'Before Medically Advised’ Discharges Following Hospitalization for Asthma Exacerbation: Disparities in Treatment and Outcomes

Abstract INTRODUCTION Before medically advised (BMA) discharges – alternatively known as ‘against medical advice'—are associated with poor outcomes such as increased readmission among patients with asthma. However, it is unclear what factors contribute to these worsened outcomes or what care these patients receive upon discharge. In this study, we evaluated patterns of post-discharge care (i.e. medication prescriptions, referrals, and follow-up) after hospitalizations for asthma exacerbation among patients discharging BMA versus non-BMA. METHODS We developed a cohort using electronic health record data of patients ≥ 18 years old within the Johns Hopkins Health System who had an admission for asthma exacerbation, as defined by ICD-10 codes, and were discharged to home. All admissions were classified as either a BMA or planned (i.e. non-BMA) discharge according to their discharge disposition. Demographics, clinical characteristics, and 30-day readmission were compared between BMA and non-BMA discharges using chi-square and Mann-Whitney U tests. We then evaluated the proportion of discharges in which the patient received each of the following at discharge: an oral steroid prescription, inhaled corticosteroid prescription, outpatient referral for any service, or scheduled follow-up with a primary care physician or pulmonologist within 14-days. Differences in each component of discharge care were compared using logistic regression models with clustered standard errors, adjusted for age, race, sex, length of stay, history of exacerbation, insurance, time of discharge, and medical center. RESULTS This cohort included 5,507 admissions for asthma exacerbation, of which 205 (3.7%) resulted in a BMA discharge. Compared to non-BMA discharges, those discharged BMA were younger (39 vs 48 years, p<0.001) with a higher area deprivation index (67 vs 50, p<0.001). Readmission at 30 days more commonly occurred after a BMA discharge (15 vs 10%, p=0.03). Compared to non-BMA discharges, those who discharged BMA were less likely to receive an oral steroid prescription (54% vs 76%, p<0.001 ), inhaled corticosteroid prescription (32% vs 49%, p<0.001), outpatient referral (9% vs 34%, p<0.001), or scheduled 14-day follow-up (19% vs 27%, p=0.01) (Figure 1). All results were similar in adjusted models, and patients discharging BMA were particularly less likely to receive an outpatient prescription for oral steroids (OR 0.25, 95% CI 0.18-0.35) CONCLUSIONS Compared to non-BMA discharges, patients discharged BMA following hospitalization for an asthma exacerbation were less likely to receive outpatient steroids, inhaled corticosteroids, referrals, or follow-up, and they more likely to be readmitted at 30 days. These treatment gaps present potential opportunities to improve care.

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