Discharge against Medical Advice
August 8, 2019 | Healthcare Risk, Quality, & Safety Guidance
A discharge against medical advice (AMA) can be loosely defined as any discharge from a care setting prior to the time authorized for discharge by the healthcare provider responsible for the patient's care. This can include patients formally discharged AMA, as well as patients who leave without a discharge process. There are also cases in which patients leave without being seen by a medical provider, but that subject is outside the scope of this guidance article (see Patients Who Leave without Being Seen for more information).
Although discharges AMA constitute a small percentage of an acute care facility's overall discharges, they pose large potential liabilities for the facility and staff. These liabilities can include civil damages for patient injuries, accreditation issues, and licensing issues for staff and the facility.
In one very large study, the overall rate of discharge AMA was determined to be 1.44% of discharges from hospitals (Ibrahim et al.). This constitutes approximately 1 in 70 discharges and 500,000 patients per year nationwide (Ibrahim et al.; Southern et al.). In a large study of 148,000 inpatients at an academic medical center, the rate of discharge AMA was found to be 2.4% (Southern et al.). One literature survey noted that between 1% and 2% of hospitalized patients leave the hospital AMA, but the proportion is highly variable, ranging from 0.6% in rural hospitals to 13% in inner city hospitals, and from 0.1% among postpartum patients to 51% for patients in anorexia nervosa inpatient treatment programs (Kraut et al.). Another literature review concerning discharges AMA among persons who use illicit drugs found 13 studies that identified substance misuse as a significant predictor of leaving the hospital AMA. The prevalence of leaving the hospital AMA ranged from 25% to 30% in these studies (Lianping and Lianlian).
The characteristics of patients discharged AMA have also been extensively studied. Studies have demonstrated that patients discharged AMA are more likely to be younger, to be male, to lack private insurance, to have substance use disorder or psychiatric diagnoses, and to have fewer medical comorbidities compared with patients with planned discharges (Southern et al.). One of the primary predictors of patient propensity to leave AMA is having been discharged AMA previously (Kraut et al.).
There are distinct consequences for people who are discharged AMA. One study found a sevenfold increase in the readmission rate for patients discharged AMA compared with patients who were discharged at the appropriate time (Hwang et al.). Patients who had experienced myocardial infarction (MI) and were discharged AMA had a 60% higher risk for death, readmission for MI, or unstable angina up to two years after discharge compared with patients who were discharged in the standard manner (Fiscella et al.). Patients with asthma who were discharged AMA had a fourfold increased risk of readmission to the emergency department within 30 days and a threefold increased risk of readmission to the hospital within 30 days (Baptist et al.). One case-controlled study found a 2.51-fold increase in mortality among patients discharged AMA...