Are Patients Who Leave Against Medical Advice (ama) At Risk For Higher Mortality And Hospital Readmission At 30 Days?

Are Patients Who Leave against Medical Advice (AMA) At Risk for Higher Mortality and Hospital Readmission at 30 Days?

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract Number: 57

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Background:

With 1%–2% of patients leaving the hospital against medical advice (AMA), the potential for these patients to suffer adverse health outcomes is of major concern. Prior studies have shown an increased rate of hospital readmission, but none have been able to evaluate the risk of death after discharge. Using 5 years of Veterans Administrafcn (VA) data, we examined 30‐day readmission and 30‐day mortality rates in AMA patients.

Methods:

The study sample included 2,204,703 medical admissions to 129 VA hospitals from 2004 to 2008. Univariate analyses compared patients leaving AMA to those discharged to home. Primary outcomes of interest were 30‐day mortality and all‐cause hospital readmission. Demographic characteristics and comorbid conditions were also compared between groups. Patients discharged to a nursing home (6.13%), transferred to another hospital (2.33%), discharged to a nonstandard setting (1.28%), and those who died in‐hospital during the index admission (2.68%) were excluded.

Results:

Of the final sample of 1.930,947 patients, 31,769 (1.65%) left AMA. When comparing characteristics of AMA patients to those discharged to home, AMA patients were more likely to be African American (22.4% vs. 18.5%), have chronic liver disease (11.5% vs. 5.88%), and have a history of alcohol (23.6% to 8.37%) or drug abuse (11.59% to 3.32%), for all, x² dt = 1, P < 0.0001. AMA patients had a higher 30‐day readmission rate (17.7% vs. 11.0%, P < 0.0001; relative risk increase = 60.9%) and higher 30‐day mortality rate (0.75% vs. 0.61%, P = 0.001; relative risk increase = 23%). For patients leaving AMA who are readmitted, mean time to readmission was 9.8 days (SD = 8.6). In Cox proportional hazard modeling controlling for demographics and comorbidity, the largest hazard for patients having a 30‐day readmission is leaving AMA (HR = 1.36, 95% Cl 1.32–1.93). Similar modeling for 30‐day mortality reveals an increased hazard rate for patients discharged AMA (HR = 1.15, 95% Cl 1.08–1.22).

Conclusions:

Patients leaving AMA are at increased risk for adverse health outcomes including hospital readmission and death. This is the first study to demonstrate a higher risk of death, as prior studies did not have data on out‐of‐hospital deaths. Because of the higher risk of adverse outcomes, hospilalists should consider targeting AMA patients for postdischarge interventions such as phone follow‐up, home visits, or substance abuse counseling to improve outcomes. Alternatively, identifying and ameliorating the factors that cause patients to leave AMA may help to reduce the number of patients who leave before clinical stability.

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