title: Patients leaving against medical advice (AMA) from the emergency department--disease prevalence and willingness to return.
abstract: BACKGROUND
  How patients fare once they leave the emergency department (ED) against medical advice (AMA), and the extent of illness burden that accompanies them, remains unstudied.
  
  
  OBJECTIVE
  To determine the fate of patients leaving the ED AMA for a defined period of time post-discharge.
  
  
  METHODS
  This was a prospective follow-up study of a convenience sample of patients leaving the ED AMA during two 6-month periods in consecutive calendar years at an urban academic ED with 32,000 annual patient visits.
  
  
  RESULTS
  A total of 199 patients were identified, with 194 enrolled. Categories of discharge diagnoses included cardiovascular, undifferentiated abdominal pain, respiratory, and cellulitis. Of the 194 patients studied, 126 patients (64.9%, 95% confidence interval [CI] 57.6-71.5%) stated that their symptoms had improved or resolved. Of these 126 patients, 109 (86.5%, 95% CI 78.9-91.7%) had their original AMA discharge diagnoses referable to cardiovascular pathology. Ninety-five patients (75.4%, 95% CI 66.7-82.4%) with improved or abated symptoms did not plan to return. Of those with improved or abated symptoms, 31 patients (24.6%, 95% CI 17.6-33.2%) did return, and with further evaluation, 15 of them were found to have significant clinical findings. Of the 68 patients with continuing symptoms, 36 (52.9%, 95% CI 40.5-64.9%) returned for further evaluation. A total of 127 patients did not return. Twenty-five patients (19.7%, 95% CI 15.9-25.4%) expressed a reluctance to return to the same ED for fear of embarrassment. Seven patients (5.5%, 95% CI 4.8-8.7%) who did not seek alternative care but were still having symptoms did not return due to job or family commitments or because they would follow-up with a personal physician.
  
  
  CONCLUSIONS
  Patients who leave the ED AMA have significant pathology.
authors.affiliation: Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Jerrard
authors.forename: Rose M
authors.initials: RM
authors.lastname: Chasm
mesh_terms: D000368:Aged; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data; D016312:Treatment Refusal / Q000706:statistics & numerical data*