Training on premature discharge prevention could equip clinicians with additional tools to support patients in receiving their full course of treatment in hospital.

A large-scale cohort study led by Vancouver Coastal Health Research Institute (VCHRI) researcher Dr. John Staples and University of British Columbia (UBC) research coordinator Mayesha Khan has found links between patient-physician sex discordance and premature departure from hospital. The study findings point to the need for changes to processes of care that will encourage patients to complete their treatment in hospital.

Dr. John Staples is an academic general internist at Vancouver General Hospital and a clinical associate professor at UBC.

Patient-physician sex discordance is when the sex of a patient is different from the sex of the physician providing their medical care. Prior research has found that sex discordance is associated with reduced rapport between physicians and patients, along with adverse health outcomes, such as an increased risk of post-operative and unplanned hospital readmission. 

“Building on prior findings, our research is the first to examine patient-physician sex discordance as a risk factor for before medically advised departure from hospital,” states Staples. 

Known as patient-initiated, before medically advised (BMA), or ‘against medical advice’, discharge from hospital, patients who leave hospital before their in-patient medical care is complete are up to seven times more likely to be readmitted to hospital within two weeks. They are also up to three times more likely to die within one year.

“We know that BMA departure from hospital is a risk factor for premature morbidity and mortality, and that patients who initiate these departures often already have risk factors for adverse outcomes.”  

Patients who initiate a BMA discharge are more likely to be male, be younger in age, experience socioeconomic marginalization and have unstable housing. They are also more likely to have previous BMA discharges and be diagnosed with one or more medical conditions, particularly substance use disorder, mental illness, HIV infection, cirrhosis of the liver or asthma.

Sex-discordance linked to BMA discharge, but only among male patients

In their study, published in the Journal of General Internal Medicine, the research team reviewed patient records from 1.9 million hospitalizations in British Columbia over the course of a 15-year time frame.

Among male hospitalized patients, the researchers identified 178,652 who had a female attending physician and 800,295 who had a male attending physician for the majority of their hospital stay. Sex discordance among male patients was associated with a statistically significant eight per cent relative increase in the risk of BMA discharge. 

For male patients, patient-physician sex discordance was also associated with an increased risk of unplanned readmission or death within 30 days of discharge. 

Among female hospitalized patients, the researchers identified 732,366 who had a male attending physician and 214,805 who had a female attending physician for the majority of their hospital stay. Sex discordance among female patients was not associated with a statistically significant increase in the risk of BMA discharge.

“We found that patient-physician sex discordance was associated with a small increase in BMA discharge among male patients, while a similar increase was not observed among female patients.”

“One interpretation of our results suggests that patient-physician sex discordance might contribute in subtle ways to failures of communication between some patients and physicians, arising from differences in values, nonverbal behaviours and preferred styles of communication,” says Khan.

Mayesha Khan is a research coordinator in the Staples Lab, as well as with Road Safety and Public Health Research at UBC and VCHRI.

“This may erode trust, provoke treatment non-adherence and lead to adverse outcomes, such as BMA discharge, unplanned readmission and death,” Khan adds. 

Differences in outcomes may also reflect differences in approaches to care between male and female physicians. Prior research suggests that female physicians are likelier to take a preventative medicine approach to care, conduct in-depth investigations and offer additional psychological or social supports, says Khan. These steps may lengthen the duration of a patient’s hospital stay and frustrate more risk-tolerant male patients, increasing the likelihood of a BMA discharge.

Discriminatory attitudes towards female physicians among male patients was also cited by the research team as a potential contributing factor for BMA discharge. “As more female physicians enter the workforce, there may be an implicit bias against them from years of male over-representation in this role,” says Khan. 

Interventions could help prevent BMA discharge

“It is not ethical or feasible to ensure that hospitalized patients are only treated by physicians of the same sex,” notes Khan. “But, there are many other interventions that could help prevent BMA discharge.” 

Among these interventions are adequate addictions and pain treatment for patients with substance use disorder, and less restrictive hospital stay policies that enable patients to temporarily leave the hospital setting or receive visitors during their stay. 

“We believe that improvements in routine processes of care in hospital will help clinicians work with patients to ensure they complete the recommended course of care in hospital, ultimately decreasing rates of BMA discharge regardless of the sex of the attending physician.”

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