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Discharge against medical advice following PCI is 'an infrequent but deadly problem'
In an analysis of more than 2 million patients who underwent PCI procedures in the United States from 2010 to 2014, the rate of discharge against medical advice following PCI was 0.5%. While this number is low, researchers noted that discharge against medical advice was strongly associated with hospital readmission within 30 days.
The rate of readmission at 30 days was 16.8% for patients who were discharged against medical advice and 8.5% among patients who were discharged home (P < .001). Discharge against medical advice was identified as the strongest predictor for 30-day readmission (OR = 1.89; 95% CI, 1.71-2.08), Chun Shing Kwok, MBBS, MSc, BSC, from Keele Cardiovascular Research Group at Keele University and the department of cardiology at Royal Stroke Hospital, both in Stoke-on-Trent, United Kingdom, and colleagues reported in JACC: Cardiovascular Interventions.
Predictors of discharge against medical advice following PCI were acute MI (OR = 1.37; 95% CI, 1.25-1.51), smoking (OR = 1.71; 95% CI, 1.57-1.86), drug abuse (OR = 1.82; 95% CI, 1.6-2.06) and alcohol abuse (OR = 1.53; 95% CI, 1.32-1.78). Compared with discharge to home, patients who were discharged against medical advice following PCI were more likely to have neuropsychiatric reasons for noncardiac reasons for readmission and acute MI for cardiac causes of readmission, according to the findings.
“Interventions should be developed to reduce discharge against medical advice in high-risk groups and initiate interventions to avoid complications and readmission when it occurs,” Kwok and colleagues wrote.
While discharge against medical advice is not uncommon in the ED setting, it is associated with greater risk for worse outcomes and other adverse consequences, according to the researchers.
“No previous study has evaluated discharge against medical advice in patients who undergo PCI,” Kwok and colleagues wrote.
A point for future research, according to the researchers, is to look at trends in discharge against medical advice after PCI over time. This study showed an increase in the temporal trend for discharge against medical advice at the index PCI procedure, with an increase from 0.44% in 2010 to 0.59% in 2014 (P < .001).
“This analysis represents the largest report of discharge against medical advice patients following PCI to date and has identified an infrequent but deadly problem,” Cardiology Today’s Intervention Editorial Board Member David P. Faxon, MD, and Natalia C. Berry, MD, both from Brigham and Women’s Hospital, wrote in a related editorial. “Early recognition, early involvement of the health care team, including care managers, social workers, psychiatrists, addiction counselors, and others, is imperative. The interventional cardiologist is often the first person to care for the patient, particularly those with ST-segment elevation myocardial infarction, and therefore needs to take on the task of identifying susceptible patients and bringing together the needed heath care resources to prevent the serious consequences of [discharge against medical advice].”
Disclosures: The authors, Berry and Faxon report no relevant financial disclosures.