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 AMA resulted in an underestimation of the impact of alcoholism on resource utilization.