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Advancing the science of discharges against medical advice: taking a deeper dive
  1. David Alfandre
  1. VHA National Center for Ethics in Health Care, NYU School of Medicine, Department of Medicine and Population Health, New York NY 10010, USA
  1. Correspondence to Dr David Alfandre, VHA National Center for Ethics in Health Care, NYU School of Medicine, Department of Medicine and Public Health, New York NY 10010, USA; david.alfandre{at}

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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 …

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  • Contributors The author listed has contributed sufficiently to the project in order to be included as author and only those who are qualified to be authors are listed in the byline. The manuscript has not been previously published and is not under consideration in the same or substantially similar form in any other peer-reviewed media.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the US Department of Veterans Affairs, the US Government or the VA National Center for Ethics in Health Care.

  • Competing interests None declared.

  • Patient consent Not requried.

  • Provenance and peer review Commissioned; internally peer reviewed.

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