Patient-Physician Sex Discordance and "Before Medically Advised" Discharge from Hospital: A Population-Based Retrospective Cohort Study

Abstract

Background: Patient-physician sex discordance (when patient sex does not match physician sex) has been associated with reduced clinical rapport and adverse outcomes including post-operative mortality and unplanned hospital readmission. It remains unknown whether patient-physician sex discordance is associated with "before medically advised" hospital discharge (BMA discharge; commonly known as discharge "against medical advice").

Objective: To evaluate whether patient-physician sex discordance is associated with BMA discharge.

Design: Retrospective cohort study using 15 years (2002-2017) of linked population-based administrative health data for all non-elective, non-obstetrical acute care hospitalizations from British Columbia, Canada.

Participants: All individuals with eligible hospitalizations during study interval.

Main measures: Exposure: patient-physician sex discordance.

Outcomes: BMA discharge (primary), 30-day hospital readmission or death (secondary).

Results: We identified 1,926,118 eligible index hospitalizations, 2.6% of which ended in BMA discharge. Among male patients, sex discordance was associated with BMA discharge (crude rate, 4.0% vs 2.9%; adjusted odds ratio [aOR] 1.08; 95%CI 1.03-1.14; p = 0.003). Among female patients, sex discordance was not associated with BMA discharge (crude rate, 2.0% vs 2.3%; aOR 1.02; 95%CI 0.96-1.08; p = 0.557). Compared to patient-physician sex discordance, younger patient age, prior substance use, and prior BMA discharge all had stronger associations with BMA discharge.

Conclusions: Patient-physician sex discordance was associated with a small increase in BMA discharge among male patients. This finding may reflect communication gaps, differences in the care provided by male and female physicians, discriminatory attitudes among male patients, or residual confounding. Improved communication and better treatment of pain and opioid withdrawal may reduce BMA discharge.

Keywords: discharge before medically advised; hospitalization [MeSH]; patient discharge [MeSH]; patient-initiated discharge; patient-physician sex discordance.; unplanned hospital readmission [MeSH].