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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, Χ2 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.

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Acknowledgements

The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development (HSR&D) Service, Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP) (HFP 04-149). Mr. Glasgow is supported by the University of Iowa Clinical and Translational Science Program (5TL1RR024981-02).

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. This research was presented at the annual meeting of the Society of Hospital Medicine, April 2010, Washington DC.

Conflict of Interest

None disclosed.

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Correspondence to Justin M. Glasgow MS.

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Glasgow, J.M., Vaughn-Sarrazin, M. & Kaboli, P.J. Leaving Against Medical Advice (AMA): Risk of 30-Day Mortality and Hospital Readmission. J GEN INTERN MED 25, 926–929 (2010). https://doi.org/10.1007/s11606-010-1371-4

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KEY WORDS

  • readmission
  • mortality
  • against medical advice