Reconsidering Against Medical Advice Discharges
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KeywordsHospital Discharge System Change Sufficient Data Medical Advice Significant Variability
T he Author Replies—I appreciate Dr. Meyer’s correction regarding the exclusion for Against Medical Advice (AMA) discharges in the Centers for Medicare and Medicaid Services (CMS) readmission calculation. I also agree that the current CMS readmission calculations may have an impact on hospital discharge practices. It is both reasonable and prudent to assume that hospitals that choose to reduce their AMA discharges may have a resultant increase in their readmissions as calculated by CMS. Currently however, we don’t have sufficient data to reliably predict that this policy will affect hospital practice in this way. This would be an area deserving of further study. As hospitals institute systems changes to make discharge practices more patient-centered (e.g., reducing AMA discharges), they should consider all the potential impacts on both the hospital and the patient.
The CMS exclusion for AMA discharges in the readmission calculation raises a number of other questions. Most importantly, if there are no clear professional standards for how an AMA discharge is determined, there is likely to be significant variability in the clinical use of the term.1 How will this affect the quality and generalizability of CMS readmission data? Also, AMA discharges are associated with higher rates of hospital readmission up to 6 months later, suggesting that they may have persistent effects.2 What potential data related to this effect may be lost when patients discharged AMA are not included in the CMS calculations? Continued research in this area will help to address these and other questions.
The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or the National Center for Ethics in Health Care.