Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission

J Gen Intern Med. 2010 Sep;25(9):926-9. doi: 10.1007/s11606-010-1371-4. Epub 2010 Apr 28.


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.

Design: A 5-year retrospective cohort of all patients discharged from a Veterans Administration (VA) hospital.

Subjects: 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.

Measurements: 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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Cohort Studies
  • Female
  • Hospitals, Veterans / statistics & numerical data*
  • Humans
  • Iowa / epidemiology
  • Male
  • Middle Aged
  • Mortality*
  • Patient Discharge / statistics & numerical data*
  • Patient Readmission / statistics & numerical data*
  • Retrospective Studies
  • Treatment Refusal / statistics & numerical data*
  • Young Adult