Association of Discharge Against Medical Advice with Surgical Outcomes and Healthcare Costs.

Abstract

Patients who leave the hospital prematurely often remain in a compromised clinical state, which can increase the risk of complications. Discharge against medical advice (DAMA) has been associated with increased morbidity, fragmented care, and higher healthcare costs, but its impact on major surgical populations remains understudied. We sought to evaluate trends, risk factors, and postoperative outcomes among surgical patients who were DAMA. The Nationwide Readmissions Database (2016 to 2020) was used to identify adult patients (18 years or older) undergoing major operations. Trends in DAMA incidence over time, risk factors associated with DAMA, as well as the impact of DAMA on postoperative outcomes and 30-day healthcare expenditures were assessed using multivariable regression models. Among 1,768,752 surgical patients, 3,951 (0.22%) were DAMA (17.0% in 2016 vs 25.3% in 2020; p < 0.001). Male sex (adjusted odds ratio [AOR] 1.67, 95% CI 1.54 to 1.79), younger age (AOR 0.97 per year, 95% CI 0.97 to 0.97), and substance use disorder (AOR 2.44, 95% CI 2.24 to 2.65) were associated with DAMA. DAMA patients had longer index hospital stays (9.85 vs 8.08 days; p < 0.001), higher hospitalization costs ($43,379 vs $39,872; p < 0.001), and increased 30-day readmission risk (AOR 1.75, 95% CI 1.62 to 1.88). DAMA was also linked to fragmented care (AOR 1.98, 95% CI 1.71 to 2.29), higher DAMA at readmission (17.9% vs 0.7%), and greater 30-day expenditures ($48,777 vs $39,872; p < 0.001). The rising incidence and costs of DAMA highlight the need for targeted interventions, including risk stratification, and improved discharge planning, to reduce preventable readmissions and optimize resource usage.