COVID-19 infection and attributable mortality in UK care homes: cohort study using active surveillance and electronic records (March–June 2020)

  1. Peter F Dutey-Magni
  2. Haydn Williams
  3. Arnoupe Jhass
  4. Greta Rait
  5. Fabiana Lorencatto
  6. Harry Hemingway
  7. Andrew Hayward
  8. Laura Shallcross

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Abstract

Background

epidemiological data on COVID-19 infection in care homes are scarce. We analysed data from a large provider of long-term care for older people to investigate infection and mortality during the first wave of the pandemic.

Methods

cohort study of 179 UK care homes with 9,339 residents and 11,604 staff. We used manager-reported daily tallies to estimate the incidence of suspected and confirmed infection and mortality in staff and residents. Individual-level electronic health records from 8,713 residents were used to model risk factors for confirmed infection, mortality and estimate attributable mortality.

Results

2,075/9,339 residents developed COVID-19 symptoms (22.2% [95% confidence interval: 21.4%; 23.1%]), while 951 residents (10.2% [9.6%; 10.8%]) and 585 staff (5.0% [4.7%; 5.5%]) had laboratory-confirmed infections. The incidence of confirmed infection was 152.6 [143.1; 162.6] and 62.3 [57.3; 67.5] per 100,000 person-days in residents and staff, respectively. Sixty-eight percent (121/179) of care homes had at least one COVID-19 infection or COVID-19-related death. Lower staffing ratios and higher occupancy rates were independent risk factors for infection.

Out of 607 residents with confirmed infection, 217 died (case fatality rate: 35.7% [31.9%; 39.7%]). Mortality in residents with no direct evidence of infection was twofold higher in care homes with outbreaks versus those without (adjusted hazard ratio: 2.2 [1.8; 2.6]).

Conclusions

findings suggest many deaths occurred in people who were infected with COVID-19, but not tested. Higher occupancy and lower staffing levels were independently associated with risks of infection. Protecting staff and residents from infection requires regular testing for COVID-19 and fundamental changes to staffing and care home occupancy.

Article activity feed

  1. Version published to 10.1093/ageing/afab060
  2. ScreenIT

    SciScore for 10.1101/2020.07.14.20152629: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: Thank you for sharing your data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and limitations: The unique surveillance system we established in partnership with FSHCG tracked infections across a large number of care homes. To our knowledge, this is the most complete reporting system for COVID-19 infections in care homes published to date. It is possible that care homes that paid less attention to active surveillance to support control will have had higher levels of uncontrolled outbreaks compared to those seen in this study. Our estimates of mortality attributable to COVID-19 are dependent on our definition of ‘outbreak’ versus ‘non-outbreak’ care homes. We used a sensitive definition (≥1 case/home) due to under-ascertainment caused by the lack of testing. However, it is possible that we incorrectly classified some care homes with only a few cases throughout the pandemic as having experienced outbreaks. Other key limitations relate to the completeness of individual-level data. We lacked information on comorbidity and ethnicity, shown to be important risk factors for adverse outcomes in COVID-19,4 but we were able to identify individuals with dementia, and adjust for receipt of nursing care which will partially capture comorbidity. The number of infections was under-reported in the individual-level dataset by comparison with the manager-reported daily infection tallies, and we lacked information on the overall rate of testing in each care home. Finally, our measures of care home occupancy were based on the pre-pandemic period and did not take ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We found bar graphs of continuous data. We recommend replacing bar graphs with more informative graphics, as many different datasets can lead to the same bar graph. The actual data may suggest different conclusions from the summary statistics. For more information, please see Weissgerber et al (2015).

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2020.07.14.20152629 on medRxiv