Readmission Rates of Patients Discharged against Medical Advice: A Matched Cohort Study

Mark Choi,Haerin Kim,Hong Qian,Anita Palepu,Jerson Laks

doi:10.1371/journal.pone.0024459

Abstract

ObjectiveWe compared the readmission rates and the pattern of readmission among patients discharged against medical advice (AMA) to control patients discharged with approval over a one-year follow-up period.MethodsA retrospective matched-cohort study of 656 patients(328 were discharged AMA) who were followed for one year after their initial hospitalization at an urban university-affiliated teaching hospital in Vancouver, Canada that serves a population with high prevalence of addiction and psychiatric disorders. Multivariate conditional logistic regression was used to examine the independent association of discharge AMA on 14-day related diagnosis hospital readmission. We fit a multivariate conditional negative binomial regression model to examine the readmission frequency ratio between the AMA and non-AMA group.Principal FindingsAMA patients were more likely to be homeless (32.3% vs. 11%) and have co-morbid conditions such as psychiatric illnesses, injection drug use, HIV, hepatitis C and previous gastrointestinal bleeding. Patients discharged AMA were more likely to be readmitted: 25.6% vs. 3.4%, p<0.001 by day 14. The AMA group were more likely to be readmitted within 14 days with a related diagnosis than the non-AMA group (Adjusted Odds Ratio 12.0; 95% Confidence Interval [CI]: 3.7–38.9). Patients who left AMA were more likely to be readmitted multiple times at one year compared to the non-AMA group (adjusted frequency ratio 1.6; 95% CI: 1.3–2.0). There was also higher all-cause in-hospital mortality during the 12-month follow-up in the AMA group compared to non-AMA group (6.7% vs. 2.4%, p = 0.01).ConclusionsPatients discharged AMA were more likely to be homeless and have multiple co-morbid conditions. At one year follow-up, the AMA group had higher readmission rates, were predisposed to multiple readmissions and had a higher in-hospital mortality. Interventions to reduce discharges AMA in high-risk groups need to be developed and tested.

Highlights

Discharge against medical advice (AMA) makes up 1 to 2% of overall discharges in an acute hospital setting and are known to be higher with certain patient populations [1,2]
Several studies in various settings including obstetric, paediatric, general medicine wards and emergency room have shown that readmission rates of patients discharged AMA are much higher than their counterparts discharged with approval [2,3,4,5,6,7,8,9,10]
Readmission of patients discharged against medical advice leads to greater financial burden on the health care system [11,12,13] and to delays in investigation and treatment of acute illnesses that may lead to higher mortality [1]

Summary

Introduction

Discharge against medical advice (AMA) makes up 1 to 2% of overall discharges in an acute hospital setting and are known to be higher with certain patient populations [1,2]. Several studies in various settings including obstetric, paediatric, general medicine wards and emergency room have shown that readmission rates of patients discharged AMA are much higher than their counterparts discharged with approval [2,3,4,5,6,7,8,9,10]. Readmission of patients discharged against medical advice leads to greater financial burden on the health care system [11,12,13] and to delays in investigation and treatment of acute illnesses that may lead to higher mortality [1]. Weingart et al showed that patients discharged AMA from the general medicine ward at Beth Israel

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Discussion

Conclusion