also the health care system.…”

Audit of documentation proficiency of emergency department patients who are discharged against medical advice before and after implementation of a checklist

“…[9] AMA discharge is associated with increased risks of mortality and 30-day re-admission. [2] It is hence especially important for patients who discharge AMA to be informed and understand the first warning symptoms of clinical deterioration following discharge that should prompt a return visit to the ED for reassessment and treatment.…”

“…Approximately 1%-2% of discharges at ED in the United States are AMA; this figure goes up to 6% in disadvantaged inner-city populations. [1] Southern, Nahvi & Arnsten [2] have demonstrated that inpatients whom leave AMA have higher 30-day re-admission rates (odds ratio = 1.84, 95% CI: 1.69-2.01) and increased risk of mortality (odds ratio = 2.05, 95% CI: 1.48-2.86).…”