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

Overview

Journal Am J Med

Specialty General Medicine

Date 2012 Apr 20

PMID 22513194

Citations 78

Authors

William N Southern

Shadi Nahvi

Julia H Arnsten

Affiliations

Soon will be listed here.

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.

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References

Ibrahim S, Kwoh C, Krishnan E . Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007; 97(12):2204-8. PMC: 2089112. DOI: 10.2105/AJPH.2006.100164. View

Myers R, Shaheen A, Hubbard J, Kaplan G . Characteristics of patients with cirrhosis who are discharged from the hospital against medical advice. Clin Gastroenterol Hepatol. 2009; 7(7):786-92. DOI: 10.1016/j.cgh.2009.03.020. View

Hollenbeck B, Miller D, Taub D, Dunn R, Khuri S, Henderson W . The effects of adjusting for case mix on mortality and length of stay following radical cystectomy. J Urol. 2006; 176(4 Pt 1):1363-8. DOI: 10.1016/j.juro.2006.06.015. View

Fiscella K, Meldrum S, Barnett S . Hospital discharge against advice after myocardial infarction: deaths and readmissions. Am J Med. 2007; 120(12):1047-53. DOI: 10.1016/j.amjmed.2007.08.024. View

Saitz R, Ghali W, Moskowitz M . Characteristics of patients with pneumonia who are discharged from hospitals against medical advice. Am J Med. 1999; 107(5):507-9. DOI: 10.1016/s0002-9343(99)00262-4. View

Seaborn Moyse H, Osmun W . Discharges against medical advice: a community hospital's experience. Can J Rural Med. 2004; 9(3):148-53. View

Berger J . Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008; 3(5):403-8. DOI: 10.1002/jhm.362. View

Fiscella K, Meldrum S, Franks P . Post partum discharge against medical advice: who leaves and does it matter?. Matern Child Health J. 2007; 11(5):431-6. DOI: 10.1007/s10995-007-0194-3. View

DAgostino Jr R, DAgostino Sr R . Estimating treatment effects using observational data. JAMA. 2007; 297(3):314-6. DOI: 10.1001/jama.297.3.314. View

10.

Escobar G, Greene J, Scheirer P, Gardner M, Draper D, Kipnis P . Risk-adjusting hospital inpatient mortality using automated inpatient, outpatient, and laboratory databases. Med Care. 2008; 46(3):232-9. DOI: 10.1097/MLR.0b013e3181589bb6. View

11.

van Walraven C, Escobar G, Greene J, Forster A . The Kaiser Permanente inpatient risk adjustment methodology was valid in an external patient population. J Clin Epidemiol. 2009; 63(7):798-803. DOI: 10.1016/j.jclinepi.2009.08.020. View

12.

DAgostino Jr R . Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998; 17(19):2265-81. DOI: 10.1002/(sici)1097-0258(19981015)17:19<2265::aid-sim918>3.0.co;2-b. View

13.

Meltzer D, Manning W, Morrison J, Shah M, Jin L, Guth T . Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002; 137(11):866-74. DOI: 10.7326/0003-4819-137-11-200212030-00007. View

14.

Maraldi C, Volpato S, Kritchevsky S, Cesari M, Andresen E, Leeuwenburgh C . Impact of inflammation on the relationship among alcohol consumption, mortality, and cardiac events: the health, aging, and body composition study. Arch Intern Med. 2006; 166(14):1490-7. DOI: 10.1001/archinte.166.14.1490. View

15.

Alfandre D . "I'm going home": discharges against medical advice. Mayo Clin Proc. 2009; 84(3):255-60. PMC: 2664598. DOI: 10.4065/84.3.255. View

16.

Southern W, Berger M, Bellin E, Hailpern S, Arnsten J . Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. Arch Intern Med. 2007; 167(17):1869-74. PMC: 2838181. DOI: 10.1001/archinte.167.17.1869. View

17.

Charlson M, Pompei P, Ales K, MacKenzie C . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40(5):373-83. DOI: 10.1016/0021-9681(87)90171-8. View

18.

Armenian S, Chutuape M, Stitzer M . Predictors of discharges against medical advice from a short-term hospital detoxification unit. Drug Alcohol Depend. 1999; 56(1):1-8. DOI: 10.1016/s0376-8716(99)00027-7. View

19.

Weingart S, Davis R, Phillips R . Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998; 13(8):568-71. PMC: 1496999. DOI: 10.1046/j.1525-1497.1998.00169.x. View

20.

Glasgow J, Vaughn-Sarrazin M, Kaboli P . Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010; 25(9):926-9. PMC: 2917668. DOI: 10.1007/s11606-010-1371-4. View