Leaving Hospital Against Medical Advice Raises Readmission, Death Risk

Allan Garland, MD, MA Co-Head, Section of Critical Care Medicine Associate Professor of Medicine and Community Health Sciences University of Maniitoba 820 Sherbrook St / GF-222 Winnipeg, Manitoba R3A 1R9MedicalResearch.com Interview with:
Allan Garland, MD, MA
Co-Head, Section of Critical Care Medicine
Associate Professor of Medicine and Community Health Sciences
University of Maniitoba
820 Sherbrook St / GF-222
Winnipeg, Manitoba R3A 1R9

 

MedicalResearch.com: What are the main findings of the study?

Answer:   Our study evaluated consequences of leaving the hospital against medical advice (AMA).  It is a large, population-based analysis, that evaluated all hospitalizations from which patients were discharged alive, among all adults in the Canadian province of Manitoba over a 19 year period; this was over 1.9 million hospitalizations.  Outcomes assessed were hospital readmission and death over 6 months after the event.  Specifically, we compared these outcomes for those who left the hospital against medical advice, compared to those who remained in the hospital until their doctors felt it was safe to be discharged — and these comparisons adjusted for a variety of patient and illness characteristics.

Among the 1.9 million hospitalizations, there were 21,417 that ended with the patients leaving against medical advice, this is 1.1% of the total.  Without adjustment for other variables, leaving against medical advice was associated with double the rate of unscheduled hospital readmission within 30 days (24.0 vs. 12.1%); after adjustment, the odds of unscheduled hospital readmission within 30 days was 3-fold higher for someone who left against medical advice compared to one who did not.  After adjustment, the odds of death at 90 days were 2.51-fold higher for those who left against medical advice.

The increased rates of hospital readmission and death associated with leaving the hospital against medical advice were both evident within one week after hospitalization, and though the excess risks of readmission and death declined subsequently, they appeared to plateau,  remaining above baseline out to at least 6 months

MedicalResearch.com: Were any of the findings unexpected?

Answer:  We were somewhat surprised that the adverse consequences of  leaving the hospital against medical advice were so persistent.  If the effects were solely related to incomplete treatment of the acute illness for which they were admitted to the hospital, you would expect the effect to decay back to baseline within a time period shorter than the 6 months of our study.  The persistence of these effects suggests that these adverse consequences may also relate to a second mechanism, for example patient characteristics or health behaviors that correlate with the tendency to leave against medical advice.  One candidate is a general tendency to nonadherence with medical recommendations, which has previously been associated with increased mortality.  An implication of this finding is that interventions aimed at reducing the consequences for patients of leaving the hospital against medical advice may require not only efforts to convince them to stay, but also longitudinal interventions extending beyond hospitalization.

MedicalResearch.com: What should clinicians and patients take away from your report?

Answer:  The primary thing is that we have convincingly shown that leaving the hospital against medical advice is associated with adverse consequences for patients.  This information could be used to try and convince those contemplating leaving against medical advice to not do so.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Answer:  The next planned stage in our research efforts is to dig deeper into the reasons people leave the hospital against medical advice, and the mechanisms that cause the adverse effects of doing so.  Our eventual goal is to design an intervention strategy that can be used to reduce the adverse consequences associated with leaving the hospital against medical advice.

Citation:

Rates of readmission and death associated with leaving hospital against medical advice: a population-based study

Allan Garland, Clare D. Ramsey, Randy Fransoo,  Kendiss Olafson, Daniel Chateau, Marina Yogendran, and Allen Kraut

Rates of readmission and death associated with leaving hospital against medical advice: a population-based study CMAJ cmaj.130029; published ahead of print August 26, 2013, doi:10.1503/cmaj.130029

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