CG REPORT 6 Q2: How does mortality in care homes compare with pre-pandemic periods?
Our report on care homes included three distinct questions and we’ve addressed each one individually. Follow the links for Question 1 and Question 3. You can also read and download the full report here.
CG Report 6 took a hard look at excess mortality – an epidemiological term for the number of reported deaths during a crisis above what we would have expected to see under non-crisis conditions, covering deaths from all causes. For the COVID-19 pandemic, that means mortality that can be attributed to COVID-19, but also mortality from other causes (such as dementia or cardiac health) in excess of what we would expect to see in a “normal” year.
In particular, we looked at how mortality in care homes during the COVID-19 pandemic compared with mortality in care homes from before the pandemic’s onset. In order to answer this question, we looked at 17 cohort studies that assessed excess mortality compared to a previous, pre-pandemic period. Every single study reported excess mortality (both COVID and non-COVID related) during waves one and/or two of the pandemic.
Contextualizing the data: Reductions in Emergency Department visits for non-COVID related illnesses indicate substantially limited access to healthcare services, which could help account for non-COVID related excess mortality. For example, in England, a 29% decrease in hospital deaths related to heart failure was accompanied by a 31% increase in heart failure deaths at home and a 28% increase in heart failure deaths in care homes and hospices.
Sundaram 2021 study in Ontario analysed data from March – December 2020 for approximately 14.7 million residents. Mortality rates rose during March 2020 and were higher in all pandemic months through December 2020. However, a substantial reduction in hospitalisations and Emergency Department visits occurred during 2020 compared to previous years.
Decarie retrospective cohort analysed data on those dying in and outside of nursing homes in Quebec and British Columbia from January 1 to June 30. At the pandemic’s peak, excess mortality increased >150% in nursing home settings.
Canoui-Poitrine reported 13,505 excess deaths in a cohort of 494,753 adults in 6,515 French nursing homes compared with 2014-19 (a 43% increase). During the first pandemic, the mortality rate among nursing home residents ranged from 5.3% in Lozère (a rural département with the lowest population density) to 22.2% in the socially-deprived Paris suburb, Seine-Saint-Denis.
Cusack’s study using the Coroner’s database of death inquiries in the District of Kildare in Ireland from March to June 2020 reported an unexplained residual excess of 60 deaths due to natural causes (a 38% increase compared with the 2015-19 period). Of 139 COVID-19 deaths notified to June 30, 2020, 113 were residents of nursing and residential homes; 25 occurred in the General Hospital (patients admitted directly from the community); and one in the General Community. COVID-19 deaths in nursing and residential homes accounted for 61% of all such deaths in Ireland.
Cangiano assessed COVID and non-COVID deaths in an Italian nursing home in Milan over two months and reported mortality was 40% compared to 6.4% in the previous year (63 deaths/157 patients in 2020 vs ten deaths/155 patients in 2019). In addition, an increase was seen in both COVID-19 positive (43%) and negative (24%) patients.
Ballotari study in Northern Italy in the Mantua and Cremona provinces (Lombardy Region) reported in the first wave that the nursing care home population excess mortality risk compared to the non-care home population was more than double the 2018 risk, while in a non-nursing care home population, it rose by approximately 60%, and varied by region.
Alacevich retrospective analysis between January 1 and March 31 of 2020 in 1,440 municipalities in the Lombardy Region, Italy, noted that official data on COVID-19 deaths in care homes for Italy was not available and that the analysis could not differentiate between fatalities that happened inside a care home from the death counts. The data showed that municipalities with care homes in Lombardy registered a higher mortality rate of 6.5%, against a national average of 3.1%
Modig analysis from April to June 2020 reported excess mortality in care homes, home care, and independent living in Sweden. Individuals living in care homes experienced the highest excess mortality compared with home care and independent living. During April, the number of excess deaths was higher at every age in the care home group than in the other two groups. However, it was impossible to identify the mechanism behind the excess mortality in the care home groups.
Burton’s study in Scotland reported that 32% of care homes had any cases of COVID-19 up to October 2020. Approximately half of the deaths attributed to COVID-19 were accounted for by the 5% of those over-70s who were care-home residents. Life expectancy fell by almost six months based on care home-specific life expectancy.
Davies 2021 analysed excess deaths in England from March to May 2020 and reported total deaths in care homes were 52,268, 93% above the five-year average (n=27,128). Communities with an increased risk of excess mortality had a high density of care homes and a high proportion of members on income support, living in overcrowded homes and/or non-white ethnicity.
Hollinghurst 2020 population-based study in Wales reported deaths in care homes increased significantly in 2020 compared with the same period of 2016 to the year-end of 2019. The study analysed data on Welsh residents (including >12,000 individuals per year in over 500 care homes) from March 23 to June 14, 2020.
Wu J retrospective cohort analysed the national death registry of all adult deaths between March 2 and June 30, 2020 in England and Wales. Total excess mortality of 57,860 was reported. In care homes or hospices in England and Wales, an excess of 25,611 deaths (44% of the total) was found when compared with historical data between 2014 and 2020: 61% (15,623) of these excess deaths were related to COVID-19.
Of these excess deaths 6,267 were due to dementia, 2,358 to ill-defined conditions in care homes or hospices, of which only 783 and 1,003 were recorded as COVID-19 related. There were 1,495 fewer deaths due to cancer than expected, and 1,211 excess deaths due to cardiac disease in care homes. Wu et al. noted that care home residents who became unwell during the pandemic may not have been referred to or decided not to go to the hospital for fear of becoming infected.
In England, Shoaib 2021 reported 36,974 adults with admission and primary diagnosis of heart failure between February 1 and May 31, 2020. There was a 29% decrease in hospital deaths related to heart failure with a concomitant 31% increase in heart failure deaths at home and a 28% increase in heart failure deaths in care homes and hospices.
O’Donnell analysed the UK’s registered deaths over 12 months (March 2020-21). During the 12 months, 798,643 deaths were registered, of which 147,282 were COVID-19 deaths, and 17,672 were considered additional non-COVID-19 deaths. Deaths in care homes increased above expected levels by 134% during the first wave and 10% in the second wave but fell below expected levels by 3% between waves.
Greenwald reported on 28,389,098 US Medicare and dual-eligible recipients from 29 Feb to 30 Nov 2020 and found that, in long-term care facilities, mortality increased from 20.3% to 24.6% compared with 2017-2019.
Signorelli reported that the COVID-19 epidemic had seen significant mortality in at least seven of the metropolitan areas studied. Different definitions, case ascertainment strategies, and lengths of follow-up will account for variations in reported deaths.