More than 9 million people visit the emergency department (ED) annually for evaluation of acute chest pain.[1, 2] Most of these patients are placed on observation status while being assessed for an acute coronary syndrome (ACS). Traditionally, serial cardiac enzymes and absence of changes suggestive of ischemia on electrocardiogram rule out ACS. Patients are then stratified based on their presentation and risk factors. However, healthcare providers are not comfortable discharging even low‐risk patients without further testing.[3] Routine treadmill stress testing is usually performed, often complimented by an imaging modality. A negative stress test before discharge reassures both the physician and the patient that the chest pain is not caused by an obstructive coronary lesion.

Patients with chest pain who have been discharged from the ED after ruling out an ACS are frequently readmitted for chest pain within 1 year.[4] It is unclear whether stress testing can prevent these readmissions by preventing return to the ED or by influencing the decision of ED physicians to admit patients for observation.[5, 6, 7] Even if stress testing can reduce ED visits or readmissions, it is not known whether the savings from preventing these visits can offset the initial cost of stress testing. The purpose of this study was to examine the impact of stress testing on readmission for chest pain, and to determine whether stress testing can reduce overall costs.

METHODS

RESULTS

A total of 3315 patients admitted with chest pain during the study period met the inclusion criteria. Of these, 2376 (71.7%) had a stress test on index admission. Table 1 describes the baseline characteristics of the study population. Receipt of a stress test during index admission was positively associated with white race, private insurance, and number of cardiac comorbidities. The propensity model included these covariates as well as study year, age (80+ vs younger), sex, and smoking status. The C statistic, which quantifies the model's ability to discriminate subjects who received a stress test from those who did not, was 0.63 (95% confidence interval [CI]: 0.61 to 0.65). Of patients who returned to the ED, we were able to find propensity matches for 69% to create a matched sample of 1776 patients. Of patients who were readmitted, we were able to find matches for 83% to create a matched sample of 186 patients.

DISCUSSION

In this retrospective cohort study of patients admitted with low‐risk chest pain, we found that a majority (>70%) underwent stress testing prior to discharge. Within 1 year approximately 8% returned to the ED with chest pain. Stress testing at index admission was associated with 40% reduction in the odds of subsequent ED visits for chest pain; however, once in the ED, having a previous stress test did not significantly affect the decision to admit. Despite the reduction in readmission rates, the overall hospital costsincluding cost of index admission, subsequent ED visits, and readmissionswere higher for patients who had a stress test at index admission.

Two other studies have evaluated the impact of stress testing on return ED visits.[5, 6] In a cohort of 1195 low‐risk chest pain patients at a tertiary center in New York, patients who underwent stress testing were less likely to return to the ED for chest pain within 3 months compared to those who did not get a stress test (10% vs 15%, P<0.001).[5] In contrast, another prospective study of 692 low‐risk chest pain patients found no difference in return ED visits between patients who were evaluated versus those who were not evaluated for underlying coronary artery disease at index admission by stress testing or cardiac catheterization (39% vs 40%; P=0.85).[6] In this study, the lack of difference may have been due to the population sampled, which had high rates of return in both groups. In our study, we also found that having a previous stress test does not significantly impact the decision to admit the patient. This was consistent with the results of another prospective cohort study of low‐risk chest pain patients presenting to the ED.[7]

Previous studies offer conflicting interpretations of the cost implications of stress testing in this population. Based on studies conducted in the 1990s that showed that mandatory stress testing in the ED was cost‐effective compared to hospital admission,[15, 16] the most recent scientific statement by the American Heart Association recommends stress testing for all low‐risk chest pain patients.[17] However, more recent studies have questioned the value of diagnostic testing beyond serial electrocardiograms and cardiac enzymes in low‐risk patients.[18, 19, 20, 21, 22] In a study done at our institution among patients admitted with low‐risk chest pain, the rate of positive stress tests was noted to be extremely low, and patients had a benign course; at 30 days the rates of major cardiovascular events was as low as 0.3%.[19] Other studies also showed no difference in outcomes among patients who received inpatient, outpatient, or no stress testing.[21, 22]

These studies have generally been limited to the initial hospitalization period. Our study extends these findings in terms of resource utilization to the year following hospitalization. This is important because physicians might order stress tests to reassure patients or themselves that the pain is noncardiac, with the hope that this will decrease subsequent ED visits or readmissions. In our study, stress tests did reduce both ED visits and readmissions, but the index cost of hospitalization was so much higher with stress testing that the reduced readmissions did not offset the initial costs. Because stress tests have not been shown to change cardiovascular outcomes but did increase costs, it may be time to reevaluate the need for any kind of inpatient stress testing in these patients.

Our study has several limitations. The retrospective nature of the study subjects it to confounding. We adjusted for demographics, insurance, and comorbidities, but other unmeasured elements of the patients' presentation might have affected stress test ordering and subsequent return to the ED. In addition, we relied on administrative data, and comorbidities may not have been documented completely. During the follow‐up period, we did not take into account patients who presented to the EDs of other hospitals or those who might have died. Because there is only one other hospital in our city, and it does not perform angioplasties, it is unlikely that we missed many infarctions this way, but we may not have included all ED visits. Similarly, we included only costs accrued within our healthcare system. If patients presented to outside facilities for testing or treatment, we were unable to capture it. It is possible that patients who did not undergo initial stress testing may have been more likely to have subsequent testing at outside facilities, which would have reduced the difference in cost that we observed. However, given the magnitude of this difference, it is unlikely that including outside costs would have completely eliminated the difference. The data in our study were collected over a 3‐year period. Secular trends in the healthcare system over that time could potentially have affected our results. To reduce this bias, we included the year of the study in the propensity model. Also, the study was performed at a single hospital, and the results might not be generalizable to other institutions. Ours is a large independent academic medical center serving both a tertiary and a community role. Therefore, the population it serves would appear to be representative of the general population having chest pain without ACS.

Finally, we did not collect data on the results of stress tests. It is probable that the decision to admit a patient is modified by the results of a previous test, and this was not explored in our analysis. Presumably, patients with positive tests would be more likely, and those with negative tests less likely, to be admitted than patients who had no previous test. Previous studies have shown that among low‐risk chest pain patients, the rate of abnormal stress tests is <15%, and among these only a minority (0.6%0.7%) can benefit from revascularization.[19, 20] Therefore, testing should result in a lower rate of readmissions overall, which is what we observed in this study. Once patients reached the ED, however, the decision to admit was not associated with having a previous stress test. This could be due to a high rate of positive tests among patients who came to the ED, or a lack of discrimination by ED physicians. Although our study design could not distinguish between these 2 possibilities, studies have shown that fear of litigation and aversion to risk play an important role in this decision,[23, 24] and it is possible that these considerations override the results of previous stress tests, which cannot categorically rule out current ischemia.

In an era of rising healthcare costs and limited resources, the care of low‐risk chest pain is an attractive target for cost‐reduction strategies. Low‐risk chest pain accounts for 1.8 % of all admissions, at an average annual cost of $3.4 billion in the United States,[25] so figuring out how to prevent such admissions has important economic implications. Although stress testing did keep patients from returning to the ED, it did not affect the ED physicians' decisions to admit. We found that stress testing does decrease subsequent resource utilization, but not enough to offset the initial cost of testing. Thus, stress testing does not appear to be a cost‐effective means to reduce readmissions.

Disclosures: Jaya Mallidi and Michael Rothberg had full access to all of the data in the study and take full responsibility for the integrity of the data and accuracy of the analysis. The authors report no conflicts of interest.

More than 9 million people visit the emergency department (ED) annually for evaluation of acute chest pain.[1, 2] Most of these patients are placed on observation status while being assessed for an acute coronary syndrome (ACS). Traditionally, serial cardiac enzymes and absence of changes suggestive of ischemia on electrocardiogram rule out ACS. Patients are then stratified based on their presentation and risk factors. However, healthcare providers are not comfortable discharging even low‐risk patients without further testing.[3] Routine treadmill stress testing is usually performed, often complimented by an imaging modality. A negative stress test before discharge reassures both the physician and the patient that the chest pain is not caused by an obstructive coronary lesion.

Patients with chest pain who have been discharged from the ED after ruling out an ACS are frequently readmitted for chest pain within 1 year.[4] It is unclear whether stress testing can prevent these readmissions by preventing return to the ED or by influencing the decision of ED physicians to admit patients for observation.[5, 6, 7] Even if stress testing can reduce ED visits or readmissions, it is not known whether the savings from preventing these visits can offset the initial cost of stress testing. The purpose of this study was to examine the impact of stress testing on readmission for chest pain, and to determine whether stress testing can reduce overall costs.

METHODS

RESULTS

A total of 3315 patients admitted with chest pain during the study period met the inclusion criteria. Of these, 2376 (71.7%) had a stress test on index admission. Table 1 describes the baseline characteristics of the study population. Receipt of a stress test during index admission was positively associated with white race, private insurance, and number of cardiac comorbidities. The propensity model included these covariates as well as study year, age (80+ vs younger), sex, and smoking status. The C statistic, which quantifies the model's ability to discriminate subjects who received a stress test from those who did not, was 0.63 (95% confidence interval [CI]: 0.61 to 0.65). Of patients who returned to the ED, we were able to find propensity matches for 69% to create a matched sample of 1776 patients. Of patients who were readmitted, we were able to find matches for 83% to create a matched sample of 186 patients.

DISCUSSION

In this retrospective cohort study of patients admitted with low‐risk chest pain, we found that a majority (>70%) underwent stress testing prior to discharge. Within 1 year approximately 8% returned to the ED with chest pain. Stress testing at index admission was associated with 40% reduction in the odds of subsequent ED visits for chest pain; however, once in the ED, having a previous stress test did not significantly affect the decision to admit. Despite the reduction in readmission rates, the overall hospital costsincluding cost of index admission, subsequent ED visits, and readmissionswere higher for patients who had a stress test at index admission.

Two other studies have evaluated the impact of stress testing on return ED visits.[5, 6] In a cohort of 1195 low‐risk chest pain patients at a tertiary center in New York, patients who underwent stress testing were less likely to return to the ED for chest pain within 3 months compared to those who did not get a stress test (10% vs 15%, P<0.001).[5] In contrast, another prospective study of 692 low‐risk chest pain patients found no difference in return ED visits between patients who were evaluated versus those who were not evaluated for underlying coronary artery disease at index admission by stress testing or cardiac catheterization (39% vs 40%; P=0.85).[6] In this study, the lack of difference may have been due to the population sampled, which had high rates of return in both groups. In our study, we also found that having a previous stress test does not significantly impact the decision to admit the patient. This was consistent with the results of another prospective cohort study of low‐risk chest pain patients presenting to the ED.[7]

Previous studies offer conflicting interpretations of the cost implications of stress testing in this population. Based on studies conducted in the 1990s that showed that mandatory stress testing in the ED was cost‐effective compared to hospital admission,[15, 16] the most recent scientific statement by the American Heart Association recommends stress testing for all low‐risk chest pain patients.[17] However, more recent studies have questioned the value of diagnostic testing beyond serial electrocardiograms and cardiac enzymes in low‐risk patients.[18, 19, 20, 21, 22] In a study done at our institution among patients admitted with low‐risk chest pain, the rate of positive stress tests was noted to be extremely low, and patients had a benign course; at 30 days the rates of major cardiovascular events was as low as 0.3%.[19] Other studies also showed no difference in outcomes among patients who received inpatient, outpatient, or no stress testing.[21, 22]

These studies have generally been limited to the initial hospitalization period. Our study extends these findings in terms of resource utilization to the year following hospitalization. This is important because physicians might order stress tests to reassure patients or themselves that the pain is noncardiac, with the hope that this will decrease subsequent ED visits or readmissions. In our study, stress tests did reduce both ED visits and readmissions, but the index cost of hospitalization was so much higher with stress testing that the reduced readmissions did not offset the initial costs. Because stress tests have not been shown to change cardiovascular outcomes but did increase costs, it may be time to reevaluate the need for any kind of inpatient stress testing in these patients.

Our study has several limitations. The retrospective nature of the study subjects it to confounding. We adjusted for demographics, insurance, and comorbidities, but other unmeasured elements of the patients' presentation might have affected stress test ordering and subsequent return to the ED. In addition, we relied on administrative data, and comorbidities may not have been documented completely. During the follow‐up period, we did not take into account patients who presented to the EDs of other hospitals or those who might have died. Because there is only one other hospital in our city, and it does not perform angioplasties, it is unlikely that we missed many infarctions this way, but we may not have included all ED visits. Similarly, we included only costs accrued within our healthcare system. If patients presented to outside facilities for testing or treatment, we were unable to capture it. It is possible that patients who did not undergo initial stress testing may have been more likely to have subsequent testing at outside facilities, which would have reduced the difference in cost that we observed. However, given the magnitude of this difference, it is unlikely that including outside costs would have completely eliminated the difference. The data in our study were collected over a 3‐year period. Secular trends in the healthcare system over that time could potentially have affected our results. To reduce this bias, we included the year of the study in the propensity model. Also, the study was performed at a single hospital, and the results might not be generalizable to other institutions. Ours is a large independent academic medical center serving both a tertiary and a community role. Therefore, the population it serves would appear to be representative of the general population having chest pain without ACS.

Finally, we did not collect data on the results of stress tests. It is probable that the decision to admit a patient is modified by the results of a previous test, and this was not explored in our analysis. Presumably, patients with positive tests would be more likely, and those with negative tests less likely, to be admitted than patients who had no previous test. Previous studies have shown that among low‐risk chest pain patients, the rate of abnormal stress tests is <15%, and among these only a minority (0.6%0.7%) can benefit from revascularization.[19, 20] Therefore, testing should result in a lower rate of readmissions overall, which is what we observed in this study. Once patients reached the ED, however, the decision to admit was not associated with having a previous stress test. This could be due to a high rate of positive tests among patients who came to the ED, or a lack of discrimination by ED physicians. Although our study design could not distinguish between these 2 possibilities, studies have shown that fear of litigation and aversion to risk play an important role in this decision,[23, 24] and it is possible that these considerations override the results of previous stress tests, which cannot categorically rule out current ischemia.

In an era of rising healthcare costs and limited resources, the care of low‐risk chest pain is an attractive target for cost‐reduction strategies. Low‐risk chest pain accounts for 1.8 % of all admissions, at an average annual cost of $3.4 billion in the United States,[25] so figuring out how to prevent such admissions has important economic implications. Although stress testing did keep patients from returning to the ED, it did not affect the ED physicians' decisions to admit. We found that stress testing does decrease subsequent resource utilization, but not enough to offset the initial cost of testing. Thus, stress testing does not appear to be a cost‐effective means to reduce readmissions.

Disclosures: Jaya Mallidi and Michael Rothberg had full access to all of the data in the study and take full responsibility for the integrity of the data and accuracy of the analysis. The authors report no conflicts of interest.

More than 9 million people visit the emergency department (ED) annually for evaluation of acute chest pain.[1, 2] Most of these patients are placed on observation status while being assessed for an acute coronary syndrome (ACS). Traditionally, serial cardiac enzymes and absence of changes suggestive of ischemia on electrocardiogram rule out ACS. Patients are then stratified based on their presentation and risk factors. However, healthcare providers are not comfortable discharging even low‐risk patients without further testing.[3] Routine treadmill stress testing is usually performed, often complimented by an imaging modality. A negative stress test before discharge reassures both the physician and the patient that the chest pain is not caused by an obstructive coronary lesion.

Patients with chest pain who have been discharged from the ED after ruling out an ACS are frequently readmitted for chest pain within 1 year.[4] It is unclear whether stress testing can prevent these readmissions by preventing return to the ED or by influencing the decision of ED physicians to admit patients for observation.[5, 6, 7] Even if stress testing can reduce ED visits or readmissions, it is not known whether the savings from preventing these visits can offset the initial cost of stress testing. The purpose of this study was to examine the impact of stress testing on readmission for chest pain, and to determine whether stress testing can reduce overall costs.

METHODS

RESULTS

A total of 3315 patients admitted with chest pain during the study period met the inclusion criteria. Of these, 2376 (71.7%) had a stress test on index admission. Table 1 describes the baseline characteristics of the study population. Receipt of a stress test during index admission was positively associated with white race, private insurance, and number of cardiac comorbidities. The propensity model included these covariates as well as study year, age (80+ vs younger), sex, and smoking status. The C statistic, which quantifies the model's ability to discriminate subjects who received a stress test from those who did not, was 0.63 (95% confidence interval [CI]: 0.61 to 0.65). Of patients who returned to the ED, we were able to find propensity matches for 69% to create a matched sample of 1776 patients. Of patients who were readmitted, we were able to find matches for 83% to create a matched sample of 186 patients.

DISCUSSION

In this retrospective cohort study of patients admitted with low‐risk chest pain, we found that a majority (>70%) underwent stress testing prior to discharge. Within 1 year approximately 8% returned to the ED with chest pain. Stress testing at index admission was associated with 40% reduction in the odds of subsequent ED visits for chest pain; however, once in the ED, having a previous stress test did not significantly affect the decision to admit. Despite the reduction in readmission rates, the overall hospital costsincluding cost of index admission, subsequent ED visits, and readmissionswere higher for patients who had a stress test at index admission.

Two other studies have evaluated the impact of stress testing on return ED visits.[5, 6] In a cohort of 1195 low‐risk chest pain patients at a tertiary center in New York, patients who underwent stress testing were less likely to return to the ED for chest pain within 3 months compared to those who did not get a stress test (10% vs 15%, P<0.001).[5] In contrast, another prospective study of 692 low‐risk chest pain patients found no difference in return ED visits between patients who were evaluated versus those who were not evaluated for underlying coronary artery disease at index admission by stress testing or cardiac catheterization (39% vs 40%; P=0.85).[6] In this study, the lack of difference may have been due to the population sampled, which had high rates of return in both groups. In our study, we also found that having a previous stress test does not significantly impact the decision to admit the patient. This was consistent with the results of another prospective cohort study of low‐risk chest pain patients presenting to the ED.[7]

Previous studies offer conflicting interpretations of the cost implications of stress testing in this population. Based on studies conducted in the 1990s that showed that mandatory stress testing in the ED was cost‐effective compared to hospital admission,[15, 16] the most recent scientific statement by the American Heart Association recommends stress testing for all low‐risk chest pain patients.[17] However, more recent studies have questioned the value of diagnostic testing beyond serial electrocardiograms and cardiac enzymes in low‐risk patients.[18, 19, 20, 21, 22] In a study done at our institution among patients admitted with low‐risk chest pain, the rate of positive stress tests was noted to be extremely low, and patients had a benign course; at 30 days the rates of major cardiovascular events was as low as 0.3%.[19] Other studies also showed no difference in outcomes among patients who received inpatient, outpatient, or no stress testing.[21, 22]

These studies have generally been limited to the initial hospitalization period. Our study extends these findings in terms of resource utilization to the year following hospitalization. This is important because physicians might order stress tests to reassure patients or themselves that the pain is noncardiac, with the hope that this will decrease subsequent ED visits or readmissions. In our study, stress tests did reduce both ED visits and readmissions, but the index cost of hospitalization was so much higher with stress testing that the reduced readmissions did not offset the initial costs. Because stress tests have not been shown to change cardiovascular outcomes but did increase costs, it may be time to reevaluate the need for any kind of inpatient stress testing in these patients.

Our study has several limitations. The retrospective nature of the study subjects it to confounding. We adjusted for demographics, insurance, and comorbidities, but other unmeasured elements of the patients' presentation might have affected stress test ordering and subsequent return to the ED. In addition, we relied on administrative data, and comorbidities may not have been documented completely. During the follow‐up period, we did not take into account patients who presented to the EDs of other hospitals or those who might have died. Because there is only one other hospital in our city, and it does not perform angioplasties, it is unlikely that we missed many infarctions this way, but we may not have included all ED visits. Similarly, we included only costs accrued within our healthcare system. If patients presented to outside facilities for testing or treatment, we were unable to capture it. It is possible that patients who did not undergo initial stress testing may have been more likely to have subsequent testing at outside facilities, which would have reduced the difference in cost that we observed. However, given the magnitude of this difference, it is unlikely that including outside costs would have completely eliminated the difference. The data in our study were collected over a 3‐year period. Secular trends in the healthcare system over that time could potentially have affected our results. To reduce this bias, we included the year of the study in the propensity model. Also, the study was performed at a single hospital, and the results might not be generalizable to other institutions. Ours is a large independent academic medical center serving both a tertiary and a community role. Therefore, the population it serves would appear to be representative of the general population having chest pain without ACS.

Finally, we did not collect data on the results of stress tests. It is probable that the decision to admit a patient is modified by the results of a previous test, and this was not explored in our analysis. Presumably, patients with positive tests would be more likely, and those with negative tests less likely, to be admitted than patients who had no previous test. Previous studies have shown that among low‐risk chest pain patients, the rate of abnormal stress tests is <15%, and among these only a minority (0.6%0.7%) can benefit from revascularization.[19, 20] Therefore, testing should result in a lower rate of readmissions overall, which is what we observed in this study. Once patients reached the ED, however, the decision to admit was not associated with having a previous stress test. This could be due to a high rate of positive tests among patients who came to the ED, or a lack of discrimination by ED physicians. Although our study design could not distinguish between these 2 possibilities, studies have shown that fear of litigation and aversion to risk play an important role in this decision,[23, 24] and it is possible that these considerations override the results of previous stress tests, which cannot categorically rule out current ischemia.

In an era of rising healthcare costs and limited resources, the care of low‐risk chest pain is an attractive target for cost‐reduction strategies. Low‐risk chest pain accounts for 1.8 % of all admissions, at an average annual cost of $3.4 billion in the United States,[25] so figuring out how to prevent such admissions has important economic implications. Although stress testing did keep patients from returning to the ED, it did not affect the ED physicians' decisions to admit. We found that stress testing does decrease subsequent resource utilization, but not enough to offset the initial cost of testing. Thus, stress testing does not appear to be a cost‐effective means to reduce readmissions.

Disclosures: Jaya Mallidi and Michael Rothberg had full access to all of the data in the study and take full responsibility for the integrity of the data and accuracy of the analysis. The authors report no conflicts of interest.

Approximately 1% to 2% of inpatient stays result in discharges against medical advice (AMA).[1] Though relatively infrequent, AMA discharges warrant attention as they are associated with higher morbidity, increased risk of readmission, and greater 30‐day mortality.[2] A recent study found a 30‐day readmission rate among AMA patients of 24.5%, nearly twice that of matched non‐AMA patients, and a 30‐day mortality rate of 1.3%, also nearly double that of planned discharges.[3] Discharges AMA may be expected to decrease index length of stay, yet accounting for 30‐day readmissions they are estimated to increase costs 56% higher than expected from an initial hospitalization.[4] Patients note several possible reasons for leaving AMA including family emergencies, dissatisfaction with care, financial concerns, or simply feeling better, among others.[5, 6, 7] Risk factors for AMA discharges include previous AMA discharge, having no primary care physician, younger age, lack of insurance, male sex, substance abuse, and lower socioeconomic status.[4, 6, 7, 8]

A number of prior studies have assessed risk factors for AMA discharges, the long‐ and short‐term outcomes, patient reasons for leaving, and physician perceptions of why patients leave AMA.[3, 5, 7, 9] However, there is limited information about opportunities for discharge transition interventions in this potentially more vulnerable population. Because of the increased short‐term and long‐term risks to these patients, treatment and follow‐up plans at the time of discharge may carry even greater importance than follow‐up plans with standard discharges. This study analyzed AMA documentation and what interventions were carried out at the time of discharge.

METHODS

We reviewed the records of all adult patients, ages 18 years and older, admitted to a university‐affiliated tertiary care hospital in Dayton, Ohio (a 520‐bed hospital with approximately 17,000 adult patient encounters per year) over a 2‐year period, and who subsequently left AMA. A hospital database identified 351 adult AMA cases (1.0% of adult admissions). A single reviewer performed an in‐depth review of the 291 patient admissions to the general medical service between January 1, 2009 and December 31, 2010, and manually reviewed and abstracted the data of interest. The Wright State University institutional review board approved the study.

Documentation review focused on the presence of a specified AMA note, the presence of documentation addressing informed consent, patient decision‐making capacity, patient health literacy, follow‐up plans, whether or not medications were prescribed, and whether or not any warning indicators of impending AMA were apparent. These items represented key elements of the discharge policy and procedure in place at our institution during the period of study. We speculated that nurses may be more immediately available at the time of AMA discharge and thus might carry out AMA documentation more often than physicians. To assess this we recorded the role (nurse vs provider) of the writer of AMA notes. We also assessed patient gender, length of stay, prior AMA, 30‐day emergency department (ED) re‐encounters, and 30‐day hospital readmission after AMA discharge.

Informed consent was deemed present if patients signed the hospital's standardized AMA form. Decision‐making capacity was assessed as present if there was specific mention of the patient's capacity on the day of discharge. Any mention of health literacy or the patient's stated understanding of his medical condition at any time during the hospitalization was considered positive documentation of healthcare literacy. Follow‐up plans included any mention of where and when the patient would return. Discharge medications included prescribed medication or indication that no medications were warranted. Warning indicators included specific mention of the patient's desire to leave AMA. For example, patients who left the unit without informing staff were considered to have given no warning of AMA. Alternatively, when documentation was present stating that the patient had verbally expressed a desire to leave AMA, this was considered advanced warning of AMA.

RESULTS

Mean age and gender distribution were similar to those reported in other AMA studies (Table 1).[3] Thirty‐day ED revisit and 30‐day hospital readmission frequencies for medical service patients were 121 (41.6%) and 88 (30.2%), respectively, also similar to those reported in other AMA studies.[3]

Although our intent was to conduct a quantitative assessment of discharge interventions, we found stated reasons for leaving similar to those previously reported. In our study, AMA patients tended to be younger, more likely male, and at increased risk for AMA discharge if they had prior AMA discharges (Table 1). The most common reasons found in the medical record for leaving AMA were caring for sick family members, financial concerns, feeling better, and occasionally dissatisfaction with care, reasons similar to those reported in previous studies.[5, 7, 9, 10]

AMA notes were present in 276 (94.8%) charts. AMA notes were written by physicians in 163 (59.1%) and nurses in 110 (37.8%) encounters. The informed consent form was present in 88 (30.2%) charts, mentioned in the note but not present in the electronic medical record in 111 (38.1%), and not signed in 92 (31.6%) charts. Decision‐making capacity and health literacy were documented in 108 (37.1%) and 75 (25.8%) records, respectively. Warning of impending AMA was present in 217 (74.6%) charts. Medications prescribed and follow‐up plans were only documented in 71 (24.4%) and 91 (31.3%) charts, respectively (Table 2).

Patients with documentation of medications given did not have decreased 30‐day ED revisits (33.8% vs 44.3%, P = 0.12) or 30‐day hospital readmission (23.9% vs 32.4%, P = 0.18). Similarly, there was no relationship between documentation of follow‐up plans and 30‐day ED revisits (37.4% vs 43.7%, P = 0.31) or 30‐day hospital readmission (29.7% vs 30.7%, P = 0.87). Finally, there was no relationship between physician versus nurse authorship of AMA notes and 30‐day ED revisits (37.4% vs 46.4%, P = 0.14) or 30‐day hospital readmission (28.2% vs 31.8%, P = 0.52) (Table 3).

Physician documentation of the AMA was associated with an increased frequency of discharge medication being prescribed (36.2% vs 10.0%, P 0.001) and with an increased finding of documented follow‐up plans (43.6% vs 16.4%, P 0.001). A documented warning of impending AMA was associated with an increased frequency of discharge medication being prescribed (30.4% vs 6.8%, P 0.001) and increased frequency of follow‐up plans being documented (37.3% vs 13.5%, P 0.001) (Table 3).

DISCUSSION

To gain insights into opportunities for discharge transition interventions in this potentially more vulnerable population,[1, 5] we analyzed AMA documentation and what interventions were carried out at the time of discharge. Our intent was a quantitative assessment of discharge interventions, but we also found stated reasons for leaving AMA that were similar to those previously reported.[5, 6, 10]

We identified several opportunities for improved documentation as well as targeted discharge intervention among AMA patients. Documentation in the charts of AMA patients was often suboptimal. In our study, a physician's AMA note was present only half of the time. Mention of the patient's mental status or health literacy was present in only one‐fourth of cases. Protection from litigation in AMA cases is enhanced when these elements and others, like informed consent, are present in the medical record.[11]

Physician documentation of the AMA was associated with an increased frequency of discharge medication being prescribed and with an increased finding of documented follow‐up plans. This association might be confounded by the fact that physicians can prescribe whereas most nurses cannot. The findings that a documented warning of impending AMA was associated with an increased frequency of discharge medication being prescribed (30.4% vs 6.8%, P 0.001) and increased frequency of follow‐up plans being documented (37.3% vs 13.5%, P 0.001) suggest opportunities for improvement through early inquiry about potential for AMA as well as early responses when patients threaten to leave AMA.

An important focus of our study was on documentation of discharge medications and follow‐up plans. These elements were documented in 31% and 25% of charts, respectively. A warning of impending AMA was present in 74.6% of encounters, yet medications and follow‐up plans were documented at a much lower rate. This represents an area where caregivers have the possibility to intervene, but are not documenting that they are doing so. We found no relationship between the documentation of giving prescriptions and giving explicit follow‐up plans with decreased rates of return to the ED or readmission, but that possibility may still warrant future prospective study.

Our study did not attempt to explain why only a minority of AMA discharges include medication prescription or follow‐up plans, but a number of potential explanations are possible. Some AMA discharges may occur unannounced with a patient simply walking off the ward giving little or no advance notice. It is also possible that provider perceptions and attitudes toward AMA patients may influence potential interventions.[12] An AMA discharge is against the caregiver's preferred advice for the patient, and it may seem illogical to offer patients second‐best advice. Perhaps some providers have the misconception that medications cannot or must not be prescribed for an AMA discharge. However, second‐best therapy may be better than no therapy, and some follow‐up better than no follow‐up plan.

Given the high rates of ED return and 30‐day readmission, the associated increased healthcare costs as well as increased morbidity and mortality associated with AMA dispositions, a continued search for effective intervention strategies and opportunities is warranted. Recently, programs for transition of care/discharge have demonstrated improved outcomes including reduced rates of readmission with standard discharges.[13] At the time of our study, effective programs such as Project BOOST (Better Outcomes for Older adult through Safe Transitions),[14] the Care Transitions Program,[15] and RED (Project Re‐engineered Discharge)[16] were not yet routinely employed, but their common elements may be applicable to the AMA population. In general, these programs focus on elements we investigated (patient understanding, follow‐up plans, medications prescribed) but add a number of additional components. Additional elements include written discharge instructions, patient education, teach‐back process, decision support, emergency plans, caregiver education, telephone follow‐up, and transition coaches to coordinate home and office follow‐up visits. Most potential interventions add significant time (and cost) to the discharge process. Thus, future studies applying these components to AMA discharges should emphasize timely identification of threatened AMA and prioritized interventions. Future studies should focus on which interventions are the most cost‐effective with AMA patients.

Limitations of our study include not being able to access information from area hospitals not in our hospital network, and thus we may not have identified all ED returns and readmissions. Additionally, interventions at the time of discharge (like prescription of medications or provider assessment of decision‐making capacity) may not have been documented and thus not available for our review. Also, our study was a retrospective review at a single institution and included a relatively small population of patients; consequently, our findings may not apply to other healthcare providers in other hospitals or settings. Our study was strengthened by reviewing all consecutive AMA cases over a 2‐year period encompassing a diverse group of healthcare providers.

CONCLUSION

In the majority of cases reviewed, some advance warning of impending AMA is apparent, affording an opportunity for interventions that may improve health outcomes. Despite this advance warning, only a minority of cases result in key interventions such as prescription of medications or development of follow‐up plans. Medical documentation of AMA dispositions is often inadequate, suggesting missed opportunities for potential intervention as well as suboptimal medicolegal scenarios. Future prospective studies examining cost‐effective interventions at the time of AMA discharge and transition of care may provide valuable insight into lowering rates of ED return and rehospitalization.

Disclosures: The views and opinions expressed in this article are those of the author(s) and do not reflect official policy or position of the United States Air Force, Department of Defense, or US government. The authors report no conflicts of interest.

Approximately 1% to 2% of inpatient stays result in discharges against medical advice (AMA).[1] Though relatively infrequent, AMA discharges warrant attention as they are associated with higher morbidity, increased risk of readmission, and greater 30‐day mortality.[2] A recent study found a 30‐day readmission rate among AMA patients of 24.5%, nearly twice that of matched non‐AMA patients, and a 30‐day mortality rate of 1.3%, also nearly double that of planned discharges.[3] Discharges AMA may be expected to decrease index length of stay, yet accounting for 30‐day readmissions they are estimated to increase costs 56% higher than expected from an initial hospitalization.[4] Patients note several possible reasons for leaving AMA including family emergencies, dissatisfaction with care, financial concerns, or simply feeling better, among others.[5, 6, 7] Risk factors for AMA discharges include previous AMA discharge, having no primary care physician, younger age, lack of insurance, male sex, substance abuse, and lower socioeconomic status.[4, 6, 7, 8]

A number of prior studies have assessed risk factors for AMA discharges, the long‐ and short‐term outcomes, patient reasons for leaving, and physician perceptions of why patients leave AMA.[3, 5, 7, 9] However, there is limited information about opportunities for discharge transition interventions in this potentially more vulnerable population. Because of the increased short‐term and long‐term risks to these patients, treatment and follow‐up plans at the time of discharge may carry even greater importance than follow‐up plans with standard discharges. This study analyzed AMA documentation and what interventions were carried out at the time of discharge.

METHODS

We reviewed the records of all adult patients, ages 18 years and older, admitted to a university‐affiliated tertiary care hospital in Dayton, Ohio (a 520‐bed hospital with approximately 17,000 adult patient encounters per year) over a 2‐year period, and who subsequently left AMA. A hospital database identified 351 adult AMA cases (1.0% of adult admissions). A single reviewer performed an in‐depth review of the 291 patient admissions to the general medical service between January 1, 2009 and December 31, 2010, and manually reviewed and abstracted the data of interest. The Wright State University institutional review board approved the study.

Documentation review focused on the presence of a specified AMA note, the presence of documentation addressing informed consent, patient decision‐making capacity, patient health literacy, follow‐up plans, whether or not medications were prescribed, and whether or not any warning indicators of impending AMA were apparent. These items represented key elements of the discharge policy and procedure in place at our institution during the period of study. We speculated that nurses may be more immediately available at the time of AMA discharge and thus might carry out AMA documentation more often than physicians. To assess this we recorded the role (nurse vs provider) of the writer of AMA notes. We also assessed patient gender, length of stay, prior AMA, 30‐day emergency department (ED) re‐encounters, and 30‐day hospital readmission after AMA discharge.

Informed consent was deemed present if patients signed the hospital's standardized AMA form. Decision‐making capacity was assessed as present if there was specific mention of the patient's capacity on the day of discharge. Any mention of health literacy or the patient's stated understanding of his medical condition at any time during the hospitalization was considered positive documentation of healthcare literacy. Follow‐up plans included any mention of where and when the patient would return. Discharge medications included prescribed medication or indication that no medications were warranted. Warning indicators included specific mention of the patient's desire to leave AMA. For example, patients who left the unit without informing staff were considered to have given no warning of AMA. Alternatively, when documentation was present stating that the patient had verbally expressed a desire to leave AMA, this was considered advanced warning of AMA.

RESULTS

Mean age and gender distribution were similar to those reported in other AMA studies (Table 1).[3] Thirty‐day ED revisit and 30‐day hospital readmission frequencies for medical service patients were 121 (41.6%) and 88 (30.2%), respectively, also similar to those reported in other AMA studies.[3]

Although our intent was to conduct a quantitative assessment of discharge interventions, we found stated reasons for leaving similar to those previously reported. In our study, AMA patients tended to be younger, more likely male, and at increased risk for AMA discharge if they had prior AMA discharges (Table 1). The most common reasons found in the medical record for leaving AMA were caring for sick family members, financial concerns, feeling better, and occasionally dissatisfaction with care, reasons similar to those reported in previous studies.[5, 7, 9, 10]

AMA notes were present in 276 (94.8%) charts. AMA notes were written by physicians in 163 (59.1%) and nurses in 110 (37.8%) encounters. The informed consent form was present in 88 (30.2%) charts, mentioned in the note but not present in the electronic medical record in 111 (38.1%), and not signed in 92 (31.6%) charts. Decision‐making capacity and health literacy were documented in 108 (37.1%) and 75 (25.8%) records, respectively. Warning of impending AMA was present in 217 (74.6%) charts. Medications prescribed and follow‐up plans were only documented in 71 (24.4%) and 91 (31.3%) charts, respectively (Table 2).

Patients with documentation of medications given did not have decreased 30‐day ED revisits (33.8% vs 44.3%, P = 0.12) or 30‐day hospital readmission (23.9% vs 32.4%, P = 0.18). Similarly, there was no relationship between documentation of follow‐up plans and 30‐day ED revisits (37.4% vs 43.7%, P = 0.31) or 30‐day hospital readmission (29.7% vs 30.7%, P = 0.87). Finally, there was no relationship between physician versus nurse authorship of AMA notes and 30‐day ED revisits (37.4% vs 46.4%, P = 0.14) or 30‐day hospital readmission (28.2% vs 31.8%, P = 0.52) (Table 3).

Physician documentation of the AMA was associated with an increased frequency of discharge medication being prescribed (36.2% vs 10.0%, P 0.001) and with an increased finding of documented follow‐up plans (43.6% vs 16.4%, P 0.001). A documented warning of impending AMA was associated with an increased frequency of discharge medication being prescribed (30.4% vs 6.8%, P 0.001) and increased frequency of follow‐up plans being documented (37.3% vs 13.5%, P 0.001) (Table 3).

DISCUSSION

To gain insights into opportunities for discharge transition interventions in this potentially more vulnerable population,[1, 5] we analyzed AMA documentation and what interventions were carried out at the time of discharge. Our intent was a quantitative assessment of discharge interventions, but we also found stated reasons for leaving AMA that were similar to those previously reported.[5, 6, 10]

We identified several opportunities for improved documentation as well as targeted discharge intervention among AMA patients. Documentation in the charts of AMA patients was often suboptimal. In our study, a physician's AMA note was present only half of the time. Mention of the patient's mental status or health literacy was present in only one‐fourth of cases. Protection from litigation in AMA cases is enhanced when these elements and others, like informed consent, are present in the medical record.[11]

Physician documentation of the AMA was associated with an increased frequency of discharge medication being prescribed and with an increased finding of documented follow‐up plans. This association might be confounded by the fact that physicians can prescribe whereas most nurses cannot. The findings that a documented warning of impending AMA was associated with an increased frequency of discharge medication being prescribed (30.4% vs 6.8%, P 0.001) and increased frequency of follow‐up plans being documented (37.3% vs 13.5%, P 0.001) suggest opportunities for improvement through early inquiry about potential for AMA as well as early responses when patients threaten to leave AMA.

An important focus of our study was on documentation of discharge medications and follow‐up plans. These elements were documented in 31% and 25% of charts, respectively. A warning of impending AMA was present in 74.6% of encounters, yet medications and follow‐up plans were documented at a much lower rate. This represents an area where caregivers have the possibility to intervene, but are not documenting that they are doing so. We found no relationship between the documentation of giving prescriptions and giving explicit follow‐up plans with decreased rates of return to the ED or readmission, but that possibility may still warrant future prospective study.

Our study did not attempt to explain why only a minority of AMA discharges include medication prescription or follow‐up plans, but a number of potential explanations are possible. Some AMA discharges may occur unannounced with a patient simply walking off the ward giving little or no advance notice. It is also possible that provider perceptions and attitudes toward AMA patients may influence potential interventions.[12] An AMA discharge is against the caregiver's preferred advice for the patient, and it may seem illogical to offer patients second‐best advice. Perhaps some providers have the misconception that medications cannot or must not be prescribed for an AMA discharge. However, second‐best therapy may be better than no therapy, and some follow‐up better than no follow‐up plan.

Given the high rates of ED return and 30‐day readmission, the associated increased healthcare costs as well as increased morbidity and mortality associated with AMA dispositions, a continued search for effective intervention strategies and opportunities is warranted. Recently, programs for transition of care/discharge have demonstrated improved outcomes including reduced rates of readmission with standard discharges.[13] At the time of our study, effective programs such as Project BOOST (Better Outcomes for Older adult through Safe Transitions),[14] the Care Transitions Program,[15] and RED (Project Re‐engineered Discharge)[16] were not yet routinely employed, but their common elements may be applicable to the AMA population. In general, these programs focus on elements we investigated (patient understanding, follow‐up plans, medications prescribed) but add a number of additional components. Additional elements include written discharge instructions, patient education, teach‐back process, decision support, emergency plans, caregiver education, telephone follow‐up, and transition coaches to coordinate home and office follow‐up visits. Most potential interventions add significant time (and cost) to the discharge process. Thus, future studies applying these components to AMA discharges should emphasize timely identification of threatened AMA and prioritized interventions. Future studies should focus on which interventions are the most cost‐effective with AMA patients.

Limitations of our study include not being able to access information from area hospitals not in our hospital network, and thus we may not have identified all ED returns and readmissions. Additionally, interventions at the time of discharge (like prescription of medications or provider assessment of decision‐making capacity) may not have been documented and thus not available for our review. Also, our study was a retrospective review at a single institution and included a relatively small population of patients; consequently, our findings may not apply to other healthcare providers in other hospitals or settings. Our study was strengthened by reviewing all consecutive AMA cases over a 2‐year period encompassing a diverse group of healthcare providers.

CONCLUSION

In the majority of cases reviewed, some advance warning of impending AMA is apparent, affording an opportunity for interventions that may improve health outcomes. Despite this advance warning, only a minority of cases result in key interventions such as prescription of medications or development of follow‐up plans. Medical documentation of AMA dispositions is often inadequate, suggesting missed opportunities for potential intervention as well as suboptimal medicolegal scenarios. Future prospective studies examining cost‐effective interventions at the time of AMA discharge and transition of care may provide valuable insight into lowering rates of ED return and rehospitalization.

Disclosures: The views and opinions expressed in this article are those of the author(s) and do not reflect official policy or position of the United States Air Force, Department of Defense, or US government. The authors report no conflicts of interest.

Approximately 1% to 2% of inpatient stays result in discharges against medical advice (AMA).[1] Though relatively infrequent, AMA discharges warrant attention as they are associated with higher morbidity, increased risk of readmission, and greater 30‐day mortality.[2] A recent study found a 30‐day readmission rate among AMA patients of 24.5%, nearly twice that of matched non‐AMA patients, and a 30‐day mortality rate of 1.3%, also nearly double that of planned discharges.[3] Discharges AMA may be expected to decrease index length of stay, yet accounting for 30‐day readmissions they are estimated to increase costs 56% higher than expected from an initial hospitalization.[4] Patients note several possible reasons for leaving AMA including family emergencies, dissatisfaction with care, financial concerns, or simply feeling better, among others.[5, 6, 7] Risk factors for AMA discharges include previous AMA discharge, having no primary care physician, younger age, lack of insurance, male sex, substance abuse, and lower socioeconomic status.[4, 6, 7, 8]

A number of prior studies have assessed risk factors for AMA discharges, the long‐ and short‐term outcomes, patient reasons for leaving, and physician perceptions of why patients leave AMA.[3, 5, 7, 9] However, there is limited information about opportunities for discharge transition interventions in this potentially more vulnerable population. Because of the increased short‐term and long‐term risks to these patients, treatment and follow‐up plans at the time of discharge may carry even greater importance than follow‐up plans with standard discharges. This study analyzed AMA documentation and what interventions were carried out at the time of discharge.

METHODS

We reviewed the records of all adult patients, ages 18 years and older, admitted to a university‐affiliated tertiary care hospital in Dayton, Ohio (a 520‐bed hospital with approximately 17,000 adult patient encounters per year) over a 2‐year period, and who subsequently left AMA. A hospital database identified 351 adult AMA cases (1.0% of adult admissions). A single reviewer performed an in‐depth review of the 291 patient admissions to the general medical service between January 1, 2009 and December 31, 2010, and manually reviewed and abstracted the data of interest. The Wright State University institutional review board approved the study.

Documentation review focused on the presence of a specified AMA note, the presence of documentation addressing informed consent, patient decision‐making capacity, patient health literacy, follow‐up plans, whether or not medications were prescribed, and whether or not any warning indicators of impending AMA were apparent. These items represented key elements of the discharge policy and procedure in place at our institution during the period of study. We speculated that nurses may be more immediately available at the time of AMA discharge and thus might carry out AMA documentation more often than physicians. To assess this we recorded the role (nurse vs provider) of the writer of AMA notes. We also assessed patient gender, length of stay, prior AMA, 30‐day emergency department (ED) re‐encounters, and 30‐day hospital readmission after AMA discharge.

Informed consent was deemed present if patients signed the hospital's standardized AMA form. Decision‐making capacity was assessed as present if there was specific mention of the patient's capacity on the day of discharge. Any mention of health literacy or the patient's stated understanding of his medical condition at any time during the hospitalization was considered positive documentation of healthcare literacy. Follow‐up plans included any mention of where and when the patient would return. Discharge medications included prescribed medication or indication that no medications were warranted. Warning indicators included specific mention of the patient's desire to leave AMA. For example, patients who left the unit without informing staff were considered to have given no warning of AMA. Alternatively, when documentation was present stating that the patient had verbally expressed a desire to leave AMA, this was considered advanced warning of AMA.

RESULTS

Mean age and gender distribution were similar to those reported in other AMA studies (Table 1).[3] Thirty‐day ED revisit and 30‐day hospital readmission frequencies for medical service patients were 121 (41.6%) and 88 (30.2%), respectively, also similar to those reported in other AMA studies.[3]

Although our intent was to conduct a quantitative assessment of discharge interventions, we found stated reasons for leaving similar to those previously reported. In our study, AMA patients tended to be younger, more likely male, and at increased risk for AMA discharge if they had prior AMA discharges (Table 1). The most common reasons found in the medical record for leaving AMA were caring for sick family members, financial concerns, feeling better, and occasionally dissatisfaction with care, reasons similar to those reported in previous studies.[5, 7, 9, 10]

AMA notes were present in 276 (94.8%) charts. AMA notes were written by physicians in 163 (59.1%) and nurses in 110 (37.8%) encounters. The informed consent form was present in 88 (30.2%) charts, mentioned in the note but not present in the electronic medical record in 111 (38.1%), and not signed in 92 (31.6%) charts. Decision‐making capacity and health literacy were documented in 108 (37.1%) and 75 (25.8%) records, respectively. Warning of impending AMA was present in 217 (74.6%) charts. Medications prescribed and follow‐up plans were only documented in 71 (24.4%) and 91 (31.3%) charts, respectively (Table 2).

Patients with documentation of medications given did not have decreased 30‐day ED revisits (33.8% vs 44.3%, P = 0.12) or 30‐day hospital readmission (23.9% vs 32.4%, P = 0.18). Similarly, there was no relationship between documentation of follow‐up plans and 30‐day ED revisits (37.4% vs 43.7%, P = 0.31) or 30‐day hospital readmission (29.7% vs 30.7%, P = 0.87). Finally, there was no relationship between physician versus nurse authorship of AMA notes and 30‐day ED revisits (37.4% vs 46.4%, P = 0.14) or 30‐day hospital readmission (28.2% vs 31.8%, P = 0.52) (Table 3).

Physician documentation of the AMA was associated with an increased frequency of discharge medication being prescribed (36.2% vs 10.0%, P 0.001) and with an increased finding of documented follow‐up plans (43.6% vs 16.4%, P 0.001). A documented warning of impending AMA was associated with an increased frequency of discharge medication being prescribed (30.4% vs 6.8%, P 0.001) and increased frequency of follow‐up plans being documented (37.3% vs 13.5%, P 0.001) (Table 3).

DISCUSSION

To gain insights into opportunities for discharge transition interventions in this potentially more vulnerable population,[1, 5] we analyzed AMA documentation and what interventions were carried out at the time of discharge. Our intent was a quantitative assessment of discharge interventions, but we also found stated reasons for leaving AMA that were similar to those previously reported.[5, 6, 10]

We identified several opportunities for improved documentation as well as targeted discharge intervention among AMA patients. Documentation in the charts of AMA patients was often suboptimal. In our study, a physician's AMA note was present only half of the time. Mention of the patient's mental status or health literacy was present in only one‐fourth of cases. Protection from litigation in AMA cases is enhanced when these elements and others, like informed consent, are present in the medical record.[11]

Physician documentation of the AMA was associated with an increased frequency of discharge medication being prescribed and with an increased finding of documented follow‐up plans. This association might be confounded by the fact that physicians can prescribe whereas most nurses cannot. The findings that a documented warning of impending AMA was associated with an increased frequency of discharge medication being prescribed (30.4% vs 6.8%, P 0.001) and increased frequency of follow‐up plans being documented (37.3% vs 13.5%, P 0.001) suggest opportunities for improvement through early inquiry about potential for AMA as well as early responses when patients threaten to leave AMA.

An important focus of our study was on documentation of discharge medications and follow‐up plans. These elements were documented in 31% and 25% of charts, respectively. A warning of impending AMA was present in 74.6% of encounters, yet medications and follow‐up plans were documented at a much lower rate. This represents an area where caregivers have the possibility to intervene, but are not documenting that they are doing so. We found no relationship between the documentation of giving prescriptions and giving explicit follow‐up plans with decreased rates of return to the ED or readmission, but that possibility may still warrant future prospective study.

Our study did not attempt to explain why only a minority of AMA discharges include medication prescription or follow‐up plans, but a number of potential explanations are possible. Some AMA discharges may occur unannounced with a patient simply walking off the ward giving little or no advance notice. It is also possible that provider perceptions and attitudes toward AMA patients may influence potential interventions.[12] An AMA discharge is against the caregiver's preferred advice for the patient, and it may seem illogical to offer patients second‐best advice. Perhaps some providers have the misconception that medications cannot or must not be prescribed for an AMA discharge. However, second‐best therapy may be better than no therapy, and some follow‐up better than no follow‐up plan.

Given the high rates of ED return and 30‐day readmission, the associated increased healthcare costs as well as increased morbidity and mortality associated with AMA dispositions, a continued search for effective intervention strategies and opportunities is warranted. Recently, programs for transition of care/discharge have demonstrated improved outcomes including reduced rates of readmission with standard discharges.[13] At the time of our study, effective programs such as Project BOOST (Better Outcomes for Older adult through Safe Transitions),[14] the Care Transitions Program,[15] and RED (Project Re‐engineered Discharge)[16] were not yet routinely employed, but their common elements may be applicable to the AMA population. In general, these programs focus on elements we investigated (patient understanding, follow‐up plans, medications prescribed) but add a number of additional components. Additional elements include written discharge instructions, patient education, teach‐back process, decision support, emergency plans, caregiver education, telephone follow‐up, and transition coaches to coordinate home and office follow‐up visits. Most potential interventions add significant time (and cost) to the discharge process. Thus, future studies applying these components to AMA discharges should emphasize timely identification of threatened AMA and prioritized interventions. Future studies should focus on which interventions are the most cost‐effective with AMA patients.

Limitations of our study include not being able to access information from area hospitals not in our hospital network, and thus we may not have identified all ED returns and readmissions. Additionally, interventions at the time of discharge (like prescription of medications or provider assessment of decision‐making capacity) may not have been documented and thus not available for our review. Also, our study was a retrospective review at a single institution and included a relatively small population of patients; consequently, our findings may not apply to other healthcare providers in other hospitals or settings. Our study was strengthened by reviewing all consecutive AMA cases over a 2‐year period encompassing a diverse group of healthcare providers.

CONCLUSION

In the majority of cases reviewed, some advance warning of impending AMA is apparent, affording an opportunity for interventions that may improve health outcomes. Despite this advance warning, only a minority of cases result in key interventions such as prescription of medications or development of follow‐up plans. Medical documentation of AMA dispositions is often inadequate, suggesting missed opportunities for potential intervention as well as suboptimal medicolegal scenarios. Future prospective studies examining cost‐effective interventions at the time of AMA discharge and transition of care may provide valuable insight into lowering rates of ED return and rehospitalization.

Disclosures: The views and opinions expressed in this article are those of the author(s) and do not reflect official policy or position of the United States Air Force, Department of Defense, or US government. The authors report no conflicts of interest.

Transitions of care, which encompass the patient experience of hospital discharge to the community, are frequently associated with clinically and financially costly adverse events.[1, 2] One important element for reducing the risk of postdischarge adverse events is provision of timely follow‐up by a clinician familiar with the patient and hospital course.[3, 4]

However, achieving this ideal is becoming more difficult because of an increased demand for primary care services (due to expanding coverage of Medicare and Medicaid) and the decreased supply of primary care physicians.[5, 6] When a timely visit with a clinician is available postdischarge, the widening discontinuity between inpatient and outpatient care providers often means this clinician is lacking essential details of the hospitalization.[7, 8]

One increasingly common innovation to improve postdischarge care access and continuity is to extend the role of inpatient providers (usually hospitalists) to provide care after discharge in a postdischarge clinic (PDC).[9, 10, 11] These clinics require an expansion of a hospitalist's duties to the outpatient setting, a requirement that has met with hospitalist resistance in initial reports.[12] However, little is known about hospitalists' experience with PDCs or attitudes toward postdischarge care. We aimed to explore these attitudes and experiences surrounding postdischarge care and PDCs.

METHODS

We conducted a cross‐sectional 17‐question Web‐based survey of hospitalists at 20 academic and 17 VA medical centers across the United States. Hospital medicine faculty at each site were identified by their group leader; members of each group then received an email survey up to 3 times. To collect responses from nonacademic hospitalists, the survey was also distributed to a large national private hospitalist employer. Due to internal limitations at the employer site, sampling was not feasible, and thus a convenience sample was obtained. Hospitalists who were not clinically active or did not have computer access to complete the survey were excluded. Responses were initially gathered on a 4‐point Likert scale; for comparisons between groups the scale was collapsed to a binary comparison using Fisher exact or ² tests. We included questions answered in partially completed surveys in both the numerator and denominator; questions not answered were excluded from both numerator and denominator. The denominator of all responses was noted. All analyses were conducted using SAS 9.3 (SAS Institute, Inc., Cary, NC). The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Of 814 hospitalists, 228 responded to the survey (28.3%). Table 1 illustrates characteristics of responding hospitalists, who were divided between university hospitals, community teaching hospitals, and community nonteaching hospitals in diverse practices in terms of location and group size.

Sixty‐one percent of responding hospitalists believed most patient problems after discharge were due to poor follow‐up with primary care providers, and 55% found it difficult to arrange timely primary care follow up (Table 2). Despite this, 87% thought patient problems after discharge should be cared for by primary care physicians, and 62% opposed the idea of hospitalists seeing patients in the clinic after discharge.

When asked if hospitalists were responsible for patients after discharge from the hospital, only 50% responded positively. However, when asked how long hospitalists were responsible for patients after discharge, 71% gave a response longer than hospital discharge, including 60% who believed this responsibility ended at 1 week or less following discharge. A minority (12%) felt it extended to 1 month following discharge (Table 3).

Responding hospitalists expressed confidence in a PDC to reduce postdischarge emergency department visits (74%). However, most felt they would require extra compensation to staff a PDC (77%). They were divided on whether they would discharge patients from the hospital earlier if they could see those patients in postdischarge follow‐up (51% would discharge patients earlier).

Compared to those who had not experienced a PDC, responding hospitalists who had provided care in a PDC trended toward responding more positively that hospitalists should provide postdischarge care (P = 0.054). Few responding hospitalists had such exposure (8.8%) at the time of the survey. Although 31% had considering starting a PDC, only 3% were starting in the next year. Of responding hospitalists with exposure to a PDC, 70% were satisfied with the experience and 85% felt their patients were satisfied. Responses did not vary by type of practice (academic vs nonacademic), group size, geographic location, or by exposure to a PDC except as above.

DISCUSSION

Responding hospitalists reported encountering significant difficulty arranging appropriate postdischarge appointments with primary care providers and feel this contributes to postdischarge complications. Nearly 75% of those surveyed felt a hospitalist‐run PDC would be effective in reducing postdischarge emergency department visits, presumably in part due to improved access to postdischarge care. However, 62% of responding hospitalists opposed providing this type of care, though those who had experienced a PDC were somewhat more likely to view providing care in a PDC favorably. Survey responses largely reflect attitudes rather than experience with PDCs, because very few respondents had ever worked in a PDC.

The juxtaposition of the confidence expressed in PDCs to reduce postdischarge emergency department visits with the less enthusiastic views of respondents about providing care in a PDC was surprising. Several explanations are possible. First, providing such care is outside the usual scope of practice of most hospitalists, and preliminary reports indicate hospitalists, as self‐selected inpatient providers, may not initially welcome this opportunity.[12] Second, responding hospitalists identified the need for extra compensation for providing this care, suggesting they would see staffing a PDC as a burden requiring extra payment. Third, only 12% of respondents felt their responsibility to their discharged patients extended to 1 month following discharge. Given this, hospitalists may not feel enough personal ownership over 30‐day readmission rates to justify the additional clinical demand of staffing a PDC.[13]

In fact, 29% of responding hospitalists felt their responsibility to the patient ended at the time of discharge. Respondents may have interpreted responsibility differently, and we cannot rule out response bias given our lower‐than‐expected response rate. However, we had anticipated many fewer hospitalists would respond this way given professional hospitalist societies have endorsed guidelines for improved transitions of care, which clearly delineate the key role hospitalists play in care transitions.[14]

Although fewer than 10% of respondents had worked in a PDC, nearly one‐third reported considering starting such a practice in the future, underscoring the importance of understanding hospitalist attitudes and experiences when creating a PDC and the significant barriers to arranging appropriate postdischarge care identified by survey respondents. The barriers to establishing a PDC may explain why few planned to start a PDC in the next year.

This study should be interpreted in the context of its design. Due to limitations in survey delivery, more rigorous sampling designs could not be used, and efforts were instead made to deliver the survey to a diverse group of hospitalists. The survey response rate was lower than anticipated and this increases the risk of response bias. Though this response rate is characteristic of other surveys of hospitalists, responses may have been from a selected population and therefore not representative of all hospitalists.[15] We sampled from a variety of practice venues, locations, academic and community practices, and practice group sizes to try to minimize this bias. Due to the low exposure rate to PDCs, hospitalist responses to experiences with PDCs should be considered exploratory.

We asked about similar content areas in the survey in multiple questions to maximize content validity; this resulted in variations in the degree of agreement or disagreement to similar prompts. For example, 62% of hospitalists opposed seeing patients in the clinic after discharge when directly asked, but nearly 50% said they would welcome the opportunity to work in a PDC if their employer required it. In another example, 50% of respondents said their responsibility for the patient ended at time of discharge, but when asked about duration of responsibility, 30% identified time of discharge as the limit. When reporting and interpreting results, we have tried to highlight responses to questions that ask most clearly and directly about the content of interest (rather than general themes), but this interpretation may also be subject to bias.

The time after hospital discharge is one of heightened risk for adverse events for the recently discharged patient. Hospitalist‐run postdischarge clinics may offer improved postdischarge care access and continuity; more research is needed on the effects of such clinics on patient outcomes, including postdischarge utilization. Until then, physicians and hospitals considering establishing PDCs should consider the barriers responding hospitalists identified to working in such a clinic, as well as the confidence they expressed in PDCs to reduce subsequent utilization.

Disclosures: Dr. Burke had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Burke was supported by grant funding from the Colorado Research Enhancement Award Program to Improve Care Coordination for Veterans. Dr. Ryan has no conflicts of interest to disclose.

Transitions of care, which encompass the patient experience of hospital discharge to the community, are frequently associated with clinically and financially costly adverse events.[1, 2] One important element for reducing the risk of postdischarge adverse events is provision of timely follow‐up by a clinician familiar with the patient and hospital course.[3, 4]

However, achieving this ideal is becoming more difficult because of an increased demand for primary care services (due to expanding coverage of Medicare and Medicaid) and the decreased supply of primary care physicians.[5, 6] When a timely visit with a clinician is available postdischarge, the widening discontinuity between inpatient and outpatient care providers often means this clinician is lacking essential details of the hospitalization.[7, 8]

One increasingly common innovation to improve postdischarge care access and continuity is to extend the role of inpatient providers (usually hospitalists) to provide care after discharge in a postdischarge clinic (PDC).[9, 10, 11] These clinics require an expansion of a hospitalist's duties to the outpatient setting, a requirement that has met with hospitalist resistance in initial reports.[12] However, little is known about hospitalists' experience with PDCs or attitudes toward postdischarge care. We aimed to explore these attitudes and experiences surrounding postdischarge care and PDCs.

METHODS

We conducted a cross‐sectional 17‐question Web‐based survey of hospitalists at 20 academic and 17 VA medical centers across the United States. Hospital medicine faculty at each site were identified by their group leader; members of each group then received an email survey up to 3 times. To collect responses from nonacademic hospitalists, the survey was also distributed to a large national private hospitalist employer. Due to internal limitations at the employer site, sampling was not feasible, and thus a convenience sample was obtained. Hospitalists who were not clinically active or did not have computer access to complete the survey were excluded. Responses were initially gathered on a 4‐point Likert scale; for comparisons between groups the scale was collapsed to a binary comparison using Fisher exact or ² tests. We included questions answered in partially completed surveys in both the numerator and denominator; questions not answered were excluded from both numerator and denominator. The denominator of all responses was noted. All analyses were conducted using SAS 9.3 (SAS Institute, Inc., Cary, NC). The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Of 814 hospitalists, 228 responded to the survey (28.3%). Table 1 illustrates characteristics of responding hospitalists, who were divided between university hospitals, community teaching hospitals, and community nonteaching hospitals in diverse practices in terms of location and group size.

Sixty‐one percent of responding hospitalists believed most patient problems after discharge were due to poor follow‐up with primary care providers, and 55% found it difficult to arrange timely primary care follow up (Table 2). Despite this, 87% thought patient problems after discharge should be cared for by primary care physicians, and 62% opposed the idea of hospitalists seeing patients in the clinic after discharge.

When asked if hospitalists were responsible for patients after discharge from the hospital, only 50% responded positively. However, when asked how long hospitalists were responsible for patients after discharge, 71% gave a response longer than hospital discharge, including 60% who believed this responsibility ended at 1 week or less following discharge. A minority (12%) felt it extended to 1 month following discharge (Table 3).

Responding hospitalists expressed confidence in a PDC to reduce postdischarge emergency department visits (74%). However, most felt they would require extra compensation to staff a PDC (77%). They were divided on whether they would discharge patients from the hospital earlier if they could see those patients in postdischarge follow‐up (51% would discharge patients earlier).

Compared to those who had not experienced a PDC, responding hospitalists who had provided care in a PDC trended toward responding more positively that hospitalists should provide postdischarge care (P = 0.054). Few responding hospitalists had such exposure (8.8%) at the time of the survey. Although 31% had considering starting a PDC, only 3% were starting in the next year. Of responding hospitalists with exposure to a PDC, 70% were satisfied with the experience and 85% felt their patients were satisfied. Responses did not vary by type of practice (academic vs nonacademic), group size, geographic location, or by exposure to a PDC except as above.

DISCUSSION

Responding hospitalists reported encountering significant difficulty arranging appropriate postdischarge appointments with primary care providers and feel this contributes to postdischarge complications. Nearly 75% of those surveyed felt a hospitalist‐run PDC would be effective in reducing postdischarge emergency department visits, presumably in part due to improved access to postdischarge care. However, 62% of responding hospitalists opposed providing this type of care, though those who had experienced a PDC were somewhat more likely to view providing care in a PDC favorably. Survey responses largely reflect attitudes rather than experience with PDCs, because very few respondents had ever worked in a PDC.

The juxtaposition of the confidence expressed in PDCs to reduce postdischarge emergency department visits with the less enthusiastic views of respondents about providing care in a PDC was surprising. Several explanations are possible. First, providing such care is outside the usual scope of practice of most hospitalists, and preliminary reports indicate hospitalists, as self‐selected inpatient providers, may not initially welcome this opportunity.[12] Second, responding hospitalists identified the need for extra compensation for providing this care, suggesting they would see staffing a PDC as a burden requiring extra payment. Third, only 12% of respondents felt their responsibility to their discharged patients extended to 1 month following discharge. Given this, hospitalists may not feel enough personal ownership over 30‐day readmission rates to justify the additional clinical demand of staffing a PDC.[13]

In fact, 29% of responding hospitalists felt their responsibility to the patient ended at the time of discharge. Respondents may have interpreted responsibility differently, and we cannot rule out response bias given our lower‐than‐expected response rate. However, we had anticipated many fewer hospitalists would respond this way given professional hospitalist societies have endorsed guidelines for improved transitions of care, which clearly delineate the key role hospitalists play in care transitions.[14]

Although fewer than 10% of respondents had worked in a PDC, nearly one‐third reported considering starting such a practice in the future, underscoring the importance of understanding hospitalist attitudes and experiences when creating a PDC and the significant barriers to arranging appropriate postdischarge care identified by survey respondents. The barriers to establishing a PDC may explain why few planned to start a PDC in the next year.

This study should be interpreted in the context of its design. Due to limitations in survey delivery, more rigorous sampling designs could not be used, and efforts were instead made to deliver the survey to a diverse group of hospitalists. The survey response rate was lower than anticipated and this increases the risk of response bias. Though this response rate is characteristic of other surveys of hospitalists, responses may have been from a selected population and therefore not representative of all hospitalists.[15] We sampled from a variety of practice venues, locations, academic and community practices, and practice group sizes to try to minimize this bias. Due to the low exposure rate to PDCs, hospitalist responses to experiences with PDCs should be considered exploratory.

We asked about similar content areas in the survey in multiple questions to maximize content validity; this resulted in variations in the degree of agreement or disagreement to similar prompts. For example, 62% of hospitalists opposed seeing patients in the clinic after discharge when directly asked, but nearly 50% said they would welcome the opportunity to work in a PDC if their employer required it. In another example, 50% of respondents said their responsibility for the patient ended at time of discharge, but when asked about duration of responsibility, 30% identified time of discharge as the limit. When reporting and interpreting results, we have tried to highlight responses to questions that ask most clearly and directly about the content of interest (rather than general themes), but this interpretation may also be subject to bias.

The time after hospital discharge is one of heightened risk for adverse events for the recently discharged patient. Hospitalist‐run postdischarge clinics may offer improved postdischarge care access and continuity; more research is needed on the effects of such clinics on patient outcomes, including postdischarge utilization. Until then, physicians and hospitals considering establishing PDCs should consider the barriers responding hospitalists identified to working in such a clinic, as well as the confidence they expressed in PDCs to reduce subsequent utilization.

Disclosures: Dr. Burke had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Burke was supported by grant funding from the Colorado Research Enhancement Award Program to Improve Care Coordination for Veterans. Dr. Ryan has no conflicts of interest to disclose.

Transitions of care, which encompass the patient experience of hospital discharge to the community, are frequently associated with clinically and financially costly adverse events.[1, 2] One important element for reducing the risk of postdischarge adverse events is provision of timely follow‐up by a clinician familiar with the patient and hospital course.[3, 4]

However, achieving this ideal is becoming more difficult because of an increased demand for primary care services (due to expanding coverage of Medicare and Medicaid) and the decreased supply of primary care physicians.[5, 6] When a timely visit with a clinician is available postdischarge, the widening discontinuity between inpatient and outpatient care providers often means this clinician is lacking essential details of the hospitalization.[7, 8]

One increasingly common innovation to improve postdischarge care access and continuity is to extend the role of inpatient providers (usually hospitalists) to provide care after discharge in a postdischarge clinic (PDC).[9, 10, 11] These clinics require an expansion of a hospitalist's duties to the outpatient setting, a requirement that has met with hospitalist resistance in initial reports.[12] However, little is known about hospitalists' experience with PDCs or attitudes toward postdischarge care. We aimed to explore these attitudes and experiences surrounding postdischarge care and PDCs.

METHODS

We conducted a cross‐sectional 17‐question Web‐based survey of hospitalists at 20 academic and 17 VA medical centers across the United States. Hospital medicine faculty at each site were identified by their group leader; members of each group then received an email survey up to 3 times. To collect responses from nonacademic hospitalists, the survey was also distributed to a large national private hospitalist employer. Due to internal limitations at the employer site, sampling was not feasible, and thus a convenience sample was obtained. Hospitalists who were not clinically active or did not have computer access to complete the survey were excluded. Responses were initially gathered on a 4‐point Likert scale; for comparisons between groups the scale was collapsed to a binary comparison using Fisher exact or ² tests. We included questions answered in partially completed surveys in both the numerator and denominator; questions not answered were excluded from both numerator and denominator. The denominator of all responses was noted. All analyses were conducted using SAS 9.3 (SAS Institute, Inc., Cary, NC). The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Of 814 hospitalists, 228 responded to the survey (28.3%). Table 1 illustrates characteristics of responding hospitalists, who were divided between university hospitals, community teaching hospitals, and community nonteaching hospitals in diverse practices in terms of location and group size.

Sixty‐one percent of responding hospitalists believed most patient problems after discharge were due to poor follow‐up with primary care providers, and 55% found it difficult to arrange timely primary care follow up (Table 2). Despite this, 87% thought patient problems after discharge should be cared for by primary care physicians, and 62% opposed the idea of hospitalists seeing patients in the clinic after discharge.

When asked if hospitalists were responsible for patients after discharge from the hospital, only 50% responded positively. However, when asked how long hospitalists were responsible for patients after discharge, 71% gave a response longer than hospital discharge, including 60% who believed this responsibility ended at 1 week or less following discharge. A minority (12%) felt it extended to 1 month following discharge (Table 3).

Responding hospitalists expressed confidence in a PDC to reduce postdischarge emergency department visits (74%). However, most felt they would require extra compensation to staff a PDC (77%). They were divided on whether they would discharge patients from the hospital earlier if they could see those patients in postdischarge follow‐up (51% would discharge patients earlier).

Compared to those who had not experienced a PDC, responding hospitalists who had provided care in a PDC trended toward responding more positively that hospitalists should provide postdischarge care (P = 0.054). Few responding hospitalists had such exposure (8.8%) at the time of the survey. Although 31% had considering starting a PDC, only 3% were starting in the next year. Of responding hospitalists with exposure to a PDC, 70% were satisfied with the experience and 85% felt their patients were satisfied. Responses did not vary by type of practice (academic vs nonacademic), group size, geographic location, or by exposure to a PDC except as above.

DISCUSSION

Responding hospitalists reported encountering significant difficulty arranging appropriate postdischarge appointments with primary care providers and feel this contributes to postdischarge complications. Nearly 75% of those surveyed felt a hospitalist‐run PDC would be effective in reducing postdischarge emergency department visits, presumably in part due to improved access to postdischarge care. However, 62% of responding hospitalists opposed providing this type of care, though those who had experienced a PDC were somewhat more likely to view providing care in a PDC favorably. Survey responses largely reflect attitudes rather than experience with PDCs, because very few respondents had ever worked in a PDC.

The juxtaposition of the confidence expressed in PDCs to reduce postdischarge emergency department visits with the less enthusiastic views of respondents about providing care in a PDC was surprising. Several explanations are possible. First, providing such care is outside the usual scope of practice of most hospitalists, and preliminary reports indicate hospitalists, as self‐selected inpatient providers, may not initially welcome this opportunity.[12] Second, responding hospitalists identified the need for extra compensation for providing this care, suggesting they would see staffing a PDC as a burden requiring extra payment. Third, only 12% of respondents felt their responsibility to their discharged patients extended to 1 month following discharge. Given this, hospitalists may not feel enough personal ownership over 30‐day readmission rates to justify the additional clinical demand of staffing a PDC.[13]

In fact, 29% of responding hospitalists felt their responsibility to the patient ended at the time of discharge. Respondents may have interpreted responsibility differently, and we cannot rule out response bias given our lower‐than‐expected response rate. However, we had anticipated many fewer hospitalists would respond this way given professional hospitalist societies have endorsed guidelines for improved transitions of care, which clearly delineate the key role hospitalists play in care transitions.[14]

Although fewer than 10% of respondents had worked in a PDC, nearly one‐third reported considering starting such a practice in the future, underscoring the importance of understanding hospitalist attitudes and experiences when creating a PDC and the significant barriers to arranging appropriate postdischarge care identified by survey respondents. The barriers to establishing a PDC may explain why few planned to start a PDC in the next year.

This study should be interpreted in the context of its design. Due to limitations in survey delivery, more rigorous sampling designs could not be used, and efforts were instead made to deliver the survey to a diverse group of hospitalists. The survey response rate was lower than anticipated and this increases the risk of response bias. Though this response rate is characteristic of other surveys of hospitalists, responses may have been from a selected population and therefore not representative of all hospitalists.[15] We sampled from a variety of practice venues, locations, academic and community practices, and practice group sizes to try to minimize this bias. Due to the low exposure rate to PDCs, hospitalist responses to experiences with PDCs should be considered exploratory.

We asked about similar content areas in the survey in multiple questions to maximize content validity; this resulted in variations in the degree of agreement or disagreement to similar prompts. For example, 62% of hospitalists opposed seeing patients in the clinic after discharge when directly asked, but nearly 50% said they would welcome the opportunity to work in a PDC if their employer required it. In another example, 50% of respondents said their responsibility for the patient ended at time of discharge, but when asked about duration of responsibility, 30% identified time of discharge as the limit. When reporting and interpreting results, we have tried to highlight responses to questions that ask most clearly and directly about the content of interest (rather than general themes), but this interpretation may also be subject to bias.

The time after hospital discharge is one of heightened risk for adverse events for the recently discharged patient. Hospitalist‐run postdischarge clinics may offer improved postdischarge care access and continuity; more research is needed on the effects of such clinics on patient outcomes, including postdischarge utilization. Until then, physicians and hospitals considering establishing PDCs should consider the barriers responding hospitalists identified to working in such a clinic, as well as the confidence they expressed in PDCs to reduce subsequent utilization.

Disclosures: Dr. Burke had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Burke was supported by grant funding from the Colorado Research Enhancement Award Program to Improve Care Coordination for Veterans. Dr. Ryan has no conflicts of interest to disclose.