title: Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission.
abstract: BACKGROUND
  With 1-2% of patients leaving the hospital against medical advice (AMA), the potential for these patients to suffer adverse health outcomes is of major concern.
  
  
  OBJECTIVE
  To examine 30-day hospital readmission and mortality rates for medical patients who left the hospital AMA and identify independent risk factors associated with these outcomes.
  
  
  METHODS
  A 5-year retrospective cohort of all patients discharged from a Veterans Administration (VA) hospital.
  
  
  METHODS
  The final study sample included 1,930,947 medical admissions to 129 VA hospitals from 2004 to 2008; 32,819 patients (1.70%) were discharged AMA.
  
  
  METHODS
  Primary outcomes of interest were 30-day mortality and 30-day all-cause hospital readmission.
  
  
  RESULTS
  Compared to discharges home, AMA patients were more likely to be black, have low income, and have co-morbid alcohol abuse (for all, Chi(2) df = 1, p < 0.001). AMA patients had a higher 30-day readmission rate (17.7% vs. 11.0%, p < 0.001) and higher 30-day mortality rate (0.75% vs. 0.61%, p = 0.001). In Cox proportional hazard modeling controlling for demographics and co-morbidity, the largest hazard for patients having a 30-day readmission is leaving AMA (HR = 1.35, 95% CI 1.32-1.39). Similar modeling for 30-day mortality reveals a nearly significant increased hazard rate for patients discharged AMA (HR = 1.10, 95% CI 0.98-1.24).
  
  
  CONCLUSIONS
  Due to the higher risk of adverse outcomes, hospitals should target AMA patients for post-discharge interventions, such as phone follow-up, home visits, or mental health counseling to improve outcomes.
authors.affiliation: The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP) at the Iowa City VA Medical Center, 601 Highway 6 West, Mailstop 152, Iowa, IA 52246-2208, USA. justin.glasgow@va.gov
authors.forename: Justin M
authors.initials: JM
authors.lastname: Glasgow
authors.forename: Mary
authors.initials: M
authors.lastname: Vaughn-Sarrazin
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kaboli
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D007484:Iowa / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009026:Mortality; D010351:Patient Discharge / Q000706:statistics & numerical data*; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016312:Treatment Refusal / Q000706:statistics & numerical data*; D055815:Young Adult