Hospitalized patients with asthma who leave against medical advice: Characteristics, reasons, and outcomes

Article Outline

• Abstract
• Methods
  • Study site
  • Sample selection
  • Study design
    • Patient characteristics
    • Reasons for leaving AMA
    • Outcomes of patients who leave AMA
  • Statistics
• Results
  • Rate of AMA discharge
  • Patient profile
  • Reasons for leaving AMA
  • Outcomes of patients who leave AMA
• Discussion
• References
• Copyright

Background

A discharge against medical advice (AMA) after an asthma hospitalization is a frustrating problem for health care providers, yet little is known about this occurrence.

Objective

To determine the baseline characteristics, reasons for leaving, and clinical outcomes of patients with asthma who leave AMA.

Methods

A retrospective study from 1999 to 2004 of all asthma discharges from 3 large hospitals in Detroit compared those who left AMA with those who left with medical approval.

Results

There were 180 patients who left AMA and 3457 patients who had a standard discharge. Patients with asthma who left AMA were more likely to be younger, male, have Medicaid or lack insurance, require intensive care unit admission, and have a lower socioeconomic status than patients with asthma discharged with approval (P < .05 for all comparisons). There was no difference in race, day of the week admitted, or month admitted. Among records that documented a reason for leaving AMA, the most common was dissatisfaction with care, although a variety of motives were found. Finally, patients who left AMA were more likely to have an asthma relapse within 30 days. This included both emergency department revisits (21.7% vs 5.4%; P < .001) and readmission to the hospital (8.5% vs 3.2%; P < .001).

Conclusion

Patients with asthma who leave AMA have demographic and hospital admission characteristics that differ from those who leave with approval. The reasons why patients with asthma leave AMA are varied. Within 30 days, patients with asthma who leave AMA have much higher readmission and emergency department return rates.

Clinical implications

Patients with asthma who leave AMA are at increased risk of relapse.

Key words: Asthma, against medical advice, relapse, recurrence, patient readmission, patient discharge, socioeconomic status, insurance, health

Abbreviations used: AMA, Against medical advice, DMC, Detroit Medical Center, ED, Emergency department, HR, Hazard ratio, ICU, Intensive care unit, WSU, Wayne State University

The purpose of a hospitalization is provision of care for patients who require more intensive management than can be administered in an ambulatory setting. Unfortunately, some patients choose to leave the hospital before it is medically safe or advisable to do so. Because the patient is leaving against medical advice (AMA), it is assumed that further care is still necessary. In the absence of care, these patients may be susceptible to potentially serious consequences including permanent disability and death. In addition, patients who leave AMA may utilize a disproportionate amount of health care resources if they require repeat urgent or emergent care after discharge.¹, ²

Previous studies have examined AMA discharges after hospitalization for a variety of conditions, including pneumonia,³ substance abuse,⁴ HIV infections,⁵ cardiac dysfunction,⁶ and admission to a general medicine ward.⁷ These studies found that factors such as age, race, insurance status, substance abuse, and psychiatric illness may be associated with patients who decide to leave AMA. However, these factors were not consistent and appear to vary by medical condition for which the patient was hospitalized. Rates of AMA discharge also differed widely across conditions. For example, these studies reported that 0.6% of patients admitted to a general medicine ward, 1.2% of patients admitted for pneumonia, 13% of patients admitted for HIV infection, and 23% of patients admitted for substance abuse left AMA. To our knowledge, no studies have examined AMA discharges in patients admitted with a principle diagnosis of asthma.

Asthma is one of the most prevalent chronic diseases in the United States.⁸ It frequently begins in childhood and can continue into adulthood.⁹, ¹⁰ The length of stay for an asthma hospitalization is often shorter than that for other chronic conditions.¹¹, ¹² Therefore, the outcomes, rationale, and factors associated with leaving AMA from an asthma admission may be different than those for other medical conditions. Our hypothesis was that hospitalized patients with asthma who leave AMA have identifiable demographic and socioeconomic characteristics, that there are recurring reasons why patients elect to leave AMA, and that patients with asthma who leave AMA are more likely to return to the emergency department (ED) or require readmission to the hospital.

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Methods 

Study site 

Wayne State University (WSU) is located in Detroit, Michigan. The Detroit Medical Center (DMC) is a complex of medical facilities affiliated with WSU and is the teaching and clinical research site for WSU School of Medicine. Three large DMC hospitals (Detroit Receiving Hospital, Harper University Hospital, and Sinai-Grace Hospital) were selected for this study to give a more comprehensive representation of patients with asthma. These 3 hospitals serve both the city and the immediate surrounding suburbs of Detroit. A central computing system stores and links data for all hospitalizations at any of the DMC facilities.

Sample selection 

From January 1, 1999, through December 31, 2004, we identified 6853 discharges of patients older than 18 years with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision, code 493.x). Of these, 25 patients expired in the hospital and were excluded. The remaining 6828 discharges were divided into 2 groups: those who left AMA and those discharged with medical approval. To avoid double-counting of patients with multiple admissions, only the first admission was included for analysis. If a patient with multiple admissions had both AMA as well as approved discharges, the patient was included only in the AMA group. We determined that 180 patients accounted for 255 AMA discharges. There were 6573 approved discharges, accounted for by 3457 unique individuals (Fig 1).

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• Fig 1. 

  Study design.

Study design 

Using a case-control study design, patients who were discharged with a primary diagnosis of asthma and left AMA (cases) were compared with those who were discharged with approval (controls). Demographic information, including biological characteristics and socioeconomic status, as well as hospital admission data were obtained. Biological characteristics that were collected included age, sex, and race/ethnicity. The socioeconomic status for each patient was estimated by entering the patient's zip code into the US Census Bureau Web site and retrieving the corresponding household income and high school graduation rate for the fiscal year 2000.¹³ Previous studies report that zip code analysis provides a reliable estimate of socioeconomic status.¹⁴, ¹⁵ Insurance status was classified as uninsured, Medicaid, Medicare, or private. Finally, pertinent information from the hospital admission was collected. These data included admission to the intensive care unit (ICU), intubation, month admitted, day of the week admitted, source of admission (ED vs other), and length of stay.

To determine the reasons for leaving AMA, 150 medical records of patients who left the hospital AMA were reviewed for any documentation of why the patient chose to leave. The remaining 30 medical records could not be located by the medical records department after multiple attempts. Two research assistants trained specifically on chart review techniques carefully perused both physician and nursing notes. One of the authors (A. P. B.) analyzed the first 10 charts reviewed by each research assistant to verify accuracy in documentation and recording. The reason for leaving was documented, and responses were grouped into common categories for analysis and reporting.

A retrospective cohort study was performed to identify possible adverse outcomes associated with an AMA discharge. Two cohorts were identified by discharge status: AMA and discharge with approval, as described. Both cohorts were followed for 30 days postdischarge for (1) readmission to the hospital for asthma and (2) return visit to the ED for asthma. A Kaplan-Meier survival analysis was constructed to compare the 2 groups. Proportion of patients readmitted was plotted against time since discharge. Separate analyses were performed for ED returns and for inpatient readmissions. Because the 3 hospitals use a linked computer database, an asthma relapse at any of the participating hospitals could be tracked.

Statistics 

In the case-control analysis, we compared the selected characteristics of those patients who left AMA (cases) with those patients who left with approval (controls) using χ² and Wilcoxon rank-sum tests as appropriate. We next used multivariate logistic regression to model the correlates of AMA discharges. We included all biological, socioeconomic, and hospital admission characteristics that were found to be significant (P < .05) in bivariate comparisons using backward elimination. Results from this model are reported as an odds ratio with a 95% CI.

In the retrospective cohort analysis, we constructed Kaplan-Meier curves to examine time to readmission. The log-rank test was used to compare the 2 curves. Finally, Cox regression models were used to identify variables associated with readmission among all patients to the ED and to the inpatient hospital setting. All statistic analyses were performed by using the SPSS statistical package, version 14.0 (SPSS Inc., Chicago, Ill).

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Results 

Rate of AMA discharge 

From 1999 to 2004, there were 6828 asthma discharges, of which 255 (3.7%) left AMA. During the same time period, for all patients above the age of 18 admitted for any nonasthma diagnosis, the aggregate AMA discharge rate was 2.1%. The odds ratio for leaving AMA after an asthma hospitalization compared with a nonasthma hospitalization was 1.86 (95% CI, 1.63-2.11).

To avoid double-counting, we determined that the 3637 unique individuals accounted for the 6828 asthma discharges (Fig 1). Among this group of unique individuals, 180 (4.9%) were found to have left AMA. During the study period, 29.4% of AMA patients had more than 1 AMA discharge.

Patient profile 

Table I summarizes the characteristics of patients discharged with a primary diagnosis of asthma. Compared with controls, patients who left the hospital AMA were younger, were more likely to be male, were less likely to have graduated from high school, had a lower household income, were more likely to have Medicaid or be uninsured, were more likely to require admission to the ICU, were more likely to require intubation, and were more likely to be admitted through the ED. There was no difference in race/ethnicity between the 2 groups. In addition, there was no difference in month admitted (P = .469) or day of the week admitted (P = .369) between AMA and control patients.

Table I. Characteristics of patients discharged AMA

Patient characteristic	AMA (n = 180)	With approval (n = 3457)	P value∗
Biological characteristics
Sex, male, % (n)	44.4 (80)	30.1 (1041)	<.001
Age, years (SD)	40.2 (12.4)	47.8 (16.0)	<.001
Age by decade, % (n)			<.001
18-30	22.2 (40)	15.5 (536)
31-40	29.4 (53)	18.5 (639)
41-50	26.1 (47)	26.2 (906)
51-60	17.8 (32)	19.1 (660)
>60	4.4 (8)	20.7 (716)
Race, % (n)			.220
Black	83.9 (151)	87.9 (3038)
White	10.0 (18)	6.8 (235)
Other (Hispanic, Asian, other, missing)	6.1 (11)	5.3 (184)
Socioeconomic characteristics
High school graduation rate, % (SD)	68.6 (8.3)	70.0 (8.3)	.020
Median household income, dollars (SD)	26924 (8992)	29342 (9283)	.002
Median household income by strata, % (n)			.011
<$20,000	13.6 (24)	7.8 (259)
$20,001 to $30,000	50.6 (89)	48.0 (1600)
$30,001 to $40,000	24.4 (43)	27.5 (916)
>$40,001	11.4 (20)	16.8 (561)
Insurance status, % (n)			<.0001
Uninsured	28.9 (52)	13.7 (472)
Medicaid	29.4 (53)	24.4 (845)
Medicare	14.4 (26)	21.0 (727)
Private (Blue Cross, commercial, HMO, PPO)	27.2 (49)	40.9 (1413)
Hospital admission characteristics
Admitted to ICU, % (n)	14.4 (26)	6.3 (219)	<.001
Required intubation, % (n)	7.2 (13)	3.6 (124)	.013
Admitted through ED, % (n)	96.1 (173)	91.9 (3176)	.040
Length of stay, median days (25th to 75th percentile)	1 (1-2)	3 (2-4)	<.001

By using a multivariate analysis to control for confounding, we found that younger age, male sex, household income less than $20,000, insurance status (Medicaid or uninsured), and admission to the ICU were all independently associated with increased odds of discharge against medical advice (Table II).

Table II. Multivariate analysis of factors associated with an AMA discharge

Variable	Odds ratio (95% CI)
Age (per decade increase)	0.74 (0.65-0.85)
Male sex	1.69 (1.22-2.32)
Household income∗
Income <$20,000	2.69 (1.16-6.26)
Insurance/payer status†
Uninsured	2.17 (1.41-3.32)
Medicaid	1.82 (1.20-2.74)
Admitted to ICU	2.04 (1.24-3.37)

Reasons for leaving AMA 

No reason for leaving AMA was reported in 64 (42.7%) of the 150 medical records reviewed (Table III). In addition, 23 (15.3%) AMA patients left without notifying anyone of their decision. Of the remaining 63 patients, the most common reason for leaving AMA was dissatisfaction with care. Complaints in this subgroup included dissatisfaction with not receiving narcotics, complaints of having to wait to see a physician, and unwillingness to consent to repeated blood tests.

Table III. Reasons for leaving AMA

The next 2 most frequently stated reasons for leaving AMA were patients who felt better and patients with family obligations/concerns (n = 11, 7.3% for both subgroups). Family obligations included items such as care of a sick child as well as care of other family members at home. Eight patients (5.3%) left because of employment or financial reasons, and 10 patients (6.7%) left because of personal reasons. The latter included issues with transportation, wanting to attend a church service, judicial court obligations, and wanting to go a party.

Outcomes of patients who leave AMA 

At 30 days, return rate to the ED for asthma was significantly higher in the AMA group than in the control group (Fig 2). Although only 5.4% of patients who were discharged with approval returned to the ED within 30 days, 21.7% of those discharged AMA did so (P < .001 by the log-rank test). In the Cox proportional hazards model, 4 factors were found to be significantly associated with return to the ED (Table IV): leaving AMA, male sex, income <$20,000, and ED as the admission source. Of these, leaving AMA had the greatest adjusted hazard ratio (HR).

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• Fig 2. 

  Kaplan-Meier plot of return to the ED. Percent of patients returning to the ED for asthma plotted against time since discharge from the hospital. Significant between-group differences were derived from a log-rank test. ^∗P < .001.

Table IV. Cox proportional hazard model for ED readmission within 30 days

As shown in Fig 3, at 30 days, the readmission rate to the hospital was 3.2% for those discharged with approval compared with 8.5% for those discharged AMA (P < .001 by the log-rank test). In the Cox proportional hazard model, factors found to be significantly associated with readmission at 30 days included leaving AMA (HR = 2.59; 95% CI, 1.41-4.74), male sex (HR = 2.07; 95% CI, 1.42-3.03), income less than $20,000 (HR = 2.72; 95% CI, 1.28-5.76), and older age (HR = 1.20; 95% CI, 1.01-1.40).

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• Fig 3. 

  Kaplan-Meier plot of readmission to the hospital. Percent of patients requiring readmission to the hospital for asthma plotted against time since discharge from the hospital. Significant between-group differences were derived from a log-rank test. ^∗P < .001.

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Discussion 

Asthma exacerbations are one of the most common reasons for ED visits and hospitalizations in the United States.¹⁶, ¹⁷ Although the majority of patients will be discharged with approval of the medical team, the findings of this study reveal that a substantial proportion will leave AMA. We also ascertained that patients with asthma who leave AMA are at a much higher risk of relapse over the period of the subsequent month than those who leave with approval.

The overall rate of leaving AMA after an asthma hospitalization was 1.86 times greater than leaving AMA for all other medical conditions. In addition, our AMA rate of 4.9% is higher than previously published rates for pneumonia (1.2%) and general medicine wards (0.6%), yet lower than patients hospitalized for HIV infections (13%) and substance abuse (23%).³, ⁴, ⁵, ⁷ These data suggest that patients with chronic medical conditions might be at a higher risk for AMA discharge, and that the number of patients leaving AMA differs considerably between conditions. Therefore, grouping patients with asthma with all hospitalized patients when trying to understand and prevent patients from leaving AMA would be inappropriate.

When comparing the baseline characteristics of those who did and did not leave AMA, we noticed some important findings. On both univariate and multivariate analysis, AMA patients were younger and more likely to be male. This is consistent with previous work on AMA patients.³, ⁷, ¹⁸, ¹⁹ However, we did not find an association between race and leaving AMA, in contrast to previous studies that have attributed African American race as a risk factor.², ³ This may be because some of these studies did not account for socioeconomic factors in their analyses.

We did find that socioeconomic factors such as median household income less than $20,000 and an insurance status of uninsured or Medicaid conferred an increased risk of leaving AMA. As has been shown in another study,⁷ when socioeconomic factors are taken into account, the effect of race as a risk factor for leaving AMA is neutralized. Another intriguing result was that patients who were initially admitted to the ICU were twice as likely to eventually leave AMA than those who were not. Therefore, it would be erroneous to assume that patients with more severe asthma will not leave AMA. Finally, we found that nearly 30% of patients with asthma who left AMA had another AMA discharge for asthma over the 6-year study period. This finding illustrates that health care providers should be cognizant of the increased AMA risk in these patients.

When exploring the reasons for leaving AMA, we found an unacceptably high number of charts (42.7%) that had no reason documented. It is unclear whether this was because the patient would not give a reason, the health care providers did not inquire, or a reason was given and not documented in the chart. When reasons were given, the most common reasons included dissatisfaction with care, subjective symptomatic improvement, and family concerns/obligations. Openly addressing such issues might reduce impulsive decision-making and AMA discharges.

One of the most concerning finding of our study was the relapse rate of asthmatics who were discharged AMA. Of patients discharged with approval, we found that 5.4% had a relapse that required a return to the ED within 1 month (Fig 2). This value is similar to the relapse rate for asthma reported in other studies.²⁰, ²¹, ²² However, of the patients who left AMA, the rate quadrupled to 21.7%. The greatest difference seen in relapse rates was in the first 3 days, with 7.2% of the AMA group and only 1.0% of the discharge with approval group returning. However, the difference in relapse rates continued over the entire month, with the curves continuing to deviate from each other. In addition, patients who left AMA were not only more likely to return to the ED but also more likely to be readmitted to the hospital (Fig 3).

Even after adjusting for all other variables, AMA patients were 4 times more likely to return to the ED and 2.5 times more likely to be readmitted than patients with asthma who were discharged with approval. In fact, leaving AMA conferred the greatest risk for returning to the ED. Most previous research on readmission rates has not taken into account AMA discharge status when evaluating factors that predict readmission for asthma.²¹, ²², ²³, ²⁴

There are several limitations to our current study. Although we did use 3 large hospitals in Detroit to try to capture as many patients as possible, we could not identify patients who were readmitted to hospitals outside our system. The urban environment where this study occurred may not be representative of other hospitals facing similar challenges. Because this was a retrospective study, we were limited by the data available for analysis. We also were unable to identify subjects who threatened to leave AMA but were discharged with approval by a healthcare provider who perhaps did not want to put a blemish on the patient's record.

Limitations were also present when we attempted to determine the reasons why asthmatics chose to leave AMA. Of the 180 records, 30 could not be located even after multiple attempts. Also, the fact that 42.7% of charts contained no documented reason for leaving may mean that the most common causes for AMA discharges are actually different that what was found in this study. However, the more frequently documented reasons given by patients with asthma who left AMA were similar to those in other conditions.¹, ²⁵

The results of this study do provide information that may be applied toward patient care and further research endeavors. Previous research for conditions other than asthma has examined interventions to decrease the occurrence of AMA discharges.²⁶, ²⁷, ²⁸, ²⁹, ³⁰ One study found that a patient advocate decreased AMA discharges by 32% from an inpatient psychiatry ward.³⁰ Another study found that social support decreased the rate of AMA discharges among HIV-positive injection drug users.²⁸ If a patient does leave AMA, a telephone follow-up can improve care by assessing patient symptoms, coordinating follow-up care, and reinforcing discharge instructions.²⁹ Further research incorporating a patient-relations specialist, social worker, or follow-up telephone call appears warranted for patients with asthma at risk of an AMA discharge.

In conclusion, we have shown that patients who leave against medical advice after an asthma hospitalization are different than patients who leave AMA for other medical conditions. We have also shown that the reasons for leaving AMA are varied, and include dissatisfaction with care, family obligations, subjective improvement, and others. Finally, we have shown that patients with asthma who leave AMA are at a much higher risk for relapse over the following month. Further research is needed to devise strategies capable of decreasing the rate of AMA discharges after an asthma hospitalization.

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