Case No. 1
A 41-year-old woman with a history of asthma presents to the emergency department (ED) with shortness of breath and wheezing. She is diagnosed with a mild asthma exacerbation. After three albuterol nebulizer treatments, she still has wheezing on physical examination but appears comfortable and has no oxygen requirement. She has a primary medical doctor at the hospital and follows up with her regularly.
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The hospitalist recommends that she stay in the hospital for further treatment, but the patient says she has a nebulizer machine at home and asks to be discharged. In addition, she is worried about her frail elderly mother, for whom she is the primary caretaker. The hospitalist acknowledges her concerns but continues to recommend that she remain in the hospital for additional care and monitoring. She becomes visibly upset and insists that she must return home. She asks for prescriptions for albuterol and prednisone and is discharged against medical advice (AMA).
Case No. 2
A 52-year-old man with a history of hypertension and diabetes presents to the ED with left foot pain. He frequently presents with this complaint but often leaves AMA before treatment is completed. He has no known physical address or telephone number and has no known outpatient healthcare providers. Physical examination reveals several ulcers on the dorsum of the foot, one with purulent drainage, and generalized lower extremity pallor. His left leg is cool to the touch, and vascular surgery is consulted for suspected limb-threatening ischemia; IV antibiotics are started for suspected osteomyelitis.
During the interview, he states that he wishes to leave the hospital because he has “things to take care of.” The hospitalist recommends that he remain in the hospital for limb-preserving surgery and antibiotics. He then explains that he is homeless and needs to return to his shelter to keep his bed. He is able to articulate the risks of premature discharge and the medical concerns, and it is determined that he has the capacity to participate in discharge planning. The hospitalist therefore discharges him AMA.
Background
AMA discharges represent 1%–2% of all inpatient discharges.¹,² Despite being a small percentage of total discharges, these patients have disproportionately high healthcare costs. One study reported that healthcare costs among these patients were 56% higher than expected.² Furthermore, AMA patients suffer higher than expected rates of morbidity, mortality, and hospital readmission.
For example, in one case-control study in an urban teaching hospital, patients discharged AMA from the general medicine service had a 21% 15-day readmission rate compared to a 3% readmission rate among age, gender, and diagnosis-matched controls.3,4,5
Additionally, history of AMA discharge appears to confer risk of increased future utilization of healthcare resources. In a cohort study of hospital admissions among HIV-infected patients with high rates of intravenous drug abuse, patients discharged AMA (13% of the cohort) were not only more likely to be readmitted within 30 days for a related diagnosis (odds ratio = 5.0) but also were more likely to have increased length of stay during the year following the index admission.6
These studies highlight the barriers to safe and effective transitions of care for this vulnerable population and demonstrate the increased burden that this population places on the health system.
Several retrospective studies have identified psychosocial and demographic risk factors associated with AMA discharge. These include younger age, male sex, substance abuse, lack of a primary care physician or health insurance, and history of previous AMA discharge.1,3,7,8 Insurance status is also associated with AMA discharge, with increased odds of AMA discharge among Medicare and Medicaid patients and patients without health insurance.9,10