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

doi:10.1016/j.amjmed.2011.12.017

The American Journal of Medicine

Volume 125, Issue 6, June 2012, Pages 594-602

Portions of this research were presented at the Annual Meeting of the Society of General Internal Medicine, April 2010, Minneapolis, MN and at the Annual Meeting of the Society of Hospital Medicine, April 2010, Washington DC.

https://doi.org/10.1016/j.amjmed.2011.12.017 Get rights and content

Abstract

Background

Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown.

Methods

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.

Results

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).

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.

Section snippets

Study Setting and Patients

Montefiore Medical Center is an urban academic medical center in the Bronx, NY, consisting of 2 hospitals (381 and 706 beds) affiliated with the Albert Einstein College of Medicine. We extracted data on all general medical inpatients who survived to discharge in both hospitals from July 1, 2002 through June 30, 2008. We excluded patients transferred to another facility, discharged to skilled nursing facilities, or requiring home-care services because differences between such patients and those

Study Population

Of 148,810 discharges, 5285 (3.6%) died in the hospital, 9320 (6.3%) were transferred to another hospital, 23,926 (16.1%) were discharged to a skilled nursing facility, 26,178 (17.6%) required home-care services, and 21 (0.01%) left the hospital without notifying nursing staff; these were all excluded. There were 3544 (2.4%) discharges against medical advice and 80,536 (54.1%) planned discharges. The 5 diagnosis groups with the highest proportion of discharges against medical advice were:

Discussion

In a large, carefully controlled retrospective study of 148,000 inpatients at an urban academic medical center, we found that discharge against medical advice was associated with approximately double the risk of death within 30 days. In addition, we found a strong and significantly increased risk for readmission associated with discharge against medical advice. When hospitalized patients are considering leaving the hospital against medical advice, they are often asked to sign waivers attesting

Acknowledgment

We are grateful to the Works in Progress Study Group of the Einstein/Montefiore Division of General Internal Medicine for valuable feedback.

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: Funding: This work was supported by the CTSA Grant UL1 RR025750 and KL2 RR025749 and TL1 RR025748 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and the Clinical Investigation Core of the Center for AIDS Research at the Albert Einstein College of Medicine and Montefiore Medical Center, funded by the National Institutes of Health (NIH P30 AI51519). Drs Arnsten and Nahvi also were supported by NIH R25 DA023021.

: Conflict of Interest: None.

: Authorship: All authors had full access to the data and played a role in writing this manuscript.

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Clinical research studyIncreased Risk of Mortality and Readmission among Patients Discharged Against Medical Advice

Abstract

Background

Methods

Results

Conclusions

Section snippets

Study Setting and Patients

Study Population

Discussion

Acknowledgment

J Allergy Clin Immunol

Am J Med

Drug Alcohol Depend

Am J Med

J Chronic Dis

J Urol

J Clin Epidemiol

Mayo Clin Proc

Factors associated with patients who leave acute-care hospitals against medical advice

Am J Public Health

Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission

J Gen Intern Med

Leaving hospital against medical advice among HIV-positive patients

CMAJ

Discharges against medical advice: a community hospital's experience

Can J Rural Med

Characteristics of patients with cirrhosis who are discharged from the hospital against medical advice

Clin Gastroenterol Hepatol

Patients discharged against medical advice from a general medicine service

J Gen Intern Med

What happens to patients who leave hospital against medical advice?

CMAJ

Post partum discharge against medical advice: who leaves and does it matter?

Matern Child Health J

Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital

Psychiatr Serv

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