Cherry Picking Patients 20130225

Dr. Stephen Hwang of St.Michael's Hospital in Toronto says it is important to be proactive in ensuring followup for patients who leave against medical advice. (The Canadian Press)

People who leave hospital against medical advice are more than twice as likely to be readmitted within a month compared with patients who are discharged as scheduled, a new Canadian report shows.

Patients who leave hospital earlier than their health team recommends are known to be at increased risk of harm, including readmission to hospital and death, according to previous studies.

Tuesday's report from the Canadian Institute for Health Information paints a profile of the characteristics of people who are more likely to leave hospital against medical advice and quantifies readmission rates.

In 2011-2012, a total of 25,137 admission or 1.3 per cent of acute hospital admissions ended with patients leaving against medical advice across the country, excluding Quebec.

Compared with patients with routine discharges, those who left early were:

  • More than twice as likely to be readmitted within a month (24 per cent versus nine per cent).
  • More than three times as likely to visit emergency within a week (35 per cent versus 11 per cent.)
  • Had an average of 2.3 inpatient admissions per year compared with 1.3 for other patients.

Self-discharged patients were more likely to be younger and male, and a have a history of leaving against medical advice, CIHI said. They were also more likely to have mental health issues and diagnoses of psychoactive substance abuse.

"The current study found that patients were more likely to leave against medical advice between evening and early morning hours," the report's authors concluded.

"It is telling that patients who leave against medical advice are also more likely to live in low-income neighbourhoods; they likely have more restricted options for child care and less flexibility in their places of employment."

Dr. Stephen Hwang, a scientist and physician at St. Michael’s Hospital in Toronto, speculated on one factor: At night, the team that regularly looks after a patient and has a good understanding of patient issues aren't available, which emphasizes the importance of improving handover instructions for all patients.

"It's very frustrating when a patient wants and insists on leaving when we think it's inadvisable," Hwang said. "I always try to understand the situation from the patient's perspective."

Sometimes, after having an open and honest conversation to understand why the patient wants to leave, he or she will reconsider, Hwang said, adding the majority don't change their mind.

In those cases, Hwang said, it's important to be more proactive in ensuring followup, such as having the patient leave with antibiotics in hand or calling in a couple of days with the aim of giving the patient the best chance of staying out of hospital.

In a second part of the report, the institute's authors said nearly one per cent of discharges — almost 53,000 people — left against medical advice from emergency departments in Alberta and Ontario. The rates are comparable to those in other countries, they said.

With files from CBC's Amina Zafar