Mayo Clinic Proceedings Home

Discharge Against Medical Advice in the United States, 2002-2011



      To describe the national frequency, prevalence, and trends of discharge against medical advice (DAMA) among inpatient hospitalizations in the United States and identify differences across patient- and hospital-level characteristics, overall and in clinically distinct diagnostic subgroups.

      Patients and Methods

      We conducted a retrospective, cross-sectional analysis of inpatient hospitalizations (≥18 years), discharged between January 1, 2002, and December 31, 2011, using the Nationwide Inpatient Sample. Descriptive statistics, multivariable logistic, and joinpoint regression were used for statistical analyses.


      Between January 1, 2002, and December 31, 2011, more than 338,000 inpatient hospitalizations were discharged against medical advice each year, with a 1.9% average annual increase in prevalence over the decade (95% CI, 0.8%-3.0%). Temporal trends in DAMA varied by principal diagnosis. Among patients hospitalized for mental health- or substance abuse-related disorders, there was a −2.3% (95% CI, −3.8% to −0.8%) average annual decrease in the rate of DAMA. A statistically significant temporal rate change was not observed among hospitalizations for pregnancy-related disorders. Multivariable regression revealed several patient and hospital characteristics as predictors of DAMA, including lack of health insurance (odds ratio [OR], 3.78; 95% CI, 3.62-3.94), male sex (OR, 2.40; 95% CI, 2.36-2.45), and northeast region (OR, 1.91; 95% CI, 1.72-2.11). Other predictors included age, race/ethnicity, income, primary diagnosis, severity of illness, and hospital location/type and size.


      Rates for DAMA have increased in the United States, and key differences exist across patient and hospital characteristics. Early identification of vulnerable patients and preventive measures such as improved patient-provider communication may reduce DAMA.

      Abbreviations and Acronyms:

      AMA (against medical advice), DAMA (discharge against medical advice), HCUP (Healthcare Cost and Utilization Project), JPR (Joinpoint Regression), MH/SA (mental health/substance abuse), NEOMAT (Neonatal-Maternal), NH (non-Hispanic), NIS (Nationwide Inpatient Sample), OR (odds ratio)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. The Joint Commission. Discharge Disposition. Specifications Manual for Joint Commission National Quality Measures (Version 2016A). Accessed November 28, 2016.

        • Hadadi A.
        • Khashayar P.
        • Karbakhsh M.
        • Vasheghani Farahani A.
        Discharge against medical advice from a Tehran emergency department.
        Int J Health Care Qual Assur. 2016; 29: 24-32
        • Jimoh B.M.
        • Anthonia O.C.
        • Chinwe I.
        • et al.
        Prospective evaluation of cases of discharge against medical advice in Abuja, Nigeria.
        Sci World J. 2015; 2015: 314817
        • Jeong J.
        • Song K.J.
        • Kim Y.J.
        • et al.
        The association between acute alcohol consumption and discharge against medical advice of injured patients in the ED.
        Am J Emerg Med. 2016; 34: 464-468
        • Saia M.
        • Buja A.
        • Mantoan D.
        • et al.
        Frequency and trends of hospital discharges against medical advice (DAMA) in a large administrative database.
        Ann Ist Super Sanita. 2014; 50: 357-362
        • Carron P.N.
        • Yersin B.
        • Trueb L.
        • Gonin P.
        • Hugli O.
        Missed opportunities: evolution of patients leaving without being seen or against medical advice during a six-year period in a Swiss tertiary hospital emergency department.
        Biomed Res Int. 2014; 2014: 690368
        • Yong T.Y.
        • Fok J.S.
        • Hakendorf P.
        • Ben-Tovim D.
        • Thompson C.H.
        • Li J.Y.
        Characteristics and outcomes of discharges against medical advice among hospitalised patients.
        Intern Med J. 2013; 43: 798-802
        • Kraut A.
        • Fransoo R.
        • Olafson K.
        • Ramsey C.D.
        • Yogendran M.
        • Garland A.
        A population-based analysis of leaving the hospital against medical advice: incidence and associated variables.
        BMC Health Serv Res. 2013; 13: 415
        • Valevski A.
        • Zalsman G.
        • Tsafrir S.
        • Lipschitz-Elhawi R.
        • Weizman A.
        • Shohat T.
        Rate of readmission and mortality risks of schizophrenia patients who were discharged against medical advice.
        Eur Psychiatry. 2012; 27: 496-499
        • Ibrahim S.A.
        • Kwoh C.K.
        • Krishnan E.
        Factors associated with patients who leave acute-care hospitals against medical advice.
        Am J Public Health. 2007; 97: 2204-2208
      2. Stranges E, Wier L, Merrill CT, Steiner C. Hospitalizations in which patients leave the hospital against medical Advice (AMA), 2007. HCUP Statistical Brief #78. 2009. Accessed January 1, 2016.

        • Southern W.N.
        • Nahvi S.
        • Arnsten J.H.
        Increased risk of mortality and readmission among patients discharged against medical advice.
        Am J Med. 2012; 125: 594-602
        • Fiscella K.
        • Meldrum S.
        • Barnett S.
        Hospital discharge against advice after myocardial infarction: deaths and readmissions.
        Am J Med. 2007; 120: 1047-1053
        • Glasgow J.M.
        • Vaughn-Sarrazin M.
        • Kaboli P.J.
        Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission.
        J Gen Intern Med. 2010; 25: 926-929
        • Olufajo O.A.
        • Metcalfe D.
        • Yorkgitis B.K.
        • et al.
        Whatever happens to trauma patients who leave against medical advice?.
        Am J Surg. 2016; 211: 677-683
        • Weingart S.N.
        • Davis R.B.
        • Phillips R.S.
        Patients discharged against medical advice from a general medicine service.
        J Gen Intern Med. 1998; 13: 568-571
        • Saitz R.
        • Ghali W.A.
        • Moskowitz M.A.
        The impact of leaving against medical advice on hospital resource utilization.
        J Gen Intern Med. 2000; 15: 103-107
        • Carrese J.A.
        Refusal of care: patients' well-being and physicians' ethical obligations: “but doctor, I want to go home”.
        JAMA. 2006; 296: 691-695
        • Kaplan G.G.
        • Panaccione R.
        • Hubbard J.N.
        • et al.
        Inflammatory bowel disease patients who leave hospital against medical advice: predictors and temporal trends.
        Inflamm Bowel Dis. 2009; 15: 845-851
        • Franks P.
        • Meldrum S.
        • Fiscella K.
        Discharges against medical advice: are race/ethnicity predictors?.
        J Gen Intern Med. 2006; 21: 955-960
        • Brook M.
        • Hilty D.M.
        • Liu W.
        • Hu R.
        • Frye M.A.
        Discharge against medical advice from inpatient psychiatric treatment: a literature review.
        Psychiatr Serv. 2006; 57: 1192-1198
        • Sclar D.A.
        • Robison L.M.
        Hospital admission for schizophrenia and discharge against medical advice in the United States.
        Prim Care Companion J Clin Psychiatry. 2010; 12 (pii: PCC.09m00827. doi: 10.4088/PCC.09m00827yel): e1-e6
        • Tawk R.
        • Freels S.
        • Mullner R.
        Associations of mental, and medical illnesses with against medical advice discharges: the National Hospital Discharge Survey, 1988-2006.
        Adm Policy Ment Health. 2013; 40: 124-132
        • Letterie G.S.
        • Markenson G.R.
        • Markenson M.M.
        Discharge against medical advice in an obstetric unit.
        J Reprod Med. 1993; 38: 370-374
        • Fiscella K.
        • Meldrum S.
        • Franks P.
        Post partum discharge against medical advice: who leaves and does it matter?.
        Matern Child Health J. 2007; 11: 431-436
        • Tucker Edmonds B.
        • Ahlberg C.
        • McPherson K.
        • Srinivas S.
        • Lorch S.
        Predictors and adverse pregnancy outcomes associated with antepartum discharge against medical advice.
        Matern Child Health J. 2014; 18: 640-647
      3. Healthcare Cost and Utilization Project (HCUP). Introduction to the HCUP Nationwide Inpatient Sample (NIS) 2011. November 2015. Accessed January 1, 2016.

      4. Houchens R, Elixhauser A. Final report on calculating Nationwide Inpatient Sample (NIS) variances for data years 2011 and earlier. HCUP Methods Series Report # 2003-02 online. December 14, 2015. Accessed January 1, 2016.

      5. Elixhauser A, Steiner C, Palmer L. Clinical Classifications Software (CCS), 2015. 2015. Accessed February 13, 2017.

      6. National Cancer Institute. Joinpoint Regression Program, Version, Statistical Methodology and Applications Branch, Surveillance Research Program. 2016. Accessed January 4, 2015.

        • Kim H.J.
        • Fay M.P.
        • Feuer E.J.
        • Midthune D.N.
        Permutation tests for joinpoint regression with applications to cancer rates.
        Stat Med. 2000; 19: 335-351
        • Windish D.M.
        • Ratanawongsa N.
        Providers' perceptions of relationships and professional roles when caring for patients who leave the hospital against medical advice.
        J Gen Intern Med. 2008; 23: 1698-1707
        • Onukwugha E.
        • Saunders E.
        • Mullins C.D.
        • et al.
        A qualitative study to identify reasons for discharges against medical advice in the cardiovascular setting.
        BMJ Open. 2012; 2 (pii: e000902. doi:10.1136/bmjopen-2012-000902)
        • Onukwugha E.
        • Saunders E.
        • Mullins C.D.
        • Pradel F.G.
        • Zuckerman M.
        • Weir M.R.
        Reasons for discharges against medical advice: a qualitative study.
        Qual Saf Health Care. 2010; 19: 420-424
        • Cooper L.A.
        • Roter D.L.
        • Johnson R.L.
        • Ford D.E.
        • Steinwachs D.M.
        • Powe N.R.
        Patient-centered communication, ratings of care, and concordance of patient and physician race.
        Ann Intern Med. 2003; 139: 907-915
        • Street Jr., R.L.
        • Gordon H.
        • Haidet P.
        Physicians' communication and perceptions of patients: is it how they look, how they talk, or is it just the doctor?.
        Soc Sci Med. 2007; 65: 586-598
        • Spooner K.K.
        • Salemi J.L.
        • Salihu H.M.
        • Zoorob R.J.
        Disparities in perceived patient-provider communication quality in the United States: trends and correlates.
        Patient Educ Couns. 2016; 99: 844-854
        • Alfandre D.J.
        “I'm going home”: discharges against medical advice.
        Mayo Clin Proc. 2009; 84: 255-260
        • Mahalik J.R.
        • Burns S.M.
        • Syzdek M.
        Masculinity and perceived normative health behaviors as predictors of men's health behaviors.
        Soc Sci Med. 2007; 64: 2201-2209
        • Bertakis K.D.
        • Azari R.
        • Helms L.J.
        • Callahan E.J.
        • Robbins J.A.
        Gender differences in the utilization of health care services.
        J Fam Pract. 2000; 49: 147-152
        • Courtenay W.H.
        Constructions of masculinity and their influence on men's well-being: a theory of gender and health.
        Soc Sci Med. 2000; 50: 1385-1401
        • Grzywacz J.G.
        • Stoller E.P.
        • Brewer-Lowry A.N.
        • Bell R.A.
        • Quandt S.A.
        • Arcury T.A.
        Gender and health lifestyle: an in-depth exploration of self-care activities in later life.
        Health Educ Behav. 2012; 39: 332-340
        • O'Brien R.
        • Hunt K.
        • Hart G.
        ‘It's caveman stuff, but that is to a certain extent how guys still operate’: men's accounts of masculinity and help seeking.
        Soc Sci Med. 2005; 61: 503-516
        • Kawachi I.
        • Daniels N.
        • Robinson D.E.
        Health disparities by race and class: why both matter.
        Health Aff (Millwood). 2005; 24: 343-352
        • Blanchard J.
        • Lurie N.
        R-E-S-P-E-C-T: patient reports of disrespect in the health care setting and its impact on care.
        J Fam Pract. 2004; 53: 721-730
        • Flores G.
        Culture and the patient-physician relationship: achieving cultural competency in health care.
        J Pediatr. 2000; 136: 14-23
        • Cook B.L.
        • Zuvekas S.H.
        • Carson N.
        • Wayne G.F.
        • Vesper A.
        • McGuire T.G.
        Assessing racial/ethnic disparities in treatment across episodes of mental health care.
        Health Serv Res. 2014; 49: 206-229
        • Gerbasi J.B.
        • Simon R.I.
        Patients' rights and psychiatrists' duties: discharging patients against medical advice.
        Harv Rev Psychiatry. 2003; 11: 333-343
        • Holden P.
        • Vogtsberger K.N.
        • Mohl P.C.
        • Fuller D.S.
        Patients who leave the hospital against medical advice: the role of the psychiatric consultant.
        Psychosomatics. 1989; 30: 396-404
        • Targum S.D.
        • Capodanno A.E.
        • Hoffman H.A.
        • Foudraine C.
        An intervention to reduce the rate of hospital discharges against medical advice.
        Am J Psychiatry. 1982; 139: 657-659
        • Tajeu G.S.
        • Kazley A.S.
        • Menachemi N.
        Lower satisfaction among hospitals that disproportionately treat black patients.
        J Health Hum Serv Adm. 2015; 38: 290-316
        • Institute of Medicine
        Crossing the Quality Chasm: A New Health System for the 21st Century.
        National Academy Press, Washington, DC2001
        • Institute of Medicine
        Envisioning the National Health Care Quality Report.
        National Academy Press, Washington, DC2001
        • Barry M.J.
        • Edgman-Levitan S.
        Shared decision making–pinnacle of patient-centered care.
        N Engl J Med. 2012; 366: 780-781
        • Alfandre D.
        Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda.
        J Gen Intern Med. 2013; 28: 1657-1662
        • Seaborn Moyse H.
        • Osmun W.E.
        Discharges against medical advice: a community hospital's experience.
        Can J Rural Med. 2004; 9: 148-153
        • Tabatabaei S.M.
        • Sargazi Moakhar Z.
        • Behmanesh Pour F.
        • Shaare Mollashahi S.
        • Zaboli M.
        Hospitalized pregnant women who leave against medical advice: attributes and reasons.
        Matern Child Health J. 2016; 20: 128-138
        • Onukwugha E.C.
        • Shaya F.T.
        • Saunders E.
        • Weir M.R.
        Ethnic disparities, hospital quality, and discharges against medical advice among patients with cardiovascular disease.
        Ethn Dis. 2009; 19: 172-178
        • Fiest K.M.
        • Jette N.
        • Quan H.
        • et al.
        Systematic review and assessment of validated case definitions for depression in administrative data.
        BMC Psychiatry. 2014; 14: 289
        • Pang J.X.
        • Ross E.
        • Borman M.A.
        • et al.
        Validation of coding algorithms for the identification of patients hospitalized for alcoholic hepatitis using administrative data.
        BMC Gastroenterol. 2015; 15: 116
      7. Healthcare Cost and Utilization Project (HCUP). HCUP Quality Control Procedures. March 17, 2016. Accessed June 1, 2016.