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Original research article
Discharge against medical advice after hospitalisation for acute myocardial infarction
  1. Chun Shing Kwok1,2,
  2. Mary Norine Walsh3,
  3. Annabelle Volgman4,
  4. Mirvat Alasnag5,
  5. Glen Philip Martin6,
  6. Diane Barker2,
  7. Ashish Patwala2,
  8. Rodrigo Bagur1,
  9. David L Fischman7,
  10. Mamas A Mamas1,2
  1. 1 Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
  2. 2 Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
  3. 3 Department of Cardiology, St Vincent Heart Center, Indianapolis, Indiana, USA
  4. 4 Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
  5. 5 Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
  6. 6 Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
  7. 7 Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr. Mamas A Mamas, Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, ST47QB, UK; mamasmamas1{at}


Background 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 USA in the Nationwide Readmission Database who were admitted between the years 2010 and 2014. Descriptive statistics were presented for variables according to discharge home or AMA. The primary end point was all-cause 30-day unplanned readmissions and their causes.

Results 2663 019 patients were admitted with AMI of which 10.3% (n=162 070) of 1569 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 to 2.40); patients who discharged AMA had >twofold increased crude rate of readmission for AMI (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 to 4.03, p<0.001). We estimate that there are 1420 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.

  • acute myocardial infarction
  • quality and outcomes of care

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  • Contributors 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.

  • 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 International.

  • Competing interests None declared.

  • Ethics approval This 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 with the HCUP Data Use Agreement.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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