This study is the first to demonstrate that general medical patients discharged AMA suffer worse health outcomes than those discharged to home. There were higher rates of 30-day readmission and of 30-day mortality. With more than one in six AMA patients returning to the hospital within 30 days, there is significant need to consider ways to improve care and management of these patients.
While elevated rates of readmission after discharge are disconcerting, the elevated mortality rates in patients discharged AMA are particularly worrisome. Being discharged AMA had an increased hazard for 30-day mortality (HR
1.10), suggesting that being discharged AMA is a high mortality risk group. In multivariable models, the risk associated with discharge AMA was even greater than that associated with several other co-morbid conditions such as liver disease or myocardial infarction. Paradoxically, despite almost 1 in 4 AMA patients having a history of alcohol abuse compared to only 1 in 12 for regularly discharged patients, alcohol abuse was not a significant predictor of mortality and was associated with lower risk of readmission. This finding may simply reflect that these patients avoid medical care until it is absolutely necessary and thus manage to stay out of the hospital for 30 days after discharge even though they are known to be frequent users of the health care system.
The hazard rates for comorbidities in the models show that 30-day readmission is a complex interaction of factors and deserves further studies to understand which sub-populations of patients are at the greatest risk. For example, the hazard models suggest that congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are protective against readmission. Considering that these two populations typically have high rates of readmission, this finding seems counter-intuitive. However, further reflection highlights that patients with CHF and COPD that are readmitted are often those with multiple comorbid conditions. So what these models suggest is that CHF and COPD are not themselves significant risks for readmission, but in combination with several other conditions creates an unstable health environment that frequently leads to readmission.
The higher risks of adverse outcomes observed in this study strongly suggest that hospitals should target AMA patients for discharge transition interventions. Potential interventions include phone follow-up, home visits, or mental health counseling. Alternatively, identifying and ameliorating the factors that cause patients to leave AMA may help to reduce the number of patients who leave before achieving clinical stability. This may include factors related to the health care team such as provider communication style, access to social services support, or involvement of family in care decisions. Whether targeting patients before or after discharge, clear communication is likely to play a significant role in improving outcomes.
In a study interviewing physicians after a patient left AMA, the authors found that poor communication likely contributed in many cases where a patient left AMA.6
Perhaps improved patient-centered communication, especially early in the admission, can help avoid patients leaving AMA. Review of the re-admission hazard modeling does provide some support for this idea. The patients at highest risk for readmission were likely to have suffered an acute event (arrhythmia, MI) from which they may feel comparatively better and not realize the risk associated with their condition, or had a mental co-morbidity (dementia, psychosis) that may limit their ability to comprehend the severity of their medical situation. If the patient does not understand early on why they are in the hospital and how long they likely will need to be there, it is quite easy for them to get frustrated with the process and leave before it is medically appropriate. Regardless, being discharged AMA had the highest independent hazard of readmission (HR = 1.36), and thus, AMA patients deserve attention as a high-risk group.
These analyses have limitations; most notably the VA population may not be generalizable to other health care settings. While VA patients are not representative of the general medical population in the US, patients in VA who leave AMA are similar, suggesting these findings are meaningful for the general medical population of the US. The AMA patients in this study were younger, more likely to be male, black, have low income, and abuse alcohol than other patients in the cohort, which mimics the characteristics of AMA patients in prior studies.1–3,7,8
Furthermore, the observed AMA discharge rate of 1.7% falls into the 1–2% range observed in other studies.
One other consideration about studying patients in VA is the potential for dual care. It is estimated that approximately 79% of VA patients have another form of health care coverage and thus may obtain care from both VA and the private sector.9
While this study cannot account for any readmissions to the private sector, this may be of less concern when focusing on patients discharged AMA. Prior studies suggest that AMA patients are less likely to have insurance, meaning in the VA system AMA patients may be more likely to have only VA provided care.
Another potential limitation of this study is its use of administrative data. Administrative data cannot capture all clinical and social factors, such as the relationship between providers and patient, which may contribute to the measured outcomes. It also lacks measures of severity of illness, and there is the potential for unmeasured co-morbidity. However, VA administrative data are highly reliable in recording mortality, making it an excellent first step in understanding the relationship between discharge AMA and risk of death.