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

Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.
The American journal of medicine (Impact Factor: 5). 04/2012; 125(6):594-602. DOI: 10.1016/j.amjmed.2011.12.017
Source: PubMed


Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown.
We examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (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.
Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR](adj) 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (OR(matched) 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (OR(adj) 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (OR(matched) 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 <.001).
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.

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Available from: Julia H Arnsten, Apr 13, 2014
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    • "AUD affects the course of diabetes, leading to increased morbidity, hospital admissions and readmissions, and mortality (Engler et al., 2013). AUD are a risk factor for hospital discharge against medical advice, and patients discharged against medical advice have higher readmission rates and have higher in-hospital mortality (Southern et al., 2012). AUD have been recognized as a significant variable in predictive multivariate models of hospital unplanned readmissions (Billings et al., 2006; Howell et al., 2009). "
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    ABSTRACT: Aims Alcohol use disorders (AUD) have been associated with an increased risk of unplanned hospital readmissions (URA). We analyzed in a sample of 87 Spanish Hospitals if surgical patients with AUD had a higher risk of URA and if among patients with URA, those with AUD had an excess length of hospital stay, higher hospital expenses and increased risk of mortality Method We analyzed data of patients who underwent surgical operations during the period between 2008-2010. URA was defined as unplanned readmissions during the first 30 days after hospital departure. The primary outcome was risk of URA in patients with AUD. Secondary outcomes were mortality, excess length of stay and over expenditure Results A total of 2,076,958 patients who underwent surgical operations were identified: 68,135 (3.3%) had AUD, and 62,045 (3.0%) had at least one URA. Among patients with AUD 4,212 (6.2%) had at least one URA and among patients without AUD 57,833 (2.9%) had at least one URA. Multivariable analysis demonstrated that AUD was an independent predictor of developing URA (Odds Ratio: 1.56; 95% CL: 1.50-1.62). Among surgical patients with URA, those with AUD had longer lengths of hospital stay (2.9 days longer), higher hospital costs (2,885.8 Euros or 3,858.3 US Dollars), higher risk of death (OR: 2.16, 95% CL: 1.92-2.44) and higher attributable mortality (11.2%) Conclusions Among surgical patients, AUD increase the risk of URA, and among patients with URA, AUD heighten the risk of in-hospital death, and cause longer hospital stays and over expenditures
    Drug and alcohol dependence 04/2014; 137(1). DOI:10.1016/j.drugalcdep.2014.01.009 · 3.42 Impact Factor
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    • "Leaving the emergency department without treatment or against medical advice (AMA) is associated with poor outcomes, including an increased risk for mortality and readmission [11,12]. Among wealthier nations, there is a wide range of reasons that patients sign out AMA, while in a limited number of studies from poorer nations financial constraints are the more common cause. "
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    ABSTRACT: Some reports indicate financial concerns as a factor affecting ED patients leaving the acute care setting against medical advice (AMA). In India, no person is supposed to be denied urgent care because of inability to pay. Since a large proportion of the Indian health care system is financed by out-of-pocket expenses, we investigate the role of financial constraints for ED patients at a private hospital in India in leaving AMA. A prospective ED-based cross-sectional survey of patients leaving AMA was conducted at a private hospital in India from 1 October 2010 to 31 December 2010. Descriptive statistics and the chi-square test were used to identify associations between financial factors and the decision to leave the hospital AMA. Overall, 55 (3.84%) ED patients left AMA, of which 46 (84%) reported leaving because of financial restrictions. Thirty-nine (71%) respondents indicated the medical bill would represent more that 25% of their annual income. Females (19/19) were more likely to leave AMA for financial reasons compared to males (27/36, p = 0.017). Among females who signed out AMA, the decision was never made by the female herself. The number of people leaving the ED AMA in a private Indian hospital is relatively high, with most leaving for financial reasons. In most cases, women did not decide to leave the ED AMA for themselves, whereas males did. This survey suggests that steps are needed to ensure that the inability to pay does not prevent emergent care from being provided.
    International Journal of Emergency Medicine 02/2014; 7(1):13. DOI:10.1186/1865-1380-7-13
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    • "From electronic health records, the participant’s health insurance, administrative details about the index hospitalization and prior utilization, and whether the participant left the hospital against medical advice (AMA) are obtained. Leaving AMA has been shown to predict readmission, as well as higher mortality [38]. "
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