Patients Who Discharge From Hospital Against Medical Advice Have Double Rate of Readmission

MedicalResearch.com Interview with:

Professor Mamas Mamas (BM BCh, MA, DPhil, MRCP) Professor of Cardiology at Keele University and an Honorary Professor of Cardiology at the University of Manchester

Prof. Mamas

Professor Mamas Mamas (BM BCh, MA, DPhil, MRCP)
Professor of Cardiology at Keele University and an
Honorary Professor of Cardiology at the University of Manchester

MedicalResearch.com: What is the background for this study?

Response: Discharge against medical advice occurs in 1 to 2% of all medical admissions but little / no data around how frequently this occurs in the context of PCI or the outcomes associated with such a course of action. We undertook this study to understand both how commonly discharge against medical advice occurs, the types of patients it occurs in and outcomes in terms of both readmission rates and causes of readmisison.  

MedicalResearch.com: What are the main findings? 

Response: We found that patients that discharge against medical advice had two times the rates of unplanned readmissions within 30 days compared to those patients discharged home. We found that young, male patients admitted with an index admission with acute myocardial infarction were more likely to discharge against medical advice, and other important predictors included smoking, alcohol and drug abuse.

We showed that patients who discharged against medical advice were twice as likely to be readmitted with the diagnosis code of acute MI and 4 times as likely to be readmitted with an acute neuropsychiatric episode.

MedicalResearch.com: What should readers take away from your report?

Response: Patients that discharge against medical advice are a high risk group. not only were these patients twice as likely to be readmitted with the diagnosis code of acute MI and 4 times as likely to be readmitted with an acute neuropsychiatric episode, but their in-hospital mortality rate during the re-admission episode was 1.5x greater and MACE 3x greater.

Readers should consider what protocols are in place at their institution to deal with such patients and what arrangements are made for follow up or at least arrangements to ensure that they receive appropriate therapy (such as antiplatelet drugs). 

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: Areas of future focus include why do patients self discharge:

  • Why do they have a two fold increased readmission rate with AMI? Is it because they don’t receive drugs if they self discharge such as anti-platelets?
  • What community structures are needed to identify patients that self discharge and mechanisms to deliver therapies / drugs that are know to impact on outcomes post PCI?. 
  • The 4 fold readmission rate with psychiatric reasons in patients who DAMA is interesting, is this related to greater baseline mental health problems in this group?
  • Can these be targeted by exposure to mental health services whilst an inpatient during PCI? or at least referral to these services prior to PCI.

I have no conflicts of interest

Citation:

JACC: Cardiovascular Interventions

Source Reference: Kwok CS, et al “Discharge against medical advice after percutaneous coronary intervention in the United States” JACC Cardiovasc Interv 2018; DOI: 10.1016/j.jcin.2018.03.049. 

Jul 17, 2018 @ 12:43 am  

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