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Mental illness increases risk for discharge against medical advice

Certain factors, including mental illness, race, low income and being uninsured, were associated with a heightened risk for deciding to leave the hospital against the advice of a health care provider, according to a study published in the Journal of the American Geriatrics Society.

“Discharge against medical advice is associated with greater risk of hospital readmission and higher morbidity, mortality, and costs, but with a rapidly increasing elderly inpatient population, there is a lack of national data on [discharge against medical advice] in this subgroup,” Carlijn Lelieveld, MSc, from Erasmus University in Rotterdam, the Netherlands, and colleagues wrote.

Lelieveld and colleagues analyzed national data on all United States hospitalizations from the 2003 to 2013 National Inpatient Sample (n = 29,290,852) to determine the trends, diagnoses and individual and health care factors associated with hospital discharges against medical advice in elderly patients aged 65 years or older. They compared their results to patients aged 18 to 64 years.

Data indicated that out of 12 million hospitalizations overall, more than 50,000 older adults left the hospital against medical advice in 2013. However, the risk for discharge against medical advice was four times lower in elderly adults than those aged 18 to 64 years. A subtle increasing trend in the rates of discharge was observed in both age groups from 2003 to 2013 — the rate in patients aged 18 to 64 years increased from 1.44% to 1.78% and increased in those aged 65 years and older from 0.37% to 0.42%. The highest risk for discharge against medical advice for both groups was seen in patients hospitalized for mental illness, men, those insured by Medicaid and those without health insurance. More prominent risk factors of discharge against medical advice for elderly adults included race/ethnicity and poverty, with blacks and low income older adults displaying a 65% and 57% increased risk, respectively.

“One of the reasons mentioned in previous studies for leaving the hospital against medical advice is suboptimal communication, which may indeed affect older minority patients more,” Jashvant Poeran, MD, PhD, coauthor from the Icahn School of Medicine at Mount Sinai, said in a related release. “More research is needed to find out why exactly race/ethnicity and poverty are more pronounced as risk factors in older patients, especially since Medicare theoretically offers universal health coverage for patients aged 65 years or older.”

These findings are a crucial initial step in determining the rationale behind why certain patients leave the hospital against medical advice and how it varies between younger and older adults, the researchers noted.

“The patients’ social supports and functional and cognitive abilities were not measured in the original sample. Each of these could influence an older person’s ability to leave the hospital against medical advice,” Rosanne Leipzig, MD, PhD, coauthor also from the Icahn School of Medicine, said in the release. “This information will be important in order for hospitals and health care providers to address this issue.” – by Alaina Tedesco

Disclosure: The researchers report no relevant financial disclosures.