Outcomes/Effectiveness Research

Leaving hospitals against medical advice puts heart attack patients at substantial risk for rehospitalization or death within 2 years

Patients who have heart attacks and decide to leave the hospital against doctor's orders have a significant chance of either ending up right back in the hospital or dying within 2 years of their walkouts, according to a recent study. Kevin Fiscella, M.D., M.P.H., and colleagues at the University of Rochester School of Medicine, reviewed California hospital discharge data from 1998 to 2000. They found that 1,079 patients (1.1 percent) who came into the hospital after suffering heart attacks left against their doctor's advice. These patients were usually young, male, Black, had low incomes, and had either Medicaid or no insurance. This group only stayed in the hospital an average of 4 days compared with 8 days for patients who had heart attacks but opted to stay put.

Early leavers also were unlikely to transfer to another hospital or receive typical cardiac interventions, such as pacemakers, stents, angioplasty, or bypass surgery. Tracking this group's progress, the team found that nearly 30 percent of the patients were either readmitted with coronary symptoms or died within 90 days of deciding to leave the hospital. Within 2 years, they were nearly 60 percent more likely to be either readmitted to a hospital with similar symptoms or die than those who stayed in the hospital for their full course of treatment.

This study provides clinicians with evidence to persuade patients to remain in the hospital and be fully treated. Further, because these statistics show a real health risk for patients who decide to leave against advice, clinicians can arrange for early followup care if these patients choose to leave the hospital, the authors suggest. This study was funded in part by the Agency for Healthcare Research and Quality (HS10910).

See "Hospital discharge against advice after myocardial infarction: Death and readmissions," by Dr. Fiscella, Sean Meldrum, M.S., and Steve Barnett, M.D., in the December 2007 American Journal of Medicine 120(12), pp. 1047-1053.

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