Patients Leaving California Hospitals Against Medical Advice
In 2023, there were 71,552 discharges against medical advice in California, representing 2.8% of all discharges.
Why Are Patients Who Leave California Hospitals Against Medical Advice Important?
A patient is defined as leaving a California hospital against medical advice (AMA) when they choose to leave the hospital before the treating physician recommends discharge. Patients leaving AMA are exposed to higher risks due to inadequately treated medical issues, which may result in the need for readmission.
The first visualization compares readmission rates of patients readmitted after leaving AMA compared to those who did not previously leave AMA. The readmission rates are displayed by the number of days between the previous discharge and the subsequent readmission.
In the second visualization, discharges can be compared side by side across groups, including percent of AMA discharges and percent of all discharges. Patient encounters where the patient left against medical advice multiple times (more than once) are also displayed. The percent of AMA discharges more than once is the count of AMA discharges where the patient left against medical advice more than once divided by the total count of AMA discharges more than once for that category. The visualization can be filtered by seven key categories: admission type, age, assigned sex at birth, expected payer, homeless status, primary diagnosis, and race/ethnicity group. When the percentage of AMA discharges is higher than percentage of all discharges for a subcategory, then a disproportionately high number of discharges are AMA for that subcategory. However, when the percentage of AMA discharges is lower than the percentage for all discharges, then a disproportionately low number of discharges are AMA for that subcategory.
Key Findings – 2023
- In 2023 data, patients who leave the hospital AMA tend to have higher readmission rates than patients who were discharged by a healthcare provider. 9.9% of patients discharged AMA were readmitted within a day, as opposed to 0.9% of patients whose discharge was consistent with clinical recommendations.
- Admissions from the emergency department account for less than half of all discharges (47.7%), but are overrepresented in AMA discharges. ED admissions make up 59.0% of AMA discharges and 63.4% of AMA discharges more than once.
- Patients aged 65 and over comprise most discharges (46.7%) but represent a smaller proportion of patients leaving AMA (20.1%) and AMA more than once (13.9%). In comparison, patients aged 40-64 represent a greater proportion of AMA discharges (49.0%) and AMA discharges more than once (55.6%) compared to their proportion of all discharges (29.7%).
- Despite making up less than half of all discharges (45.3%), male patients represent a majority of AMA discharges (64.3%) and AMA discharges more than once (70.4%).
- Although Medicare patients comprise most of total discharges (47.5%), Medi-Cal patients have greater AMA discharges (54.9%) and discharges more than once (64.8%).
- Patients experiencing homelessness represent a greater proportion of patients who leave AMA (19.4%) and more than once (28.4%) compared to total discharges (4.4%).
- Patients leaving AMA are much more likely to have a primary diagnosis related to sepsis, substance use disorders, hypertensive heart disease, diabetes, and chronic obstructive pulmonary disease (COPD), compared to patients who do not leave AMA. Substance use disorders make up a disproportionately high percentage of patients who leave AMA (23.2%) and more than once (22.0%), compared to total discharges (4.4%). In comparison, maternal discharges make up a disproportionately low number of patients who leave AMA (3.0%) and more than once (1.1%) relative to total discharges (23.6%).
- From 2019-2023, maternal care (labor/delivery) had a decreased share of all discharges. However, the proportion of AMA discharges and AMA discharges more than once stayed relatively consistent for maternal care.
- Overall, hypertensive heart disease increased as a proportion of AMA discharges and AMA discharges more than once from 2019-2023.
- Black patients have a disproportionately high percentage of AMA discharges (16.1%) and AMA discharges more than once (19.7%) compared to total discharges (9.4%).
Visualization
How HCAI Created This Product
- The Patients Leaving California Hospitals Against Medical Advice data product was created using HCAI’s Patient Discharge Data (PDD) for the years 2019-2023.
- Records of patients who left against medical advice were identified when their disposition was listed as: “left against medical advice” or “discontinued care.”
- The ten primary diagnoses used in the visualizations represent the most common diagnoses present across all discharges as well as AMA discharges in 2019-2023. The primary diagnosis uses International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and code groupings to determine categorization. The ICD-10-CM is a system used by healthcare providers to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care.
- From 2019 to 2022, “homeless” encounters were identified by an ICD-10-CM diagnosis code of “Z59.0” (homelessness) in any diagnosis position and/or patient ZIP code of “ZZZZZ” (homeless). For 2023, homeless encounters were identified with the homeless indicator = “Y”.
Glossary
Expected Payer: The payer type that was expected to pay the greatest share of the patient’s bill at the time of discharge, not the payer type that actually paid.
| Payer Groupings | Inpatient Discharges |
|---|---|
| Medicare: A federal health insurance program funded by the Centers for Medicare & Medicaid Services (CMS) under the Social Security Amendments of 1965 that provides healthcare benefits to those aged 65 years and over and to disabled beneficiaries of any age. Includes Medicare Advantage and Medicare Fee-for-Service (Traditional Medicare) | Medicare |
| Medi-Cal: A public health insurance program that provides free or low-cost medical services and healthcare benefits to low-income individuals, financed from state and federal funds; California’s version of Medicaid. Includes Medi-Cal Managed Care and Medi-Cal Fee-for-Service. | Medi-Cal |
| Private Health Insurance: Coverage by private, non-profit or commercial health plans or through organizations. Includes individual coverage purchased through Covered California, and organized charity payers (e.g., March of Dimes, Shriners). | Private Coverage |
| Other Government: Public insurance programs other than Medicare or Medi-Cal, including federal, state, county and veteran-specific programs. | County Indigent, Other Government |
| Self-Pay or Uninsured: Coverage where the greatest share of the patient’s bill is not expected to be paid by any other form of insurance or health plan. Includes uninsured patients, as well as instances when insurance does not cover the treatment, or the patient would like to keep the medical procedure private. | Other Indigent, Self-Pay |
| All Other Payers: Includes payers not categorized elsewhere: Workers’ Compensation, Automobile Medical, disability insurance, third-party payment not included in any other category or stays for which no payment will be required by the facility (e.g. courtesy patients). | Workers’ Compensation, Other Payer |
Type of Admission: The priority of inpatient admission.
| Type of Admission | Definition |
|---|---|
| Elective | The patient’s condition permits adequate time to schedule the services. |
| Emergency | The patient requires immediate medical intervention as the result of severe, life threatening or potentially disabling conditions. Medical intervention means that there is an intent to modify an outcome and/or treat a medical condition. |
| Urgent | The patient requires immediate attention for the care and treatment of a physical or mental disorder. Medical attention refers to the immediate care that is given before treatment to address a patient’s most critical problems like cardiac distress, respiratory distress, and/or bleeding. |
Additional Information
Topic: Healthcare Utilization
Source Link: Department of Health Care Access and Information: Patient Discharge Data
Citation: HCAI – Patient Discharge Data – Patients Leaving California Hospitals Against Medical Advice, 2019-2023
Temporal Coverage: 2019-2023
Spatial/Geographic Coverage: Statewide
Frequency: Annually