While most physicians say patients who discharge from the hospital against medical advice (AMA) put themselves at great risk, little research has been conducted to prove that theory. So two hospitalists at the Montefiore Medical Center in Bronx, N.Y., put it to the test, and they found that discharge AMA could literally be a matter of life or death.
In their award-winning HM10 research poster (PDF), Will Southern, MD, MS, and Julia Arnsten, MD, MPH, discovered that discharge AMA significantly increases the risk for both mortality and readmission in a general medical inpatient population. Their research equally divided more than 7,100 inpatients into two groups that were identical in every measurable domain, including admission laboratory values, acuity of illness, and medical history; one of the two groups chose discharge AMA.
Results showed that the AMA group was at a 45% increased risk of mortality and readmission within 30 days, whereas the non-AMA group was at approximately half the risk, with only a 27% chance of mortality and readmission.
Acknowledging the possibility that patients intuitively know when they are ready to leave and the fundamental medical, behavioral, and psychiatric differences in patients who discharge AMA, Dr. Southern says, "the real question is, 'If I [the hospitalist] intervene and, by whatever means necessary, try to convince the patients not to leave AMA, are their outcomes improved?' "
According to Dr. Southern, outcomes can be improved through patient communication, engagement, and intervention. "If you're interested in leaving AMA, it's OK, it's your choice," he says, "but your chances of being dead within the next 30 days are about double and your chances of being readmitted are about double."
Dr. Southern says that, although their findings are a useful starting point for further disease-centric study, for the practicing hospitalist with a patient considering discharge AMA, "it's about finding out why someone needs to leave: They need to feed their cat, cash their Social Security check, whatever the reason is."