Objective: Ethnic disparities in hospital discharges against medical advice (AMA) have been examined in previous studies. However, the institutional factors affecting health decision making have received much less attention. This study examines the evidence for a joint impact of ethnicity and hospital quality on the likelihood of a discharge AMA in patients with cardiovascular disease (CVD). Methods: Adult patients hospitalized with a primary admissions diagnosis of CVD from 2000 to 2005 were identified in a state-wide confidential inpatient hospital discharge dataset. The dataset was augmented with information from several sources, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A high quality hospital was defined as a hospital whose performance exceeded the state average on each JCAHO hospital performance measure. A hierarchical generalized linear logistic model of a discharge against medical advice controlling for various individual and contextual factors was estimated using cross-sectional data Results: A total of 2,593 of the 328,342 hospitalizations for CVD (0.8%) resulted in a discharge AMA. The patients self-identified as non-caucasian in thirty percent (N=100,074) of the hospitalizations. Fifteen percent (N=48,177) of the hospitalizations occurred in high quality hospitals. The adjusted odds of a discharge AMA in a low quality hospital were lower for non-Caucasians (OR=0.74; p=0.0005) compared to Caucasians while the adjusted odds of a discharge AMA in a high quality hospital were unchanged between Caucasians and non-Caucasians (OR=0.95; p=0.6). Among Caucasians, a discharge AMA was less likely (OR=0.75; p=0.01) at a high quality hospital compared to a low quality hospital while, among non-Caucasians, the odds of a discharge AMA were unchanged (OR=0.96; p=0.74) across hospital quality groups. Conclusion: The two unique and complementary findings here are that: 1) institutional quality mediates the relationship between ethnicity and hospital discharges AMA; and 2) the relationship between hospital quality and discharges AMA varies with ethnicity.