It can be a hassle to stay in the hospital. Who's going to take care of your house? Your kids? Your pets? And who will pay for the visit if you do not have health insurance or your coverage is insufficient? For these reasons and more, some people choose to leave the hospital against medical advice, and experts say that can lead to less-than-favorable outcomes. A new report from the Agency for Healthcare Research and Quality reveals that people who leave the hospital against doctor's orders are at higher risk of adverse health outcomes and have increased hospital readmission rates, compared with patients who follow doctors' advice.
Still, it's within a patient's right to choose to leave the hospital, even if doctors advise that it's not a good idea. "Medical decisions are a partnership between the patient and the doctor, but the patient is nearly always the final decision maker," says Steven Stack, a member of the board of the American Medical Association and an emergency room physician in Lexington, Ky., who did not participate in the AHRQ research.
There were 368,000 hospital stays in the United States in 2007 that ended when patients left against medical advice, according to the AHRQ report. That was about 1.2 percent of all hospitalizations. The total who left early was up 39 percent from a decade earlier, the report says. Those who left early tended to stay for about 2½ days less than those who followed doctors' orders. People ages 45 to 64 were most likely to leave the hospital against medical advice, and men were more likely to do so than women.
The report notes three categories of people who tend to leave the hospital against doctors' orders:
Patients who are worried about medical bills. As might be expected, the medical bill for those who checked themselves out early was cheaper ($5,300) than those who stayed for the advised length of time ($10,400), according to the AHRQ report. People who lived in poorer communities were more likely to leave the hospital early than those who lived in wealthier communities, the report states. "Some patients just make a reasonable decision from a financial perspective that they don't believe that they can afford to stay in the hospital," Stack says.
Patients with alcohol or substance abuse problems. People who were admitted to the hospital for alcoholism were 11.6 times more likely to leave the hospital against medical advice than other patients, and those admitted for substance abuse disorders were 10.8 times more likely to check themselves out early, according to the AHRQ report. "This is not surprising," Stack says, because patients with addictions "have a particularly strong urge to leave the hospital and get back to the alcohol or the substance that they abuse."
People who have nonspecific chest pain or diabetes with complications. Those who experienced this type of chest pain were 3.6 times more likely to sign out of the hospital against doctors' orders than other patients, and diabetics experiencing complications were 2.7 times more likely to check themselves out.
Patients who check out early may pay a price later. For nonspecific chest pain, especially, it can be risky to leave the hospital before the doctor determines the cause of the discomfort. It can be "very difficult to determine a cause . . . and no one test is a clear and perfect test," Stack says. "Sometimes it takes a couple of days in the hospital to make sure it's not your heart, not your lungs, not an infection." And following doctor's orders is key to preventing complications of diabetes. A 2003 study published in the Canadian Medical Association Journal found that patients who checked out of the hospital against medical advice were more likely than a control group to be readmitted within 15 days. To limit the risk of adverse outcomes, the authors of that study wrote, these patients should be given a follow-up appointment when they leave the hospital and get any necessary prescriptions at that time, too. The authors acknowledged a hurdle: People who leave the hospital against doctors' orders usually don't have a primary-care doctor.