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Journal of General Internal Medicine

, Volume 34, Issue 4, pp 486–488 | Cite as

Trends, Management Patterns, and Predictors of Leaving Against Medical Advice among Patients with Documented Noncompliance Admitted for Acute Myocardial Infarction

  • Gbolahan O. OgunbayoEmail author
  • Tara A. Shrout
  • Naoki Misumida
  • Ahmed Abdel-Latif
  • Susan S. Smyth
  • Adrian W. Messerli
  • Khalid M. Ziada
Concise Research Reports

KEY WORDS

noncompliance high-risk patients leaving against medical advice (LAMA) acute myocardial infarction (AMI) 

INTRODUCTION

Noncompliance (NC) and leaving against medical advice (LAMA) are risk factors for poor outcomes, including hospital readmission and mortality.1,2 This study aims to investigate the relationship between NC and LAMA, describe characteristics of NC patients, evaluate the clinical management of acute myocardial infarction (AMI) in NC patients, and identify predictors of LAMA in this population. We hypothesized that NC would be associated with higher rates of LAMA.

METHODS

We identified adults with a primary diagnosis of AMI and documented NC using the National Inpatient Survey (2010–2014). Documented NC is defined by the ICD-9-CM Diagnosis Code V15.81 as a personal history of noncompliance with medical treatment, presenting hazards to health. We used logistic regression to perform temporal trend analysis for documented NC among patients with a primary diagnosis of AMI. We then compared demographic and clinical characteristics as well as outcomes, primarily LAMA, between this group and patients without documented NC. Weighted regression analysis was used to identify predictors of LAMA.

RESULTS

Of the 2,988,294 patients with a primary diagnosis of AMI, 4.7% (n = 141,346) had documented NC. The incidence of NC increased from 3.9% in 2010 to 5.4% in 2014 (p trend< 0.001). The NC group was younger, more often male, and more likely to be black or Hispanic, was more likely to be uninsured or on Medicaid as well as have comorbidities including hypertension, diabetes, chronic pulmonary disease, and obesity. Rates of substance abuse and specific psychiatric disorders were significantly higher in the NC group.

LAMA was more than four times more likely in patients with NC (Fig. 1). Patients in the NC cohort were more likely to undergo coronary angiography or PCI, a finding that was due to a higher incidence of balloon angioplasty and not stent placement. They were also more likely to receive bare metal stents. In multivariate analysis, NC increased the risk of LAMA (OR 2.29, 95% CI 2.09–2.5; p < .001), regardless of the type of AMI [STEMI (OR 2.42, 95% CI 2.04–2.87; p < .001); NSTEMI (OR 2.22, 95% CI 2.0–2.46; p < .001)]. Male gender, current tobacco abuse, anxiety, adjustment and personality disorders as well as being on Medicaid insurance were all significantly associated with LAMA in the NC cohort, while interventions (coronary angiography, PCI, and CABG) were associated with a lower odds for LAMA (Table 1).
Fig. 1

Forest plot showing factors associated with LAMA in the NC population. PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting.

Table 1

Comparison of Factors in Patients With and Without Documented Noncompliance (NC)

 

Noncompliant (118,037)

Others (2,235,161)

P value

Demographics

Age

59.6 ± 12.8

67.9 ± 14.2

< 0.001

 Female

36,444 (30.9)

889,746 (39.8)

< 0.001

 Caucasian

69,556 (58.9)

1,561,253 (69.8)

< 0.001

 Black

23,540 (19.9)

222,422 (10)

< 0.001

 Hispanic

12,092 (10.2)

169,591 (7.6)

< 0.001

Comorbidities

 Hypertension

92,911 (78.7)

1,596,251 (71.4)

< 0.001

 Diabetes mellitus

57,437 (48.7)

810,899 (36.3)

< 0.001

 Chronic pulmonary disease

27,631 (23.4)

463,342 (20.7)

< 0.001

 Renal failure

23,329 (19.8)

453,285 (20.3)

0.065

 Obesity

27,388 (23.2)

314,524 (14.1)

< 0.001

 Current smoker

53,529 (45.3)

511,964 (22.9)

< 0.001

 Depression

9855 (8.3)

170,022 (7.6)

< 0.001

 Psychoses

5577 (4.7)

53,046 (2.4)

< 0.001

 Adjustment disorder

410 (0.3)

4115 (0.2)

< 0.001

 Anxiety disorder

9023 (7.6)

153,708 (6.9)

< 0.001

 Personality disorder

438 (0.4)

1468 (0.1)

< 0.001

 Alcohol abuse

9726 (8.2)

65,067 (2.9)

< 0.001

 Drug abuse

10,629 (9)

48,823 (2.2)

< 0.001

Insurance

 Medicare

47,726 (40.4)

1,298,251 (58.1)

< 0.001

 Medicaid

17,832 (15.1)

144,254 (6.5)

< 0.001

 Self-pay

17,625 (14.9)

131,570 (5.9)

< 0.001

Management

 Coronary angiography

82,846 (70.2)

1,493,239 (66.8)

< 0.001

 PCI

54,648 (46.3)

1,006,638 (45.0)

< 0.001

 Stent placement

48,897 (41.4)

933,130 (41.7)

0.374

 Bare metal stent placement

18,909 (16)

251,210 (11.2)

< 0.001

 Plain old balloon angioplasty

5751 (4.9)

73,508 (3.3)

< 0.001

 CABG

7759 (6.6)

153,044 (6.8)

0.148

Disposition

 Routine discharge

80,540 (68.2)

1,341,797 (60)

< 0.001

 Left against medical advice

4359 (3.7)

18,168 (0.8)

< 0.001

 Died during hospitalization

2746 (2.3)

118,671 (5.3)

< 0.001

PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting

DISCUSSION

This study reports an increasing incidence of documented NC among patients (admissions) for AMI. As has been reported previously,1,3,4 we also found that young males of ethnic minorities and those with mental disorders have higher LAMA rates. Although there appears to be no bias against patients with NC with regard to intervention, practice patterns (i.e., stent placement versus plain old balloon angioplasty and bare metal stent versus drug eluting stent) may have been affected by medical compliance. This is a shift in previous knowledge of management patient with AMI that suggests lower rates of intervention in this patient population.1

Our study suggests that NC is a strong predictor of LAMA. Early identification of patients at-risk for LAMA (males, tobacco users, personality disorders, low income) may prevent truncated care, hospital readmissions, higher health care costs, and mortality following AMI. Given recent studies that support shorter duration of dual antiplatelet therapy,5 we anticipate that practice patterns may also change. Better understanding of patient family issues, living situation, and previous medical experiences may also impact outcomes of this study and patient care.6

CONCLUSION

The incidence of NC in patients admitted with an AMI was higher in young, black and Hispanic males, and low-income patients with Medicaid or no insurance. NC patients were significantly more likely to LAMA. Predictors of LAMA in this population included current tobacco abuse and adjustment, anxiety or personality disorders, and being insured by Medicaid.

References

  1. 1.
    Fiscella K, Meldrum S, Barnett S. Hospital Discharge against Advice after Myocardial Infarction: Deaths and Readmissions. Am J Med. 2007;120(12):1047–1053.  https://doi.org/10.1016/j.amjmed.2007.08.024
  2. 2.
    Garland A, Ramsey CD, Fransoo R, Olafson K, Chateau D, Yogendran M, Kraut A. Rates of readmission and death associated with leaving hospital against medical advice: A population-based study. Can Med Assoc J. 2013.  https://doi.org/10.1503/cmaj.130029
  3. 3.
    Jeremiah J, O’Sullivan P, Stein M. Who leaves against medical advice? J Gen Intern Med. 1995;10(7):403–405.  https://doi.org/10.1007/BF02599843
  4. 4.
    Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12):2204–2208.  https://doi.org/10.2105/AJPH.2006.100164
  5. 5.
    Gargiulo G, Windecker S, da Costa BR, Feres F, Hong MK, Gilard M, Kim HS, Colombo A, Bhatt DL, Kim BK, Morice MC, Park KW, Chieffo A, Palmerini T, Stone GW, Valgimigli M. Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials. BMJ. 2016:i5483.  https://doi.org/10.1136/bmj.i5483.
  6. 6.
    Alfandre D. Reconsidering against medical advice discharges: Embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med. 2013.  https://doi.org/10.1007/s11606-013-2540-z

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Gbolahan O. Ogunbayo
    • 1
    • 2
    Email author
  • Tara A. Shrout
    • 1
    • 2
  • Naoki Misumida
    • 1
  • Ahmed Abdel-Latif
    • 1
  • Susan S. Smyth
    • 1
  • Adrian W. Messerli
    • 1
  • Khalid M. Ziada
    • 1
  1. 1.University of Kentucky Medical CenterLexingtonUSA
  2. 2.Division of Cardiovascular Medicine, The Gill Heart and Vascular Institute University of KentuckyLexingtonUSA

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