Early Readmission of Elderly Patients with Congestive Heart Failure

To the Editor:-The prospective investigation on factors associated with increased likelihood of early readmission in elderly patients with documented congestive heart failure by Vinson et a1 was of great interest.’ Recurrent heart failure was the most common indication for readmission, and noncompliance with medication and diet accounted for one-third of contributing factors. This statement requires comment. In addition to the findings reported by the authors, there is evidence that cardiovascular manifestations, recurrent heart failure, and uncontrolled hypertension are important consequences of non-compliance with drugs, particularly in elderly Indeed, it has been documented by means of continuous medication monitoring that partial compliance with diuretic therapy was followed by cardiac deterioration and the need for hospitalization.6 However, information on hospital admissions due to non-compliance is sparse. Its prevalence was reported as 3%-7.4% in departments of general or internal medicine and 3.8% in a department of cardiology. Unfortunately, the authors did not mention their definition of compliance, nor did they provide information on how drug compliance and adherence to diet were assessed. This stands in contrast to the otherwise well documented data on their study population. Notwithstanding the difficulties in measuring adherence to diets, it is known that subjective estimates of patients’ drug compliance are inappropriate and may be grossly mi~leading.~-~ In the study of Vinson et al, a considerable percentage of non-cardiac readmissions was reported to be due to dehydration which was related to excessive diuretic use. Perhaps there actually was overprescribing of diuretics. Overcompliance with drugs may be a problem, but partial compliance appears to be much more frequent. The elderly are no exception. ‘O-” Another point worth mentioning in the conclusions would be that patient education, discharge planning, and enhanced follow-up should include careful assessment of therapy.I3 The patient’s part is only one side of compliance. The other is the prescribing physician and his obligation to comply with principles of optimal therapy. Is ‘perfect’ compliance to be expected with an average of 6.0 f 2.6 drugs prescribed at discharge? Finally, a possible pitfall of the study is the likelihood that therapy had been considerably changed after the patients were discharged from h~spital .’~ These potential influences on the outcome of congestive heart failure as well as on compliance have not been evaluated. In conclusion, without sound evaluation of compliance, the role of non-compliant patient behavior as a cause of rehospitalization will remain a matter of speculation.