Prevalence and characteristics of long COVID in elderly patients: An observational cohort study of over 2 million adults in the US

Author summary Why was this study done? The quoted incidence of long COVID varies widely because of differences in definition and measurement method. Long COVID in the elderly is likely to be underreported because they are less likely to respond to surveys, and symptoms may be confused with other chronic diseases.Lingering ill health after infections is not limited to COVID-19. We postulate that some patients may fit the diagnostic criteria of long COVID after a bout of influenza. We call this condition "long Flu." Comparing and contrasting long COVID and long Flu may shed light on the understanding of long COVID, a disease still shrouded in mystery. What did the researchers do and find? We used the World Health Organization long COVID definition on 2 million Medicare patients with COVID-19 between April 2020 and June 2021. We applied the same definition to almost 900,000 influenza patients during the 2018 and 2019 Flu seasons to identify long Flu.Long COVID occurred in 16.6% of outpatients and 29.2% of inpatients. The corresponding rates for long Flu were 17% and 24.6%. Using only the designated long COVID code, the estimated rates would be 0.5% and 2.6%, way below the reported rates in most studies.Despite the similar overall incidence rates, long COVID patients suffered with notably different symptoms compared to long Flu patients and were also more likely to access inpatient and outpatient healthcare services. What do these findings mean? The use of designated long COVID diagnostic codes alone is likely to result in gross underreporting of long COVID in this population.Long COVID is associated with greater healthcare utilization than long Flu, suggesting a bigger impact on individual health and well-being, as well as on healthcare expenditure. BackgroundIncidence of long COVID in the elderly is difficult to estimate and can be underreported. While long COVID is sometimes considered a novel disease, many viral or bacterial infections have been known to cause prolonged illnesses. We postulate that some influenza patients might develop residual symptoms that would satisfy the diagnostic criteria for long COVID, a condition we call "long Flu." In this study, we estimate the incidence of long COVID and long Flu among Medicare patients using the World Health Organization (WHO) consensus definition. We compare the incidence, symptomatology, and healthcare utilization between long COVID and long Flu patients. Methods and findingsThis is a cohort study of Medicare (the US federal health insurance program) beneficiaries over 65. ICD-10-CM codes were used to capture COVID-19, influenza, and residual symptoms. Long COVID was identified by (a) the designated long COVID code B94.8 (code-based definition), or (b) any of 11 symptoms identified in the WHO definition (symptom-based definition), from 1 to 3 months post-infection. A symptom would be excluded if it occurred in the year prior to infection. Long Flu was identified in influenza patients from the combined 2018 and 2019 Flu seasons by the same symptom-based definition for long COVID. Long COVID and long Flu were compared in 4 outcome measures: (a) hospitalization (any cause); (b) hospitalization (for long COVID symptom); (c) emergency department (ED) visit (for long COVID symptom); and (d) number of outpatient encounters (for long COVID symptom), adjusted for age, sex, race, region, Medicare-Medicaid dual eligibility status, prior-year hospitalization, and chronic comorbidities. Among 2,071,532 COVID-19 patients diagnosed between April 2020 and June 2021, symptom-based definition identified long COVID in 16.6% (246,154/1,479,183) and 29.2% (61,631/210,765) of outpatients and inpatients, respectively. The designated code gave much lower estimates (outpatients 0.49% (7,213/1,479,183), inpatients 2.6% (5,521/210,765)). Among 933,877 influenza patients, 17.0% (138,951/817,336) of outpatients and 24.6% (18,824/76,390) of inpatients fit the long Flu definition. Long COVID patients had higher incidence of dyspnea, fatigue, palpitations, loss of taste/smell, and neurocognitive symptoms compared to long Flu. Long COVID outpatients were more likely to have any-cause hospitalization (31.9% (74,854/234,688) versus 26.8% (33,140/123,736), odds ratio 1.06 (95% CI 1.05 to 1.08, p < 0.001)), and more outpatient visits than long Flu outpatients (mean 2.9(SD 3.4) versus 2.5(SD 2.7) visits, incidence rate ratio 1.09 (95% CI 1.08 to 1.10, p < 0.001)). There were less ED visits in long COVID patients, probably because of reduction in ED usage during the pandemic. The main limitation of our study is that the diagnosis of long COVID in is not independently verified. ConclusionsRelying on specific long COVID diagnostic codes results in significant underreporting. We observed that about 30% of hospitalized COVID-19 patients developed long COVID. In a similar proportion of patients, long COVID-like symptoms (long Flu) can be observed after influenza, but there are notable differences in symptomatology between long COVID and long Flu. The impact of long COVID on healthcare utilization is higher than long Flu.