HCUP Fact Book No. 6: Hospitalization in the United States, 2002 (continued)

Overview of Hospitals

Overview of Hospitals in the United States

The following tables and charts provide an overview of the types of U.S. hospitals in 1997 and 2002, as defined by the American Hospital Association (AHA).³ This Fact Book presents information specifically pertaining to U.S. community hospitals. The AHA defines community hospitals as "all non-Federal, short-term (or acute care) general and specialty hospitals whose facilities and services are available to the public."³ Children's hospitals and academic medical centers are also considered to be community hospitals.

Additionally, national estimates of general characteristics for community hospitals in the NIS for 1997 and 2002 follow.

Select for Table 1, AHA Hospital Categories, 1997, 2002.

Select for Figure 1 (5 KB), Types of U.S. Hospitals, 2002.

Select for Table 2, Characteristics of U.S. Community Hospitals, 1997, 2002.

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Gender and Age Characteristics

Who Is Admitted to the Hospital?

Gender Characteristics of Hospitalizations

• Nearly 60 percent of all hospitalizations are for women—just as in 1997.
• Among hospitalized patients 0-17 and 45-64, there are nearly equal numbers of males and females. However, for patients 18-44, 3 out of 4 hospitalized patients are women, many of whom are hospitalized for pregnancy-related conditions.

Select for Figure 2 (4 KB), Gender of Patients in the Hospital (All Ages).

Age Characteristics of Hospitalizations

• The mean age for hospitalized patients is about 48 years, which is similar to 1997, when the mean age was 47 years.
• People age 65 and older continue to account for more hospital stays than any other age group. This group is followed closely by individuals ages 18-44.
• While people 65 and older comprise about 12 percent⁴ of the U.S. population, they account for about 35 percent of all hospital stays. In contrast, people 18-44 comprise roughly 40 percent of the U.S. population but account for only 27 percent of all hospital stays.

Select for Figure 3 (8 KB), Percent of Hospital Stays by Age Group.

Select for Figure 4 (11 KB), Percent of Population vs. Percent of Hospital Stays.

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Common Diagnoses

Why Are Patients Admitted to the Hospital?

Most Frequent Reasons for Hospitalizations^v

• The most common reason for hospitalization continues to be infant birth (newborns), which accounts for 11 percent of all hospital discharges.
• Cardiovascular diseases continue to be a common reason for hospitalization. Five of the top 10 conditions for hospitalization relate to cardiovascular disease: coronary atherosclerosis (hardening of the heart arteries and other heart disease), congestive heart failure, chest pain, heart attack, and irregular heart beat.
• Chest pain—a nonspecific diagnosis—replaced stroke as 1 of the top 10 reasons for hospitalization. From 1997 to 2002, admission from stroke decreased by 12 percent (638,431 admissions to 564,129 admissions). Hospitalizations resulting from stroke have fallen from the 7th most frequent reason for admission to the 15th.
• Similar to 1997, one of the most frequent reasons for hospitalization in 2002 is a mental health diagnosis—affective disorders (primarily depression). Affective disorders continue to account for nearly 2 percent of all discharges from the hospital.

Select for Table 3, Top 10 Principal Diagnoses in U.S. Hospitals.

Most Common Reasons for Hospitalization by Age Groups

• Pneumonia is the only diagnosis in the top 10 conditions for each age group.
• For patients 18-44, 9 of the top 10 reasons for hospitalization pertain to pregnancy and delivery. When pregnancy and childbirth are excluded, 3 of the top 10 conditions relate to mental illness or substance abuse. Alcohol-related conditions dropped from the 4th most common condition in 1997 to the 11th in 2002, representing a drop of 18 percent.
• Depression is 1 of the top 10 conditions for patients in 3 different age groups: 1-17, 18-44, and 45-64.
• For all age groups 45 and older, hardening of the arteries, heart attack, and congestive heart failure are among the top 10 reasons for hospitalization.
• Some conditions are in the top 10 only within particular age groups:
  • Hip fracture—patients 80 and older.
  • Cardiac dysrhythmia—patients 65 and older.
  • Urinary tract infection—patients less than 1 year of age, as well as patients 80 and older.
  • Asthma—patients 1-17.

Select for Table 4, Top 10 Principal Diagnoses by Age Group.

Most Common Reasons for Hospital Stays by Body System

Major Diagnostic Categories (MDCs) are used to define "body systems." MDCs are broad categories of Diagnosis Related Groups (DRGs) that relate to an organ or a system (the digestive system, for example).

• Diseases of the circulatory system remain the most frequent reason for hospitalization, accounting for 17 percent of all hospital stays. These include conditions such as coronary atherosclerosis (hardening of the heart arteries), congestive heart failure, heart attack, and irregular heart beat.
• The next most common reasons for hospitalization by body system continue to be pregnancy and childbirth (diagnoses received by women), followed by newborns and other perinatal conditions (diagnoses received by babies).
• Hospitalizations for all mental disorders combined account for approximately 4 percent of all hospital stays in short-term community hospitals and rank as the 8th most common reason for hospitalization by body system, just as in 1997.
• The top 10 common reasons for hospital stays by body system (based on Major Diagnostic Categories) are nearly identical to those in 1997 with one exception—diseases of the endocrine system now appear in the top 10, replacing diseases of the female reproductive system. This change is attributable to a single Diagnosis Related Group, obesity-related operating room (OR) procedures, which increased by more than 370 percent (from 16,429 discharges in 1997 to 77,335 discharges in 2002).

Select for Table 5, Top 10 Reasons for Hospital Stay, by Body System.

Comorbidities

Comorbidities are defined as coexisting medical problems listed as secondary diagnoses on a patient's hospital record; they are not the principal diagnosis or the main reason for admission, and they are distinguished from complications that arise during the hospital stay.⁵

Comorbidities can make a hospital stay more expensive and complicated. Conditions are designated as comorbidities if they are not directly related to the principal diagnosis and are likely to have originated prior to the hospital stay.

• Nearly 60 percent of hospitalized patients have at least one comorbidity—an increase from 54 percent in 1997. Thirty-seven percent of hospital stays had two or more comorbidities, compared with 33 percent of hospital stays in 1997—a 12-percent increase.

Select for Figure 5 (5 KB), Comorbidities Among Hospitalized Patients.

Most Common Comorbidities

• Hypertension is the most common comorbidity. About 30 percent of patients with comorbidities have hypertension in addition to their principal diagnosis—up from 20 percent in 1997. It is not clear to what extent this increase is due to more careful coding of underlying conditions, better detection of disease, or increased prevalence.
• Depression and obesity are among the 10 most frequent comorbidities, appearing as secondary diagnoses for about 5 percent and 4 percent of all hospital stays, respectively. These conditions were not among the top 10 comorbidities in 1997.
• The 4th most common comorbidity—fluid and electrolyte disorders—is associated with many conditions and may be a marker for the severity of the principal diagnosis or may actually be a condition that arises in the hospital.

Select for Table 6, Top 10 Comorbidities for Hospital Stays.

Variations in Comorbidities by Age Group

• The most common comorbidity for patients under 18 is fluid and electrolyte disorders.
• For adults (18 years and older), hypertension is, by far, the most common comorbidity. For adults younger than 80, the second most common comorbidity is diabetes, while the second most common for those 80 and older is fluid and electrolyte disorders.
• Depression and obesity are among the top 10 comorbidities for adolescents and adults up to age 64.
• Alcohol and drug abuse continue to be common comorbidities. Drug abuse is a top 10 comorbidity for children and adolescents 1-17 and for adults 18-44. Alcohol abuse is a top 10 comorbidity for adults in both the 18-44 and 45-64 age groups.

Select for Table 7, Top 10 Comorbidities by Age Group.

^v Go to the Appendix for the complete listing of all principal diagnoses.

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Source of Admissions

How Are Patients Admitted to the Hospital?

Admission Status

Admission status refers to how a patient presents to the hospital: routine, from the emergency department, from another hospital, or from a long-term facility. Each of these categories is described below.

Routine admission—Patient was not admitted from the emergency department or any other health care facility. This admission source includes admission from home, via physician or clinic referral, or birth.

Emergency department (ED) admission—Patient was admitted to the hospital through the ED.

Admission from another hospital—Patient was admitted to this hospital from another short-term, acute care hospital. This usually signifies that the patient required the transfer in order to obtain more specialized services that the originating hospital could not provide.

Admission from long-term care facility—Patient was admitted from a long-term facility, such as a nursing home.

The 2002 hospital data indicate:

• Approximately 50 percent of admissions are routine in nature.
• About 43 percent of all hospital admissions originate in the ED.
• The remaining 7 percent of hospital admissions are from another short-term hospital, a long-term hospital, or of unknown origin.

Select for Figure 6 (5 KB), Nature of Admissions.

Admissions Through the Emergency Department

Admissions through the ED tend to more expensive and serious than routine admissions.

• In 2002, about 43 percent of all hospital admissions originated in the ED. This finding is a nearly 18 percent increase above 1997, when 37 percent of admissions were initiated through the ED.
• Six of the top 10 conditions for which patients are admitted through the ED continue to be related to the circulatory system: congestive heart failure, chest pain, coronary atherosclerosis (hardening of the heart arteries), heart attack, irregular heart beat, and stroke.
• Two of the top 10 conditions for ED admissions relate to respiratory problems—pneumonia (6 percent of admissions through the ED) and chronic obstructive lung disease (3 percent). Asthma is no longer among the top 10 conditions admitted through the ED. In 1997, asthma ranked 9th and in 2002, 13th.
• In 1997, 2 infections, pneumonia and septicemia, were among the 10 most frequent conditions admitted through the ED. However, in 2002, pneumonia remains the only infection in this category. Septicemia dropped from the 10th to the 16th most frequent condition for admission through the ED.
• Among the 10 most frequent reasons for admission through the ED, 2 new conditions emerged in 2002: fluid and electrolyte disorders and affective disorders. These conditions were ranked 11th and 13th, respectively, in 1997.

Select for Table 8, Top 10 Principal Diagnoses for Hospital Discharges Admitted Through the ED.

Admissions Through the ED by Payer

• Medicare cases represent 45 percent of all hospitalizations beginning in the ED, followed by private hospitalizations (26 percent), Medicaid hospitalizations (20 percent), and uninsured hospitalizations (7 percent).
• The percent of hospitalizations that begin in the ED varies by payer type: 61 percent of uninsured hospitalizations, 57 percent of Medicare hospitalizations, 39 percent of Medicaid hospitalizations, and 31 percent of privately insured hospitalizations.

Select for Figure 7 (13 KB), Percent of Hospital Stays Attributed to Each Payer.

Variations in ED Admissions by Age Group and Gender

• The percentage of people admitted to the hospital through the ED increased for all age groups, with the largest increase seen for elderly patients.
• For patients 1-17 years of age, a 10-percent increase occurred in the percent of patients admitted through the ED. In 2002, 45 percent of admissions occurred through the ED, compared with 41 percent in 1997.
• For patients ages 45 and older, the proportion admitted through the ED increased the most. For patients 80+, 55 percent were admitted through the ED in 1997, as compared with 64 percent in 2002—a 19-percent increase.
• Individuals 18-44 years of age have the lowest percentage of admissions that begin in the ED—35 percent—relative to any other age group.
• Overall, a greater proportion of hospitalizations for males—48 percent—originate in the ED, as compared with 40 percent for females. In younger age groups, a substantially greater proportion of hospitalizations for males begin in the ED, as compared with females; however, for adults 65 years and above, slightly more hospitalizations for females originate in the ED.

Select for Figure 8 (7 KB), Admissions Initiated Through the ED.

Select for Figure 9 (8 KB), Percent of Hospitalizations Beginning in the ED by Gender.

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Hospital Charges

How Much Do Hospitals Charge?

Hospital charges are the amount the hospital bills for the entire inpatient stay and do not include most professional (physician) fees. Costs tend to reflect the actual costs of producing a service, while charges represent what the hospital billed for the case (but not what was actually reimbursed).

• After adjusting for inflation,⁶ the average hospital charge increased by 24 percent from $13,900 in 1997 to $17,300 in 2002.
• Over this same time period, the average cost^vi for a hospital stay remained essentially the same—$7,500.

Conditions With the Highest Charges

• The most expensive conditions have average charges more than five times higher than the overall average hospital charge.
• The most expensive condition is infant respiratory distress syndrome; the average charge for this condition is more than $90,000.
• Many of these expensive conditions involve invasive or high-technology procedures. For example, infant respiratory distress syndrome can involve lengthy stays in intensive care. In fact, 4 of the top 10 most expensive conditions in the hospital are related to care of infants with complications: respiratory distress, prematurity, heart defects, and intrauterine hypoxia/birth asphyxia.
• Three of the top 10 most expensive conditions relate to the circulatory system: heart valve disorders, heart defects, and aneurysms.
• The conditions with the highest charges continue to be relatively uncommon. The 10 most expensive conditions combined represent less than 1.5 percent of all discharges.
• Even though long lengths of stay can result in high expense, 4 of the 10 most expensive reasons for hospital stays are NOT among those with the longest stays: cardiac congenital anomalies; heart valve disorders; aneurysms; and adult respiratory failure, insufficiency, and/or arrest.

Select for Table 9, Principal Diagnoses With the Highest Mean Charges.

Conditions With the Longest Lengths of Stay

• The average length of stay is 5 days—6 percent shorter than in 1997.
• The two conditions with the longest hospital stays continue to be related to infants: respiratory distress and prematurity. Each condition has a mean length of stay of 24 days.
• Conditions with lengthy hospital stays continue to be relatively uncommon. Collectively, the 10 conditions with the longest stays represent only 2 percent of all discharges.
• Even though long lengths of stay can be costly, 4 of the 10 conditions with the longest lengths of stay are NOT among the most expensive conditions: tuberculosis, schizophrenia and related disorders, preadult mental disorders, and rehabilitation care—all non-surgical, non-intensive care conditions.

Select for Table 10, Principal Diagnoses With the Longest Mean Length of Stay.

^vi This cost represents the resource costs to produce services plus an additional allowance for bad debt (approximately 5 percent) and ordinary net income (approximately 3 percent), based on the long-run average for the industry.

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Payers of Care

Who is Billed for Hospital Care?

Aggregate charges, or the "national bill," is the sum of all charges for all hospital stays in U.S. non-Federal community hospitals. The aggregate charges for 2002 are $650 billion—an increase of 32 percent from 1997, when the aggregate charges were $492 billion (adjusted for inflation).

Payer information is presented in five general payer categories as follows:

• Medicare—fee-for-service and managed care Medicare patients.
• Medicaid—fee-for-service and managed care Medicaid patients.
• Private insurance—Blue Cross, commercial carriers, private health maintenance organizations (HMOs), and preferred provider organizations (PPOs).
• Uninsured—an insurance status of "self-pay" and "no charge."
• Other—Workers' Compensation, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), Title V, and other government programs.

Payers of Hospital Care

• Medicare and Medicaid are billed for more than half (56 percent) of all hospitalizations. Medicare is billed for 34 percent and Medicaid is billed for 22 percent. This pattern has remained relatively stable since 1997, when the percentages were 35 percent and 20 percent, respectively.
• Private insurance is billed for 36 percent of all hospitalizations, which is comparable to the 1997 figure—37 percent.
• Uninsured hospitalizations continue to account for approximately 5 percent of all hospitalizations.
• The remaining 3 percent of hospitalizations is billed to other insurers or cannot be determined.

Select for Figure 10 (5 KB), Percent of Hospital Stays Billed to Each Payer.

Select for Figure 11 (5 KB), Percent of National Bill by Payer.

Medicare

• About 39 million individuals—13 percent of the U.S. population—are covered by Medicare.²
• Medicare continues to be billed for approximately 44 percent of the national hospital bill.
• The most common reason for hospitalization for Medicare beneficiaries is congestive heart failure, followed by pneumonia and coronary atherosclerosis.
• The aggregate total billed to Medicare is $283 billion—an increase of 29 percent from 1997, after adjusting for inflation.

Select for Table 11, Top 10 Principal Diagnoses for Medicare.

Medicaid

• About 33 million individuals, 12 percent of the U.S. population, are covered by Medicaid.²
• Medicaid continues to be billed for approximately 18 percent of the national hospital bill.
• Six of the top 10 most frequent reasons for hospitalization billed to Medicaid continue to be related to infancy and childbirth. These 6 conditions comprise 1 out of every 3 Medicaid hospitalizations.
• Medicaid is billed for nearly 40 percent of stays associated with infants born in the hospital (up from 34 percent in 1997) and 47 percent of all normal pregnancy and delivery stays (up from 40 percent in 1997).
• Previous C-section appears as a top 10 condition for Medicaid patients, rising from 15th in 1997 to 10th in 2002. Medicaid is billed for 38 percent of all previous C-sections.
• Medicaid is billed for 54 percent of all hospital stays for schizophrenia (up from 51 percent in 1997) and 33 percent of all stays for depression (up from 28 percent in 1997).
• Medicaid is billed for about 35 percent of all hospital stays for asthma, essentially unchanged since 1997.
• The aggregate total billed to Medicaid is $119 billion—an increase of 47 percent from 1997, after adjusting for inflation.

Select for Table 12, Top 10 Principal Diagnoses for Medicaid.

Private Insurers

• About 200 million individuals, 70 percent of the U.S. population, are covered by private insurers.²
• Private insurers continue to be billed for about 31 percent of the national hospital bill.
• Private insurers are billed for 54 percent of all stays for infants born in the hospital, 59 percent of all stays for trauma to vulva and perineum due to childbirth, and 46 percent of all normal pregnancy stays.
• Four of the top 10 conditions billed to private insurers are related to infancy and childbirth. These conditions comprise about 1 of every 4 private payer discharges—just as in 1997.
• Three of the top 10 conditions billed to private insurers are related to the cardiovascular system, as was the case in 1997.
• Unlike 1997, affective disorders (primarily depression) and previous C-section are in the top 10 conditions for privately insured patients in 2002.
• The aggregate total billed to private insurers is $203 billion—an increase of 31 percent from 1997, after adjusting for inflation.

Select for Table 13, Top 10 Principal Diagnoses for Private Insurers.

Uninsured

• About 44 million individuals, 15 percent of the U.S. population, are uninsured.²
• Only 5 percent of hospitalized patients are uninsured at the time of discharge from the hospital, a figure unchanged since 1997. These individuals are billed for 4 percent of the national hospital bill.
• Hospitalizations for tuberculosis among the uninsured rose by 56 percent. Twenty-five percent of hospital discharges for this infection are for the uninsured, compared to 16 percent in 1997.
• Five percent of stays for infants born in the hospital are uninsured, just as in 1997, despite increases in coverage by the State Children's Health Insurance Program (SCHIP).^vii
• Among uninsured patients, 2 of the top 10 conditions are related to mental health or alcohol-related mental disorders. About 20 percent of hospital stays for alcohol abuse disorders and 8 percent of stays for depression are uninsured. It is not possible to determine if this finding is because insurance does not cover these conditions or because these conditions occur more frequently among uninsured patients. Substance-related mental disorders was a top 10 condition for the uninsured in 1997, but in 2002, it fell to 14th.
• Diabetes is an ambulatory care sensitive condition—a condition for which appropriate outpatient care should prevent the need for hospitalization in many cases. More than 8 percent of all diabetes admissions occur in patients who are uninsured.
• The aggregate bill for the uninsured is $25 billion—an increase of 39 percent from 1997, after adjusting for inflation.

Select for Table 14, Top 10 Principal Diagnoses for the Uninsured.

Aggregate Charges

The aggregate total billed for hospital care has increased significantly from 1997 to 2002 for each of the four major payer categories, with the largest increases in charges seen for Medicaid and the uninsured. In the 5-year period from 1997 to 2002, aggregate billing:

• Increased 29 percent for Medicare.
• Increased 47 percent for Medicaid.
• Increased 31 percent for private insurers.
• Increased 39 percent for the uninsured.

The percent of the population covered by each of these payer types has remained relatively stable from 1997 to 2002.^2,7

Select for Figure 12 (7 KB), Percent Increase in Aggregate Billing from 1997-2002.

Select for Figure 13 (5 KB), Percent of Population Covered by Each Payer Type, 1997 and 2002.

^vii To evaluate the impact of SCHIP, individual States that record SCHIP as a specific pay source may be used for further study.

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Disposition Status

How Are Patients Discharged from the Hospital?

Discharge status indicates the disposition of the patient at discharge from the hospital. Categories include: routine (to home), to another short-term hospital, to a nursing home, to home health care, or against medical advice.

Discharge Status

• More than 75 percent of discharges are routine in nature—patients return home following completion of hospital treatment.
• Another 11 percent of discharges go to long-term care/other facilities, while 2 percent go to other short-term hospitals.
• Approximately 2 percent of all hospitalizations end in death, a figure slightly lower than in 1997.
• Less than 1 percent of patients leave against medical advice, as was the case in 1997.

Select for Figure 14 (6 KB), Discharge Status.

Discharges to Other Institutions

• Hospitalizations that result in discharges to other institutions tend to be those in which a patient's functional status has been compromised, such as stroke or hip fracture.
• Older patients are more often discharged from the hospital to other institutions than are younger patients. About 21 percent of patients ages 65-84 and 41 percent of patients ages 85 and older are discharged to long-term care and other similar facilities, including skilled nursing facilities, intermediate care facilities, and nursing homes.
• Only about 3 percent and 8 percent of patients ages 18-44 and 45-64, respectively, are discharged to long-term care.

Select for Figure 15 (7 KB), Percent of Discharges to Another Institution.

Select for Table 15, Top 10 Principal Diagnoses for Discharges to Other Institutions.

Conditions With Highest In-Hospital Mortality

In-hospital mortality refers to hospitalizations in which the patient died during his or her hospital stay. Patients may be admitted to the hospital for end-of-life care; therefore, mortality for some conditions is expected to be high. Some of the conditions listed are not necessarily the underlying cause of death. For example, shock and cardiac arrest are immediate reasons for death, but other diagnoses, such as trauma, may be the underlying reasons.

• The two conditions with the greatest percentage of admissions resulting in in-hospital mortality^viii continue to be cardiac arrest/ventricular fibrillation (54 percent) and shock (52 percent).
• The two illnesses with the greatest numbers of in-hospital deaths are infection-related: pneumonia (70,890 deaths, not shown) and septicemia (61,439 deaths). However, the percentage of admissions for these conditions resulting in in-hospital death is much smaller than for many other conditions: 6 percent and 18 percent, respectively.
• Septicemia replaced coma as 1 of the top 10 conditions with the highest percent of in-hospital mortality. In 1997, septicemia was the 11th most common condition that resulted in in-hospital death; in 2002, it was the 7th, with nearly 18 percent of admissions resulting in death.
• Four of the top 10 conditions with the highest percent of in-hospital mortality are related to cancer, a fact unchanged since 1997. These diagnoses include malignant neoplasm without specification of site, cancer of the liver and intrahepatic bile duct, leukemia, and cancer of bronchus or lung.

Select for Table 16, Principal Diagnoses with the Highest Percent of Inpatient Mortality.

Conditions With Highest In-Hospital Mortality by Age Group

• Among all age groups, the condition with the largest number of admissions resulting in in-hospital deaths is cardiac arrest and ventricular fibrillation. For infants younger than 1 year, 84 percent admitted for cardiac arrest and ventricular fibrillation die at the hospital, while 46 percent of cardiac arrest admissions for patients 18-44 result in death in the hospital.
• In the youngest age category, the greatest number of in-hospital deaths is attributable to prematurity and low birthweight—nearly 13,000 deaths.
• For children ages 1-17, hospitalizations for brain injury result in the greatest number of in-hospital deaths (1,151 deaths).
• For the 18-44 age group, brain injuries (4,369 deaths) and HIV/AIDS (3,693 deaths) account for the highest number of in-hospital deaths.
• For individuals ages 45-64, the largest numbers of hospitalizations ending in death are for stroke (11,163 deaths), septicemia (10,418 deaths), and cancer metastasis (10,264 deaths).
• For age groups 65 years and older, pneumonia results in the most in-hospital deaths (59,934 deaths).

Select for Table 17, Top 10 Conditions with the Highest Number of In-Hospital Deaths by Age Group.

Patients Leaving Against Medical Advice

• The most common conditions among patients who leave against medical advice involve medical problems, such as pneumonia or diabetes, rather than surgical problems. Chest pain, coronary atherosclerosis, pneumonia, congestive heart failure, and diabetes remain top 10 reasons for discharge against medical advice.
• Pancreatic disorders other than diabetes and skin/subcutaneous infections rank among the top 10 diagnoses in 2002 for patients who leave against medical advice, replacing asthma and schizophrenia, which were in the top 10 in 1997.
• Among the top 10 diagnoses for patients who leave the hospital against medical advice, three are mental health-related illnesses, unchanged since 1997. Among these top ten conditions, 17 percent of all discharges in which patients leave the hospital against medical advice are for substance- or alcohol-related mental disorders.

Select for Table 18, Top 10 Principal Diagnoses for Which Patients Left Against Medical Advice.

^viii In-hospital mortality is a form of case-fatality ratio—the percentage of patients with this principal diagnosis who died while in the hospital.

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