“Against Medical Advice” discharge linked to higher readmission, mortality

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1. Patients who left the hospital Against Medical Advice (AMA) were 2.1 times as likely to be readmitted within 30-days, and 2.51 times as likely to die within 90-days. 

2. Patients leaving AMA were also found to be in the lowest socioeconomic category, and suffer from mental disorders and substance abuse. 

Evidence Rating Level: 3 (Average)        

Study Rundown: This population-based study investigated the increased risk of morbidity and mortality associated with patients who leave the hospital AMA. The researchers used analyzed 30-day readmission rates and 90-day mortality rates as primary outcomes.

Within the population, 21,417 patient episodes or 1.1% of patients resulted in patients leaving the hospital against the advice of their clinician. Within this group, patients who left against medical advice were 2.10 (95% CI 1.99-2.21) times as likely to be readmitted within thirty days compared to instances where that same patient was admitted for the appropriate amount of time. Researchers also found that patients who left the hospital early were 2.51 (95% CI 2.18-2.89) times as likely to die within 90-days after discharge compared to patients with similar demographic and clinical circumstances. Perhaps more interestingly, patients found to leave the hospital before advised discharge were overwhelmingly low-income, admitted for mental disorders or birth complications, and also dealing with comorbidities of alcohol abuse, diabetes, and drug abuse. This study is revealing but researchers admit that they were unable to account for acuity in their analysis. The secondary correlations potentially reveal much more about the external circumstances that influence these episodes.

Click to read the study in Canadian Medical Association Journal

Relevant Reading: Who leaves against medical advice?

In-Depth [retrospective cohort]:  Researchers measured readmission risk based on two different circumstances 1. Difference in readmission risk after the same person is discharged once with an AMA discharge and once without an AMA discharge, 2. Difference in readmission risk between two different people, where one was properly discharged according to AMA advice and the other left against AMA guidance (individuals had similar demographic and clinical characteristics). In both cases, the results were very similar. Additionally, among individuals who were readmitted within 30-days of being discharged without medical consent, 45.2% were in the lowest socioeconomic stratum, 21.7% were admitted with a mental disorder, 10% with complications of pregnancy, 28.1% comorbid with alcohol abuse, and 11.2% comorbid with drug abuse.

By Jordan Anderson and Andrew Bishara

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