Physician Practices in Against Medical Advice Discharges

Abstract

Background: Patients discharged against medical advice (AMA) have disproportionately high health care costs and increased morbidity, mortality, and hospital readmissions. Although patient risk factors for discharge AMA are known, there are little data regarding physician discharge practices surrounding AMA discharges. Methods: We performed a cross-sectional analysis of patients discharged AMA from a large, urban, academic medical center. Our study predictors included patient demographics and admission characteristics: primary service team, time of discharge, documentation of anticipated AMA discharge, and length of stay. The primary outcomes were physician discharge practices including a scheduled follow-up appointment, documentation of informed consent, documentation of a risk/benefit discussion, and notification of the attending physician. Our coprimary outcome was the incidence of 30-day hospital readmission. Results: Among AMA discharges, 33% had follow-up appointments scheduled upon discharge. There was documentation of a risk/benefit discussion (69%), informed consent (63%), and notification of the attending physician (72%) in most discharges. Physician discharge practices were not associated with 30-day hospital readmission. Conclusions: Adherence to discharge best practices in AMA discharges was inconsistent and suboptimal, particularly for scheduling follow-up appointments, but was not associated with hospital readmission. Our results highlight the difficulty in facilitating safe transitions of care for patients discharged AMA.

Against Medical Advice Discharge: A Narrative Review and Recommendations for a Systematic Approach

“…Interestingly, this study did not show a relationship between physician discharge practices and risk of readmission. 31…”

Harms and Contributors of Leaving Against Medical Advice in Patients With Infective Endocarditis

“…In one study, among all patients who left AMA, only 33% had follow-up appointments, 63% had informed consent, and 69% of patients had documentation of risk and benefits and discussion with the physician. However, these practices were not shown to be associated with increased 30-day readmission 10,13,14 . Patients leaving AMA result in a higher cost to the health care system after readmission.…”

“…In addition, we did not have details of the patient's insurance status, cost of care, and post-AMA physician follow-up status, which can independently affect a patient's long-term outcome. [13][14][15][16] Our study participants did not have uniform access to a specialist in substance use disorder or a psychiatrist. Multidisciplinary treatment of these patients with specialists in substance use disorders and psychiatry might contribute to improving the management of these patients in terms of reducing AMA rates and further hospitalizations.…”

A step-by-step approach to patients leaving against medical advice (AMA) in the emergency department

“…They should go through the discharge process like any other discharge: give instructions, inform patients of any investigations that may have been conducted before discharge and provide the relevant prescriptions [ 30 , 32 , 37 ]. Even though it has been shown that up to 94% of attending physicians agree that AMA patients should receive medication and follow-up arrangements [ 40 ], studies indicate that only a quarter of these patients do receive a prescription and that only a third of them are discharged with a follow-up plan [ 40 – 42 ].…”

“…Exhaustive documentation was found in only 4% of the charts in a small study [44]. Capacity is documented in about 20-60% of files [30,[40][41][42]44], and a discussion about risks is documented in about 60-70% of files [30,42]. The primary reason to designate the discharge as AMA is the fear of legal liability [33].…”