Study Identifies Factors Associated With Hospital Discharges Against Doctors’ Advice

Authors analyze 29 million hospital stays

A new study has found that certain factors are linked with a person’s decision to leave the hospital against the advice of his or her care provider. Some of these factors are more pronounced in older versus younger individuals. The findings, which were published in the Journal of the American Geriatrics Society, may help health care providers address this growing problem, according to the authors.

Discharge against medical advice is linked with an increased risk of hospital readmission, higher morbidity and mortality, and increased costs. To examine the factors involved, a team led by Jashvant Poeran, MD, PhD, of the Icahn School of Medicine at Mount Sinai in New York City, analyzed national data on all U.S. hospitalizations. They were especially interested in differences between patients 65 years of age or older and those aged 18 to 64 years.

Their analysis, which included more than 29 million hospital stays listed in the 2013 National Inpatient Sample, found that more than 50,000 older hospitalized adults (out of 12 million people under hospital care overall) left their hospitals against medical advice that year; however, older men and women were four times less likely to do so than people 18 to 64 years of age. From 2003 to 2013, rates increased from 1.44% to 1.78% in those aged 18 to 64 years, and from 0.37% to 0.42% in those 65 years of age or older.

In both age groups, men, people insured by Medicaid or those without health insurance, and individuals living with mental health concerns had the highest risks of leaving the hospital against medical advice. In older adults, race/ethnicity and poverty were more pronounced as risk factors, with older African-American individuals at 65% increased risk and low-income older people at 57% increased risk of leaving the hospital against medical advice.

“One of the reasons mentioned in previous studies for leaving the hospital against medical advice is suboptimal communication, which may indeed affect older minority patients more,” Poeran said. “More research is needed to find out why exactly race/ethnicity and poverty are more pronounced as risk factors in older patients, especially since Medicare theoretically offers universal health coverage for patients aged 65 years or older.”

According to the investigators, the findings are an important first step to additional studies that seek to determine the exact reasons why people may leave the hospital against medical advice and how those reasons differ between older and younger individuals.

“The patients’ social supports and functional and cognitive abilities were not measured in the original sample. Each of these could influence an older person’s ability to leave the hospital against medical advice,” said Rosanne Leipzig, MD, PhD, the team’s senior clinician. “This information will be important in order for hospitals and health care providers to address this issue.”

Source: Wiley; June 19, 2017.