CMAJ. 2013 Oct 1;185(14):1207-14. doi: 10.1503/cmaj.130029. Epub 2013 Aug 26.
Leaving hospital against medical advice may have adverse consequences. Previous studies have been limited by evaluating specific types of patients, small sample sizes and incomplete determination of outcomes. We hypothesized that leaving hospital against medical advice would be associated with increases in subsequent readmission and death.
In a population-based analysis involving all adults admitted to hospital and discharged alive in Manitoba from Apr. 1, 1990, to Feb. 28, 2009, we evaluated all-cause 90-day mortality and 30-day hospital readmission. We used multivariable regression, adjusted for age, sex, socioeconomic status, year of hospital admission, patient comorbidities, hospital diagnosis, past frequency of admission to hospital, having previously left hospital against medical advice and data clustering (patients with multiple admissions). For readmission, we assessed both between-person and within-person effects of leaving hospital against medical advice.
Leaving against medical advice occurred in 21 417 of 1 916 104 index hospital admissions (1.1%), and was associated with higher adjusted rates of 90-day mortality (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.18-2.89), and 30-day hospital readmission (within-person OR 2.10, CI 1.99-2.21; between-person OR 3.04, CI 2.79-3.30). In our additional analyses, elevated rates of readmission and death associated with leaving against medical advice were manifest within 1 week and persisted for at least 180 days after discharge.
Adults who left the hospital against medical advice had higher rates of hospital readmission and death. The persistence of these effects suggests that they are not solely a result of incomplete treatment of acute illness. Interventions aimed at reducing these effects may need to include longitudinal interventions extending beyond admission to hospital.
未经医嘱擅自离院可能会产生不良后果。既往研究因评估特定类型的患者、样本量小以及对结局的不完全确定而受到限制。我们假设未经医嘱擅自离院与随后的再入院和死亡风险增加相关。
在一项基于人群的分析中，纳入了 1990 年 4 月 1 日至 2009 年 2 月 28 日期间曼尼托巴省所有因住院并存活出院的成年人，我们评估了全因 90 天死亡率和 30 天再入院率。我们使用多变量回归，调整了年龄、性别、社会经济地位、入院年份、患者合并症、医院诊断、既往住院频率、既往未经医嘱擅自离院以及数据聚类（多次入院的患者）。对于再入院，我们评估了未经医嘱擅自离院的个体间和个体内效应。
在 1916104 例索引住院就诊中，有 21417 例（1.1%）未经医嘱擅自离院，且与更高的校正后 90 天死亡率（比值比 [OR] 2.51，95%置信区间 [CI] 2.18-2.89）和 30 天再入院率相关（个体内 OR 2.10，CI 1.99-2.21；个体间 OR 3.04，CI 2.79-3.30）。在我们的额外分析中，与未经医嘱擅自离院相关的再入院和死亡风险升高在出院后 1 周内显现，并持续至少 180 天。
未经医嘱擅自离院的成年人再入院和死亡风险更高。这些影响的持续存在表明，它们不仅仅是急性疾病治疗不充分的结果。旨在减少这些影响的干预措施可能需要包括延长至入院后的纵向干预。
