Our study found that approximately one-third of RSV hospitalizations resulted in institutional and professional home care needs immediately following discharge and were comparable to care needs of adults hospitalized with influenza or acute MI. RSV hospitalizations had similar durations of inpatient and ICU stays when compared with influenza, acute MI, and stroke hospitalizations. Consistent with the age-related trends for RSV-associated hospitalizations in the US [32] and other prior studies, [1, 4, 17, 19, 33] the present study found that a high percentage of RSV hospitalizations were among older adults (> 70%) and adults with high-risk conditions (> 90%). Further, our study found that a notable proportion (11%) of younger adults with RSV also required a higher level of care post-discharge than prior to admission. Among these younger adults, about 90% had at least one of the underlying risk conditions, demonstrating that even younger adults with underlying risk conditions required additional healthcare resources after RSV hospitalization discharge.
Few studies have documented the post-discharge care needs for adults hospitalized with RSV. A chart-review study [34] reported that 76% of older adults and 73% of other adults without chronic lung disease hospitalized with RSV required follow-up care after discharge, indicating a substantial post-discharge burden is present across different age groups. In a prospective global study that included adults ≥ 18 years who were hospitalized with RSV, 24.5% required professional home care, and 11.6% required institutional care after discharge [13]. In a retrospective study of US adults hospitalized with RSV, 10–16% required skilled nursing either at home or at a nursing facility post-discharge compared with 6.7% before the RSV admissions [34]. Among the subgroups examined, older adults and immunocompromised adults most frequently required skilled nursing [34]. This is consistent with our study, where older adults discharged from RSV hospitalization entered institutional care and home health programs at a much higher proportion than younger adults. However, in contrast to our study, many of these previous studies had limited sample sizes, and some did not indicate whether the higher-level care needs were immediately following discharge or within a defined period post-discharge.
The higher-level care needs after RSV hospitalization may partially be explained by the acute functional decline associated with RSV hospitalization in older adults [35]. In a longitudinal US study, older adults who were living in a community with assistance prior to admission had a significant decline in instrumental activities of daily living at 6 months after RSV hospitalization, while there were no significant changes in older adults living independently in the community [35]. This highlights that even among community-dwelling individuals, certain subgroups are at higher risk for functional decline from RSV hospitalization and the ensuing loss of independence that contributes to the need for elevated care after discharge.
The present study found that the needs for professional home health or institutional care immediately after discharge were comparable between the RSV and influenza cohorts. Additionally, hospitalizations with RSV exhibited a similar mean length of hospital and ICU stay as hospitalizations with influenza. This corroborates findings from prior studies which reported that the morbidity, mortality, and medical resource utilization of RSV hospitalizations were of similar magnitude as influenza hospitalizations [13, 14]. A previous study by Pastula et al. 2017, also reported a higher mean LOS (6 days) for RSV hospitalizations as compared to influenza hospitalizations (3.6 days) [15]. Similar trends were also seen in other countries [17, 18]. Unlike a few other published studies, [13, 14, 17, 36] our study found lower ICU admissions and mechanical ventilator use in patients hospitalized with RSV as compared to those with influenza. This is likely due to the higher proportion of underlying pulmonary conditions in the influenza cohort (71.2%) than in the RSV cohort (43.8%). Furthermore, lower utilization of high-intensity care (such as ICU admission and mechanical ventilator use) despite similar lengths of hospital and ICU stays in the RSV cohort as compared to the influenza cohort suggests that there may be differences in the type of resources used in the hospital across the two cohorts depending on underlying risk conditions. Given how infrequent RSV testing is in the US, this finding may not be representative of all patients with RSV infection [8].
Our study is unique in that we descriptively compared healthcare utilization and post-discharge care of RSV to completely different but important medical events of acute MI and stroke. Healthcare providers and payer organizations have focused on these common but serious medical conditions because effective preventive interventions are available. There have been substantial investments and awareness towards disease prevention efforts for influenza, acute MI, and stroke [20, 37]. By documenting that healthcare resource utilization and overall immediate post-discharge care needs for adults hospitalized with RSV are similar to needs of adults hospitalized with influenza, acute MI, or stroke, this study underscores the need for prioritizing RSV prevention efforts among older adults similar to influenza, acute MI, and stroke. With the recent regulatory approvals and US Advisory Committee on Immunization Practices (ACIP) recommendations of RSV vaccines for adults aged ≥ 75 years and those 60 to 74 years with risk conditions, [12, 38, 39] efficient implementation and high uptake among older adults will be important for RSV prevention [31].
Several limitations of this study should be noted. The PHD is an administrative and billing data set, not collected for research purposes; therefore, there may be reporting errors and omissions, thereby leading to potential misclassification. Although the admitting source was limited to a non-healthcare facility point of origin, mostly involving community-dwelling individuals, the extent of patients’ specific health and functional assistance needs in that setting prior to the hospitalization is unknown. Despite data contribution from over 1,190 hospitals across the US, [25] the patients hospitalized with RSV, influenza, acute MI, or stroke in the current study may not be representative of all US adults. In particular, RSV testing is not generally routinely conducted in adults presenting to the hospital with acute respiratory symptoms [8]. Therefore, the RSV cohort is an undercount of RSV-associated hospitalizations and may not be representative of the full clinical spectrum of adults hospitalized with RSV. This study only considered primary hospital diagnosis for identification of hospitalizations associated with conditions of interest. In the case of RSV, it is possible that hospitals use a different code as the primary diagnosis if an underlying condition is exacerbated that requires serious management, further undercounting patients with RSV and potentially impacting the representativeness of this cohort.
This study required a 90-day clean post-discharge period (i.e., no subsequent hospitalization associated with either of the four conditions of interest within 90 days of their previous hospitalizations associated with any of the four conditions of interest) to identify qualifying hospitalizations for inclusion. Readmissions within a short window due to the four conditions were not included and it is likely that there is additional higher-level care after discharge from the readmission that is not captured in the current study. Furthermore, since this study descriptively summarized outcomes associated with RSV hospitalizations to influenza, acute MI, and stroke hospitalizations using summary measures, no statistical inference testing was done across the four cohorts or in a pairwise fashion. When characterizing cardiovascular comorbidities, all acute MI hospitalizations were identified as having these and given that acute MI can occasionally result from non-cardiovascular factors, [40] it is possible that not all patients hospitalized with acute MI had cardiovascular comorbidities. This potential misclassification is not likely to impact the results presented in this study. Despite these limitations, the study includes information on a large number of patients across demographic profiles, payers, and diverse US geographic regions that improved prior study limitations on care immediately after discharge.
In conclusion, this study documents that immediate post-discharge care needs among adults hospitalized with RSV infection are considerable, especially among older adults. Adults discharged from RSV hospitalization had similar or higher use of professional home care as compared to adults discharged from influenza, acute MI, or stroke hospitalization. Elevated care involving institutional care immediately after discharge from RSV hospitalization was common with similar frequency as discharge from influenza or acute MI hospitalization. Given the substantial care needs following RSV hospitalizations, efforts to implement preventive strategies, including RSV vaccination in older adults, are needed to reduce the continued healthcare burden after RSV hospitalization.
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