The impact of leaving against medical advice on hospital resource utilization

OBJECTIVE: To assess the effect of hospital discharge against medical advice (AMA) on the interpretation of charges and length of stay attributable to alcoholism. DESIGN: Retrospective cohort. Three analytic strategies assessed the effect of having an alcohol-related diagnosis (ARD) on risk-adjusted utilization in multivariate regressions. Strategy 1 did not adjust for leaving AMA, strategy 2 adjusted for leaving AMA, and strategy 3 restricted the sample by excluding AMA discharges. SETTING: Acute care hospitals. PATIENTS: We studied 23,198 pneumonia hospitalizations in a statewide administrative database. MEASUREMENTS AND MAIN RESULTS: Among these admissions, 3.6% had an ARD, and 1.2% left AMA, In strategy 1 an ARD accounted for a $1,293 increase in risk-adjusted charges for a hospitalization compared with cases without an ARD (p = .012). ARD-attributable increases of $1,659 (p = .002) and $1,664 (p = .002) in strategies 2 and 3 respectively, represent significant 28% and 29% increases compared with strategy 1. Similarly, using strategy 1 an ARD accounted for a 0.6-day increase in risk-adjusted length of stay over cases without an ARD (p = .188). An increase of 1 day was seen using both strategies 2 and 3 (p = .044 and p = .027, respectively) representing significant 67% increases attributable to ARDs compared with strategy 1, CONCLUSIONS: Discharge AMA affects the interpretation of the relation between alcoholism and utilization. The ARD-attributable utilization was greater when analyses adjusted for or excluded AMA cases, Not accounting for leaving BMA resulted in an underestimation of the impact of alcoholism on resource utilization.