Benheim Talia S, Kimmel Simeon D, George Miriam, Dow Patience M
Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA.
J Gen Intern Med. 2025 Jan 28. doi: 10.1007/s11606-025-09358-0.
"Before medically advised" (BMA) discharges are rising among hospitalized people with opioid use disorder (OUD) and associated with worse outcomes. However, little is known about BMA discharge among the growing share of U.S. Medicare beneficiaries with OUD.
To examine patterns of hospital readmissions and mortality by discharge type among Medicare beneficiaries with OUD.
Retrospective cohort study using 100% national inpatient Medicare data from 2016 to 2019.
Fee-for-service Medicare beneficiaries age 18 + with an OUD diagnosis during an inpatient hospitalization. Discharge types were classified as BMA, home, skilled nursing facilities (SNFs), or non-SNF institutional settings.
Using linear probability models adjusted for demographic, clinical, and hospital covariates, we examined 30-day unplanned all-cause readmission and mortality probabilities across discharge types. Secondarily, we assessed time until readmission and mortality, repeated readmissions or BMA discharges, readmission to different hospitals, and primary readmission diagnoses.
Among 339,712 hospitalized Medicare beneficiaries with OUD, 13,997 (4.1%) were discharged BMA. Within 30 days, 25.5% of patients discharged BMA were readmitted and 2.5% died. Compared to other discharges, readmissions after BMA discharge occurred sooner (9.9 vs. 12.8-13.3 days), and were more likely to happen repeatedly (23.4% vs. 13.1-18.3%), end in another BMA discharge (20.9% vs. 0.8-3.5%), and take place at different hospitals (50.8% vs. 29.8-37.6%). Adjusted readmission probabilities for BMA discharges were 7.1 percentage points (pp) higher than home discharges and 6.0-8.9 pp higher than SNF and non-SNF discharges (all p < 0.001). Adjusted mortality probabilities for BMA discharges were 0.7 pp higher than home discharges, but 0.8-1.9 pp lower than SNF and non-SNF discharges (all p < 0.001).
BMA discharge among Medicare beneficiaries with OUD is associated with fragmented patterns of post-discharge care, and increased readmissions and deaths relative to home discharges. Efforts are needed to address the drivers and consequences of BMA discharge among individuals with OUD in Medicare.
在患有阿片类药物使用障碍（OUD）的住院患者中，“在医学建议之前”（BMA）出院的情况正在增加，且与更差的预后相关。然而，对于美国越来越多患有OUD的医疗保险受益人中的BMA出院情况，人们知之甚少。
研究患有OUD的医疗保险受益人的出院类型与医院再入院和死亡率的模式。
使用2016年至2019年100%的全国住院医疗保险数据进行回顾性队列研究。
年龄在18岁及以上、在住院期间被诊断为患有OUD的按服务收费的医疗保险受益人。出院类型分为BMA、回家、熟练护理设施（SNF）或非SNF机构环境。
使用针对人口统计学、临床和医院协变量进行调整的线性概率模型，我们研究了不同出院类型的30天非计划全因再入院和死亡概率。其次，我们评估了再入院和死亡前的时间、重复再入院或BMA出院情况、再次入住不同医院的情况以及首次再入院诊断。
在339,712名患有OUD的住院医疗保险受益人中，13,997人（4.1%）为BMA出院。在30天内，BMA出院的患者中有25.5%再次入院，2.5%死亡。与其他出院类型相比，BMA出院后的再入院发生得更快（9.9天对12.8 - 13.3天），并且更有可能反复发生（23.4%对13.1 - 18.3%），最终以另一次BMA出院告终（20.9%对0.8 - 3.5%），并且发生在不同医院（50.8%对29.8 - 37.6%）。BMA出院的调整后再入院概率比回家出院高7.1个百分点（pp），比SNF和非SNF出院高6.0 - 8.9个百分点（所有p < 0.001）。BMA出院的调整后死亡概率比回家出院高0.7个百分点，但比SNF和非SNF出院低0.8 - 1.9个百分点（所有p < 0.001）。
患有OUD的医疗保险受益人中的BMA出院与出院后护理模式的碎片化相关，并且相对于回家出院，再入院和死亡人数增加。需要努力解决医疗保险中患有OUD的个体中BMA出院的驱动因素和后果。
