Hospital factors lead to many discharges against medical advice

Patients who leave a hospital against the advice of a physician may be characterized as “difficult” or “uncooperative.” But a new study suggests that in many cases that label is unfair.

The analysis found that in about 1 in 5 cases, gaps in quality of care and other factors beyond patients’ control explain why they leave hospital before completing the recommended treatment.

Dr Kushinga Bvute

Clinicians can be quick to blame patients for so-called discharge against medical advice (AMA), which accounts for up to 2% of hospital admissions and is associated with increased risk mortality and readmission. But “as providers, we’re very involved in why these patients left,” said Kushinga Bvute, MD, MPH, a second-year internal medicine resident at Florida Atlantic University in Boca Raton, who has led the new study. Medscape Medical News. Bvute and his colleagues presented their findings on April 6 at the 2022 annual meeting of the Society of General Internal Medicine (SGIM), in Orlando, Florida.

Bvute and colleagues reviewed the records of 548 AMA discharges—out of a total of 354,767 discharges—from Boca Raton Regional Hospital from January 2020 to January 2021. In 44% of cases, patients cited their own reasons for departure. But in nearly 20% of AMA discharges, researchers identified treatment-related factors.

Hospital reasons cited by patients for leaving AMA were general wait times (3.5%), provider wait times (2.6%), provider care (2.9%) , the hospital environment (2.7%), the desire for a private room (2%), and seeking medical care elsewhere (6.2%).

Patient-related factors were refusal of treatment (27%), feeling of improvement (3.5%), addiction financial problems (2.9%), financial complications (2.9%) and dependent care (2.4%). Ten (1.8%) fled, according to the researchers.

Nearly 60% of patients discharged from the AMA were men, with an average age of 56 years (standard deviation, 19.13). The average stay was 1.64 days.

In about a third of cases, there was no documented reason for leaving, underscoring the need for better notification, the researchers said.

To deal with AMA discharges, hospitals “need to focus on the factors they influence, such as high-quality patient care, the hospital environment, and provider-patient relationships,” the researchers report.

New procedures needed

The hospital is working on procedures to ensure that the reasons for AMA discharges are documented. The administration is also implementing preventative measures, such as communicating with patients about the risks of leaving and providing discharge plans to reduce the likelihood of a patient returning, Bvute said. Medscape Medical News.

Bvute said the findings should encourage individual clinicians to “remove any stereotypes that are sometimes attached to having those three letters on your charts.”

Data has been collected during the COVID-19 pandemic, but Bvute does not believe that fear of exposure to the coronavirus caused many patients to leave hospital prematurely.

The study is notable for approaching AMA discharges from a quality improvement perspective, David Alfadre, MD, MPH, health ethicist at the VA National Center for Ethics in Health Care in Washington, told Medscape, DC.

Alfandre, who was not involved in the study, said it reflects a growing recognition that hospitals can take steps to reduce the adverse effects associated with AMA discharges. “It starts to shift the conversation to saying, it’s not just the patient’s problem, it’s the health care provider’s problem,” he said.

Alfadre co-wrote a 2021 analysis showing that hospital characteristics explained 7.3% of the variation in the probability of a patient being discharged from the AMA. However, research is needed to identify effective interventions in addition to established use of buprenorphine and naloxone for patients with opioid use disorder. “I think everyone recognizes that the quality of communication is poor, but that doesn’t really help us operationalize that to know what to do,” he said.

Emily Holmes, MD, MPH, medical director of the Changing Health Outcomes Through Integrated Care Excellence Program at IU Health in Indianapolis, cautioned that the data may be skewed because the AMA’s definition of discharge may be subjective.

The reasons are not systematically documented and can be difficult to grasp because they are often multifactorial, Holmes told Medscape. “For example, long wait times are more of a problem when a patient is worried about their finances and caring for a child,” she said.

But Holmes, who was not involved in the study, said it encouraged clinicians “to think about what we can do systematically to reduce AMA discharges.”

Bvute, Alfadre and Holmes reported no relevant financial relationships.

2022 Annual Meeting of the Society for General Internal Medicine (SGIM): Abstract PS1-29. Presented April 6, 2022.

Mary Chris Jaklevic is a medical journalist in the Midwest.

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