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Said A. Ibrahim, MD, MPH, C. Kent Kwoh, MD and Eswar Krishnan, MD, MPH

Said A. Ibrahim is with the Center for Health Equity Research and Promotion, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pa. C. Kent Kwoh is with the Center for Health Equity Research and Promotion, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, and the Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh. Eswar Krishnan is with the Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh.

Correspondence: Requests for reprints should be sent to Said A. Ibrahim, MD, MPH, Associate Professor of Medicine, VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive C (151C-U), Pittsburgh, PA 15240 (e-mail: said.ibrahim2{at}va.gov).

Objectives. We examined hospital- and patient-related factors associated with discharge against medical advice (termed self-discharge) after emergency admission to acute-care hospitals.

Methods. We analyzed data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project using logistic regression models to assess the relationship between self-discharge and a set of patient and hospital characteristics.

Results. Of 3 039 050 discharges in the sample, 43 678 were against medical advice (1.44%). In multivariable modeling, predictors of self-discharge included having Medicaid insurance (adjusted odds ratio [AOR]=3.32; 95% confidence interval [CI]=3.22, 3.42), having Medicare insurance (AOR=1.64; 95% CI=1.59, 1.70), urban location (AOR=1.66; 95% CI=1.61, 1.72), medium (AOR=1.25; 95% CI=1.20, 1.29) or large (AOR=1.08, 95% CI=1.05, 1.12) hospital (defined by the number of beds), shorter hospital stay (OR=0.84; 95% CI=0.84, 0.85), and African American race (AOR=1.10; 95% CI=1.07, 1.14). Teaching hospitals had fewer self-discharges (AOR=0.90; 95% CI=0.88, 0.92). Other predictors of discharge against medical advice included age, gender, and income.

Conclusions. Approximately 1 in 70 hospital discharges in the United States are against medical advice. Both hospital and patient characteristics were associated with these decisions.