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The impact of leaving against medical advice on hospital resource utilization
R Saitz1, W A Ghali, M A Moskowitz
1Health Care Research Unit, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA 02118, USA. rsaitz@bu.edu
Insights
Discharge against medical advice (AMA) significantly impacts the perceived cost and length of hospital stays for alcoholism. Failing to account for AMA discharges underestimates the true resource utilization associated with alcohol-related diagnoses.
Area of Science:
- Health Services Research
- Public Health
- Healthcare Management
Background:
- Alcohol-related diagnoses (ARD) contribute to healthcare utilization.
- Discharge against medical advice (AMA) is a factor in patient disposition.
- Understanding the impact of AMA on ARD-related costs and stay length is crucial for accurate resource allocation.
Purpose of the Study:
- To evaluate how hospital discharge against medical advice (AMA) influences the assessment of charges and length of stay linked to alcoholism.
- To determine if accounting for AMA discharges alters the interpretation of resource utilization in patients with alcohol-related diagnoses.
Main Methods:
- Retrospective cohort study of 23,198 pneumonia hospitalizations.
- Three analytical strategies were employed: 1) no adjustment for AMA, 2) adjustment for AMA, and 3) exclusion of AMA discharges.
- Multivariate regressions assessed the effect of alcohol-related diagnoses (ARD) on risk-adjusted utilization.
Main Results:
- Patients with ARD experienced higher hospital charges and longer lengths of stay when AMA discharges were accounted for or excluded.
- Adjusting for AMA discharges revealed a 28-29% increase in charges and a 67% increase in length of stay attributable to ARDs compared to analyses not accounting for AMA.
- ARDs were associated with a $1,293 increase in charges and a 0.6-day increase in stay when AMA was not considered.
Conclusions:
- Discharge against medical advice (AMA) significantly affects the interpretation of alcoholism's impact on healthcare utilization.
- Analyses that adjust for or exclude AMA cases show a greater ARD-attributable utilization.
- Failure to account for AMA discharges leads to an underestimation of alcoholism's true effect on 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 AMA resulted in an underestimation of the impact of alcoholism on resource utilization.