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Who Is Most Likely to Demand Hospital Discharge Against Medical Advice?

Patients who insist on being discharged from the hospital against medical advice have an increased risk of readmission, higher rates of morbidity and mortality, and, ultimately, greater healthcare costs.

A study in the Journal of the American Geriatrics Society provides information that can help hospitals better identify patients at highest risk to leave despite care provider recommendations. A study team led by the Icahn School of Medicine at Mount Sinai in New York reviewed nearly 30 million hospital stays from the 2013 National Inpatient Sample to create a profile of patients most likely to demand premature discharge.

For the study, the group was divided between patients aged 65 and older compared to adults aged 18-64. Data review determined that more than 50,000 hospitalized older adults, out of 12 million people under hospital care overall, left the hospital against medical advice that year. Yet, those patients were four times less likely to do so than patients in the younger cohort.

From 2003 to 2013, rates of unrecommended departure jumped up in those aged 18-64 from 1.44% to 1.78%, while rising 0.37% to 0.42% in patients 65 and older. Across both age groups, patients leaving against medical advice had common characteristics: Medicaid or no health insurance, and mental health concerns.


For older adults, race/ethnicity and poverty appeared to play a bigger role in the risk of leaving the hospital against medical advice. The report noted that older African-American patients were at 65% increased risk and low-income older people were at 57% greater risk of doing that.

"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 corresponding author Jashvant Poeran, MD, PhD, of Icahn. "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."

Coauthor Rosanne Leipzig, MD, PhD, added that future research should try to tease out exactly why the patients are leaving against medical advice and how much of a role is played by functional and cognitive abilities, as well as social support.