By Carolyn Crist

(Reuters Health) – Patients who discharge themselves from the hospital against medical advice are twice as likely to be back within 30 days as those who leave when doctors say they’re ready, a large U.S. study finds.

“Discharges against medical advice are a common occurrence among inpatients in the U.S., affecting 1 to 2 percent of discharges,” said the study’s author Dr. Nilay Kumar of the University of the Wisconsin School of Medicine and Public Health in Madison.

Patients discharged against medical advice tend to be young males with a low socioeconomic status, substance abuse, mental health disorders and no health insurance coverage, he added.

“They tend to leave against medical advice repeatedly and get readmitted to different hospitals within that 30-day period,” Kumar told Reuters Health by email.

To see how leaving the hospital against medical advice influenced the odds of ending up hospitalized again, Kumar analyzed data on 23 million hospitalizations of patients over age 18. The data, from 2014, covered 22 states and more than 2,000 hospitals, he notes in the American Journal of Medicine.

Kumar found that 2.4. million hospitalizations, or about 10 percent, had at least one unplanned readmission within 30 days. In addition, about 290,000, or 1.3 percent, resulted in a discharge against medical advice.

About 20 percent of patients discharged against medical advice had a readmission within 30 days as compared with 10 percent of patients who had a routine discharge.

Those discharged from one hospital against medical advice were also 2.3 times more likely to be readmitted to a different hospital, and more than 18 times more likely to be discharged against medical advice a second time.

The most common cause of hospital admission for patients who were later discharged against medical advice was alcohol-related disorders, accounting for 9 percent, followed by substance use, skin infections, sepsis and diabetes complications.

“These patients tend to receive fragmented care by way of readmission to different hospitals,” Kumar said. “Discontinuity of care is associated with higher rates of in-hospital mortality and longer hospital stays.”

Overall, the rates of discharge against medical advice ranged widely among hospitals, from zero to 12.5 percent with an average of about 1 percent. About a third of hospitals accounted for two-thirds of the discharges against medical advice, and these hospitals were more likely to have higher numbers of patients, to be located in large metropolitan areas with more than 1 million residents and to be private investor-owned hospitals.

This could be explained by a higher proportion of admitted patients with substance abuse, mental illness and homelessness at these hospitals, Kumar said.

“It’s important to look at patients’ narratives into why they leave the hospital because if we can understand, then we may be able to help,” said Dr. Jeffrey Berger of NYU Winthrop Hospital in Mineola, New York, who wasn’t involved in the study.

Berger, who has written about the ethical and professional obligations associated with discharges against medical advice, cited one case, for example, in which an older male patient wanted to leave early so he could return home to feed his dog. In another case, an elderly man needed to take care of his wife with mental health issues.

“It’s important to recognize that behavioral health is often not supported in communities across the country,” Berger said in a phone interview. “It adds insult to injury when we leave patients and their families without adequate care, especially as they’re heading out the door of our hospital.”

SOURCE: American Journal of Medicine, online February 1, 2019.