Abstract
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. 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. 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. Discharge AMA and non-AMA discharge. Thirty-day all-cause readmission and in-hospital mortality rate. 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. 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.
Highlights
Individuals who leave the hospital against medical advice (AMA) are at high risk for readmission
Within the AMA cohort, 85% were younger than 65 years, 63% were male, 55% had Medicaid or other coverage, and 39% were in the lowest income quartile
AMA discharge was associated with a 2.01 increased adjusted odds of readmission and a 0.80 decreased adjusted odds of in-hospital mortality compared with non-AMA discharge
Summary
Individuals who leave the hospital against medical advice (AMA) are at high risk for readmission. They account for 1% to 2% of all hospital discharges.[1,2,3,4] Patients leaving the hospital AMA are more often younger and male, have lower household incomes, more likely to be homeless, less likely to have physical comorbidity, and more likely to have mental illness, including alcohol and drug use.[2,3] Prior studies have shown that patients discharged AMA have higher rates of 30-day all-cause readmission and 30-day to 90-day mortality rates, even after adjusting for clinical and socioeconomic confounders. We identified patient and hospital factors associated with readmissions and assessed total health care use associated with 30-day readmissions
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