Self-discharge: An 'Infrequent but Deadly Problem' After PCI

Patrice Wendling

July 31, 2018

Your patient declares, "I'm outta here!" after their percutaneous coronary intervention (PCI), but do such patients really understand the ramifications of self-discharge?

A new study of more than 2 million PCI procedures shows that patients who discharged against medical advice (DAMA) are uncommon but are twice as likely to be readmitted with an acute myocardial infarction (MI) as those discharged home (39.4% vs 19.5%; P < .001).

"Patients that discharge against medical advice have a twofold increase risk of admission with myocardial infarction — that to me is a really, really important message," senior author Mamas Mamas, BMBCh, DPhil, Keele University, Stoke-on-Trent, United Kingdom, told | Medscape Cardiology.

"I think the infarcts they come in with are probably much more serious, as well."

Indeed, if DAMA patients are readmitted with MI, the mortality rate is double that of non-DAMA patients readmitted with MI (5.0% vs 2.4%; P < .001).

"Another important factor and limitation of this work is that we're only seeing the patients that survive to discharge," said Mamas. "What we're not seeing are the patients that discharge against medical advice that die in the community."

Data from the Paris registry show that mortality risk is "stratospheric in the first 7 days" after PCI if dual antiplatelet therapy (DAPT) is discontinued, he noted.

"So it may be that patients are just simply not surviving to be readmitted with a myocardial infarction," he said. "I really think we're only seeing the tip of the iceberg here."

DAMA represents up to 2% or so of all hospital discharges and is associated with a higher likelihood of worse outcomes. The phenomenon has not been evaluated specifically in the PCI setting, said Mamas, who noted that a recent study by his team piqued their interest after it found that DAMA was one of the strongest predictors of 30-day readmission after contemporary PCI.

The present study was published online July 23 in JACC Cardiovascular Interventions.

Predicting DAMA

Using data from 2,021,104 patients with a PCI in the Nationwide Readmission Database between 2010 and 2014, the investigators, led by Chun Shing Kwok, MBBS, MSc, also from Keele University, identified 10,049 (0.5%) DAMA patients.

The 30-day readmission rate, the study's primary outcome, was 16.8% among DAMA patients and 8.5% among patients discharged home (P < .001).

For all readmissions, DAMA was associated with more death than a routine discharge (3.2% vs. 2.0%), more in-hospital major adverse cardiac events (6.1% vs 2.4%), and more DAMA for readmission (13.9% vs 1.1%; P for all < .001).

The cost of readmission was also significantly higher with DAMA ($13,718 vs $11,380), particularly among DAMA patients readmitted with acute MI ($15,183 vs $11,936; P for both < .001).

Consistent with published results in other settings, DAMA correlated with smoking (odds ratio [OR], 1.71), alcohol misuse (OR, 1.53), drug abuse (OR, 1.82), and dementia (OR, 1.52). DAMA was less likely to occur among women (OR, 0.58) and patients having elective PCI (OR, 0.66).

When the investigators looked at independent predictors of unplanned 30-day readmission after PCI — once again DAMA was the strongest predictor (OR, 1.89; 95% confidence interval, 1.71 - 2.08).

Nonspecific chest pain was the most common cause of noncardiac readmission for patients with and without DAMA (19.7% vs 20.2%).

DAMA patients, however, were four times as likely to be readmitted for neuropsychiatric reasons (8.3% vs 2.4%) — mainly depression, bipolar disorder, and mood disorders (43.3%).

The dataset did not capture pharmacotherapy data, such as DAPT, or whether patients had any follow-up medical care. However, one study of general admissions suggests that among DAMA patients, only 21.4% of patients had medications prescribed.

A DAMA Care Pathway

Mamas and his team call for improved communications with patients, including more truthful and accurate information regarding wait times, better access to prescription medications after PCI, and inpatient interventions to reduce potential risks.

"In the UK, we have substance and addiction teams within the hospital, so if you think that your patient may have these issues, then you need to get that team in early on," Mamas said.

These teams may be able to prevent self-discharge by providing morphine cover or opioids in a controlled manner or by prescribing medications so alcoholic patients don't develop tremors or withdrawal symptoms, he said.

"These are the sort of things that we're not very good at as interventional cardiologists or even things that we consider," Mamas said. "We're good at planning a procedure, planning the strategy, taking the procedure, and prescribing the DAPT. We're not so good at all the peripheral social factors, which in many cases might impact the patient's outcome much more than what we've done for them."

In an  accompanying editorial, David P. Faxon, MD, and Natalia C. Berry, MD, both from Brigham and Women's Hospital, Boston, Massachusetts, note that the analysis represents the largest report of DAMA following PCI to date and "has identified an infrequent but deadly problem."

They highlight the investigators' suggestions for improvement but write, "Probing further, it seems that there are more concrete solutions that might be offered to DAMA patients or those at risk for DAMA."

The editorialists suggest improving access to care and follow-up through early office visits, home visits, or telemedicine. "Shorter follow-up time (several days after discharge) may be indicated to assess the need for continued medical management or even identify early rationale for readmission in DAMA patients," they write.

Faxon and Berry also say that "DAPT should be physically provided to patients before they leave the hospital," in cases where medication availability or affordability is an issue. In addition, stents that allow for shorter DAPT "may be indicated in subsets of DAMA patients who are at documented risk for medication noncompliance."

Two thirds of the cohort who didn't discharge against medical advice ended up with a drug-eluting stent compared with only half of DAMA patients, "which suggests to me that the operators probably are able to think in those patients that are considered to be high risk, about bare metal use," said Mamas.

The data are older, he said, and newer drug-eluting stent platforms, such as BioFreedom (Biosensors International), have been shown to be efficacious with very short DAPT regimens.

"You may want to consider using this in patients who you may feel are at very high risk of discharging or nonadherence to medications — people who have problems with mental health, problems with substance abuse, alcohol abuse," Mamas said. "The rates are incredibly high in these patient groups."

"In the elective situation, if you have a patient that you think is unlikely to adhere to advice or to prescriptions, then I think you really have to question why you're doing the procedure," said Mamas. "Because certainly from an elective perspective, there is no mortality benefit in doing the PCI and so you might choose then to medically manage such patients."

The study was supported by a grant from the Research and Development Department at the Royal Stoke Hospital. The work was conducted as part of Kwok's PhD, which is supported by Biosensors International. The authors and editorialists report having no relevant conflicts of interest.

JACC Cardiovasc Interv 2018;11:1354-1364, 1365-1367. Abstract, Editorial

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