Factors Associated with Discharge against Medical Advice among Acute Stroke Patients: Analysis of the Nationwide Emergency Department Sample.

INTRODUCTION

Patients discharged against medical advice have been shown to have worse outcomes across a host of different conditions. However, risk factors related to increased odds of discharge against medical advice remain understudied in patients who suffer from acute cerebral infarction.

METHODS

We retrospectively examined the 2019 National Emergency Department Sample Database for stroke patients. Multivariable logistic regression was used to estimate associations between patient- and hospital-level factors and the outcome of discharge against medical advice.

RESULTS

Of the 603,623 encounters for acute ischemic stroke, 8,858 (1.5%) were discharged against medical advice. Predictors of discharge against medical advice were lower income quartile and having either Medicaid insurance (odds ratio [OR] 1.32, 95% confidence interval [CI]: 1.10-1.58) or being uninsured (OR 1.28, 95% CI: 1.03-1.58). Vascular comorbidities associated with discharge against medical advice included prior tobacco use (OR 1.60, 95% CI: 1.45-1.78) and coronary artery disease (OR 1.19, 95% CI: 1.04-1.35). Treatment with thrombectomy (OR 0.33, 95% CI: 0.13-0.78) or systemic thrombolysis (OR 0.39, 95% CI: 0.23-0.66) was inversely associated with discharge against medical advice. A high modified Charlson comorbidity index (3+ vs. 0, OR 0.49, 95% CI: 0.42-0.56) was also associated with a lower odds of discharge against medical advice. Presenting to a Northeastern hospital had the highest rate of discharge against medical advice, when compared to other regions (p < 0.05).

CONCLUSIONS

Certain patient-level, socioeconomic, and regional factors were associated with discharge against medical advice following acute stroke. These patient- and systems-level factors warrant heightened attention in order to optimize acute care and secondary prevention strategies.