Patients leaving hospital against medical advice more likely to be readmitted or die

People who leave hospital against their doctors' orders are more likely to be readmitted to hospital or die, according to a new study in CMAJ (Canadian Medical Association Journal).

"Leaving the hospital against medical advice was associated with increased risks of readmission to hospital and death that persisted for at least 6 months," writes Dr. Allan Garland, Faculty of Medicine, University of Manitoba, Winnipeg, with coauthors. "Potential mechanisms for these associations directly related to the patients' acute illness include more severe illness or incomplete treatment of the illness."

Researchers looked at 1 916 104 adult admissions and live discharges over almost 20 years (1990) in Manitoba to determine rates of unplanned admission to hospital within 30 days and death within 90 days after discharge. There were 21 417 (1.1%) instances of patients leaving hospital against medical advice. People who left hospital against medical advice had 3 times the rate of readmission in the month following. Of readmissions within 30 days among patients who left hospital against medical advice, one-quarter occurred within 1 day and 75% within 2 weeks. People who were older, male, of lower socioeconomic status and who had multiple admissions to hospital in the preceding 5 years were more likely to be readmitted. The odds of death within 90 days were two and a half times higher for people who left hospital against medical advice.

"For both hospital readmission and death, the elevated rates among patients who left against medical advice started out high and then declined, but remained elevated to at least 180 days," write the authors.

They suggest that these elevated levels of risk may be linked to both the illness for which the patients were admitted to hospital or to their characteristics or health behaviors, such as not following medical advice or medication orders.

Other smaller studies exist, but his study was large, with more than 21 000 instances of patients leaving hospital against medical advice.

"Although strategies targeted at trying to convince patients not to leave prematurely might diminish the early effects of leaving against medical advice, reducing the persistently elevated risk will likely require longitudinal interventions extending beyond hospital admission," conclude the authors.