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Leaving Hospital Against Medical Advice (AMA): Higher Rates of Hospital Readmission and Death

Reporter: Aviva Lev-Ari, PhD, RN

Rates of readmission and death associated with leaving hospital against medical advice: a population-based study

CMAJ August 26, 2013 First published August 26, 2013, doi:10.1503/cmaj.130029

• © Canadian Medical Association

http://www.cmaj.ca/content/early/2013/08/26/cmaj.130029

Published: Aug 26, 2013 | Updated: Aug 26, 2013

By Chris Kaiser, Cardiology Editor, MedPage Today

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

• Adults who left the hospital against medical advice had higher rates of hospital readmission and death.
• Note that the increased risk persisted for at least 180 days after discharge suggesting that they are not solely a result of incomplete treatment of acute illness.

In one of the largest and most comprehensive studies of its kind, researchers found that leaving the hospital against medical advice more than doubled the risk of mortality and rehospitalization, a risk that persisted out to 6 months.

Out of nearly 2 million index hospital admissions, the 1.1% of patients who left before being officially discharged were two-and-a-half times more likely to die within 90 days (OR 2.51), according toAllan Garland, MD, co-head of the section of critical care medicine at the University of Manitoba in Winnipeg, and colleagues.

Patients who left against medical advice also had three times the rate of readmissions in the month following their departure (OR 3.04), the researchers reported online in the Canadian Medical Association Journal.

The risk of readmission appears to be strongest early on, as one-quarter of rehospitalizations occurred within 1 day of leaving against the doctor’s orders and 75% occurred within 2 weeks.

“For both hospital readmission and death, the elevated rates among patients who left against medical advice started out high and then declined, but remained significantly elevated to at least 180 days,” wrote the authors.

One of the obvious reasons for early adverse events is incomplete treatment of the index acute illness. “But because the risk persisted out to 6 months, there are likely other factors involved,” Garland told MedPage Today in an interview.

One hypothesis is that these patients as a group are less compliant with medical advice or medication orders in the outpatient setting, he said.

“Even if we identify those at risk of leaving the hospital against medical advice and perform an intervention to keep them in the hospital, we might still need to address longer-term risk factors based on potential unhealthy outpatient behaviors,” Garland said.

This is all speculative at this point, he pointed out, but noted they are planning two additional phases of the study. These will evaluate why people leave against medical advice and then quantify personal characteristics and health habits that contribute to a general failure to adhere to physician advice.

“We already know that the strongest predictor for people leaving against medical advice is having done so in the past,” Garland said. “You might call them ‘frequent flyers,’ and an intervention at the hospital probably isn’t enough. We will probably need longitudinal interventions as well that address health habits.”

In related work yet unpublished, Garland’s group identified several index diagnoses that are associated with patients leaving the hospital against advice. These include substance abuse, overdose, tuberculosis, and diabetic ketoacidosis — findings that confirm similar smaller studies.

Patients less likely to leave against medical advice included those having major surgery and those admitted with a cancer diagnosis — unique findings because these patient populations are typically excluded from such studies, Garland said.

Most of the studies examining this topic have been small, or from single hospitals, or aimed at specific types of patients. In contrast, the current study looked at 1,916,104 adult admissions and live discharges over 19 years (1990–2009) in Manitoba with more than 21,000 incidents of patients leaving against medical advice (the most for one patient was 39 times).

The mean age of patients who left prematurely was 42, and 54 for those who stayed. Men were more likely than women to leave against medical advice, as were younger patients and those with certain chronic conditions such as hypertension and diabetes.

“It’s rare that patients want to leave against medical advice, but when they do, healthcare professionals should explain the risk to them,” Garland said. “They can point to our paper — which demonstrated in a rigorous and broad way — that what they’re about to do is known to be harmful.”

A limitation of the study is the potential for misclassified discharge information. Also, the authors had no data on the severity of the acute illness, nor did they know if readmissions or deaths were for the same reason as the index admission. Finally, results may not be applicable to regions that do not have publicly funded universal health coverage.

Although those with a lower income were more likely to leave the hospital against medical advice, it was not due to the potential burden of medical bills because Canada has universal health coverage.

Garland pointed to anecdotal evidence that suggests this group of patients feels outside financial pressure to resume work as soon as possible — an area that could be addressed during an inpatient intervention.

http://www.medpagetoday.com/TheGuptaGuide/PublicHealth/41182?xid=nl_mpt_guptaguide_2013-08-26&utm_source=guptaguide&utm_medium=email&utm_content=mpt&utm_campaign=08%7C26%7C2013&userid=99985&eun=g5099207d10r&email=avivalev-ari@alum.berkeley.edu&mu_id=5099207