Association of Discharge Against Medical Advice with Surgical Outcomes and Healthcare Cost.

Background: Patients who leave the hospital prematurely often remain in a compromised clinical state, which may increase the risk of complications. Discharge against medical advice (DAMA) has been associated with increased morbidity, fragmented care, and higher healthcare costs, but its impact on major surgical populations remains understudied. We sought to evaluate trends, risk factors, and postoperative outcomes among surgical patients who were DAMA.

Methods: The Nationwide Readmissions Database (2016-2020) was used to identify adult patients (≥18 years) undergoing major operation. Trends in DAMA incidence over time, risk factors associated with DAMA, as well as impact of DAMA on postoperative outcomes and 30-day healthcare expenditures were assessed using multivariable regression models.

Results: Among 1,768,752 surgical patients, 3,951 (0.22%) were DAMA (17.0% in 2016 vs. 25.3% in 2020; p<0.001). Male sex (AOR 1.67, 95% CI 1.54-1.79), younger age (AOR 0.97 per year, 95% CI 0.97-0.97), and substance use disorder (AOR 2.44, 95% CI 2.24-2.65) were associated with DAMA. DAMA patients had longer index hospital stays (9.85 vs. 8.08 days; p<0.001), higher hospitalization costs ($43,379 vs. $39,872; p<0.001), and increased 30-day readmission risk (AOR 1.75, 95% CI 1.62-1.88). DAMA was also linked to fragmented care (AOR 1.98, 95% CI 1.71-2.29), higher DAMA at readmission (17.9% vs. 0.7%), and greater 30-day expenditures ($48,777 vs. $39,872; p<0.001).

Conclusions: The rising incidence and costs of DAMA highlight the need for targeted interventions, including risk stratification, and improved discharge planning, to reduce preventable readmissions and optimize resource utilization.