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.
He adds that the reasons patients leave AMA have been well documented, but are important for caregivers to fully understand so they can try to grapple with the underlying reasons the patient wants to leave.
For starters, he says, many have underlying behavioral and mental health issues and find the physical health care setting suffocating and/or intolerable.
The second reason patients leave is concern about paying the bill, especially if they are uninsured.
Third, they have family members such as small children they need to take care of. "They worry, 'who is going to take care of my mother while I'm here?'" Conway says.
The fourth reason is that as some patients begin to feel better, they don't see a need for hospitalization. They think, "I have a life to live," Conway says. They might not like the lights or the noise, or may feel they are not being treated well by hospital staff or nurses. They may want to smoke or perhaps don't like the food.
Finally, patients who leave the hospital AMA are much more likely than other patients to have done it before.
With all these aspects taken in concert, a profile of the person most likely to leave AMA can be developed. "We need to screen for this as a risk factor," Conway says.
That's why hospitals need to try to build the care plan around the patient who might leave AMA from the start. First, he says, hospitals need to begin discharge planning from day one; to find out what concerns patients have about their situations at home or wherever they are that might pressure them to leave before they are medically discharged.
In some hospitals, discharge planning begins before the patient even arrives at the hospital door.
"Historically, we have not built the care plan around the patient. The patient is only told what the care plan is," he says.
Conway says that at IHI, and many facilities around the country, hospital planners are trying to determine how they can, from the start, "put together a range of options that allow the patient to get better even though they've left the hospital, without them reappearing in two weeks because the disease has gotten worse.
"We have to set up a plan B, and negotiate with the patient to follow that plan, because if we keep focusing on plan A, they will opt out."
Some strategies include making sure that the patient comes to a walk-in-clinic every other day, or agrees to accept a phone call check-in every day after the patient returns home.
"Of course the hospital team wants to have the patient in bed for four days, but when it becomes obvious the patient is determined to leave, how do we come up with a model that does some of the care on the outpatient side?"
Conway is optimistic, but realistic at the same time. "We know we can do a significant amount of work that can reduce the number of AMAs," he says. "Will it ever go away entirely? Probably not. People will be people."