INTRODUCTION: The Covid-19 pandemic has caused significant increases in mortality in the United States, and nursing homes were particularly impacted early in the pandemic. With questions around underreporting, limited testing, and indirect effects, it is difficult to understand the true impact of the pandemic on US mortality while only examining the deaths attributed to Covid-19. Prior analyses have looked at excess mortality, the increase in mortality over what would have been expected in 2020 if the Covid-19 pandemic had not occurred, focusing on temporal and spatial relationships between excess mortality and direct Covid-19 attributed mortality. The true impact of Covid-19 by place of death remains to be understood. Recent historical trends in mortality by place of death have shown a decreasing share of deaths occurring in hospitals while deaths in homes have increased and deaths in nursing homes have not changed significantly.
OBJECTIVE: This observational study aims to characterize the impact of the Covid-19 pandemic on nursing homes in the US by examining direct Covid-19 mortality, excess mortality, and the relationship between direct and excess mortality by place of death at a state level.
METHODS: Vital statistics data around mortality by place of death from CDC WONDER and the NVSS Provisional Covid-19 Deaths dataset were used along with US Census data to create a time series for US mortality by place of death from 2013 to 2020. The analysis was restricted to individuals above the age of 65 to limit fields with missing or suppressed data and stratified by 10-year age category. 2020 mortality in the absence of Covid-19 was estimated using the historical average mortality and the simple linear extrapolation of historical mortality within each age group, place of death, and state. Excess deaths were divided into those assigned to Covid-19 and those not assigned to Covid-19 and compared by place of death, age category, and state.
RESULTS: 26.2% of direct Covid-19 deaths were found to occur in nursing homes, while 63.1% of Covid-19 deaths occurred in hospitals and 5.3% occurred at home. The excess mortality rate was found to be the highest at home, with 1.78 more deaths per thousand person-years occurring in 2020 in the US than would have been expected in the absence of Covid-19, despite a low direct Covid-19 mortality rate of only 0.162 deaths per thousand person-years. Excess mortality rates in nursing homes across the US were relatively low at 0.296 deaths per thousand person-years, with a direct Covid-19 mortality rate (1.29 deaths per thousand person-years) that was higher than the estimated excess mortality. Despite the high direct Covid-19 mortality compared to excess mortality in nursing homes, a regression model examining the extent to which Covid-19 mortality and historical mortality predicted 2020 mortality in nursing homes suggested that for every 100 deaths assigned to Covid-19, there were 107 more all-cause deaths in 2020. Nursing home excess mortality was found to be highest in Utah, and lowest in North Carolina and New York.
CONCLUSION: This work suggests that direct Covid-19 mortality captures most of the impact of Covid-19 on mortality in US nursing homes in individuals over the age of 65. A significant difference was discovered between direct Covid-19 mortality and excess mortality in decedent’s homes, which warrants additional study. / 2022-11-23T00:00:00Z
| Identifer | oai:union.ndltd.org:bu.edu/oai:open.bu.edu:2144/43465 |
| Date | 24 November 2021 |
| Creators | McGregor, Anna |
| Contributors | Stokes, Andrew C., Franzblau, Carl |
| Source Sets | Boston University |
| Language | en_US |
| Detected Language | English |
| Type | Thesis/Dissertation |
| Rights | Attribution-NonCommercial 4.0 International, http://creativecommons.org/licenses/by-nc/4.0/ |
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