“Communication is key” when managing patients who seek discharge against medical advice

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Mamas A Mamas

Chun Shing Kwok (Keele Cardiovascular Research Group, Keele University, Stroke-on-Trent, UK) and others report in JACC: Cardiovascular Interventions that only 0.5% of percutaneous coronary intervention (PCI) patients discharge themselves against medical advice (DAMA). However, they note that the risk of readmission at 30 days is significantly increased in such patients and, therefore, interventions are needed to prevent DAMA in high-risk groups. Study author Mamas A Mamas (Keele Cardiovascular Research Group, Keele University, Stroke-on-Trent, UK) speaks to Cardiovascular News about the findings.

Given that DAMA is an infrequent event in the general patient population, why was it important to evaluate its incidence in patients who have undergone PCI?

In a previous study, we observed that DAMA was one of the strongest predictors of unplanned readmissions following PCI. However, prior to the present study, we did not have any literature about DAMA, including its predictors or clinical outcomes, in the PCI setting. From a theoretical standpoint, DAMA may carry quite a poor prognosis—particularly if patients self-discharged prior to receiving dual antiplatelet therapy (DAPT) as they would be at very high risk of stent thrombosis.

In your study, smoking and drug abuse were important predictors of DAMA. Why do you think this is?

Patients with drug abuse problems will also often have a personal history of mental health problems, which is known to predispose to DAMA. Patients with a history of drug abuse may also DAMA in order to use abuse drugs illicitly, as being an inpatient in hospital may prevent them from doing so.

How can the risk of DAMA be reduced in such patients?

Early engagement with the substance abuse team may prevent DAMA, for example, through prescription of methadone during their inpatient stay. Early engagement with mental health services/psychiatrists may again reduce risk of patients with mental health problems absconding.

What impact do you think monetary concerns—either because of cost of further treatment or money lost due to not earning —have on the risk of DAMA?

I believe that monetary concerns are very relevant; patients with the lowest income have the highest risk of DAMA.

The risk of 30-day readmission was significantly increased among DAMA. What were the key reasons for this readmission?

The greatest differences between the causes of readmissions for those who discharged themselves before medically recommended and those who did not were seen in the rates of acute myocardial infarction and psychiatric illnesses.

Of those with unplanned readmission at 30 days, DAMA patients were four times more likely to have a neuropsychiatric reason for being readmitted. Such patients often have a history of mental health disorders, so this increased rate of psychiatric disorders is not surprising.

However, twice as many DAMA patients had acute myocardial infarction as the cause of readmission compared with non-DAMA patients. This is an important finding as it may mean that they discharged themselves prior to receiving DAPT; if there are no mechanisms to get DAPT to them in the community, they will be at high risk of developing stent thrombosis.

Furthermore, the dataset did not capture post-discharge mortality. Therefore, it is entirely possible that patients developed a stent thrombosis and died in the community; as a result, they would not have been picked up by the dataset as a “readmission”.

If a patient wants to be discharged before medically recommended, what can be done to encourage them to stay in hospital?

Communication is key. Understanding their motivation as to why they want to self-discharge may identify the core underlying issues. It is important to communicate to the patient why they are required to remain in hospital and why discharging themselves may increase risks to their health. It is often very useful to get family members on side to support the medical team in continuing the care of their family member.

If a patient cannot be persuaded to stay in hospital, what steps can be taken to reduce their risk of readmission?

The key here is prescription of DAPT and other cardiac medications. Ensuring that patients are given a supply of cardiac medications, either from the hospital or from community pharmacists, is vital. Early engagement with their primary care provider is also important. Often patients can be identified as being at high risk for DAMA, which may expalin why bare metal stents was used at much higher rates that were drug-eluting stents in the DAMA cohort in our study. So for high risk groups, interventionalists should consider using platforms that only require short DAPT regimens. I think for high-risk DAMA groups, or those patients that are unlikely to adhere to DAPT regimens, it is important to consider the need for PCI. While there tends to be fewer options for patients with acute coronary syndromes (i.e. PCI is usually necessary), if PCI is not going to provide a prognostic benefit, optimal management should be carefully considered in patients with stable angina (i.e. whether medical management may be a better option for them)

If patient has severe dementia or severe mental health issues (i.e. not capable of making their own decisions), what steps could be taken to make them stay in hospital?

Again, I think that as interventionalists we have to consider whether we should be offering PCI to such challenging patients. Full discussion with family members regarding the need for adherence to DAPT regimens should take place up front and only after this should decisions be taken as to whether PCI would be appropriate in such cases.

What further research in this area is needed?

I think it is important to understand why patients choose to self-discharge post PCI. It is also important to study post discharge outcomes. Our analysis tells us what happens when they are readmitted. What we do not know is how big the black hole is between self-discharge and readmission—many of these patients may not survive their stent thrombosis/cardiac event to be readmitted. I think that this is important and only through such follow-up information will we know the true prognostic impact of DAMA.

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