Profile of Patients Hospitalized for Heart Failure Who Leave Against Medical Advice

Abstract Background There is a paucity of information on patients hospitalized with heart failure [HF] who leave against medical advice [AMA]. Objectives We sought to identify patient and hospital characteristics and outcomes of patients with HF who left AMA compared to those conventionally discharged to home [CDH]. Methods Using the Get With The Guidelines-Heart Failure registry, data were analyzed from January 2010 to June 2019. In addition, outcomes were examined from a subset of hospitalizations with Medicare-linked claims between January 2010 and November 2015. Fully eligible population included 561,823 patients; the Medicare-linked subset included 74,502 patients. Results In total, 8747 patients (1.56%) left AMA. The proportion of patients leaving AMA increased from 1.1 to 2.1% over the years of study. Patients leaving a HF hospitalization AMA, compared to patients CDH, were more likely younger, minorities, Medicaid covered or uninsured. The Medicare-linked subset of patients who left AMA had substantially higher 30-day and 12-month readmission rates and higher mortality at each assessment point over 12 months compared to patients who were CDH. After risk adjustments, the hazard ratio of mortality in the Medicare-linked subset AMA group compared to the CDH group was 1.25 (95% CI 1.03, 1.51), p=0.005. Conclusions One in 64 hospitalized patients with HF left AMA. An AMA discharge status was associated with higher risk for adverse 30 day and 12-month outcomes compared to being conventionally discharged home. Strategies that identify patients at risk of leaving AMA and policies to direct interventional strategies are warranted. Condensed Abstract We investigated patient characteristics, hospital factors and clinical outcomes associated with patients leaving a HF hospitalization against medical advice compared with being conventionally discharged to home. Using GWTG, a national registry, we found that patients who left AMA were more likely to be younger, minorities, Medicaid insured or uninsured; they had higher readmission and post-discharge mortality rates. Hospital characteristics associated with higher AMA discharges were for-profit structure and Western U.S. location. As HF prevalence increases, attention and interventions that support patients who chose to leave AMA and the hospitals from which they leave are needed.