Advertisement
Mayo Clinic Proceedings Home

Thirty-Day Readmission Rate in Acute Heart Failure Patients Discharged Against Medical Advice in a Matched Cohort Study

      Abstract

      Objective

      To determine the readmission rate in patients with acute heart failure (AHF) discharged against medical advice (AMA).

      Methods

      We performed a retrospective analysis using the 2014 National Readmission Database. Patients admitted with a primary diagnosis of AHF were selected. Only those discharged to home and who left AMA were included in the study. The primary outcome was 30-day readmission. We compared the readmission rates among those discharged AMA vs routinely discharged patients using propensity score matching (PSM) to address imbalance in variables between the 2 groups. We matched 3 routinely discharged patients to 1 patient who left AMA.

      Results

      We identified 273,489 patients with AHF, of whom 116,869 qualified for further study analysis. A total of 2014 patients (1.7%) were in the AMA group and 114,855 (98.3%) were in the routinely discharged group. After PSM, 6042 routinely discharged patients were matched with 2014 patients from the AMA group. The standard mean difference for each variable was less than 10% postmatching. The 30-day readmission rate among those who left AMA was higher than among those routinely discharged (33% vs 20.1%; P<.001). Heart failure (44.8%) was the most common cause of readmission in the AMA group. Patients who left AMA were more likely to be readmitted to a different hospital compared with those routinely discharged (37.4 vs 23.1%; P<.001). They also had a high rate of leaving AMA during the readmission (18 vs 2%; P<.001).

      Conclusion

      Patients with AHF discharged AMA had a significantly higher 30-day readmission rate than did the routinely discharged group.

      Abbreviations and Acronyms:

      AHF (acute heart failure), AMA (against medical advice), CCS (Clinical Classifications Software), HF (heart failure), ICD-9 (International Classification of Diseases, 9th revision), IQR (interquartile range), NRD (National Readmission Database), PSM (propensity score matching)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ibrahim S.A.
        • Kwoh C.K.
        • Krishnan E.
        Factors associated with patients who leave acute-care hospitals against medical advice.
        Am J Public Health. 2007; 97: 2204-2208
        • Glasgow J.M.
        • Vaughn-Sarrazin M.
        • Kaboli P.J.
        Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission.
        J Gen Intern Med. 2010; 25: 926-929
        • Aliyu Z.Y.
        Discharge against medical advice: sociodemographic, clinical and financial perspectives.
        Int J Clin Pract. 2002; 56: 325-327
        • Stevenson L.W.
        • Pande R.
        Witness to progress.
        Circ Heart Fail. 2011; 4: 390-392
        • Shah M.
        • Patnaik S.
        • Patel B.
        • et al.
        The day of the week and acute heart failure admissions: relationship with acute myocardial infarction, 30-day readmission rate and in-hospital mortality.
        Int J Cardiol. 2017; 249: 292-300
        • Lu M.L.R.
        • De Venecia T.A.
        • Goyal A.
        • et al.
        Psychiatric conditions as predictors of rehospitalization among African American patients hospitalized with heart failure.
        Clin Cardiol. 2017; 40: 1020-1025
        • Arora S.
        • Patel P.
        • Lahewala S.
        • et al.
        Etiologies, trends, and predictors of 30-day readmission in patients with heart failure.
        Am J Cardiol. 2017; 119: 760-769
        • National Readmission Database (NRD)
        Health Care Utilization Project.
        Agency for Healthcare Research and Quality, Rockville, MD2014
        • Agrawal S.
        • Garg L.
        • Shah M.
        • et al.
        Thirty-day readmissions after left ventricular assist device implantation in the United States: insights from the Nationwide Readmissions Database.
        Circ Heart Fail. 2018; 11: e004628
        • Patel B.
        • Sablani N.
        • Garg J.
        • et al.
        Thirty-day readmissions after cardiac implantable electronic devices in the United States: insights from the Nationwide Readmissions Database.
        Heart Rhythm. 2018; 15: 708-715
        • HCUP
        NRD description of data elements.
        (Accessed October 14, 2017)
        • Hwang S.W.
        • Li J.
        • Gupta R.
        • Chien V.
        • Martin R.E.
        What happens to patients who leave hospital against medical advice?.
        CMAJ. 2003; 168: 417-420
        • Ziaeian B.
        • Fonarow G.C.
        The prevention of hospital readmissions in heart failure.
        Progr Cardiovasc Dis. 2016; 58: 379-385
        • Bergethon K.E.
        • Ju C.
        • DeVore A.D.
        • et al.
        Trends in 30-day readmission rates for patients hospitalized with heart failure: findings from the Get With The Guidelines-Heart Failure Registry.
        Circ Heart Fail. 2016; 9 (pii: e002594. https://doi.org/10.1161/CIRCHEARTFAILURE.115.002594.)
        • Choi M.
        • Kim H.
        • Qian H.
        • Palepu A.
        Readmission rates of patients discharged against medical advice: a matched cohort study.
        PloS One. 2011; 6: e24459
        • Garland A.
        • Ramsey C.D.
        • Fransoo R.
        • et al.
        Rates of readmission and death associated with leaving hospital against medical advice: a population-based study.
        CMAJ. 2013; 185: 1207-1214
        • Fiscella K.
        • Meldrum S.
        • Barnett S.
        Hospital discharge against advice after myocardial infarction: deaths and readmissions.
        Am J Med. 2007; 120: 1047-1053
        • Akinbodewa A.A.
        • Adejumo O.A.
        • Adejumo O.A.
        • et al.
        Evaluation of administration of discharge against medical advice: ethico-legal considerations.
        Niger Postgrad Med J. 2016; 23: 141-145
        • Spooner K.K.
        • Salemi J.L.
        • Salihu H.M.
        • Zoorob R.J.
        Discharge against medical advice in the United States, 2002-2011.
        Mayo Clin Proc. 2017; 92: 525-535
        • Weingart S.N.
        • Davis R.B.
        • Phillips R.S.
        Patients discharged against medical advice from a general medicine service.
        J Gen Intern Med. 1998; 13: 568-571
        • Jeremiah J.
        • O’Sullivan P.
        • Stein M.D.
        Who leaves against medical advice?.
        J Gen Intern Med. 1995; 10: 403-405
        • Saitz R.
        • Ghali W.A.
        • Moskowitz M.A.
        The impact of leaving against medical advice on hospital resource utilization.
        J Gen Intern Med. 2000; 15: 103-107
        • Smith D.B.
        • Telles J.L.
        Discharges against medical advice at regional acute care hospitals.
        Am J Public Health. 1991; 81: 212-215
        • Anis A.H.
        • Sun H.
        • Guh D.P.
        • Palepu A.
        • Schechter M.T.
        • O’Shaughnessy M.V.
        Leaving hospital against medical advice among HIV-positive patients.
        CMAJ. 2002; 167: 633-637
        • Bueno H.
        • Ross J.S.
        • Wang Y.
        • et al.
        Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006.
        JAMA. 2010; 303: 2141-2147
        • Schaefer G.R.
        • Matus H.
        • Schumann J.H.
        • et al.
        Financial responsibility of hospitalized patients who left against medical advice: medical urban legend?.
        J Gen Intern Med. 2012; 27: 825-830
        • Onukwugha E.
        • Saunders E.
        • Mullins C.D.
        • Pradel F.G.
        • Zuckerman M.
        • Weir M.R.
        Reasons for discharges against medical advice: a qualitative study.
        Qual Saf Health Care. 2010; 19: 420-424
        • Manouchehri J.
        • Goodarzynejad H.
        • Khoshgoftar Z.
        • Sheikh Fathollahi M.
        • Aghamohammadi Abyaneh M.
        Discharge against medical advice among inpatients with heart disease in Iran.
        J Tehran Heart Cent. 2012; 7: 72-77