Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission.

Abstract

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. OBJECTIVE: To examine 30-day hospital readmission and mortality rates for medical patients who left the hospital AMA and identify independent risk factors associated with these outcomes. DESIGN: A 5-year retrospective cohort of all patients discharged from a Veterans Administration (VA) hospital. SUBJECTS: The final study sample included 1,930,947 medical admissions to 129 VA hospitals from 2004 to 2008; 32,819 patients (1.70%) were discharged AMA. MEASUREMENTS: Primary outcomes of interest were 30-day mortality and 30-day all-cause hospital readmission. RESULTS: Compared to discharges home, AMA patients were more likely to be black, have low income, and have co-morbid alcohol abuse (for all, Chi(2) df = 1, p < 0.001). AMA patients had a higher 30-day readmission rate (17.7% vs. 11.0%, p < 0.001) and higher 30-day mortality rate (0.75% vs. 0.61%, p = 0.001). In Cox proportional hazard modeling controlling for demographics and co-morbidity, the largest hazard for patients having a 30-day readmission is leaving AMA (HR = 1.35, 95% CI 1.32-1.39). Similar modeling for 30-day mortality reveals a nearly significant increased hazard rate for patients discharged AMA (HR = 1.10, 95% CI 0.98-1.24). CONCLUSIONS: Due to the higher risk of adverse outcomes, hospitals should target AMA patients for post-discharge interventions, such as phone follow-up, home visits, or mental health counseling to improve outcomes.