Burden of 30-Day Readmissions Associated With Discharge Against Medical Advice Among Inpatients in the United States

Abstract

Background: Discharges against medical advice are common among inpatients in the United States. The impact of discharge against medical advice on readmission rates and subsequent hospitalization outcomes is uncertain. We sought to ascertain the effect of discharge against medical advice on 30-day readmission rates and outcomes of readmission.

Methods: We used the 2014 Nationwide Readmissions Database to identify index hospitalizations among patients older than 18 years of age. The primary exposure variable was discharge against medical advice, and the primary outcome measure was all-cause unplanned 30-day readmission. We used multivariate hierarchical logistic regression modeling to ascertain the effect of discharge against medical advice on 30-day readmission rates.

Results: There were an estimated 23,110,641 index hospitalizations nationwide with an overall unplanned 30-day readmission rate of 10.2%. 1.3% of index admissions resulted in a discharge against medical advice. Patients who were discharged against medical advice were younger (mean age 47.1 years vs 56.5 years, P < 0.001) with a higher proportion of males (61.1% vs 39.5%, P < 0.001) compared with patients with a routine discharge. Discharge against medical advice was associated with significantly higher odds of 30-day readmission (risk-adjusted odds ratio [OR] 2.06, 95% confidence interval [CI] 2.03-2.09, P < 0.001). Discharge against medical advice was associated with higher odds of readmission to a different hospital (OR 2.35, 95% CI 2.22-2.49, P < 0.001) and repeat discharge against medical advice after readmission (OR 18.41, 95% CI 17.46-19.41, P < 0.001). The most common cause of readmission after discharge against medical advice was alcohol-related disorders (9%). Hospital-level rates of discharge against medical advice ranged from 0% to 12.5%.

Conclusions: Discharge against medical advice is associated with over twice the odds of all-cause unplanned 30-day readmission compared with routine discharge. There is large hospital-level variation in rates of discharge against medical advice. Interventions to reduce discharges against medical advice, particularly at hospitals with high rates of such discharges, may reduce the overall readmission burden in this challenging and high-risk patient population.

Keywords: 30-Day readmissions; Discharge against medical advice; Outcomes research.