Tactics for Reducing AMA Discharges

Posted on Wed, Jul 27, 2016
Tactics for Reducing AMA Discharges

By Adam Corley, MD, FACEP, FAAEM
A few weeks ago, I cared for a very nice woman who was suffering from a mild cerebral vascular accident (CVA). Her symptoms of weakness in her arm and leg and mildly slurred speech had been going on for more than a few hours, so I didn’t consider her a TPA candidate.
I ordered all of the usual treatment and tests for CVA, including a CT of the brain, which confirmed the diagnosis. I went back in to re-examine her, discuss my findings and recommendations, and to let her know that she would need to be admitted to the hospital for additional testing and to see a neurologist.
Her exam was unchanged and she listened patiently as I discussed her test results and my recommendations. She asked several questions to better understand her diagnosis and prognosis and she asked me what would happen if she wasn’t admitted to the hospital. I went over the details of my proposed hospitalization, the tests that we would run and the importance of seeing a neurologist.
My patient then told me that she would not be able to stay in the hospital. She was the only caregiver for her sick husband and felt that she could get all of the necessary testing as an outpatient. We discussed the risks, benefits and alternatives to hospitalization and discharge, which she seemed to understand. I made a few phone calls to make sure that she could have easy access to the necessary outpatient testing, treatments and specialists, wrote her prescriptions, and encouraged her to return if her condition worsened or if she changed her mind. She completed the necessary paperwork and then I discharged her home from the ER with a diagnosis of acute ischemic CVA.
Patients like this who are discharged against medical advice (AMA) make up 1 to 2 percent of all medical admissions and represent unique ethical, legal, financial and operational challenges in healthcare.
A 2007 study published in the Journal of Allergy and Clinical Immunology showed that patients with asthma who leave AMA are four times more likely to return to the ER within 30 days and nearly three times more likely to require readmission to the hospital. A study in the International Journal of Clinical Practice concluded that the average length of stay for a readmission following AMA discharge was 2.4 days longer and cost 56 percent more.
Several studies have examined the demographic correlations for patients deciding to leave AMA. Substance abuse, lack of insurance, Medicaid and lower socioeconomic status tend to correlate with higher AMA rates.
Recently, I have noticed certain groups and hospital systems considering focusing on reducing AMA discharges as a quality measure. The thinking is that if we can reduce patients leaving AMA, they will receive the care necessary to properly treat their illness and probably save the patient, hospital, insurance company or government payer money at the same time. However, it is critically important to approach this issue in a careful and deliberate manner to preserve patient liberty.
Patients who are competent to manage their own healthcare and understand the treatment recommendations presented to them should have the autonomy to make decisions that they feel are in their own best interest. Even the sagest medical advice may not be right for some patients or in certain situations.
As we work to improve the quality of healthcare in American and continue to focus on population health, it is critically important to maintain patient autonomy and the sanctity of the doctor-patient relationship. Patients should be free to choose the right treatment course for them or to forgo treatment all together if that is their choice. We must avoid the temptation to apply a one-size-fits-all mentality to the delivery of healthcare.
Excellent physician communication, systems that reduce barriers to healthcare delivery, individualized solutions to improve patient experience and a flexible approach to meeting patient needs are all excellent tactics to reduce AMA discharges. However, a heavy-handed approach to pressure patients to comply with recommended treatment would be wrong. We should respect patient autonomy and encourage people to make their own healthcare decisions — even if we disagree with them. 

Dr. Adam Corley is a practicing emergency physician with more than 10 years of clinical and leadership experience. Dr. Corley serves as Executive Vice President for EmCare’s West Division. He also serves as the medical director for several EMS services and the Anderson County Texas Sheriff’s Department. Dr. Corley lectures and writes on a variety of topics, including decision science and behavioral economics, management of disruptive behavior in healthcare, conflict resolution and healthcare leadership.

Mark Boles
Dr. Corley.....thanks so much for your insight on this topic, not only is it on-point professionally, it resonates for me personally as I wrestle with my mother's current wishes regarding her care. Difficult as it may be, whatever is done needs to be her ultimate decision.

Thanks again!

7/27/2016 6:53:42 PM