Association of Hospital Discharge Against Medical Advice With Readmission and In-Hospital Mortality

Abstract

Importance: Hospital readmissions contribute to higher expenditures and may sometimes reflect suboptimal patient care. Individuals discharged against medical advice (AMA) are a vulnerable patient population and may have higher risk for readmission.

Objectives: To determine odds of readmission and mortality for patients discharged AMA vs all others, to characterize patient and hospital-level factors associated with readmissions, and to quantify their overall cost burden.

Design, setting, and participants: Nationally representative, all-payer cohort study using the 2014 National Readmissions Database. Eligible index admissions were nonobstetrical/newborn hospitalizations for patients 18 years and older discharged between January 2014 and November 2014. Admissions were excluded if there was a missing primary diagnosis, discharge disposition, length of stay, or if the patient died during that hospitalization. Data were analyzed between January 2018 and June 2018.

Exposures: Discharge AMA and non-AMA discharge.

Main outcomes and measures: Thirty-day all-cause readmission and in-hospital mortality rate.

Results: There were 19.9 million weighted index admissions, of which 1.5% resulted in an AMA discharge. Within the AMA cohort, 85% were younger than 65 years, 63% were male, 55% had Medicaid or other (including uninsured) coverage, and 39% were in the lowest income quartile. Thirty-day all-cause readmission was 21.0% vs 11.9% for AMA vs non-AMA discharge (P < .001), and 30-day in-hospital mortality was 2.5% vs 5.6% (P < .001), respectively. Individuals discharged AMA were more likely to be readmitted to a different hospital compared with non-AMA patients (43.0% vs 23.9%; P < .001). Of all 30-day readmissions, 19.0% occurred within the first day after AMA discharge vs 6.1% for non-AMA patients (P < .001). On multivariable regression, AMA discharge was associated with a 2.01 (95% CI, 1.97-2.05) increased adjusted odds of readmission and a 0.80 (95% CI, 0.74-0.87) decreased adjusted odds of in-hospital mortality compared with non-AMA discharge. Nationwide readmissions after AMA discharge accounted for more than 400 000 inpatient hospitalization days at a total cost of $822 million in 2014.

Conclusions and relevance: Individuals discharged AMA have higher odds of 30-day readmission at significant cost to the health care system and lower in-hospital mortality rates compared with non-AMA patients. Patients discharged AMA are also more likely to be readmitted to different hospitals and to have earlier bounce-back readmissions, which may reflect dissatisfaction with their initial episode of care.

Figure 1.. Flowchart of Eligible Index Admissions, Unweighted

Flowchart illustrating exclusionary criteria to identify the eligible index admissions evaluated in the study. After applying exclusions, eligible index admissions represented 61% of the total sample set of admissions within the Nationwide Readmissions Database. These numbers represent unweighted frequencies of hospital discharge data reported through the State Inpatient Databases. Standardized weights designed by Healthcare Costs and Utilization Project were applied to obtain weighted estimates of index admissions and readmissions that were nationally representative.

Figure 2.. Timing of Readmissions Within 30 Days for Patients Discharged Against Medical Advice (AMA) vs Non-AMA Patients

Distribution of the timing of readmissions after AMA vs non-AMA discharge. Data presented reflect the cumulative percentage of 30-day readmissions on each day after initial discharge. Nineteen percent of all 30-day readmissions after AMA discharge occur within the first day after initial hospital discharge, compared with just 6% for non-AMA discharges.