Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: a national cohort study

  1. Marcello Morciano
  2. Jonathan Stokes
  3. Evangelos Kontopantelis
  4. Ian Hall
  5. Alex J. Turner

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Abstract

Background

To estimate excess mortality for care home residents during the COVID-19 pandemic in England, exploring associations with care home characteristics.

Methods

Daily number of deaths in all residential and nursing homes in England notified to the Care Quality Commission (CQC) from 1 January 2017 to 7 August 2020. Care home-level data linked with CQC care home register to identify home characteristics: client type (over 65s/children and adults), ownership status (for-profit/not-for-profit; branded/independent) and size (small/medium/large). Excess deaths computed as the difference between observed and predicted deaths using local authority fixed-effect Poisson regressions on pre-pandemic data. Fixed-effect logistic regressions were used to model odds of experiencing COVID-19 suspected/confirmed deaths.

Results

Up to 7 August 2020, there were 29,542 (95% CI 25,176 to 33,908) excess deaths in all care homes. Excess deaths represented 6.5% (95% CI 5.5 to 7.4%) of all care home beds, higher in nursing (8.4%) than residential (4.6%) homes. 64.7% (95% CI 56.4 to 76.0%) of the excess deaths were confirmed/suspected COVID-19. Almost all excess deaths were recorded in the quarter (27.4%) of homes with any COVID-19 fatalities. The odds of experiencing COVID-19 attributable deaths were higher in homes providing nursing services (OR 1.8, 95% CI 1.6 to 2.0), to older people and/or with dementia (OR 5.5, 95% CI 4.4 to 6.8), amongst larger (vs. small) homes (OR 13.3, 95% CI 11.5 to 15.4) and belonging to a large provider/brand (OR 1.2, 95% CI 1.1 to 1.3). There was no significant association with for-profit status of providers.

Conclusions

To limit excess mortality, policy should be targeted at care homes to minimise the risk of ingress of disease and limit subsequent transmission. Our findings provide specific characteristic targets for further research on mechanisms and policy priority.

Article activity feed

  1. Version published to 10.1186/s12916-021-01945-2
  2. ScreenIT

    SciScore for 10.1101/2020.11.11.20229815: (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: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths & Limitations: To our knowledge, this is the first independent analysis that uses national administrative records from all care homes in England to estimate the impact of COVID-19. We find comparable total deaths to official estimates,5 adding stratifications of excess deaths by key care home characteristics and multivariable analysis to add a more nuanced understanding of these deaths. Local-authority fixed effects were used to account for time-invariant measured and unmeasured determinants and confounders that differ across local authority. Our study also has limitations. Firstly, we can observe the counts of COVID-19 attributed fatalities across care homes but not whether non-fatal COVID-19 cases occurred. This case data is not available, though serological and whole genome sequencing studies give insights to this.24 The attribution of COVID-19-related deaths is based on statements from providers to the CQC starting from 10th April 2020 and not always testing-confirmed or reflected in the death certificate. COVID- 19 attributable deaths occurred before the 10th April would have been miscoded. The reported lower rates of testing could lead to some relevant deaths not having COVID-19 listed as a contributory factor, leading to apparently higher non-COVID-19 excess deaths.5,10,21 No data was available on occupancy rates at care home level. We instead used maximum bed capacity as reported in March 2020, assuming full occupancy. In the UK, occupancy rates were estimat...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    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.
    • Thank you for including a protocol registration statement.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  3. ScreenIT

    SciScore for 10.1101/2020.11.11.20229815: (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

    Software and Algorithms
    SentencesResources
    We searched MEDLINE for published
    MEDLINE
    suggested: (MEDLINE, RRID:SCR_002185)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:

    Strengths & Limitations To our knowledge, this is the first independent analysis that uses national administrative records from all care homes in England to estimate the impact of COVID-19. We find comparable total deaths to official estimates,5 adding stratifications of excess deaths by key care home characteristics and multivariable analysis to add a more nuanced understanding of these deaths. Local-authority fixed effects were used to account for time-invariant measured and unmeasured determinants and confounders that differ across local authority. Our study also has limitations. Firstly, we can observe the counts of COVID-19 attributed fatalities across care homes but not whether non-fatal COVID-19 cases occurred. This case data is not available, though serological and whole genome sequencing studies give insights to this.24 The attribution of COVID-19-related deaths is based on statements from providers to the CQC starting from 10th April 2020 and not always testing-confirmed or reflected in the death certificate. COVID19 attributable deaths occurred before the 10th April would have been miscoded. The reported lower rates of testing could lead to some relevant deaths not having COVID-19 listed as a contributory factor, leading to apparently higher non-COVID-19 excess deaths.5,10,21 No data was available on occupancy rates at care home level. We instead used maximum bed capacity as reported in March 2020, assuming full occupancy. In the UK, occupancy rates were estimated ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

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

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  4. Version published to 10.1101/2020.11.11.20229815v1 on medRxiv