Characteristics and outcomes of discharges against medical advice among hospitalised patients

Abstract

Background: Discharge against medical advice (DAMA) occurs when an in-patient chooses to leave the hospital before discharge is recommended by the treating clinicians. The long-term outcomes of patients who DAMA are not well documented.

Aim: The objective of this long-term and hospital-wide study is to examine characteristics of patients who DAMA, their rates of readmission and mortality after self-discharge.

Methods: Administrative data of admissions to Flinders Medical Centre between July 2002 and June 2011 were used to compare readmissions and mortality among patients who DAMA with those who did not. The outcomes were adjusted for age, gender, emergency admission status, comorbidity, mental health diagnoses, and alcohol and substance abuse.

Results: In the study period, 1562 episodes (1.3%) of 121,986 admissions to Flinders Medical Centre were DAMA. Compared with those who did not leave against medical advice, these patients were younger, more often male, more likely of indigenous ethnicity and had less physical comorbidity, but greater mental health comorbidity. Half of the DAMA group stayed less than 3 days. In multivariate analysis, the relative risk for 7-day, 28-day and 1-year readmission in the DAMA group was 2.36 (95% confidence interval (CI), 1.99-2.81; P < 0.001), 1.66 (95% CI, 1.44-1.92; P < 0.001) and 1.31 (95% CI, 1.19-1.45; P < 0.001), respectively, compared with standard discharges. Furthermore, DAMA was associated with twofold (P = 0.02), 1.4-fold (P = 0.025) and 1.2-fold (P = 0.049) increase in 28-day, 1-year and up-to-9-year mortality, respectively, compared with non-DAMA.

Conclusions: Patients who self-discharged against medical advice carry a significant risk of readmission and mortality. Patients with characteristics of 'at risk of DAMA' should have greater attention paid to their care before and especially after any premature discharge.

Keywords: discharge against medical advice; hospital medicine; mortality; readmission.