Department of Cardiology, Lehigh Valley Hospital Network, Allentown, PA.
Department of Internal Medicine, Lehigh Valley Hospital Network, Allentown, PA.
Mayo Clin Proc. 2018 Oct;93(10):1397-1403. doi: 10.1016/j.mayocp.2018.04.023. Epub 2018 Jul 10.
To determine the readmission rate in patients with acute heart failure (AHF) discharged against medical advice (AMA).
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.
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).
Patients with AHF discharged AMA had a significantly higher 30-day readmission rate than did the routinely discharged group.
确定因医嘱拒绝而出院的急性心力衰竭（AHF）患者的再入院率。
我们使用 2014 年国家再入院数据库进行回顾性分析。选择因主要诊断为 AHF 入院的患者。仅包括出院回家且医嘱拒绝的患者。主要结局为 30 天再入院。我们使用倾向评分匹配（PSM）比较医嘱拒绝出院与常规出院患者的再入院率，以解决两组间变量的不平衡。我们将 3 名常规出院患者与 1 名医嘱拒绝出院的患者匹配。
我们确定了 273489 名 AHF 患者，其中 116869 名符合进一步研究分析的条件。共有 2014 名患者（1.7%）在医嘱拒绝出院组，114855 名（98.3%）在常规出院组。PSM 后，6042 名常规出院患者与医嘱拒绝出院组的 2014 名患者相匹配。每个变量的标准均数差值小于匹配后 10%。医嘱拒绝出院组的 30 天再入院率高于常规出院组（33%比 20.1%；P<.001）。心力衰竭（44.8%）是医嘱拒绝出院组再入院的最常见原因。与常规出院组相比，医嘱拒绝出院组更有可能被转往其他医院（37.4%比 23.1%；P<.001）。他们在再入院期间医嘱拒绝出院的比例也很高（18%比 2%；P<.001）。
因医嘱拒绝而出院的 AHF 患者 30 天再入院率明显高于常规出院组。
