(650) Patient-directed discharge during antepartum hospitalization and risk for adverse outcomes at delivery

Objective: Antepartum (AP) hospitalizations are typically unplanned and often cause social stress. Patients with social and mental health risk factors may be more likely to leave the hospital via patient-directed discharge (PDD). We evaluated predictors of PDD at AP hospitalization and the effect of AP PDD on risk for adverse outcomes at delivery.

Study Design: We conducted a serial cross-sectional analysis of October-December delivery hospitalizations with an AP admission in the preceding 9 months included in the National Readmissions Database during 2016-2021. Our primary exposure was PDD (versus routine discharge) at first AP hospitalization. Using the chi-square test, we evaluated the association between demographic and clinical factors and AP PDD. Using survey-adjusted logistic regression, we evaluated the association between AP PDD and the following adverse outcomes at delivery: non-transfusion severe maternal morbidity (SMM), transfusion, hypertensive disorders (HDP), preterm delivery (PTD) and stillbirth.

Results: We identified 152,748 AP hospitalizations with delivery follow-up in NRD during 2016-2021, with 3.3% of AP discharges categorized as PDD. Compared to routine discharge, AP PDD was associated with higher likelihood of any mental health condition (38.4% vs 27.0%; p< 0.01), any substance use disorder (44.4% vs 14.1%, p < 0.01), lowest income quartile (45.2% vs 36.0%; p< 0.01), and Medicaid insurance (78.8% vs 57.9%; p < 0.01). At delivery, history of AP PDD was associated with increased risk for SMM (adjusted OR [aOR] 1.42, 95% CI 1.16, 1.73), transfusion (aOR 1.63, 95% CI 1.32, 2.02), HDP (aOR 1.44, 95% CI 1.28, 1.61), PTD (aOR 1.45, 95% CI 1.29, 1.63) and stillbirth (aOR 1.80, 95% CI 1.39, 2.33).

Conclusion: About 3% of antepartum patients will self-discharge. Patient-directed discharge is more common in patients with adverse social determinants of health and mental health conditions. PDD is associated with higher risk of adverse delivery outcomes. Screening for PDD risk factors during antepartum admission and providing interventions to at-risk patients may reduce adverse delivery outcomes.