Patients leaving against medical advice (AMA) from the emergency department--disease prevalence and willingness to return

Abstract

Background: How patients fare once they leave the emergency department (ED) against medical advice (AMA), and the extent of illness burden that accompanies them, remains unstudied.

Objective: To determine the fate of patients leaving the ED AMA for a defined period of time post-discharge.

Methods: This was a prospective follow-up study of a convenience sample of patients leaving the ED AMA during two 6-month periods in consecutive calendar years at an urban academic ED with 32,000 annual patient visits.

Results: A total of 199 patients were identified, with 194 enrolled. Categories of discharge diagnoses included cardiovascular, undifferentiated abdominal pain, respiratory, and cellulitis. Of the 194 patients studied, 126 patients (64.9%, 95% confidence interval [CI] 57.6-71.5%) stated that their symptoms had improved or resolved. Of these 126 patients, 109 (86.5%, 95% CI 78.9-91.7%) had their original AMA discharge diagnoses referable to cardiovascular pathology. Ninety-five patients (75.4%, 95% CI 66.7-82.4%) with improved or abated symptoms did not plan to return. Of those with improved or abated symptoms, 31 patients (24.6%, 95% CI 17.6-33.2%) did return, and with further evaluation, 15 of them were found to have significant clinical findings. Of the 68 patients with continuing symptoms, 36 (52.9%, 95% CI 40.5-64.9%) returned for further evaluation. A total of 127 patients did not return. Twenty-five patients (19.7%, 95% CI 15.9-25.4%) expressed a reluctance to return to the same ED for fear of embarrassment. Seven patients (5.5%, 95% CI 4.8-8.7%) who did not seek alternative care but were still having symptoms did not return due to job or family commitments or because they would follow-up with a personal physician.

Conclusion: Patients who leave the ED AMA have significant pathology.