• acute myocardial infarction
• quality and outcomes of care

Against medical advice (AMA) discharges continue to confound. These discharges, when patients leave the hospital prior to a clinically specified and physician-recommended endpoint, are associated with worse health and health services outcomes. Although their prevalence has remained between 1% and 2%, the rate is markedly higher in vulnerable populations with mental health and substance use disorders, HIV and the uninsured.1 2 Compared with patients discharged conventionally, 30-day mortality is higher, and 30-day readmissions are more likely after AMA discharges.3

Contemporary research on AMA discharges has primarily been directed towards elucidating the patient-related factors that are associated with its adverse outcomes. Identifying the demographic variables and patient comorbidities that are more likely with AMA discharges is intended to uncover what drives this phenomenon and to point towards what interventions can mitigate their impact. Also, because readmissions are more common after AMA discharges, and acute myocardial infarction (AMI) is a targeted condition for Medicare’s Readmission Reduction Program, reducing readmissions after AMI is an important goal for improving healthcare quality and resource utilisation. Although AMA discharges are excluded from Medicare’s readmission penalty calculation for patients admitted with AMI, attempts to reduce AMA discharges are welcomed.

The report by Kwok and coauthors in their Heart paper,4 focuses on the high-risk cohort of patients admitted with AMI. The investigators drew on 2010–2014 hospital data from the Nationwide Readmission Database and included adults hospitalised with an admission diagnosis of AMI who were either discharged home or AMA. The authors examined independent demographic, comorbidity, procedural and hospital variables associated with AMA …