Association of Hospital Discharge Against Medical Advice With Readmission and In-Hospital Mortality

Abstract

IMPORTANCE Hospital readmissions contribute to higher expenditures and may sometimes reflect suboptimal patient care. Individuals discharged against medical advice (AMA) are a vulnerable patient population and may have higher risk for readmission. OBJECTIVES To determine odds of readmission and mortality for patients discharged AMA vs all others, to characterize patient and hospital-level factors associated with readmissions, and to quantify their overall cost burden. DESIGN, SETTING, AND PARTICIPANTS Nationally representative, all-payer cohort study using the 2014 National Readmissions Database. Eligible index admissions were nonobstetrical/newborn hospitalizations for patients 18 years and older discharged between January 2014 and November 2014. Admissions were excluded if there was a missing primary diagnosis, discharge disposition, length of stay, or if the patient died during that hospitalization. Data were analyzed between January 2018 and June 2018. EXPOSURES Discharge AMA and non-AMA discharge. MAIN OUTCOMES AND MEASURES Thirty-day all-cause readmission and in-hospital mortality rate. RESULTS There were 19.9 million weighted index admissions, of which 1.5% resulted in an AMA discharge. Within the AMA cohort, 85% were younger than 65 years, 63% were male, 55% had Medicaid or other (including uninsured) coverage, and 39% were in the lowest income quartile. Thirty-day all-cause readmission was 21.0% vs 11.9% for AMA vs non-AMA discharge (P < .001), and 30-day in-hospital mortality was 2.5% vs 5.6% (P < .001), respectively. Individuals discharged AMA were more likely to be readmitted to a different hospital compared with non-AMA patients (43.0% vs 23.9%; P < .001). Of all 30-day readmissions, 19.0% occurred within the first day after AMA discharge vs 6.1% for non-AMA patients (P < .001). On multivariable regression, AMA discharge was associated with a 2.01 (95% CI, 1.97-2.05) increased adjusted odds of readmission and a 0.80 (95% CI, 0.74-0.87) decreased adjusted odds of in-hospital mortality compared with non-AMA discharge. Nationwide readmissions after AMA discharge accounted for more than 400 000 inpatient hospitalization days at a total cost of $822 million in 2014. CONCLUSIONS AND RELEVANCE Individuals discharged AMA have higher odds of 30-day readmission at significant cost to the health care system and lower in-hospital mortality rates compared with non-AMA patients. Patients discharged AMA are also more likely to be readmitted to different hospitals and to have earlier bounce-back readmissions, which may reflect dissatisfaction with their initial episode of care.

Implementation of a comprehensive hospitalist‐led initiative to improve care for patients with opioid use disorder

“…National data show that 1.5% of all hospitalizations end in self-directed, or AMA, discharge. 34 COMET patients self-directed discharge more frequently (<7%), though fairly comparable to prior literature for those with h Pain was defined using a combination of code lists developed by experts in the field outside of Duke, with customization by our project team. The input sources included a paper by Tian et al 24 for chronic pain, CMS' Chronic Condition Warehouse (CCW) grouper for fibromyalgia, chronic pain and fatigue, and AHRQ's Clinical Classification System (CCW) groupers for musculoskeletal pain, low back pain, nervous system pain and pain syndrome, nonspecific chest pain, abdominal pain, abdominal pain and other digestive and abdominal signs and symptoms, and headache including migraine.…”

Predictive Modeling of Hospital Readmission: Challenges and Solutions

“…A retrospective cohort analysis based on 2014 National Readmission Database shows that patients discharged against medical advice (AMA) are of larger possibility of 30-day readmission compared with non-AMA individuals, which has caused huge loss to the healthcare system and higher hospital mortality. Patients discharged from the AMA are also more likely to have an earlier rebound and readmission, which may reflect their dissatisfaction with the initial care [168].…”

Impact of medications for opioid use disorder among persons hospitalized for drug use-associated skin and soft tissue infections

“…Therefore, an admission for a SSTI that occurs after a longer period of time (e.g., 10 days) is likely to represent a new infection. Our approach was also guided by existing evidence that readmissions after AMA discharges occur within short time periods such as 1 day (Tan, Feng, Joyce, Fisher, & Mostaghimi, 2020).…”