University of Manchester



Discharge Against Medical Advice after Hospitalization for Acute Myocardial InfarctionRunning title: Discharge against medical advice after acute myocardial infarctionChun Shing Kwok MBBS MSc BSc1,2, Mary Norine Walsh MD3, Annabelle Volgman MD4, Mirvat Alasnag MD5, Glen P. Martin PhD6, Diane Barker MD2, Ashish Patwala MD2, Rodrigo Bagur MD PhD1, David L Fischman MD7, Mamas A Mamas BM BCh DPhil1,21. Keele University, Stoke-on-Trent, UK.2. Royal Stoke University Hospital, Stoke-on-Trent, UK.3. St Vincent Heart Center, Indianapolis, Indiana, USA.4. Rush University Medical Center, Chicago, Illinois, USA.5. Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.6. Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.7. Thomas Jefferson University Hospital, Philadelphia, USA.Corresponding author:Dr Chun Shing KwokKeele Cardiovascular Research Group, Centre for Prognosis ResearchKeele University, Stoke-on-Trent, UKE-mail: shingkwok@.ukTel: +44 1782 732911 Fax: +44 1782 734719Keywords: acute myocardial infarction; quality and outcomes of careWord count: 3,000The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non-exclusive licence for UK Crown and US Federal Government employees) on a worldwide basis to the BMJ Publishing Group Ltd, and its Licensees to permit this article (if accepted) to be published in Heart and any other BMJPGL products and to exploit all subsidiary rights, as set out in our licence.AbstractBackground: Discharge against medical advice (AMA) occurs infrequently but is associated with poor outcomes. There are limited descriptions of discharges AMA in national cohorts of patients with acute myocardial infarction (AMI). This study aims to evaluate discharge AMA in AMI and how it affects readmissions.Methods: We conducted a cohort study of patients with AMI in the United States in the Nationwide Readmission Database who were admitted between the years 2010-2014. Descriptive statistics were presented for variables according to discharge home or against medical advice. The primary endpoint was all-cause 30-day unplanned readmissions and their causes. Results: 2,663,019 patients were admitted with AMI of which 10.3% (n=162,070) of 1,569,325 patients had an unplanned readmission within 30-days. The crude rate of discharge AMA remained stable between 2010 and 2014 at 1.5%. Discharge AMA was an independent predictor of unplanned all-cause readmissions (OR 2.27 95%CI 2.14-2.40); patients who discharged AMA had >2-fold increased crude rate of readmission for acute myocardial infarction (30.4% vs 13.4%) and higher crude rate of admissions for neuropsychiatric reasons (3.2% vs 1.3%). After adjustment, discharge AMA was associated with increased odds of readmissions for AMI (OR 3.65 95%CI 3.31-4.03, p<0.001). We estimate that there are 1,420 excess cases of AMI among patients who discharged AMA.Conclusions: Discharge AMA occurs in 1.5% of the population with AMI and these patients are at higher risk of early readmissions for re-infarction. Interventions should be developed to reduce discharge AMA in high-risk groups and initiate interventions to avoid adverse outcomes and readmission.Key Questions:What is already known about the subject?Discharge against medical advice (AMA) with patients leaving hospital before the treating physician’s recommendation, occurs in 1-2% of all medical admissions and it poses a challenge for physicians.There are limited descriptions of discharges AMA in national cohorts of patients with acute myocardial infarction (AMI).What does the study add?Discharge AMA in patients admitted with an AMI occurs in less than 2% of patients.These patients represent a high-risk cohort with a 2-fold increase in odds of 30-day unplanned readmission and a four-fold increase in re-infarction within 30 days.How might this impact on clinical practice?Interventions should be developed to reduce discharge AMA in high-risk groups and avoid adverse outcomes and readmission when it occurs. IntroductionDischarge against medical advice (AMA) with patients leaving hospital before the treating physician’s recommendation, occurs in 1-2% of all medical admissions[1] and it poses a challenge for physicians. Discharge AMA may be associated with lack of trust and poor/patient/provider communications, which may be markers for poor outpatient treatment adherence, and decreased utilization of necessary healthcare services. [2] A variety of factors have been associated with discharge AMA including financial constraints, family pressures, dissatisfaction with the hospital routine and treatment for substance seeking behaviour.[3] Discharge AMA is important because it is associated with greater risk of 30-day mortality.[4]Management of acute myocardial infarction (AMI) includes pharmacotherapy and interventional treatments shown to improve prognosis. Among discharge AMA patients there are concerns of inadequate treatment for their index AMI. Continuation of medications such as beta-blockers, angiotensin converting enzyme inhibitors, statins and dual antiplatelet therapy post discharge is important to lower the risk of further cardiovascular events and death.[5,6] Prolonged dual antiplatelet therapy is necessary to avoid stent thrombosis in patients who undergo percutaneous coronary intervention. To our knowledge, only one study has previously evaluated hospital discharges AMA after acute myocardial infarction (AMI) in a single state in the United States in an era when PCI was less widespread.[7] This study reported a 1.1% rate of discharged AMA with no difference in the crude rate of 30-day all-cause readmission between the discharge AMA and comparison group (9.3% vs 8.4%) [7]In this study, we examined the crude rates, trends and predictors of discharge AMA, and the association between discharge AMA and unplanned 30-day readmission in a contemporary national cohort of patients following an index admission with AMI.MethodsStudy design and participantsThe Nationwide Readmission Database (NRD) is a publicly available database of all-payer hospital inpatients stays, developed by the Agency for Healthcare Research and Quality (AHRQ) as a part of the U.S. Healthcare Cost and Utilization Project (HCUP).[8] The data are drawn from 21 states that account for approximately half of the total U.S. resident population and hospitalizations.[9,10]In the current study, we included men and women aged 18 years or older who were hospitalized with a primary diagnosis of AMI between 2010 and 2014 and were either discharged AMA or discharged home. A primary diagnosis of AMI was defined by the following International Classification of Disease – 9th Clinical Modification (ICD-9) codes: 4100*, 4101*, 4102*, 4103*, 4104*, 4105*, 4106*, 4107*, 4108* and 4109* which is a combination of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). Discharge AMA was defined from the variable "DISPUNIFORM", which represents the disposition of patient at discharge. We excluded patients who were discharged in December (because they may not have had 30-day of follow up), those who died during their index admission for AMI, those who had an elective readmission and those who were not discharged home/self-care or AMA. We only considered the first AMI admission within a calendar year for a patient.Variables and outcomesWe used ICD-9 and Clinical classification software (CCS) of diseases codes to determine comorbidities, in-hospital procedures and outcomes. Alcohol misuse was defined by the AHRQ comorbidity measure for ICD-9 codes alcohol abuse. The 30-day unplanned readmissions were defined as first rehospitalization after discharge within 30 days from admission for AMI that was not elective. The causes of readmissions were determined from the principle diagnosis based on CCS codes (Supplementary Table 1). The primary endpoint was all-cause 30-day readmissions and readmission cause.Statistical analysisStatistical analysis was performed using Stata 14.0 (College Station, Texas, USA). A flow diagram was used to show the proportion of patients at each stage of the analysis and those who were readmitted. Descriptive statistics were used to compare patients who were discharge AMA compared to those discharged home, with further stratification depending on whether or not they were readmitted. Statistical differences between groups for continuous variables were tested using the t-test and for categorical variables the chi-squared test. For all analyses, the survey estimation commands were used (e.g. svy: logistic for multiple logistic regression), following the recommendations from AHRQ for analysis of survey data to account for the complex survey design of the NRD. Using the survey estimation commands, national sample sizes were determined by applying the discharge weights to the crude sample and the weight was propagated to determine the patients excluded and the estimated final sample size analysed. Multiple logistic regression was used to determine independent variables associated with discharge AMA and the influence of discharge AMA on 30-day unplanned readmission. All variables were adjusted for in the models. A multivariable model was used to determine if discharge AMA was associated with readmissions for AMI. The excess admissions associated with AMI and excess deaths from readmission among discharge AMA patients was estimated by considering the crude rate of deaths and readmissions in the non-discharge AMA group compared to the observed crude rate of deaths and readmissions in the discharge AMA group. We further performed subgroup analysis for odds of AMI readmission depending on the subgroup of patients without a coronary angiogram and among those who had PCI. We also determined the crude rate of discharge AMA by length of stay.ResultsThere were 2,663,019 patients with acute myocardial infarction between 2010 and 2014 captured in the Nationwide Readmission Database. After exclusion of patients admitted in December (n=234,702), patients who died in-hospital (n=136,047), patients with elective readmissions (n=88,166) and patients who were discharged to short term hospital, care home or law enforcement (n=634,779) there were 1,569,325 patients included in the analysis of which 10.3% had a 30-day unplanned readmission. The crude rate of discharge AMA was 1.45% in 2010, which increased to 1.49% in 2014.Patients who were discharged AMA were younger (59.9 vs 63.5 years, p<0.001), more likely to be male (75.8% vs 66.4%, p<0.001) and more likely to be uninsured (14.6% vs 7.9%) (Table 1). Patients who discharged AMA were less likely to have private insurance (13.4% vs 31.5%, p<0.001) and more had Medicaid (19.8% vs 9.1%, p<0.001). Smokers (58.0% vs 45.0%, p<0.001), alcohol misusers (9.6% vs 3.5%, p<0.001), patients with chronic lung disease (25.0% vs 17.5%, p<0.001) and renal failure (18.1% vs 14.4%, p<0.001) had higher crude rates of discharge AMA. In addition, discharge AMA patients were less likely to receive coronary angiography (46.4% vs 86.6%, p<0.001), be treated with PCI (27.8% vs 63.3%, p<0.001) or receive a drug eluting stent (15.4% vs 46.2%, p<0.001). The crude 30-day unplanned readmission rate was 24.9% among patients who discharged AMA and 10.1% among patients discharged home. The mean time to 30-day readmission was shorter in the discharge AMA group (10.6 vs 14.1 days, p<0.001) and the discharge AMA group had longer length of stay at readmission (5.1 vs 4.5 days, p<0.001) and higher crude rate of mortality at readmission (4.2% vs 3.5%, p=0.047).Independent predictors of discharge AMA included smoking (OR 1.66 95%CI 1.57-1.75, p<0.001), alcohol misuse (OR 1.49 95%CI 1.35-1.63, p<0.001), male sex (OR 1.92 95%CI 1.81-2.03, p<0.001), and younger age (OR 0.97 95%CI 0.96-0.97, p<0.001) (Table 2). STEMI patients were more likely to discharge AMA (OR 1.16 95%CI 1.09-1.23, p<0.001). Variables associated with a reduced odds of discharge AMA included private insurance (OR 0.40 95%CI 0.36-0.43, p<0.001), receipt of CABG (OR 0.11 95%CI 0.08-0.13, p<0.001) and need for ICD/pacemaker insertion (OR 0.27 95%CI 0.18-0.40, p<0.001). Comorbidities that was associated with reduced the odds of discharged AMA included heart failure (OR 0.72 95%CI 0.52-1.00, p=0.049), atrial fibrillation (OR 0.83 95%CI 0.77-0.89, p<0.001), renal failure (OR 0.79 95%CI 0.73-0.85, p<0.001), cancer (OR 0.67 95%CI 0.57-0.78, p<0.001), depression (OR 0.87 95%CI 0.79-0.96, p=0.004) and dementia (OR 0.69 95%CI 0.58-0.81, p<0.001). In terms of non-patient data, medium hospital bed size and urban location were associated with discharge AMA whilst patients admitted to teaching hospitals were less likely to discharge AMA.Discharge AMA was an independent predictor of unplanned readmissions (OR 2.27 95%CI 2.14-2.40). Causes of 30-day unplanned readmissions according to discharge AMA status are depicted in Figure 1 and Supplementary Table 2. Patients with discharge AMA had more than a 2-fold increased crude rate of readmission for AMI (30.4% (95%CI 30.4%-30.5%) vs 13.4% (95%CI 13.4%-13.5%)) and a higher crude rate of admissions for neuropsychiatric reasons (3.2% (95%CI 3.2%-3.2%) vs 1.3% (95%CI 1.3%-1.3%)). Multivariable analysis reveals that discharge AMA was associated with increased odds of readmissions for AMI (OR 3.65 95%CI 3.31-4.03, p<0.001). We estimate that there are 1,420 excess cases of AMI among patients who discharged AMA and 58 excess deaths during readmissions among discharged AMA patients.Among patients who discharge AMA and did not receive an angiogram the odds of readmission for AMI was OR 3.59 95%CI 3.18-4.04, p<0.001. For patients who received PCI, the odds of readmission for AMI was OR 3.65 95%CI 2.94-4.53, p<0.001.The crude rate of discharge AMA peaked at 1-day length of stay whilst the corresponding peak for patients who were not discharged against medical advice was 2 days (Supplementary Table 3).DiscussionOur analysis reveals that discharge AMA in patients admitted with an AMI occurs in less than 2% of patients. Nevertheless, these patients represent a high-risk cohort with a 2-fold increase in odds of 30-day unplanned readmission and a one in three chance of readmission with re-infarction within 30 days. Once differences in baseline characteristics are adjusted for, patients who discharged AMA have a four-fold increased odd of admission with re-infarction within 30 days. Our study adds to the current understanding of discharge AMA in AMI based on the study of Fiscella et al conducted nearly 20 years ago [7] and show that the crude rates of discharge AMA have remained similar (1.5% versus 1.1% in previous study). We identify several variables associated with discharge AMA including smoking, alcohol misuse and younger males, although prevalent comorbidities such as obesity, heart failure, atrial fibrillation, renal failure, cancer and depression reduced the odds of discharge AMA. Patients who discharge AMA differ from those who are discharged home in that they are more likely to receive Medicaid or be uninsured, live in lower income areas, smoke, misuse alcohol and tend to be younger males. The study in California by Fiscella et al reported similar findings that discharge AMA was more common in younger, male low income, black, insured through Medicaid or uninsured and had less physical comorbidity and greater mental health comorbidity.[7] In addition, we observe important health service system level elements associated with AMA discharge such as bed size, urban location and teaching hospital.[11-13] Our results suggest that medium hospital bed size and those from an urban location are more likely to discharge AMA. Interestingly, we observed that patients from teaching hospitals were less likely to discharge AMA. The effect of teaching hospital was considered in a previous Statewide study in California by Fiscella et al which found a no significant differences in discharge AMA among teaching hospitals compared to non-teaching hospitals (11.1% vs 9.8%).[7] Another qualitative study of 9 patients, 10 physicians and 23 nurses/social workers, despite being limited because the study was not generalizable to community or smaller hospitals, suggests that discharge AMA was more common in teaching hospital settings because patients felt confused and frustrated.[14] However, in the current study of patients all across the United States showed that patients from teaching hospitals were less likely to discharge AMA (53.4% vs 57.8%), although the absolute difference was relatively small, hence the clinical relevance of this observation is unclear. Future work would need to both confirm this finding, and understand the mechanisms that underlie potential differences in discharge AMA amongst different institutional structures.We found that a few comorbidities were associated with discharge AMA but there may be differences in why they show the association. Smoking and alcohol misuse may make it challenging for patients to seek the substance they desire so they discharge AMA. We also observed increased discharge AMA among patients with hypertension, diabetes and chronic lung disease. One possible reason may be that these chronic conditions may have been managed by community physicians or care teams and patients may feel more comfortable and supported by these teams so are more willing to leave hospital and return to their usual care providers once the acute problem is treated. In addition, previous myocardial infarction and PCI were associated with increased discharge AMA. We speculate that this may be related to a patient’s previous experience and felt that a period of observation once problem was treated was not necessary so they choose to discharge AMA once acute problem is treated. The literature suggests that discharge AMA stigmatizes patients, reduces their access to care and can reduce the quality of informed consent discussions in discharge planning.[15]The complexity of discharge AMA in AMI may be related to the extent of care and resulting outcomes will obviously depend on the point at which the patient is discharged. A patient who undergoes PCI or CABG and chooses to leave hospital will at least receive partial treatment compared to a patient who leaves prior to coronary revascularization. It may be important for clinicians to be aware that despite differences in the extent to which patients are treated prior to discharge AMA, a physician still has a responsibility to advocate for a patient’s well-being so AMA discharges should be accompanied by reasonable efforts to coordinate a patient’s ongoing care.[16]An interesting observation in the current study is that some comorbidities including heart failure, atrial fibrillation, cancer, dementia and renal failure reduce the odds of discharge AMA. Possible explanations include that patients recognize that their condition will require long-term care and discharge AMA may damage the relationship with care professionals. Dementia may remove the patient’s autonomy to make decisions to leave against advice. Reasons for discharge AMA in cardiovascular diseases have been previously explored in a qualitative study.[14] Communications were identified as an area that required improvement and healthcare providers should be trained in cultural diversity, interpersonal skills, customer service and also be accurate and open about wait times. In the setting of an AMI patients require treatment with potent anti-thrombotic agents and may undergo percutaneous revascularisation procedures that require prolonged dual antiplatelet (DAPT) including lifelong single antiplatelet therapy. Our study demonstrates that the performance of a coronary angiogram or PCI occur less frequently in cases that discharge AMA. This may relate to the fact that patients leave prior to the possibility of performing cardiac catheterization or that the clinician don’t offer these procedures due to a concern of non-compliance with post PCI DAPT. Patients with NSTEMI may be more likely to leave prior to PCI but this is less likely in STEMI because PCI is an emergency procedure. The risks of associated with discharge AMA among NSTEMI patients includes the risks related to not getting PCI as well as PCI related complications like stent thrombosis whilst those with STEMI are more likely to only have readmissions due to complications from PCI. We observed lower crude rates of readmissions for bleeding and renal failure among patients that discharge AMA. This may be related to patients not taking their medications if they discharged AMA, but also due to the fact that these patients were younger and their baseline risk of bleeding is likely to be less. Among cases that did undergo PCI, discharge AMA patients were more likely to receive bare metal stents that require shorter DAPT regimes despite the evidence of poorer outcomes compared to drug eluting stents.[17,18] A key finding of the current study is the 4-fold increase in odds of readmissions for AMI among patients who discharge AMA. There are a few possible reasons for this finding. Patients can discharge AMA at any point in their care so there will be heterogeneity in the treatments received by patients. We found that evidence based diagnostics procedures and treatments including coronary angiograms, PCI and CABG were lower in patients who discharge AMA. The potential unstable coronary lesion poses a significant risk when left untreated compounded by the lack of secondary prevention with statins and antithrombotic therapies. Secondly, if a patient receives treatment but discharges AMA they may not receive secondary prevention medications such as antithrombotic medications and statins that would place them at increased risk of re-infarction. In addition, patients who undergo PCI may be discharged without appropriate antiplatelet therapy increasing the risk of stent thrombosis. Finally, the discharge AMA group may be discharged without the necessary tools for smoking cessation.In the current study, we report an unplanned readmissions crude rate of 10.3% which is lower that the 19.3% described by Fiscella.[7] This is likely because of better quality of care, more widespread adoption of PCI, anti-thrombotics and better provision of evidence based therapies in contemporary practice. In the study of Fiscella, the authors did not study specific causes of readmission (apart from ACS or non-ACS), or differentiate between the non-ACS causes of readmission.[7] In contrast, our analysis provides more granular insight into both cardiovascular and non-cardiovascular causes for readmissions and shows that there are a broad range of causes of unplanned readmissions with important differences between the discharge AMA and non-discharge AMA groups. Despite this lower overall lower crude rate of readmission our analysis reveals a nearly 4-fold increase in odds of unplanned readmission for AMI compared to the 2-fold increase reported by Fiscella[7] This suggests that re-infarction for discharge AMA patients have worsened over time, perhaps relating to the more widespread use of PCI as a treatment strategy, and hence a greater potential for stent thrombosis with the premature discontinuation of DAPT.Among patients that choose to discharge AMA, measures should be developed to obviate potential risks such as prescription of dual antiplatelet therapy and other secondary prevention medications prior to discharge or a means to deliver these in the community. Interventions should be developed across healthcare providers spanning secondary and primary care interface including pharmacy outreach programs to enable prescription and/continuation of therapies in the community. We observed higher crude rates of neuropsychiatric reasons for readmission in patients with discharge AMA and care may be improved by early involvement of psychiatric services particularly patients with a history of mental health conditions or substance abuse.We speculate that one of the factors that may influence patient’s decision to discharge AMA is how ill or symptomatic they are which is influenced by the severity of the acute myocardial infarction. We found that patients who discharge AMA had less circulatory support (1.8% vs 2.9%), vasopressor use (0.3% vs 0.5%) and intra-aortic balloon pump use (1.7% vs 2.8%). In addition, these patients had fewer complications such as complete heart block (0.6% vs 0.9%), ventricular fibrillation (1.2% vs 2.3%), ventricular tachycardia (4.3% vs 5.4%), cardiogenic shock (2.1% vs 2.5%) and cardiac arrest (1.2% vs 1.5%). These findings may suggest that patients who have less severe AMI are more likely to discharge AMA.There are several limitations to this study. The overall data is derived from five unique datasets corresponding to each year between 2010 and 2014 so there is no possible linkage between years and the same patient can appear more than once in different years. The dataset does not capture pharmacotherapy data and the compliance/prescription of medications is unknown. The population at risk of readmission may be overestimated because of survivorship. We do not have data on out-of-hospital mortality which would reduce the population at risk of unplanned readmissions. Causes of readmissions were identified using the primary discharge diagnosis codes which may be subject to reporting biases. In the interest of reducing potential confounding, we determined adjusted odds ratios to estimate the association between collected variables and discharge AMA. However, odds ratios, which can approximate for rate ratio, have limitations because odds ratios may overestimate associations especially the case for events which are not rare like 30-day readmissions. Another limitation of the study is that we are unable to comment definitively about reasons for our findings due to the observation nature of this study. Furthermore, even though we are able to adjust for a variety of variables such as comorbidities, hospital and system related factors and socioeconomic factors, these adjustments may not fully account for the extent of their effect on the models of the current study because of unmeasured confounders.In conclusion, discharge AMA occurs in 1.5% of the population treated for an AMI and is associated with greater risk of 30-day unplanned readmissions. These patients are at particularly high-risk for readmission due to AMI, with a nearly 4-fold independent increase in odds for these readmissions. Our multivariable analysis suggests that patients who are more likely to discharge AMA appear to be younger, male, uninsured, from low-income areas who were also smokers and misused alcohol. We estimate that there are 1,420 excess cases of AMI among patients that discharge AMA. Interventions should be developed to reduce discharge AMA in high-risk groups to avoid adverse outcomes and readmission. Contributorship CSK and MAM were responsible for the study design and concept. CSK performed the data cleaning and analysis. CSK wrote the first draft of the manuscript and all authors contributed to the writing of the paper. Transparency declarationCSK affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.Ethical committee approvalThis is anonymised data and there is no patient identifiable information. This study was determined to be exempt from review by the Medical Research Council’s “Does our study need NHS REC approval form” and was conducted in accordance to the HCUP Data Use Agreement. Acknowledgements We are grateful to the Healthcare Cost and Utilization Project (HCUP) and the HCUP Data Partners for providing the data used in the analysis. Funding The study was supported by a grant from the Research and Development Department at the Royal Stoke Hospital. This work is conducted as a part of PhD for CSK which is supported by Biosensors peting Interests and DisclosuresNone.List of Tables and FiguresTable 1: Characteristics of patients with primary diagnosis of acute myocardial infarction according to discharge against medical advice status Table 2: Independent predictors of discharge against medical adviceFigure 1: Causes of 30-day unplanned readmissionsSupplementary Table 1: Classification of Clinical Classifications Software (CCS) Codes for Readmissions CausesSupplementary Table 2: Causes of unplanned 30-day readmissionsSupplementary Table 3: Influence of length of stay on the rate of patients discharged against medical adviceTable 1: Characteristics of patients with primary diagnosis of acute myocardial infarction according to discharge against medical advice statusVariableNo discharge against medical advice (n=1,546,406)Discharge against medical advice (n=22,919)P-valueAge (year)63.5±13.259.9±13.5<0.001Female33.6%24.2%<0.001Weekend admission27.1%27.1%0.90Year2010201120122013201418.9%19.0%19.2%21.1%21.8%18.7%18.8%19.1%21.1%22.3%0.85Diagnosis of STEMI34.8%26.5%<0.001Primary expected payerMedicareMedicaidPrivateUninsuredNo chargeOther47.4%8.1%31.5%7.9%1.0%4.2%46.1%19.8%13.4%14.6%1.4%4.8%<0.001Median household income centile0-25th26-50th51-75th76-100th 29.6%25.6%24.1%20.7%37.7%25.3%21.7%15.3%<0.001Smoking45.0%58.0%<0.001Alcohol misuse3.5%9.6%<0.001Dyslipidemia67.2%49.7%<0.001Hypertension71.7%70.9%0.063Diabetes mellitus34.0%36.6%<0.001Obesity16.1%14.2%<0.001Heart failure0.5%0.7%0.003Coronary artery disease84.6%65.6%<0.001Previous myocardial infarction11.7%16.1%<0.001Previous PCI15.6%18.0%<0.001Previous CABG7.6%10.0%<0.001Valvular heart disease0.1%0.2%0.078Atrial fibrillation12.2%11.1%0.002Previous stroke/TIA6.7%7.8%<0.001Peripheral vascular disease9.9%10.2%0.32Pulmonary circulatory disorder0.07%0.10%0.18Peptic ulcer disease0.03%0.01%0.28Chronic lung disease17.5%25.0%<0.001Renal failure14.4%18.1%<0.001Liver disease1.4%2.6%<0.001Hypothyroidism9.2%5.3%<0.001Fluid and electrolyte disorders15.0%19.1%<0.001Anemia12.0%13.5%<0.001Cancer2.1%2.3%0.19Depression6.6%6.5%0.63Dementia2.4%2.2%0.12Charlson score1.2±1.51.5±1.6<0.001BedsizeSmallMediumLarge6.6%22.7%70.8%7.7%25.6%66.7%<0.001Urban location5.4%5.9%0.026Teaching hospital57.8%53.4%<0.001Circulatory support2.9%1.8%<0.001Vasopressor use0.5%0.3%0.020Intra-aortic balloon pump use2.8%1.7%<0.001Ventilation2.2%3.0%<0.001Drug eluting stent46.2%15.4%<0.001In-hospital eventsComplete heart block0.9%0.6%<0.001Ventricular fibrillation2.3%1.2%<0.001Ventricular tachycardia5.4%4.3%<0.001Stroke/TIA2.4%2.4%0.86Cardiogenic shock2.5%2.1%0.008Cardiac arrest1.5%1.2%0.014Acute kidney injury0.7%1.3%<0.001Major bleeding0.9%1.4%<0.001Blood transfusion0.19%0.02%<0.001Vascular complication0.5%0.2%<0.001Receipt of coronary angiogram86.6%46.4%<0.001Receipt of PCI63.3%27.8%<0.001Receipt of thrombolysis1.6%1.3%0.025Receipt of CABG5.8%1.0%<0.001Receipt of ICD/pacemaker0.9%0.3%<0.001Receipt of LV assist device0.15%0.07%0.040Length of stay (days)3.8±3.72.6±3.9<0.001Cost of index admission (USD)$19,035±14,357$11,451±12,501<0.001Cost of readmission (USD)$12,607±17,715$15,417±20,895<0.001Cost of index admission and readmission USD)$31,536±25,443$26,676±25,112<0.001Readmission rate at 30 days10.1%24.9%<0.001Mean time to readmission in days (SD)14.1±7.710.6±8.0<0.001Mean length of stay for readmission in days (SD)4.5±5.75.1±6.8<0.001Readmission death3.5%4.2%0.047P-value from T-test for continuous variables and Chi2-test for categorical variables.Table 2: Independent predictors of discharge against medical adviceVariableOdds ratio (95% CI)p-valueAge0.97 (0.96-0.97)<0.001Male1.92 (1.81-2.03)<0.001Diagnosis of STEMI1.16 (1.09-1.23)<0.001Primary expected payer vs MedicareMedicaidPrivateUninsuredOther1.30 (1.20-1.41)0.40 (0.36-0.43)1.13 (1.03-1.24)0.86 (0.76-0.98)<0.001<0.0010.0080.021Median household income vs 0-25th26-50th51-75th76-100th0.89 (0.84-0.95)0.88 (0.82-0.95)0.84 (0.77-0.91)0.0010.001<0.001Smoking1.66 (1.57-1.75)<0.001Alcohol misuse1.49 (1.35-1.63)<0.001Dyslipidemia0.65 (0.61-0.68)<0.001Hypertension1.10 (1.04-1.17)<0.001Diabetes mellitus1.13 (1.08-1.20)<0.001Obesity0.88 (0.82-0.95)0.001Heart failure0.72 (0.52-1.00)0.049Coronary artery disease0.79 (0.74-0.84)<0.001Previous myocardial infarction1.27 (1.18-1.36)<0.001Previous PCI1.25 (1.18-1.36)<0.001Previous CABG0.92 (0.85-1.00)0.049Atrial fibrillation0.83 (0.77-0.89)0.24Chronic lung disease1.14 (1.08-1.21)<0.001Renal failure0.79 (0.73-0.85)<0.001Liver disease0.86 (0.74-0.85)0.046Anemia0.86 (0.80-0.92)<0.001Cancer0.67 (0.57-0.78)<0.001Depression0.87 (0.79-0.96)0.004Dementia0.69 (0.58-0.81)<0.001Bed size vs SmallMedium1.20 (1.06-1.35)0.004Urban location1.15 (1.02-1.30)0.022Teaching hospital0.81 (0.76-0.87)<0.001Receipt of ventilation1.48 (1.25-1.75)<0.001Drug eluting stent0.57 (0.52-0.63)<0.001Ventricular fibrillation0.59 (0.47-0.74)<0.001Receipt of angiogram0.18 (0.17-0.19)<0.001Receipt of PCI0.57 (0.52-0.63)<0.001Receipt of CABG0.11 (0.08-0.13)<0.001Receipt of ICD/pacemaker0.27 (0.18-0.40)<0.001Receipt of thrombolysis1.22 (1.01-1.47)0.043*Acute kidney injury, major bleeding and blood transfusions were not included in analysis because there were too few events.Figure 1Supplementary Table 1: Classification of Clinical Classifications Software (CCS) Codes for Readmissions CausesCauses of ReadmissionCCS codeDiagnosisRespiratory127Chronic obstructive pulmonary disease and bronchiectasis128Asthma130Pleurisy, pneumothorax, pulmonary collapse131Respiratory failure, insufficiency and arrest132Lung disease due to external agents133Other lower respiratory disease134Other upper respiratory disease221Respiratory distress syndromeInfection1Tuberculosis2Septicemia3Bacterial infection4Mycoses5Human Immunodeficiency Virus (HIV) infection6Hepatitis7Viral infection8Other infection9Sexually transmitted infection76Meningitis77Encephalitis78Other central nervous system infection and poliomyelitis90Inflammation or infection of eye122Pneumonia123Influenza124Acute and chronic tonsillitis125Acute bronchitis126Other upper respiratory infections129Aspiration pneumonitis135Intestinal infection197Skin and subcutaneous tissue infections201Infective arthritis and osteomyelitis (except that caused by tuberculosis or sexually transmitted disease)Bleeding 60Acute posthemorrhagic anemia153Gastrointestinal hemorrhage182Hemorrhage during pregnancy; placental abruption; placenta previaPeripheral vascular disease 114Peripheral and visceral atherosclerosis115Aortic, peripheral and visceral artery aneurysms116Aortic and peripheral arterial embolism or thrombosis117Other circulatory disease118Phlebitis, thrombophlebitis and thromboembolism119Varicose veins of lower extremitiesGenitourinary 159Urinary tract infection160Calculus of the urinary tract161Other diseases of kidney and ureters162Other diseases of bladder and urethra163Genitourinary symptoms and ill-defined conditions164Hyperplasia of prostate165Inflammatory conditions of the male genital organs166Other male genital disorders170Prolapse of female genital organs175Other female genital disorders215Genitourinary congenital anomaliesRenal disease156Nephritis; nephrosis; renal sclerosis157Acute and unspecified renal failure158Chronic kidney diseaseGastrointestinal 138Esophageal disorders139Gastroduodenal ulcer (except hemorrhage)140Gastritis and duodenitis141Other disorders of stomach and duodenum142Appendicitis and other appendiceal conditions143Abdominal hernia144Regional enteritis and ulcerative colitis145Intestinal obstruction without hernia146Diverticulosis and diverticulitis147Anal and rectal conditions148Peritonitis and intestinal abscess149Biliary tract disease150Liver disease; alcohol-related151Other liver diseases152Pancreatic disorders (not diabetes)154Noninfectious gastroenteritis155Other gastrointestinal disorders214Digestive congenital anomalies222Hemolytic jaundice and perinatal jaundice250Nausea and vomiting251Abdominal painTransient ischemic attack/stroke109Acute cerebrovascular disease110Occlusion of stenosis of precerebral arteries111Other and ill-defined cerebrovascular disease112Transient cerebral ischemia113Late effects of cerebrovascular diseaseTrauma207Pathological fracture225Joint disorders and dislocations; trauma-related226Fracture of neck of femur (hip)227Spinal cord injury228Skull and face fractures229Fracture of upper limb230Fracture of lower limb231Other fractures232Sprains and strains233Intracranial injury234Crushing injury or internal injury235Open wounds of head; neck; and trunk236Open wounds of extremities239Superficial injury; contusion244Other injuries and conditions due to external causes260All (external causes of injury and poisoning)Endocrine/metabolic48Thyroid disorders49Diabetes mellitus without complication50Diabetes mellitus with complication51Other endocrine disorders53Disorders of lipid metabolism58Other nutritional and endocrine/metabolic disorders186Diabetes or abnormal glucose tolerance complicating pregnancy; childbirth; or the puerperiumNeuropsychiatric79Parkinson's disease80Multiple sclerosis81Other hereditary and degenerative nervous system conditions82Paralysis83Epilepsy, convulsions84Headache including migraine85Coma, stupor and brain damage95Other nervous system disorders216Nervous system congenital anomalies650Adjustment disorders651Anxiety disorders652Attention-deficit, conduct, and disruptive behavior disorders653Delirium, dementia, and amnestic and other cognitive disorders654Developmental disorders655Disorders usually diagnosed in infancy and childhood or adolescence656Impulse control disorders, NEC657Mood disorders658Personality disorders659Schizophrenia and other psychotic disorders660Alcohol-related disorders661Substance-related disorders662Suicide and intentional self-inflicted injury663Screening and history of mental health and substance abuse codes670Miscellaneous mental health disordersHematological/neoplastic 11Cancer of head and neck12Cancer of esophagus13Cancer of stomach14Cancer of colon15Cancer of rectum and anus16Cancer of liver and intrahepatic bile ducts17Cancer of pancreas18Cancer of other GI organs, peritoneum19Cancer of bronchus, lung20Cancer of other respiratory and intrathoracic21Cancer of bone and connective tissue22Melanoma of skin23Other non-epithelial cancer of skin24Cancer of breast25Cancer of uterus26Cancer of cervix27Cancer of ovary28Cancer of other female genital organs29Cancer of prostate30Cancer of testis31Cancer of other male genital organs32Cancer of bladder33Cancer of kidney and renal pelvis34Cancer of other urinary organs35Cancer of brain and nervous system36Cancer of thyroid37Hodgkin's disease38Non-Hodgkin's lymphoma39Leukemia40Multiple myeloma41Cancer, other and unspecified primary42Secondary malignancies43Malignant neoplasm without specification of site44Neoplasm of unspecified nature or uncertain behavior46Benign neoplasm of uterus47Other and unspecified benign neoplasm59Deficiency and other anemias61Sickle cell anemia62Coagulation and hemorrhagic disorders63Disease of white blood cells64Other hematologic conditionsRheumatology problem54Gout and other crystal arthropathiesOphthalmology problem86Cataract87Retinal detachment defects, vascular occlusion and retinopathy88Glaucoma89Blindness and vision defects91Other eye disordersENT problem92Otitis media and related conditions93Conditions associate with dizziness or vertigo94Other ear and sense organ disorderNon-specific chest pain102Non-specific chest painOral health problem136Disorders of teeth and jaw137Diseases of mouth; excluding dentalObstetric admission including pregnancy174Female infertility176Contraceptive and procreative management177Spontaneous abortion178Induced abortion179Postabortion complication180Ectopic pregnancy181Other complications of pregnancy184Early or threatened labor185Prolonged pregnancy187Malposition; malpresentation188Fetopelvic disproportion; obstruction189Previous C-section190Fetal distress and abnormal forces of labor191Polyhydramnios and other problems of amniotic cavity192Umbilical cord complication193OB-related trauma to perineum and vulva194Forceps delivery195Other complications of birth; puerperium affecting management of mother196Other pregnancy and deliver including normal218Liveborn219Short gestation; low birth weight; and fetal growth retardation220Intrauterine hypoxia and birth asphyxia223Birth trauma224Other perinatal conditionsDermatology problem198Other inflammatory condition of skin199Chronic ulcer of skin200Other skin disordersPoisoning241Poisoning by psychotrophic agents242Poisoning by other medication and drugs243Poisoning by nonmedical substancesSyncope245SyncopeOther non-cardiac 10Immunization and screening for infectious disease45Maintenance chemotherapy, radiotherapy52Nutritional deficiencies55Fluid and electrolyte disorders56Cystic fibrosis57Immunity disorder120Hemorrhoids121Other diseases of veins and lymphatics167Nonmalignant breast conditions168Inflammatory disease of female pelvic organs169Endometriosis172Ovarian cyst173Menopausal disorders202Rheumatoid arthritis and related disease203Osteoarthritis204Other non-traumatic joint disorders205Spondylosis; intervertebral disc disorders; other back problems206Osteoporosis208Acquired foot deformities209Other acquired deformities210Systemic lupus erythematosus and connective tissue disorders211Other connective tissue disease212Other bone disease and musculoskeletal deformities217Other congenital anomalies237Complication of device; implant or graft238Complications of surgical procedure or medical care240Burns246Fever of unknown origin247Lymphadenitis248Gangrene252Malaise and fatigue253Allergic reactions254Rehabilitation care; fitting of prostheses; and adjustment of devices255Administrative/social admission256Medical examination/evaluation257Other aftercare258Other screening for suspected conditions (not mental disorders or infectious disease)259Residual codes; unclassifiedHeart failure 108Congestive heart failure non-hypertensiveArrhythmia 106Cardiac dysrhythmias107Cardiac arrest and ventricular fibrillationConduction disorder 105Conduction disordersValve disorders 96Heart valve disorderHyper/hypotension 98Essential hypertension99Hypertension with complications and secondary hypertension183Hypertension complicating pregnancy; childbirth and the puerperium249ShockPericarditis 97Peri-, endo- and myocarditis, cardiomyopathyCoronary artery disease including angina 101Coronary atherosclerosis and other heart disease Acute myocardial infarction 100Acute myocardial infarctionOthers (cardiac) 103Pulmonary heart disease104Other and ill-defined heart disease213Cardiac and circulatory congenital anomaliesSupplementary Table 2: Causes of unplanned 30-day readmissionsCauses of 30-day unplanned readmissionNo DAMA (%)DAMA (%)Acute myocardial infarction13.430.4Coronary artery disease including angina13.815.4Heart failure12.611.3Arrhythmias7.05.8Infections6.24.9Other non-cardiac7.94.9Non-specific chest pain7.04.9Respiratory4.54.2Neuropsychiatric1.33.2Gastrointestinal5.22.4TIA/stroke2.81.9Renal failure2.21.4Endocrine/metabolic1.51.4Hematological/neoplasm1.60.9Peripheral vascular disease2.20.9Bleeding2.40.8Trauma1.20.8Other cardiac1.30.7Valve disorders0.50.6Pericarditis0.70.6Poisoning0.30.6Rheumatological0.80.5Genitourinary1.40.5ENT problem0.70.5Syncope0.90.4Conduction disorders0.30.1Hyper/hypotension0.00.0Opthalmological0.00.0Oral health problem0.10.0Obstetric or pregnancy problem0.00.0Dermatological0.00.0Supplementary Table 3: Influence of length of stay on the rate of patients discharged against medical adviceLength of stay (days)Rate of discharge among patients discharged AMA (%)Rate of discharge among patients not discharged AMA (%)011.7%0.6%134.6%10.8%222.4%31.3%310.9%23.1%46.4%11.6%53.8%6.4%62.4%4.2%71.6%3.0%ReferencesAlfandre DJ. “I’m going 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Effect of Gender on Unplanned Readmissions After Percutaneous Coronary Intervention (from the Nationwide Readmissions Database). Am J Cardiol. 2018;121:810-817.Kwok CS, Rao SV, Potts JE, Kontopantelis E, Rashid M, Kinnaird T, Curzen N, Nolan J, Bagur R, Mamas MA. Burden of 30-Day Readmissions After Percutaneous Coronary Intervention in 833,344 Patients in the United States: Predictors, Causes, and Cost: Insights From the Nationwide Readmission Database. JACC Cardiovasc Interv. 2018;11:665-674.Spooner KK, Salemi JL, Salihu HM, Zoorob RJ. Discharge against medical advice in the United States, 2002-2011. Mayo Clin Proc 2017;92:525-535.Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospital against medical advice. Am J Public Health 2007;97:2204-2208.Onukwugha EC, Shaya FT, Saunders E, Weir MR. Ethnic disparities, hospital quality and discharges against medical advice among patients with cardiovascular disease. 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