Shifts in Demographics and Characteristics Among Patients Leaving Against Medical Advice From Before, During, and After the COVID-19 Pandemic

Introduction: Discharges against medical advice (AMA) present a significant public health challenge and are associated with increased readmission and mortality rates. The COVID-19 pandemic altered the healthcare landscape regarding public trust in the United States, which may have impacted the demographic and clinical profile of patients with AMA discharges. The aim of this study is to identify potential changes in the demographics of AMA discharges before, during, and after the COVID-19 pandemic at a large academic medical center. Methods: This non-interventional retrospective cohort study included adult inpatients (n = 1,560) discharged AMA during three time periods: pre-COVID-19, during COVID-19, and post COVID-19. Demographic variables, the Social Deprivation Index (SDI), and comorbidities were analyzed via bivariate analysis and subsequently via multinomial logistic regression. Results: During COVID-19, Black patients made up a larger portion of AMA discharges compared to before the pandemic. The length of hospital stay before leaving AMA increased during and after the pandemic (43.1% discharged within two days before COVID-19, compared to 40.7% during the pandemic and 28.3% after the pandemic). In the post-COVID-19 period, AMA discharges were associated with higher SDI scores (M = 72.05 (SD = 28.67)) compared to before and during COVID-19 (M = 68.03 (SD = 29.43) before, 67.71 (SD = 29.87) during). Patients were also more likely to stay longer before leaving AMA than during COVID-19. Additionally, the frequency of AMA discharges originating from the ICU increased significantly following the resolution of the pandemic. Conclusion: The determinants of AMA discharges have a temporal association with the COVID-19 pandemic. Findings suggest that patients leaving AMA are now more likely to be socially disadvantaged, from minority backgrounds, to have longer hospital stays, and to be leaving directly from the ICU. Targeted interventions to improve patient trust and support in these populations are needed to reduce AMA discharges and improve outcomes.