Health care education, delivery, and quality
Hospitalized patients with asthma who leave against medical advice: Characteristics, reasons, and outcomes

https://doi.org/10.1016/j.jaci.2006.11.695Get rights and content

Background

A discharge against medical advice (AMA) after an asthma hospitalization is a frustrating problem for health care providers, yet little is known about this occurrence.

Objective

To determine the baseline characteristics, reasons for leaving, and clinical outcomes of patients with asthma who leave AMA.

Methods

A retrospective study from 1999 to 2004 of all asthma discharges from 3 large hospitals in Detroit compared those who left AMA with those who left with medical approval.

Results

There were 180 patients who left AMA and 3457 patients who had a standard discharge. Patients with asthma who left AMA were more likely to be younger, male, have Medicaid or lack insurance, require intensive care unit admission, and have a lower socioeconomic status than patients with asthma discharged with approval (P < .05 for all comparisons). There was no difference in race, day of the week admitted, or month admitted. Among records that documented a reason for leaving AMA, the most common was dissatisfaction with care, although a variety of motives were found. Finally, patients who left AMA were more likely to have an asthma relapse within 30 days. This included both emergency department revisits (21.7% vs 5.4%; P < .001) and readmission to the hospital (8.5% vs 3.2%; P < .001).

Conclusion

Patients with asthma who leave AMA have demographic and hospital admission characteristics that differ from those who leave with approval. The reasons why patients with asthma leave AMA are varied. Within 30 days, patients with asthma who leave AMA have much higher readmission and emergency department return rates.

Clinical implications

Patients with asthma who leave AMA are at increased risk of relapse.

Section snippets

Study site

Wayne State University (WSU) is located in Detroit, Michigan. The Detroit Medical Center (DMC) is a complex of medical facilities affiliated with WSU and is the teaching and clinical research site for WSU School of Medicine. Three large DMC hospitals (Detroit Receiving Hospital, Harper University Hospital, and Sinai-Grace Hospital) were selected for this study to give a more comprehensive representation of patients with asthma. These 3 hospitals serve both the city and the immediate surrounding

Rate of AMA discharge

From 1999 to 2004, there were 6828 asthma discharges, of which 255 (3.7%) left AMA. During the same time period, for all patients above the age of 18 admitted for any nonasthma diagnosis, the aggregate AMA discharge rate was 2.1%. The odds ratio for leaving AMA after an asthma hospitalization compared with a nonasthma hospitalization was 1.86 (95% CI, 1.63-2.11).

To avoid double-counting, we determined that the 3637 unique individuals accounted for the 6828 asthma discharges (Fig 1). Among this

Discussion

Asthma exacerbations are one of the most common reasons for ED visits and hospitalizations in the United States.16, 17 Although the majority of patients will be discharged with approval of the medical team, the findings of this study reveal that a substantial proportion will leave AMA. We also ascertained that patients with asthma who leave AMA are at a much higher risk of relapse over the period of the subsequent month than those who leave with approval.

The overall rate of leaving AMA after an

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      Generally, patients who leave AMA are more likely to be male, young, and without health insurance.3,5,10–12 The practice of leaving AMA varies across clinical departments, with high rates occurring among patients admitted to the intensive care units, and emergency department and low rates among obstetric patients.4,10,13,14 Unlike patients of other clinical specialties, trauma patients typically present to acute care centers from accidental and unexpected acute injury.3

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    Supported by the Blue Cross Blue Shield of Michigan Foundation.

    Disclosure of potential conflict of interest: A.P. Baptist has received grant support from the Blue Cross Blue Shield of Michigan Foundation and the National Institutes of Health loan repayment program. J. Ager has received grant support from the Blue Cross Blue Shield of Michigan Foundation. The rest of the authors have declared that they have no conflict of interest.

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