Clinical Research Details

Descriptive Information
Discharge against medical advice from the Emergency Department. Results from a tertiary care hospital in Beirut, Lebanon

Mazen El Sayed

Completed- Has Results


  • Gilbert Abou Dagher
Rana Bachir
Conditions and Keywords
All Diagnoses
Against medical advice,return visit within 72 hours,predictors of return visit
Study Design
Basic / Translational
N/A: Not Applicable
N/A: Not Applicable
N/A: Not Applicable
N/A: Not Applicable
Eligibility and IRB

Background: Patient who leave the emergency department against medical advice are at high risk for complications. AMA discharges are also considered high-risk events potentially leading to malpractice litigation.


Objectives: Our aim was to characterize patients who leave AMA in a payment prior to service ED model and to identify predictors for return visits to ED after leaving AMA.


Methods: We conducted a retrospective review study of charts of ED patients who were discharged AMA between 1/1/2012 and 1/1/2013 at a tertiary care center in Beirut Lebanon. We carried out a descriptive analysis and a bivariate analysis comparing the first visit and the return visit within 72 hours. This was followed by a Logistic regression to identify predictors of return visits after leaving AMA.


Results: A total of 1213 ED patients were discharged AMA during the study period. Mean age was 46.9 years (± 20.9). There were 654 males (53.9%), 737 married (60.8%). The majority (1059 patients (87.3 %)) had an emergency severity index of 3 or less (1 or 2). ED average length of stay was 3.8 hours (±6.8). Self payers accounted for 53.9%.  Reasons for leaving AMA were: no reason mentioned (44.1%), incomplete workup (30.5%), refusing admission (12.4%), financial reasons (7.9%), long wait times (2.9%) and others (2.2%). Discharge diagnoses were mainly cardiac (23.4%), gastrointestinal (16.4%), infectious (10.1%) and trauma (9.8%).

One hundred nineteen returned to ED within 72 hours (9.8%). Predictors of returning to ED after leaving AMA were: older age (OR 1.02 95% CI (1.01-1.03)), private insurance status (OR 4.64 95% (CI 2.89-7.47) within network insurance status (OR 7.20 95% CI (3.86-13.44), longer ED LOS during the first visit (OR 1.03 95%CI (1.01-1.05).



In our setting, the rate of return visit to ED after leaving AMA was 9.8%. Reasons for leaving AMA, high-risk discharge diagnoses and predictors of return visit were identified. Financial status was a strong predictor of return to ED after leaving AMA. 

All patients who were discharged AMA from the ED between 1/1/2012 and 1/1/2013 was done.  

A retrospective chart review of all patients who were discharged AMA from the ED between 1/1/2012 and 1/1/2013 was done.  

AMA is a separate category that is assigned electronically to patients by the discharging provider when they leave the ED in our system. A list of all patients discharged AMA during the study period was generated and their charts were included for review (initial visit). All patients who left AMA had a signed AMA form completed in their chart. Patients who returned to the ED within 72 hours of AMA discharge (return visit) were flagged and reviewed for additional data collection. 

A list of 1256 patients was identified with 43 patients excluded because of admission to hospital within the same visit (signed AMA for refusing a treatment with proven benefits or additional work up needed to reach a clear diagnosis), or missing ED charts (ED records consist of paper charting then scanning combined with electronic tracking).