Patients Discharged AMA More Likely to Be Readmitted

Discharge against medical advice (DAMA) is the strongest predictor of 30-day unplanned readmissions in heart attack patients, according to a new study.

Researchers at Keele University (Newcastle, United Kingdom), Western University (WU; London, Canada), and other institutions conducted a study that analyzed data involving 2,021,104 patients in the UK nationwide readmission database between 2010 and 2014 who underwent a percutaneous coronary intervention (PCI) procedure and who were either discharged home or against medical advice. The primary endpoint was all-cause 30-day readmissions and their causes.

The results revealed that 0.5% of patients were discharged against medical advice during the study period, and that 16.8% of those patients were readmitted within 30 days. Concomitantly, patients who did not discharge against medical advice had an 8.5% readmission rate. DAMA patients were younger, male, more likely to be smokers, misuse alcohol and drugs, and be in the lowest quartile of income. The most common non-cardiac reason for readmission was non-specific chest pain, in both DAMA and non-DAMA patients.

DAMA patients were four times as likely to be readmitted for psychiatric reasons, including depression, bipolar disorders, paranoid schizophrenia, schizoaffective disorder, and psychosis. Heart attack was the most common cardiac-related cause for readmission among both groups, with DAMA patients were twice as likely to be readmitted for this reason. Overall, DAMA patients had 1.5-fold higher mortality, 3-fold greater incidence of in-hospital major adverse cardiac events, and 12-fold greater DAMA again, in the readmission episode. The study was published in the July 2018 issue of JACC: Cardiovascular Interventions.

“Patients who undergo PCI not only have risks associated with their presenting condition, but there are also risks related to their treatment. When patients discharge against medical advice, there is a breakdown in the care relationship and the patient has chosen to discontinue care,” said senior author professor of cardiology Mamas Mamas, MD, PhD, of Keele University. “This has serious consequences as ongoing care is vital after PCI, from prescribing dual antiplatelet therapy to echocardiograms to assess other, necessary, evidence based therapies or management of newly diagnosed diabetes and more.”

The conflict between the professional values of the physician and the autonomy of the patient is the most prominent ethical dilemma in cases of DAMA. DAMA is more complicated in developing countries, especially because of communal models of decision-making. Ethical issues include recognizing a patient’s best interest and competence of decision-making capacity, in light of the fact that DAMA prevalence worldwide is highest among psychiatric patients, at 3-51%. The major legal issue is the possibility of doctors being sued for medical malpractice.

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Keele University
Western University