Study reveals factors associated with hospital discharges against doctors' advice

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. Also, some of these factors are more pronounced in older versus younger individuals. The findings, which are published in the Journal of the American Geriatrics Society, may help healthcare providers address this growing problem.

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, analyzed national data on all US hospitalizations. They were especially interested in differences for patients aged >65 years compared with those aged 18-64 years.

Their analysis, which included more than 29 million hospital stays listed in the 2013 National Inpatient Sample, revealed that >50,000 older adults in the hospital (out of 12 million people under hospital care overall) left the hospital against medical advice that year; however, older men and women were 4 times less likely to do so than people aged 18-64 years. From 2003 to 2013, rates increased in those aged 18-64 from 1.44% to 1.78%, and in those aged ?65 from 0.37% to 0.42%. 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," said Dr. Poeran. "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."

The investigators noted that 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 these 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 study team's senior clinician. "This information will be important in order for hospitals and healthcare providers to address this issue."