Written by Kimi Dunbar
Spoon Feed
Patients who are Black or have non-commercial insurance such as Medicaid are more likely to leave against medical advice (AMA); patients who leave AMA are more likely to be readmitted within 14 days.
It’s time to break down barriers
This multicenter retrospective cohort study analyzed 3,672,243 pediatric inpatient encounters across 43 U.S. children’s hospitals (2018–2022) to evaluate factors influencing discharge AMA. Among 0.08% of discharges classified as AMA (n=2,972), Black patients (aOR 1.31, 95%CI 1.19–1.44) and those with noncommercial insurance (e.g., Medicaid, aOR 1.89) had higher odds of leaving AMA, whereas Hispanic patients had lower odds (aOR 0.66). AMA discharge was associated with increased 14-day readmissions (aOR 1.41). Limitations included database coding inconsistencies and exclusion of smaller hospitals.
Why do these disparities exist? The study itself is not designed to answer this question; however, in the discussion, the authors posit some rich hypotheses. Leaving AMA might be associated with increased distrust with the medical system and less frequent shared medical decision-making among Black patients and families. Prior studies have demonstrated that patients from Hispanic backgrounds are more likely to follow their doctor’s recommendations, which may account for the decreased likelihood of leaving AMA. Families with non-commercial insurance such as Medicaid may have increased financial strain and competing responsibilities influencing their desire to discharge sooner, such as challenges related to housing, food, and job insecurity. Interestingly, the most common diagnoses for patients who left AMA were toxic ingestion, mental health diagnoses, and failure to thrive, all diagnoses that are complex and challenging to treat. Hospitalization for such illnesses might feel less productive and therefore less necessary.
How will this change my practice?
This knowledge will change how I approach AMA discharges, although they are quite rare in practice. While further research is needed to better understand this complex issue, there are important key takeaways here: the value of transparency in the treatment plan, shared decision making, and probing for underlying socioeconomic factors that could be impacting care, AMA or otherwise.
Source
Leaving Against Medical Advice From Children’s Hospitals. Pediatrics. 2024 Nov 1;154(5):e2023064958. doi: 10.1542/peds.2023-064958. PMID: 39380538
