Title: 		The Retrospective Analysis Of Against Medical Advice Discharges At A 				Community Hospital 
Authors:	Deepinder Brar, MD,
Introduction:
Between 1-2% of all hospitalizations result in patients leaving against medical advice (AMA). [1]. Those that leave AMA have a higher 30-day mortality rate [2]. In addition, they were significantly more likely to be readmitted within the next 15 to 30 days and ultimately approaching the same levels of those that had a planned discharge by 75 days [2] [3]. While the demographics of those that leave AMA are broad [4], a significant portion are individuals who utilize illicit drugs [5]. In that population, it was found that recent IV drug usage, weekends, and welfare check days were positively associated with leaving AMA [5]. Whereas, prescribed in-hospital methadone use, social support and age were negatively associated with leaving AMA [5]. 
While the literature is emerging with regards to illicit drug usage and leaving AMA, much is still unknown. Recently, a model, The HOSPITAL score, was found to be a predictor of 30-daty readmission at a community hospital in Illinois [6]. To the best of our knowledge, a similar model or scoring mechanism has not been widely utilized to predict admitted patients who have a high likelihood of leaving AMA. Therefore, by knowing when to introduce or utilize potential resources earlier, high-risk patients’ morbidity and mortality will be reduced.  
Our objective is to better evaluate and understand the core reasons why patients in a community hospital leave AMA. It is hypothesized that through understanding the reasons for AMA discharges, a model or scoring system can be developed that will potentially predict potential admission with a high likelihood for leaving AMA. 
Study Design and Data Sources: 
We intend to conduct a retrospective study of all AMA discharges within the PinnacleHealth System (Harrisburg Hospital, Community General Osteopathic Hospital, and West Shore Hospital) from October 1, 2015 to October 1, 2016. The research team will conduct a chart review of all discharges who were admitted to a facility and left AMA at any point during the course of their hospitalization. 
All information will be de-identified, compiled for analysis, and information will be destroyed at the conclusion of the study. 
Methods: 
This study will be a primarily a quantitative study, but depending upon the preliminary findings, qualitative elements may need to be added. 
The primary investigators will collect quantitative data related to information from medical records including but not limited to demographics (age, sex, gender, and ethnicity), admitting diagnosis, length of stay prior to leaving, laboratory, radiological findings, and medication history (prior and during hospitalization) as it pertains to the patient. 
Depending upon themes that may emerge, the investigators may need to add qualitative elements  including but not limited to history and physical, care team notes, etc., in order to better understand the underlying reasons, opinion, and motivations for patients that leave AMA. 
After collecting all information, all variables will be analyzed using standard statistical methods at the discretion of the in-house Biostatistician.
Importance of the Study:
This will be one of the first studies investing the reasons for AMA discharges in a community hospital setting. While, the literature related to AMA discharges is emerging, much is unknown. By better understanding core reasons, a predictive model can be developed allowing for earlier interventions which can reduce morbidity and mortality and prevent unnecessary resource utilization. 
References: 
[1] 	Stranges E, Wier L, Merrill CT, and Steiner C. Hospitalizations in 	which Patients Leave the Hospital against Medical Advice (AMA), 2007: Statistical 	Brief #78. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. 		Rockville (MD): Agency for Healthcare Research and Quality (US); 2006-.
	2009 Aug.

[2] 	Glasgow JM, Vaughn-Sarrazin M, and Kaboli PJ.  Leaving against medical advice 
	(AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010 	Sep;25(9):926-9.  

[3]	Hwang SW1, Li J, Gupta R, Chien V, and Martin RE. What happens to patients who 
	leave hospital against medical advice?. CMAJ. 2003 Feb 18;168(4):417-20. 

[4] 	Alfandre DJ. "I'm going home": discharges against medical advice. Mayo Clin 	Proc. 2009 Mar;84(3):255-60. 

[5] 	Ti L and Ti L. Leaving the Hospital Against Medical Advice Among People Who Use 	Illicit Drugs: A Systematic Review. Am J Public Health. 2015 Dec;105(12):e53-9

[6] 	Robinson R. The HOSPITAL score as a predictor of 30 day readmission in a 	retrospective study at a university affiliated community hospital. PeerJ. 2016 Sep 	8;4:e2441.