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Increased Risk of Mortality and Readmission among Patients Discharged Against Medical Advice

  • William N. Southern
    Correspondence
    Requests for reprints should be addressed to William N. Southern, MD, MS, Department of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467
    Affiliations
    Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
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  • Shadi Nahvi
    Affiliations
    Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY

    Department of Psychiatry & Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
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  • Julia H. Arnsten
    Affiliations
    Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY

    Department of Psychiatry & Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY

    Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
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      Abstract

      Background

      Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown.

      Methods

      We examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (2.4%) were discharged against medical advice, and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities or discharges with home care. Using adjusted and propensity score-matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges.

      Results

      Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR]adj 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (ORmatched 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (ORadj 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (ORmatched 1.65; 95% CI, 1.46-1.87). Finally, discharges against medical advice had shorter lengths of stay than matched planned discharges (3.37 vs 4.16 days, P <.001).

      Conclusions

      Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.

      Keywords

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