![]() Multiple studies have found that patients who leave AMA are at risk for early readmission, 3, 12, 13 which can result in higher, unnecessary health care costs. Using a case-control design, Corley and Link 11 found a 19% rate of mortality at 6 months among 33 medical patients who left AMA from a Veterans Affairs institution.įew data are available on the estimated total costs to the health care system of unanticipated AMA discharges. ![]() In a review of medical records, Link et al 10 found a 15.7% mortality rate at 1 year among 57 patients discharged AMA from a group of academic hospitals in Virginia. ![]() 9 Although a moderately sized prospective study found no relationship between AMA discharge and death, 3 2 other studies, smaller and variable in their design, found a high rate of mortality among patients who were discharged AMA. After adjustment for these phenomena, patients who left AMA had a 40% higher risk of death or readmission for myocardial infarction or unstable angina up to 2 years after discharge. 3 In a large retrospective study among almost 100,000 patients admitted with acute myocardial infarction, those who left AMA (N=1079) underwent fewer revascularization procedures and had shorter lengths of hospital stay. 8 In a study of a general medicine service, patients who left AMA were 7 times more likely to be readmitted within 15 days (21% vs 3%), almost always for the same diagnosis. Patients with asthma who were discharged AMA had a 4-times higher risk of readmission to the emergency department within 30 days (21.7% vs 5.4%) and almost a 3-times higher risk of readmission to the hospital within 30 days (8.5% vs 3.2%). 5- 7 Furthermore, patients discharged AMA, taken as a whole, are an at-risk group for both morbidity and mortality. This article examines the problem of AMA discharges-their prevalence, risks, and costs-and formulates recommendations for managing and preventing them on the basis of available evidence.Īgainst medical advice discharges continue to be a highly prevalent problem of health care quality, representing as many as 2% of all hospital discharges. Physician-patient communication, informed consent, and underlying psychiatric issues are all relevant to practical management. 4 In practice, managing this issue presents more complications than simply identifying and potentially prioritizing the relevant ethical principles. Many physicians struggle with the desire to respect the patient's wishes to leave AMA (in general, the patient's right to self-determination or autonomy) while attempting to do what they think is best for the patient (to act with beneficence). 3 The ethical dilemma that this issue raises is conceptually relatively straightforward. 1, 2 Leaving the hospital against the physician's advice may expose the patient to risk of an inadequately treated medical problem and result in the need for readmission. Studies for this review were identified by searching the relevant MeSH heading ( discharge) and key words ( against medical advice, leave, elope, hospital, and self-discharge) in PubMed databases and selecting all English-language articles from 1970 through 2008 that included data on adult medical inpatients.ĭischarge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, is a problem for many physicians who treat hospitalized patients. This article offers suggestions for interventions based on studies in other areas of clinical care as well as the psychiatric AMA discharge literature. Interventions to reduce the rate of AMA discharges have not been systematically studied. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Between 1% and 2% of all medical admissions result in an AMA discharge. This article reviews the prevalence, costs, predictors, and potential interventions for this clinical problem. Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem.
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