“Against Medical Advice” Discharges Among HIV-Infected Patients: Health and Health Services Outcomes

Abstract

Nurses are often first to identify and manage a patient leaving against medical advice (AMA), and so they are critical contributors to the development of strategies to address this problem. We studied AMA discharge in order to help develop useful interventions. We performed a cross-sectional analysis of 55,938 discharges from a single urban hospital for the years 2002-2003 and 2012-2013. AMA discharge rates were higher for HIV-infected patients than for patients with alcohol-related disorders or sickle cell anemia in both time periods, even after adjustment for age, race, sex, insurance status, and household income. For HIV infection, 25% of AMA discharges occurred in patients with multiple AMA discharges and 30-day readmission rates were higher after an AMA discharge: odds ratio 1.57 (95% confidence interval 1.01 to 2.43, p = .046). Team-based and nursing interventions that incorporate the treatment-based values and preferences of HIV-infected patients with prior AMA discharges may improve linkage to care and reduce readmissions.

Thirty-day Readmission Rates in an HIV-infected Cohort From Rio de Janeiro, Brazil

“…Indeed, discharge against medical advice had already been associated with increased risk of 30-day readmission in the general population 31 and among those with HIV 13,21,32 . Interestingly, compared to HIV-uninfected patients, HIV infected patients were shown to have a higher risk of leaving the hospital against medical advice 32 .…”

“…Indeed, discharge against medical advice had already been associated with increased risk of 30-day readmission in the general population 31 and among those with HIV 13,21,32 . Interestingly, compared to HIV-uninfected patients, HIV infected patients were shown to have a higher risk of leaving the hospital against medical advice 32 . Specifically, among HIV infected patients, leaving hospital against medical advice led to a 5-fold increased odds of 30-day readmission for a related diagnosis and was associated with longer readmission LOS (compared to those who had been formally discharged) 13 .…”

Patient-Directed Discharges Among Persons Who Use Drugs Hospitalized with Invasive Staphylococcus aureus Infections: Opportunities for Improvement

“…Thirty-day readmission rates following patient-directed discharge during infection treatment are consistently elevated across studies [12,[17][18][19], indicating the potential for ineffective treatment. Our findings of high 30-day and one-year readmission rates among persons who use drugs with patient-directed discharge are consistent with existing data.…”

Impact of Patient–Provider Attachment on Hospital Readmissions Among People Living With HIV: A Population-Based Study

“…The following characteristics that have been previously associated with readmission were accounted for as potential confounders in this analysis: patient’s age at admission (per 10 year increase); sex (female vs male); calendar year (per 10-year increase); history of injection drug use (yes vs unknown vs no [reference]); Charlson comorbidity index (per unit increase); patient CD4 cell count measured within 12 months of admission date (100 cells/mL); viral load (log 10 increase); and discharge against medical advice (yes vs no). 13,18,30,44–46…”

“…In the context of HIV, the continuum of care relies on engaging and retaining PLWH in care. It is known that patients who leave hospital against medical advice (i.e., are not retained in care) are more likely to be readmitted with a worsened condition and have higher rates of mortality 18 To prevent this, evidence has suggested that engaging with the primary care system and being attached to a healthcare provider in the community may reduce hospital utilization among patients. 19,20 Indeed, a growing number of studies suggest that suboptimal care during hospitalization and after discharge, such as wrong or missed diagnosis or premature discharge, is negatively associated with unplanned 30-day readmission.…”