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Many Hospitalized Patients Leave Facilities Against Medical Advice

Cheryl Clark, for HealthLeaders Media, August 20, 2009

Yesterday's report that 39% more patients left their hospital beds against medical advice in 2007 compared with 10 years earlier caught one of the nation's leading hospital quality experts off guard.

"We had understood this is a growing problem, but these numbers and changes are significant and surprising," says James Conway, senior vice president for the Institute for Healthcare Improvement, adding that he understands "the circumstances that are allowing this to be the case."

The report, compiled by the federal Agency for Healthcare Research and Quality, said these patients who leave against medical advice (AMA) "may be at increased risk for adverse health outcomes" and "significantly higher (hospital) readmission rates compared to other patients."

They leave because of "financial considerations and stresses, family emergencies, self-assessment of their health status, or dissatisfaction with their treatment," the report said. "Understanding the characteristics of hospital stays that result in patients leaving AMA is critical to designing strategies to prevent premature hospital departures," the report concluded.

The study, which was drawn from the Healthcare Cost and Utilization Project, found that patients who were uninsured or covered by Medicaid accounted for nearly half of all patients who left AMA in 2007.

The number of patients who left AMA grew from 264,000 to 368,000 between 1997 and 2007. The increase was much higher than the increase of all other hospital stays, which grew by 13%, from 26 million to 29 million in those 10 years.

Also, the report found, the rate of AMA patient departures was twice as high in the areas of the Northeast, 2 patients per 1,000 population, compared with the Midwest, South or the West. Additionally, patients who got out of bed and left the hospital AMA stayed only 2.7 days, compared with 5.1 days for all other hospitalized patients, and incurred costs of $5,300 compared with $10,400.

The study discovered that in general, people who left AMA were more likely to be men than women, more likely to be living in poorest communities than in the wealthiest ones, and more likely to be living in urban areas than in rural ones.

Patients with alcohol-and substance–related disorders were 11.6 and 10.8 times more likely, respectively, to leave the hospital AMA than other patients.

The finding is a concern for physicians and hospital administrators for numerous reasons, documented in numerous studies published in peer-reviewed journals.

  • Patients who leave against medical advice are far more likely than other patients to require readmission within 30 days and when they are, they are likely to be much sicker and require more expensive care.
  • Patients who leave against medical advice are more likely than other patients to have mental and behavioral illnesses or substance abuse problems that cloud their judgment. That condition can compromise their ability to sign consent that they understand the consequences of leaving AMA, which in turn might influence a legal claim against a hospital or physician who was in charge of that patient's care.
  • Patients with medical and/or behavioral problems who leave a hospital AMA may put themselves and others in jeopardy, for example, if a patient with serious cardiovascular disease is driving a car or perhaps attempts to return to the workplace and use potentially hazardous equipment while their medical issues remain unresolved.
  • It is unclear whether Medicare or Medicaid will pay for care required within 30 days under new bundled payment agreements if the patient was found to be incapable of giving that consent.
  • Readmission rates are a huge concern also because of the wide disparity from state to state on how many patients are readmitted within 30 days of hospital discharge, a disparity that hospital officials and payers are trying to reduce. For example, according to a report earlier this year in the New England Journal of Medicine, in Illinois, New York, New Jersey, Mississippi, and Louisiana, nearly 22% of patients are readmitted within 30 days while in Idaho, Utah, Oregon, Hawaii, Washington, Montana, and Wyoming, the rates are below 17%.

Those reasons, in addition to attempting to provide a higher quality level of care in healthcare settings, have prompted much more aggressive efforts to first keep patients from leaving AMA. But if they are determined to leave, to make sure they have adequate support and monitoring wherever they are determined to go, Conway says.

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